2.5 Support in Childbirth

Reports and randomized controlled trials on support in labour by one single person, a “doula”, midwife or a nurse, showed that continuous empathetic and physical support during labour resulted in many benefits, including shorter labour, significantly less medication and epidural analgesia, fewer Apgar scores of <7 and fewer operative deliveries (Klaus et al 1986, Hodnett and Osborn 1989, Hemminki et al 1990, Hofmeyr et al 1991).

This report identifies a doula as a female caregiver, who has had a basic training in labour and delivery and who is familiar with a wide variety of care procedures. She provides emotional support consisting of praise, reassurance, measures to improve the comfort of the mother, physical contact such as rubbing the mother’s back and holding her hands, explanation of what is going on during labour and delivery and a constant friendly presence. Such tasks can also be fulfilled by a nurse or midwife, but they often need to perform technical/medical procedures that can distract their attention from the mother. However, the constant comforting support of a female caregiver significantly reduced the anxiety and the feeling of having had a difficult birth in mothers 24 hours postpartum. It also had a positive effect on the number of mothers who were still breast-feeding 6 weeks postpartum.

A woman in labour should be accompanied by the people she trusts and feels comfortable with; her partner, best friend, doula or midwife. In some developing countries this could also include the TBA. Generally these will be people she has become acquainted with during the course of her pregnancy. Professional birth attendants need to be familiar with both the supportive and the medical tasks they have and be able to perform both with competence and sensitivity. One of the supportive tasks of the caregiver is to give women as much information and explanation as they desire and need. Women’s privacy in the birthing setting should be respected. A labouring woman needs her own room, where the number of attendants should be limited to the essential minimum.

However, in actual practice conditions often differ considerably from the ideal situation described above. In developed countries women in labour often feel isolated in labour rooms of large hospitals, surrounded by technical equipment and without friendly support of caregivers. In developing countries some large hospitals are so overcrowded with low-risk deliveries that personal support and privacy are impossible. Home deliveries in developing countries are often attended by untrained or insufficiently trained caregivers. Under these circumstances support of the labouring woman is deficient or even absent, for a significant number of women deliver with no attendant at all.

The implications of the above statements for the location of birth and the provision of support can be far reaching, because they suggest that caregivers in childbirth should work on a much smaller scale. Skilled care in childbirth should be provided at or near to the place where women live, rather than bringing all women to a large obstetric unit. Large units that perform 50 to 60 deliveries a day would need to restructure their services to be able to cater to women’s specific needs. Caregivers would need to reorganise work schedules in order to meet women’s need for continuity of care and support. This also has cost implications and thus becomes a political issue. Both developing and developed countries need to address and resolve these issues in their own specific ways.

In conclusion, normal birth, provided it is low-risk, only needs close observation by a trained and skilled birth attendant in order to detect early signs of complications. It needs no intervention but encouragement, support and a little tender loving care. General guidelines can be given as to what needs to be in place to protect and sustain normal birth. However, each country willing to invest in these services needs to adapt these guidelines to its own specific situation and the needs of the women as well as to ensure that the basics are in place in order to adequately serve women at low, medium and high risk and those who develop complications.