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The influence of labour support, choice of care provider and place of birth on birth outcomes

October 18, 2018

 "Given the clear benefits and no known risks…every effort should be made to ensure that all laboring women receive support, not only from those close to them but also from specially trained caregivers. This support should include continuous presence, the provision of hands-on comfort and encouragement.”1

The decisions a woman makes during her pregnancy and birth will influence her birth outcomes. Who she chooses for a care provider and where she chooses to birth will determine how she births. A caregiver’s practice, style and philosophy will influence her care, choices and what happens to her from pregnancy through to birth. The use of interventions during pregnancy and birth always introduce risk. Being informed about procedures and medications offered can help a woman make decisions that are right for her and her baby. A woman wants to have a care provider who avoids the use of interventions on a routine or frequent basis. She wants to know a range of no-risk strategies to facilitate labour progress. She wants someone who provides individualized care and knows when not to do something. Someone who understands that birth is more than just a mechanical process, but it is a powerful emotional, psychological and spiritual event. If an intervention is needed and justified it should done with minimal impact on the mother and baby.

When choosing a provider, a woman should not make assumptions based on a particular style, philosophy or whether a practitioner is male or female. With all types of practitioners there will be personal influences on their practice. There may be an OBGYN who uses very little intervention and encourages a woman that she has the ability to birth or there may be a very medically minded midwife who chooses to use more interventions and technology. A woman should be able to interview several different caregivers and be able to ask questions about their practice. Asking questions such as; what are their rates of interventions? what policy’s do they follow? and what diet recommendations do they make? can help her find someone she is comfortable with. A woman should be able to feel comfortable asking any questions.

There are choices of providers available for women, however, in some area’s these choices may be more limited. By learning about the roles and philosophies of a variety of care providers a woman is able to find who would be the best option for her. Her choice of provider will influence how and where she births. Three of the common options are obstetricians (OBGYN), family practitioners(GP) and midwives.

An obstetrician has the knowledge and skills to diagnose and treat serious complications of pregnancy and childbirth. They are surgical specialists in the pathology of women’s reproductive organs. They specialize in obstetrics and gynecology and can be board certified by passing a national qualifying exam. They often have the mentality that pregnancy and birth are high risk. They tend to think in ways that are contrary to what the normal physical and psychological outcomes can be for pregnancy and childbirth. In general, they hold the view of women, that if there is an issue it should be handled pharmaceutically or with surgery. They practice obstetric managment. Obstetric management includes medical tests, procedures, use of drugs and placing restrictions on a woman in pregnancy and birth. Obstetric interventions introduce risks as well as benefits. For low or no risk women there can be the risk of the intervention but no benefit to the mother or baby. Options offered carry risks and are limited to the confines of obstetrical training. OBGYN’s do not attend births outside of the hospital. Transfers are rare as they are trained for high risk situations.

Family practitioners are doctors but not surgeons. They are often less interventive than OBGYN’s. GP’s are often doctoring for the whole family and a relationship may be built with a woman and her family. GP’s often see a woman in early pregnancy and in the postpartum as well as seeing the baby. If a GP is a woman’s care provider for labour and birth, they may have to transfer care if there is complications. In their philosophy, GP’s can fall between the care provided by an OBGYN and a midwife. GP’s are board certified in family practice. Around 30% of GP’s also practice obstetrics. They are more interventive than midwives and do not attend births outside of the hospital, although in some area’s they may under special circumstances.

Midwives practice midwifery. Midwifery care is superior to medical management for no/low/moderately risk pregnant women. Cesarean rates are lower for women in midwifery care. They offer care that is flexible, individualized and supportive. Midwives are also attentive to the emotional issues of a woman. They use a range of low risk strategies for problems that may arise in pregnancy, in labour and birth. A typical practice often uses test and procedures that are in line with official physicians’ organizations. They offer well-woman gynecological care from pregnancy through postpartum. They can offer a continuum of care for women through menopause. Midwives offer care in all settings. If complications occur or if a woman becomes high risk during pregnancy or birth it may require a transfer. There are several routes for midwives from certified nurse midwife (in the states) to direct entry midwives. There are different certifying bodies available for women wanting to be midwives. In Canada the most common route for licensed midwives is through designated university programs with some bridging programs available for foreign trained midwives.

The location and setting that a woman chooses to birth in will influence the outcome of her birth and her recovery postpartum. There are 3 main locations that a woman may give birth in. There are hospitals, freestanding birth centers and home. Babies do get born though and births can happen anywhere including hotels, on the side of the road or even in a hospital parking lot!

Hospitals provide caregivers that are trained and competent. Equipment is available for treatment and diagnosing during labour and birth. Hospitals are institutions and are bureaucratic and as such policies and procedures are often “one size fits all” and are applied to all women. It can be more difficult for a woman who is seeking midwifery type care to get it in a hospital setting. Nurses cannot provide continuous care and doctors are usually not present until the time of birth. Hospitals can be noisy, bright, impersonal, intrusive and lack privacy. Mothers are often left alone to labour. Many smaller hospitals are not prepared to handle obstetric emergencies. Cost cuts can influence how many staff are available and they may not have adequately trained staff in maternity care. Drugs are available as a primary modality and are often offered first. Non-drug techniques may be limited, not offered or not available. There is a chance of infections in hospital due to the setting. Breastfeeding can be hard as babies are often separated from mothers for routine procedures. Staff may give bottles or pacifiers or may take babies. Nurses may have little or no training in breastfeeding support. A woman must leave her home to go to the hospital before labour or during labour.

Free standing birth centers where on the rise in the 70’s and 80’s but saw a decline as women where discouraged from using them or centers where disqualified by different regulations. There is still some around, but they have mostly been replaced by the single room maternity care in hospitals. Studies throughout the 80’s and 90’s showed that a free standing birth center is as safe as hospitals for low risk women but the ACOG (American college of obstetricians and gynecologists) still oppose their use. Birth centers are safe, provided caregivers are trained and competent. Most problems during labour and birth can be solved on site. Medications and equipment on site can be used to treat or stabilize emergencies. Accreditation criteria is required, and most centers are near to a hospital. Infection is less likely in a birth center. Care is individualized and supportive. Centers are more acceptable for births so planning to birth there or if there is a need for transfers are often less of a hassle for women. Mothers are not left alone and will have one on one support. The setting can vary but centers are more likely to be peaceful, intimate and homelike. Narcotics and epidurals are not available. A wide variety of non-drug techniques are used. Breastfeeding starts well as baby is not separated from the mother. A woman must leave her home during labour to go to the center.

Home settings are safe, provided the caregiver(s) a woman chooses are trained and competent. Most problems during labour and birth can be resolved at home. Home birth practitioners may carry medications and equipment to treat and stabilize emergencies. Some homes may be far from a hospital. Being at home is the safest place regarding acquiring infections. A woman’s needs are the sole focus of attention. In pregnancy, a woman may be hassled, because society deems homebirth as irresponsible. If a woman and/or baby needs to be transferred they are often treated poorly. There is one on one care from one or more birth attendants. At home there is the familiarity of being home and no strangers are present. Everyone there is an invited guest. Someone should be available to cook, clean and do laundry. Drugs are not available, but a wide range of non-drug techniques can be used. With the comfort of home, stress and anxiety can be reduced, which can facilitate labour. Breastfeeding has a good start as baby is never removed from mother. Bottles and pacifiers are not an issue. If there is no complications and no reason to transfer everything and everyone comes to the woman.

The common perception of birth is that it is risky and OBGYN’s and hospitals have ‘saved’ women from birth. History does not support this misconception. Maternal mortality in the USA declined after the 1930’s when sulfa drugs and antibiotics became widely available and where used to treat infection. At this time there was more stringent controls placed on obstetric training and practices, which until then was not considered a ‘professional’ medical practice. As obstetrics grew the decline of midwives began. This decline is what contributed to rising newborn death rates. Where doctors opposed midwife’s, death rates increased. Other factors contributed to the reduction of maternal deaths and these include better living conditions and nutrition, child spacing and the development of blood transfusion. No study has ever shown that out of hospital births (OHB) have worse outcomes than hospitals, provided that the women were no/low/moderate risk and had a planned homebirth (PHB) with a trained attendant. In the Netherlands where 1/3 of women have babies at home there are excellent outcomes for mothers and babies. A planned homebirth has advantages as there are fewer maternal and newborn complications. There is less use of drugs to stimulate labour and greater use of comfort measures. Women like the care better. In hospital no/low/moderate risk women are exposed to the injudicious use of drugs and procedures that are normal in a hospital setting. With every intervention into the normal process there is an introduction of risk as well as benefits. When interventions become routine the risks increase.

Women who want personal support and care in pregnancy, labour and birth are looking to another option. Although woman to woman care has been common through the ages, it has begun to be a specialized area of care. Introduced in the 70’s and made more common in the 90’s, trained women companions began to be used. There are many names that have been used, including professional labour support, woman caregivers, labour support companion, doula, monitrice and birth assistant. The most common name now is doula. Women are choosing this option because they know that the memory of labour stays with you for the rest of your life and they want to remember their time of birth in a positive way. A woman will remember how she felt and how she was treated during this time. There has been various trials and research on the impact that a continuous presence of a caring, experienced woman can give. Women who are supported in this way can experience less pain and anxiety in labour. They often express greater satisfaction with labour and feel they coped better. They have a heightened appreciation of their body’s strength and performance and themselves as women. Women with a doula often breastfeed for longer and experience less difficulty in mothering. They can have more positive feelings toward the baby and better self-esteem.

Some of the other benefits include:

· Reducing the length of labour

· Reducing the use of pain medications

· Reducing the need for IV oxytocin

· Reducing the percentage of instrumental delivery and episiotomy

· Reduce the rate of cesarean surgery

· Reduce the number of babies born in poor condition and sent to the special care unity

· Reduce prolonged hospital stays

Doula’s will stay with a mother throughout labour and are near if not in actual physical contact for virtually the whole time. They offer physical comfort measures such as cool cloths, massage and hand-holding. Doula’s offer emotional support including praise, reassurance and explanations of what is happening or what is said. They provide advocacy in that they help the women communicate her needs and support her decision. In essence, they mother the mother.

Doula’s also encourage the fathers who may need guidance. Fathers may want to be present but don’t know what to do or don’t want to do anything. A father’s presence has not been shown to have the beneficial effect of a doula. We have placed fathers in a role that doesn’t necessarily suite them. Having a doula present can enhance the father’s participation and they are more likely to offer physical support.

A woman has options to who she chooses to be present at her birth. By asking questions she will be able to find someone that fits with her, her situation and her own philosophy. Some questions that a woman can ask are:

· What is your training, background and experience?

· How do you see your role at births?

· How do you feel about________?

· What do you charge and what services do you offer?

· How many clients do you take in a month?

· Do you have limitations on where you will go or which providers you will work with?

· Will you provide references?

“What happens to her during that time(birth)makes an especially deep impression. If she emerges from the labour feeling strong, confident and nurtured, she will be in a much better position to nurture her baby in turn and to cope with stress and strains that inevitably accompany the early weeks of life with a newborn”-Klaus and Hofmeyr

This is just a basic overview and some choices may not be available in your community. But if you feel passionate about the topic of woman’s rights and woman’s choices in childbirth there are many ways to advocate for optimal care in your community. From joining advocacy groups or writing to your MLA you can join woman across the globe who are working towards better care for childbirth. Groups of women can make a difference and can work together to get choices for every woman.

      "When women support each other, incredible things happen."- authour unknown

1.      1. The thinking woman’s guide to a better birth by Henci Goer; The Berkley publishing group; 1999

2. Optimal care in childbirth, the case for a physiologic approach by Henci Goer and Amy Romano; Classic day publishing; 2012

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