Emotional Support during labor CAN’T be overlooked

Full citation: Kennell, J., Klaus, M., McGrath, S., Robertson, S., & Hinkley, C. (1991). Continuous Emotional Support During Labor in a US Hospital. JAMA, 265(17), 2197-2201.

Attention all doulas out there: this is something you really need to read. It’s one of my favorite studies of all time, actually. I discovered it in Nursing School when I was writing a report on health care policy measures which could be used to lower our abysmally high c-section rate. This study found that the importance of continuous emotional support during labor cannot be overemphasized, which isn’t really news to a midwife or doula, but is something that many doctors tend to overlook, not to mention many of our hospitals, and the field of obstetrics in general. We have whole systems devoted to the get ‘em in, get ‘em delivered, get ‘em out approach, with a lot of time and attention spent on interventions which allegedly speed up birth, such as inductions and the judicious use of pitocin, and of course, there’s the misguided idea that a cesarean is actually a safer, faster, healthier option than a vaginal birth (as our growing elective primary c-section rate would attest). What this study found was that continuous emotional support during labor not only lowered the c-section rate, but also shortened the length of labor, and even lowered the epidural rate. Pretty powerful stuff!

In this remarkable study performed at Jefferson Davis Hospital in Houston, TX, researchers paired women in labor with either a doula or a non-interactive observer, and compared the cesarean section (CS) rates of both groups to a control group which received no outside support other than the hospital staff. The doulas had all experienced a normal labor and vaginal delivery, were fluent in English and Spanish, had been trained in labor support techniques during a three week intensive, and were comfortable dealing with both patients and medical staff. During labor, the doulas offered continuous hands-on support, often holding, massaging and verbally reassuring the woman in labor, as well as explaining what was happening during labor and what would likely happen next. In contrast, the non-interactive observer, while also continuously present, maintained an inconspicuous role and never spoke with the patient. The results of this study revealed that doulas had a profound effect on the CS rate: women with doula support had an 8% CS rate as compared to a 13% CS rate for the observed group and an 18% CS rate for the control group. Doula supported women also had a lower rate of epidural use (7.8% vs. 22.6% and 55.3% for the observer and control groups, respectively) a shorter labor (an average of 7.4 hours v. 8.4 and 9.4 hours for the observer and control groups) and a reduced rate of oxytocin use, maternal fever and prolonged infant hospitalization. Although they were unable to draw any conclusive reasons for these striking differences, the researchers did conjecture that reduced maternal anxiety in the doula-supported group could have been responsible. The authors also indicated that the support given by doulas was different from the support given by male partners, and that the doulas tended to provide more physical reassurance than the male partners, perhaps because they were more familiar and comfortable with the labor process.

There you have it. The benefits of this study are self-evident: even simply having someone in the room on a continual basis proved effective in lowering the CS rate (even if they weren’t saying a word). Midwife means “with woman”, and to my way of thinking, any decent midwife worth his or her salt rarely leaves his or her patient’s side. Similarly, this might help explain why midwives, using the Midwifery Model of Care, which emphasizes a hands-on approach, have a much lower c-section rate, a lower epidural rate, and shorter, less-complicated labors in general. Or why having a doula is the next best thing, if you don’t have a midwife. Or, have a midwife *and* a doula, and amaze all your friends with the brevity and ease of your birth story! Well, that might be pushing it slightly, but you see the point. A trained labor companion, by reducing maternal anxiety, educating the patient and providing continuous support, can not only expedite delivery but also produce a better outcome. It’s really validating when you find a study that supports what you’ve known and believed all along.

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