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An updated systematic review of the effects of continuous labor support that summarizes the results of 21 randomized controlled trials involving over 15,000 women was published in The Cochrane Library in 2011, issue 2, and is available on the Childbirth Connection website. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth.Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub3.
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Background to this systematic review
An updated systematic review of the effects of continuous labor support was published in The Cochrane Library in 2012, issue 10, and is available here. This review summarizes results of 22 randomized controlled trials that involved 15,288 women.
This review is descended from the first systematic review of controlled trial research of effects of labor support, which appeared in Effective Care in Pregnancy and Childbirth(1989). It has contributed to the development of policy statements and guidelines, legislation, and programs promoting continuous labor support in many countries throughout the world.
The most recent update incorporates six new randomized controlled trials, expands outcomes included in subgroup analyses, discriminates among three types of labor support companions in a subgroup analysis, and has been updated to reflect current methodologic guidelines.
Questions and outcomes examined in the continuous support review
The main objective ("main comparison") was to assess the effects, on mothers and their babies, of continuous one-to-one support during labor compared with usual care, in any setting.
Supportive care during labor does not include clinical care, and may involve helping women with physical comfort, providing emotional support, offering information, helping women communicate their wishes to caregivers, and engaging their spouses or partners, as desired by the couple.
The new review adhered to established Cochrane Collaboration procedures for limiting bias, including a thorough strategy for identifying relevant studies, eliminating relevant studies that are not methodologically adequate, and summarizing remaining "included studies" with meta-analysis when appropriate.
Subgroup analyses were planned to compare effects of continuous labor support in different birth environments, with different caregivers, and beginning at different times:
The review identified 17 outcomes of interest for the main comparison. Primary outcomes were as follows:
Secondary outcomes were:
Pre-determined outcomes for subgroup analyses were: any analgesia/anesthesia, synthetic oxytocin during labor, spontaneous vaginal birth, cesarean birth, admission to special care nursery, and negative rating of the childbirth experience.
Numerous graphs available within the full Continuous Support For Women During Childbirth review (PDF) compare all data that were available from all included studies for the specified outcomes of interest. Overall, women who received continuous support were less likely than women who did not to:
Women receiving continuous support were more likely than those who did not to:
Overall, continuous support did not seem to impact:
Data were not available to compare subgroups with onset of continuous support before and after active labor. Here are other subgroup analysis results:
The reviewers drew the following conclusions about implications for practice:
Continuous support during labor should be the norm, rather than the exception. Hospitals should permit and encourage women to have a companion of their choice during labor and birth, and hospitals should implement programs to offer continuous support during labor… In present maternity care environments, benefits of continuous support are likely to be greater with companions who are not hospital staff members than with members of the hospital staff … Given the clear benefits and absence of adverse effects of continuous labor support, policymakers should consider including it as a covered service for all women.
The reviewers drew the following conclusions about areas warranting further research:
Ongoing work to use review results to educate professionals, women and the media and to improve practice.
Childbirth connection carried out media outreach to publicize results of this review and regularly collaborates with DONA International, a major organization for doulas, caregivers who provide support to women during labor and in the early postpartum period. We collect and publicize data about women's knowledge of and experience with continuous support in our Listening to Mothers surveys. This website includes anin-depth Pregnancy Topic for childbearing women about the established benefits of continuous labor support, options for labor support companions, and strategies for arranging for labor support.
Research shows the use of a doula has clear benefits for families during childbirth and postpartum, with no known risks!
How to Prevent a C-Section "Continuous labor support, including support provided by doulas, is one of the moat effective ways to decrease the cesarean rate." 2014
ACOG March 2014 "Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula
Implications for practice July 2013 Cochrane Libray & ACOG March 2014.docx 166.3 KB
Continuous Support helps to decrease interventions, 2011
*Results of 7 North American Trials of Labor Support including 2259 women
(comparing continuous labor support by doulas with usual care)
Numerous clinical studies have found when using a doula:
Research shows parents who receive support can: