Introduction
The nature of support in childbirth
The birth environment: implications for support
Place of birth
Men during labor and at birth
Other support people
Conclusions

Introduction
Support during childbirth can be provided by the professionals responsible for the clinical care of the woman in labor, by other individuals specifically designated to provide support other than clinical care, or by the woman’s partner, family, or friends. Controlled studies thus far have examined the contribution of the first two groups: persons specifically designated to provide support in labor. Insights into the nature and value of support by partners, family members, and friends have been gleaned from data from observational studies.

The nature of support in childbirth
A central feature of support in childbirth is the promise that the laboring woman will not, at any time, be left without available support.

The mere physical presence of a support person is not enough. That person must also provide supportive activities, which encompass both physical comfort measures and emotional support.

Physical comfort measures should be provided in response to the woman’s own needs and wishes. These will vary from culture to culture, and from individual to individual. Her supportive companion may, for example, walk with her, massage her back, offer food and fluids, help her to find a comfortable position, or assist her with a bath or shower. He or she can provide analgesic measures, such as counterpressure, cold with an ice pack or heat with a hot water bottle to painful areas of her body. The companion can help the woman to use breathing patterns that may help her relax, or other rituals that she may have practised during the pregnancy.

Emotional support may include maintaining eye contact, and providing information, praise, and encouragement. The supporting companion can help ensure that the woman understands the purpose of every procedure and the result of every examination, that she is kept informed of the progress of her labor, and that she is praised for her efforts and encouraged to continue.

The extent to which support may be seen as an integral component of care during childbirth depends on the orientation of the caregivers.
Some professionals may give priority to the technical tasks of caring for a woman in labor. Others may feel that technical tasks and emotional/physical support are intimately related in helping the woman to progress successfully throughout labor, and cannot be separated. Modern technology may make support difficult for caregivers who hold the latter view, as their time and attention may be distracted away from the woman towards the monitor or the intravenous drip.

Every woman should be able to choose her source of social support in labor. This may be her partner, another family member, or a friend.
Midwives, doctors, and nurses should respect her choice and provide, in addition to clinical care, appropriate physical and emotional support where it is needed.

The birth environment: implications for support
For much of this century, in much of the world, the subjective experiences of labor and birth were submerged by narcotic analgesia and general anesthesia, in a vain attempt to render labor painless. While women were unconscious, questions of physical and psychological support were irrelevant. When the natural childbirth movement redefined the experience of giving birth as potentially positive, these aspects of the birth environment took on a new significance.

Many aspects of the birth environment in hospitals can induce stress. The setting and the people in it may be strange to the laboring woman.

Common procedures, such as restriction of fluids and foods, vaginal examinations, electronic fetal monitoring, and confinement to bed, can further add to the stress. Fear, pain, and anxiety may be increased by a mechanized, clinical environment and by unknown attendants, and this can have potentially adverse effects on the progress of labor.

Women appreciate a constantly available, supportive companion in labor, together with appropriate care from a small number of professionals.

This form of continuous support is not always provided. A woman’s feeling of isolation can be compounded by the intermittent appearance and disappearance of unknown people, including obstetricians, midwives, nurses, and medical, nursing, or midwifery students. One study reported that a low-risk mother having her first child in a teaching hospital was attended by 16 people during 6 hours of labor, but was still left alone most of the time. A Canadian study found that women giving birth in hospital encountered an average of over six unfamiliar professionals during labor, with some women reporting up to 14 attendants. Several work-sampling studies have shown that on average less than 10% of the labor nurse’s time was spent in supportive activities.

Five controlled trials have compared the effects of labor and birth in a home-like institutional settings, i.e. birth rooms or hospital birth centers, to that in a conventional hospital labor ward. Over 8000 women have participated in these trials. The women allocated to labor and to give birth in a home-like birth setting used, on average, less pain medication during labor, were slightly less likely to have their labors augmented with oxytocin, and had a slightly greater chance of being very satisfied with their birth experience.

In the years since these trials were published, many hospitals have allocated scarce resources towards renovating their labor wards, to provide more attractive, home-like settings for birth. Such settings are undoubtedly attractive, and also provide more pleasant work environments for caregivers. It is quite possible that happier caregivers may provide better care. Nevertheless, hospitals that are considering renovations of their labor wards should be aware that there is much stronger evidence to support the need for changes in caregivers’ behavior than there is to support the need for cosmetic or structural changes to labor wards. If renovations are desired, they should be targeted towards factors that would encourage changes in behavior, such as removing lithotomy poles and replacing uncomfortable delivery beds with comfortable furniture and cushions.

Efforts to change caregivers’ behavior, to help them to provide appropriate support to laboring women, should also be introduced. Such changes do not come easily. A multicenterd trial of a marketing strategy using opinion leaders to encourage nurses to provide labor support did not have the hoped-for outcome. A follow-up study in those hospitals where the hypothesized improvements did occur showed that a highly involved nurse manager was critical to its success.

Place of birth
Most doctors and many other health professionals strongly believe that hospital births are safer than home births. This opinion, which is shared by many childbearing women, may in part stem from the poor perinatal outcomes of unplanned, precipitate home births, which include a high proportion of preterm and low-birthweight babies.

These unfortunate statistics do not, however, apply to planned homebirth for eligible women attended by caregivers experienced in home birth, backed up by a modern hospital system.

Several methodologically sound observational studies have compared the outcomes of planned home-births (irrespective of the eventual place of birth) with planned hospital-births for women with similar characteristics. A meta-analysis of these studies showed no maternal mortality, and no statistically significant differences in perinatal mortality between the groups. The number of births included in the studies was sufficiently large to rule out any major difference in perinatal mortality risk in either direction. Significantly fewer medical interventions occurred in the home-birth groups (including women transferred to hospital), and there were significantly fewer low Apgar scores, neonatal respiratory problems, and instances of birth trauma among the babies.

Only one small randomized trial, involving 11 women, has been mounted to compare home with hospital birth. This was done more to demonstrate the feasibility of randomizing women to home or hospital than concern about outcomes. The majority of the women in the hospital group were disappointed by the allocation. This finding was not surprising. Choosing a home (or hospital) birth is a very individual and personal choice for a woman based on her own priorities and values.

Maternal and perinatal mortality are so low in low-risk pregnancies that these cannot be the primary outcome measures for a trial. Yet they are the outcomes of real interest and the source of the polarized concerns. A study looking at issues of less importance would not provide data that are relevant to those who wish to make a choice based on considerations of safety.

Women who have no factors that contra-indicate a home birth, and who prefer a planned, attended home-birth with facilities for prompt transfer to hospital if necessary, should not be advised against this.

Men during labor and at birth
The acceptance of men, as husbands and partners, into labor and birth is a recent phenomenon in industrialized countries. As women in these countries have begun to reclaim birth as a positive experience, the exclusion of a woman’s sexual partner and the baby’s father has come to be seen as incongruous.
Partners are now expected to reinforce what has been taught in childbirth education classes and, if necessary, to act as advocates for the childbearing woman. They are also expected to fill the gaps in care.
More and more women planning a hospital birth feel that nurses are too busy or view the nurse’s role as purely technical in nature. They tend to rely on their partners for support, assistance with breathing techniques, and comfort measures.
Realizing that midwives and nurses often have little time to give adequate psychological support, hospitals have increasingly permitted and encouraged husbands or partners to assume active roles in women’s care during labor. In many countries in the industrialized world, the presence of women’s partners during labor has, within 20 years, gone from being occasionally permitted to being normative and virtually universal.
There has been almost no research on the support actually provided by husbands and partners. Also unresearched are the expectations that women bring to labor about the support that they will have and that they will need. In a Canadian trial, the group of women who received continuous labor support from a lay midwife reported higher levels of support from their husbands, than did women who had the usual nursing support during labor. The husbands in the ‘additional support’ group provided more physical comfort measures and emotional support to their wives (apparently as a result of the encouragement and advice they received from the trained support person), and their satisfaction with their experience was higher than that of the husbands in the control group. Studies of the impact of the father’s presence on labor and birth have been limited by small sample sizes and self-selection.
Some doubts have been expressed about handing over the supportive role to fathers. One concern relates to whether they are equipped for tasks that were formerly the responsibility of an experienced and professionally trained person. Another is the issue that the father should not be expected to provide the majority of the support when he, too, is emotionally involved. He is sharing the experience and may need support himself. Other questions relate to the possibility that the father’s presence might negatively influence the laboring woman and interfere with the normal progress of labor. When there are tensions in the couple’s relationship, practical and emotional support in labor may be both difficult for the partner to provide, and for the woman to accept.

Other support people
Apart from institutionally employed support persons, midwives, and partners, two other categories of people are currently providing support in labor: other family members and friends, and paid or volunteer companions currently referred to as labor coaches or ‘doulas’.

Hospitals vary greatly in the extent to which they permit these other support people in labor wards.
At home, and in alternative birth settings such as birthing centers, it is customary for several people to be present for at least some of the time. The freedom to choose who will be present, and when, is often a factor in a woman’s choice to give birth outside hospital. It would be unwise to assume, though, that the presence of several people will necessarily provide additional support. Family and friends, like husbands and partners, may be there to share in the experience rather than to provide support.
Just as the role of support persons arose from the splitting of care into management and support, so the role of the doula comes from the splitting of support from assessment of maternal and fetal wellbeing during labor. Once support becomes a separate activity, those responsible for care and management in labor may not know what women or couples have been taught during antenatal classes, and may be unwilling or unable to support laboring women in the use of the skills that they have learned. They may belittle the usefulness of the education program, at the same time complaining about the unreal expectations that it has created.

The potential for territorial rivalries over the provision of support is great indeed. When a labor coach or doula is recruited as an advocate for the laboring woman, rivalries with hospital staff are almost inevitable and the intended support may end up as a casualty of the conflict. One can legitimately ask if, given the constraints posed by institutional norms and policies, an employee of the hospital can provide the same quality of support and advocacy that a professional ‘outsider’ can. On the other hand, the presence of an outsider can pose a threat to the institution, which may have a negative influence on the quality of care received by the laboring woman.
The role of a special support person in labor has now been assessed by 14 controlled trials in several countries, in a variety of settings.

There was remarkable consistency in the descriptions of the experimental intervention in the various trials. ‘Support’ included continuous presence, if not for all of labor, then at least during active labor, and in 13 trials, specific mention was made that support included comforting touch and words of praise and encouragement.
The results of the trials were also remarkably consistent, despite the disparities in obstetrical routines, hospital conditions, the obstetrical risk status of the women, the differences in policies about the presence of significant others, and the differences in the professional qualifications of the persons who provided the support. The continuous presence of an experienced support person who had no prior social bond with the laboring woman reduced the likelihood of: medication for pain relief, cesarean delivery, operative vaginal delivery, and a 5-min Apgar score <7. Another beneficial effect found in six trials was the decreased likelihood of negative evaluations of the childbirth experience, of feeling very tense during labor, and of finding labor worse than expected. Individual trials have found many other benefits of intrapartum support, including less perineal trauma, a reduced likelihood of difficulty in mothering, and of early cessation of breastfeeding.

Conclusions
Given the clear benefits and the absence of known risks associated with intrapartum support, every effort should be made to ensure that all laboring women receive support, not only from those close to them but also from experienced caregivers. The support that should be routinely offered to women should include continuous presence (when wished by the mother), the provision of hands-on comfort, and verbal encouragement. Depending upon the circumstances, ensuring the provision of appropriate support may necessitate alterations in the current work activities of midwives and nurses, so that they are able to spend less time on ineffective activities and more time providing support for women.

Sources
_{Effective care in pregnancy and childbirth}

Keirse, M.J.N.C., Enkin, M.W. and Lumley, J., Social and professional support in childbirth.

Cochrane Library
Hodnett, E.D., Caregiver support during childbirth.

Home-like versus conventional institutional settings for birth.

Olsen, O. and Jewell, M.D., Home versus hospital for birth.

Gagnon, A. and Waghorn, K. (1996). Supportive care by maternity nurses: a work sampling study in an intrapartum unit. Birth, 23, 1–6.

Hodnett, E.D. (1989). Personal control and the birth environment: comparisons between home and hospital settings. J. Envir. Psychol., 9, 207–16.

Hodnett, E.D. (1996). Nursing support of the laboring woman. J. Obstet. Gynec. Neon. Nursing, 25, 257–64.

Hodnett, E.D. (1997). Commentary: are nurses effective providers of labor support? Should they be? Can they be? Birth, 24, 78–80

Olsen, O. (1997). Meta-analysis of the safety of home births. Birth, 24 4–13.

Simkin, P. (1989). The Birth Partner. The Harvard Common Press, Boston, Massachusetts.