I’m always excited when new research comes out that supports something that we already knew. This one is a Cochrane Review, published on 18 March 2019, which concluded that “companionship in labour results in positive outcomes for both women and babies”.
I’ll link the review at the bottom, for those of you who enjoy that sort of thing, but hopefully by the end of this post you won’t have to read it if you don’t want to.
Note: the wording used by the authors is women/men. Where I am directly quoting/reciting results I won’t change those words. However, I have tried to rephrase many of the results to be as inclusive as possible. It is sadly unclear how inclusive the studies themselves were.
What are Cochrane Reviews and Why are They Important?
Cochrane Reviews take large quantities of already published research and subject it to further analysis to try to glean more reliable information than can be found in a single study (single studies being somewhat limited by their small sizes).
When an academic study is published, it is important that that study is clear about what result(s) it is looking for, how it is intending to measure that result, and whether or not it found it. By being clear about those things, other academics can hopefully replicate the study at a later date, or easily compare it with other similar studies. That’s important because results that are always the same, no matter who looks for them, are robust and able to stand up to high levels of scrutiny.
On the other hand, if a study is replicated (or compared to another similar study) and finds very different results that could mean that the original results were flukes, or that they were somehow influenced by another factor that wasn’t taken into account.
Cochrane Reviews take lots and lots of studies and combine the results. They are regularly reviewed as new studies are done, so that the new studies can be included. This one used studies published up to 9th September 2018.
What the Authors Did
The authors of this review looked at over 50 studies, looking for how women, families and health care providers experienced the presence of a “labour companion”. They defined a labour companion as a: partner, friend, family member, trained supporter (doula) or nurse/midwife. I’ll use this terminology when discussing the results.
They did what is called a thematic analysis, which means they looked for common themes that appeared across all or many of the studies. They also subjected the studies to another analysis which allowed them to state a confidence level in each of the themes. Basically, that means that some of the statements the authors have made about the results are really strong, whereas some are weaker. That may be because the original studies were of poor quality, or it may be because there were only a couple of studies that covered that particular topic.
I’ve written LOW after the results that the authors have less confidence in. Hopefully these areas will be subject to further study in the future.
What the Authors Found
The authors found a number of results, which they broadly sorted into four categories.
1. Labour companions provided four main types of support:
- Informational support. They did this by providing information to parents about childbirth; helping parents to communicate effectively with health care providers (and vice versa); and helping with non-pharmalogical pain relief methods.
- Advocacy. That means they spoke up in support of the parents.
- Practical support. Practical support can mean things like holding hands, massaging, assistance with moving around during labour etc.
- Emotional support. This includes being continually present and using praise and reassurance to help parents feel confident and in control.
2. Parents’ feelings about labour companionship:
- Women felt that companionship in labour helped them to have a positive experience.
- Lack of companionship in labour could be felt as a negative experience.
- The labour companion they had chosen needed to be trustworthy and compassionate.
- They had mixed perceptions about the presence of a male labour companion. LOW
- Some men felt they were poorly integrated into the team and decision-making process.
- Most men who were labour companions felt that their presence had a positive impact on themselves. LOW
- They also felt it had a positive impact on their relationship with their partner and baby. LOW
- Some men were anxious about seeing their partner in pain. LOW
3. Doulas in particular:
- Met with parents antenatally in order to build rapport and manage expectations.
- Formed close bonds with the parents they supported. LOW
- Provided community based culturally-appropriate care to high income foreign-born women. LOW
4. The following things were identified as problematic:
- Health care providers and women may not recognise the benefit of labour companionship.
- Companionship was feared by some health care providers as potentially leading to a lack of privacy or physical space in the birth room.
- Companionship was feared by some health care providers as potentially leading to an increased risk of infection. LOW
- Some health care providers were not trained or not willing to work with labour companions, which could lead to conflict.
- Some lay labour companions were not well integrated into antenatal care, which lead to frustration. LOW
How do These Results Fit in With Other Studies?
One study also found that parents appreciated continuous support during labour, and that structural constraints and health care provider resistance were barriers to support. An additional result here was that companionship was identified as reducing obstetric interventions such as epidural or caesarean, which thereby reduced the financial costs. (Kabakian-Khasholian, 2017)
Another study found that the benefits of early labour support varied depending on the labour companion they had chosen. Some companions were anxious and encouraged women to seek medical support early in their labour, whereas some were supportive and facilitated relaxation. When companions are not well prepared, they may not support labouring women well. (Beake, 2018)
A third found that staff shortages and workloads can decrease the ability of health care providers to work supportively, and be empathetic and friendly. Additionally, some providers were unaware of effective practices, or were not receptive to new knowledge. This could potentially hamper acceptance of labour companions as a positive intervention, or hamper the restructuring of facilities in order to allow companionship. (Munabi-Babigumira, 2017)
Finally, two reviews found that women want supportive care and companions during their labours, but across the globe many women are denied companionship. Lack of companionship in labour contributes to feelings of disempowerment, fear and loneliness. (Bohren, 2015a; Shakibazadeh, 2018)
What all of These Things Mean for Parents who are Thinking About Hiring a Doula
I feel like this Cochrane Review is really useful for parents, especially those who ask “but what do doulas actually do?”, because it really lays out what other parents have experienced when hiring a doula. The authors noted that sometimes parents are not aware of the benefits of having a “labour companion” such as a doula and I would hope that this list answers that question. Combined with the already known and rather more measurable benefits such as shorter labours, less pain, fewer caesareans and assisted births, higher incidence of breastfeeding etc (There is another Cochrane Review that deals with those benefits, which I will not address in this post, but the review is linked at the bottom.), it makes a compelling case for hiring a doula.
Doulas provide a variety of different kinds of support to the families they serve, including teaching them about childbirth, helping them communicate, holding hands and providing physical support during labour, listening, encouraging and being present, as well as advocacy. They work with parents during their pregnancies to build trust and form close bonds. Parents, especially when they are the one who is pregnant, want to have trustworthy and compassionate support during their labour and childbirth experiences. Doulas provide that.
Additionally, having companionship in labour is associated with parents reporting a positive birth experiences, and lack of companionship in results in more negative experiences. This is in line with the previous research on doulas which shows that parents are more likely to report a positive birth experience after hiring a doula.
It is important to note that companions can provide good support to parents when they are prepared for the realities of seeing someone in labour. This is, in my opinion, a key factor in whether or not parents experience the positive benefits listed above. It is really important that parents are accompanied by someone who is comfortable with the sights and sounds of labour, is knowledgeable in childbirth and can remain calm in the face of a potential crisis. This is where there can be a distinct line between professional birth support and lay birth support.
Finally, if parents are living abroad, it may be that hiring a doula from the same cultural background is of particular benefit. I am hopeful that this is an area of future study, as it would be very interesting to explore this more. Pregnancy and childbirth is a vulnerable time, and even more so when parents are not living in their original country, perhaps not speaking the language fluently (or at all), perhaps bringing their own cultural expectations along. Sensitive good quality support seems to me to be even more important for these parents.