The Value of Continuous Labor Support
Abstract many maternal health specialists and patients are unfamiliar with the benefits of continuous labor support from a doula. This article reviews the medical, interpersonal, and economic benefits of continuous doula care. A case presentation of a doula-supported birth is discussed in detail, and a review of relevant, outcome-based literature is provided in order to improve understanding of this important area of maternal healthcare. Practitioners are recommended to partner with public health organizations to promote increased access to continuous doula labor support for expectant mothers.
Introduction
Continuous labor support from a doula involves having a trained maternal support practitioner who helps the person in labor through non-medical interventions in order to promote a safe and positive birthing experience. Continuous doula care has been shown to have many medical, interpersonal, and economic benefits, and is a care that should eventually be made available to all women. This article will review, through a case study of a doula-supported birth as well as data review, how and why continuous doula care is so beneficial.
Case Study
A very meaningful doula-attended birth occurred in late 2017 at a major U.S. university medical center with a mother who will be referred to as L. This was L’s first pregnancy, and due to pre-eclampsia she was being induced under midwife care. Despite induction, L very much wanted to have a natural childbirth experience with Conceptual no medication and minimal intervention. When the doula arrived, L was 4 cm dilated and was coping very well with her contractions with her husband, H, close by. Initially, she was able to talk through them as she and the doula interacted. They began L on 30-minute cycling of positions, from lying semi-prone with a peanut ball, to sitting on the birth ball, to lunging. The contractions became increasingly powerful, and H and the doula worked together, playing a very active role in helping L cope. For instance, while L was in an upright position, either H or the doula would apply counter pressure, and the other one would sit face-to-face with her, providing encouragement and breathing with her. After spending a while in the shower, L was very shaky and it was the doula’s assessment that she was in transition. However, L did not want her cervix to be checked during labor to avoid disappointing news. The doula knew and respected L’s wishes in this regard and refrained from saying anything. Within an hour L informed the doula that the pressure suddenly felt very different and she needed to have a bowel movement. The doula quickly pressed the call button and told the nurse, and then rushed back to be with L. She instructed L to keep her head up and focus on breathing out in short breaths to help her keep from pushing. The midwife came to check her and L was fully diluted. L worked with the doula and pushed for about 10 minutes; at this point the nurse rushed over to find that the baby was crowning. Between contractions, L slowly waddled over to the bed while the midwife held the baby’s head. L lay down on her side, pushed through one or two more contractions, and baby S was born in-caul! Despite induction and the attendant risk of complications, L was able to utilize doula care to help achieve a safe and natural childbirth experience. One misconception that may be common among both birth givers and healthcare professionals is that those in labor who have a partner with them do not benefit from doula care. However, this labor shows a great example of the ways that continuous doula care can complement continuous care from a partner. In this case, while L was laboring in an upright position, either H or the doula would apply counter pressure while the other one helped L maintain her rhythm. In this way, they were able to provide both physical support and emotional support in a way that would be difficult if only one support person was present. Further, while L was laboring in a restful position (i.e. lying semi-prone), H was able to rest too, while the doula provided massage and verbal support for L. This ensured that H was able to keep his energy up so that he wouldn’t be too exhausted to enjoy the experience of the birth of the baby. Further, the doula was able to provide reassurance to both L and H that things were proceeding normally. For example, when L had bloody mucus during early labor, the doula was able to reassure both L and H that the discharge was completely normal and a good sign of cervical change. L was also very grateful for the assistance that the doula provided to help initiate skin-to- skin and breast feeding, something that neither H nor L had specific experience with.
Improved Birth Outcomes
The literature overwhelmingly indicates that continuous labor support is an extremely beneficial and low-risk way to improve birth outcomes, through reduced medical intervention, increased cost-effectiveness, and increased positive mother-baby postpartum relations. The medical benefits of having a doula include (but are not limited to) decreased C-section rates, decreased use of epidurals, decreased length of labor, decreased rate of perinatal complications, and decreased use of medication [1, 2]. Other studies have documented a decreased use of oxytocin to augment labor when a birth giver has continuous doula care [1]. The benefits of doula care are also seen in women who have a partner present with them. In one study, a group of women in labor with a partner served as a control group, while a group of women in labor with a partner and a doula served as the experimental group. A significant difference in C-section rates was seen between the control group (27.9%) and the experimental group (14.7%), showing that even when a partner is present, the continuous support of a doula still provides important benefits [3]. A caveat of these findings is that the support of the doula must be continuous rather than intermittent. A study by Scott, Berkowitz, and Klaus reaffirmed the positive medical benefits of having the continuous support of a doula [4]. However, the study found that when doula care was intermittent rather than continuous, there was no notable difference in labor duration, epidural use, oxytocin use, forceps use, or C-section rates as compared to a group without doula care [4].
Postpartum Benefits
Benefits of doula care are also notable up to eight weeks postpartum. Martin et al found that two months after delivery, mothers who had a doula present through labor were observed to have a more positive level of interaction between mother and infant based on the Bayley scale of infant development [5]. Further, a separate study that followed up with mothers six to eight weeks postpartum found that mothers who had a doula had better rates of breastfeeding and initiated breastfeeding sooner after labor [2]. In the future, this research should be expanded to examine the whether the relationship between mother-child interactions and doula care is still present a year or more postpartum.
Economic Benefits
Continuous care during labor also has significant economic benefits. According to Chapple, et al. “A professional doula providing only in-hospital labor support would yield an estimated cost savings of $424.14 per delivery or $530.89 per low risk delivery” [6]. Although this study is limited in that these numbers were based on data from one U.S. state (Michigan), it is reasonable to expect that similar trends exist in other areas. The cost savings reported in this study come from the reduced use of C-section and reduced use of regional anesthesia in those who had the continuous care of a doula. Future public health research should focus on similar analyses in other regions.
Conclusion
The literature overwhelmingly shows that continuous care by a doula provides significant medical, interpersonal, and economic benefits. The case study presented at the beginning of this review provides an illustration of the way continuous labor support by a doula can facilitate a healthy birth outcome for mother and baby. In order to promote improved clinical practice, maternal health specialists should take opportunities to partner with public health organizations to promote increased access to continuous doula labor support for expectant mothers.
References
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McGrath SK, Kennell JH (2008) A randomized controlled trial of continuous labor support for middle-class couples: Effect on cesarean delivery rates. Obstetrical & Gynecological Survey 63(10): 620-621.
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Campbell D, Scott KD, Klaus MH, Falk M (2007) Female relatives or friends trained as labor doulas: Outcomes at 6 to 8 weeks postpartum. Birth 34(3): 220-227.
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Kennel JH, McGrath SK (1993) Labor support by a doula plus father vs father alone for middle income couples: The effect on perinatal outcomes. Journal of Developmental and Behavioral Pediatrics 14(4): 277.
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Alder B (2000) Continuous, but not intermittent, support from a doula significantly improves labour and delivery outcomes. Evidence-Based Obstetrics & Gynecology 2(2): 42.
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Martin S, Landry S, Steelman L, Kennell JH, McGrath S (1998) The effect of doula support during labor on mother-infant interaction at 2 months. Pediatric Research 43(13): 556.
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Chapple W, Gilliland A, Li D, Shier E, Wright E (2013) An economic model of the benefits of professional doula labor support in Wisconsin births. WMJ 112(2): 58-64.
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