More Thoughts on Research

The comments on Homebirth Research: Another Side of the Story have been interesting. Thank you to everyone who has shared your thoughts or other information you found about the study. I think the letter to the editor from De Jonge that one anonymous commenter shared was interesting, especially the point about how the methods of data collection in the study may have inflated the perinatal mortality rate in the low risk group. If she is correct in this assessment, I believe it does call the validity of the study into question.

That said, I think that the Evers study raises a lot of questions that require further research.

• is midwifery care, with referral to obstetric care if complications arise, optimal care for low risk women?
• are there specific aspects the midwifery system in the Netherlands that are suboptimal (such as, protocols for intervals to check the fetal heart rate, as mentioned in the paper, or as one response to the study pointed out, the use of midwives assistants to watch over women until close to time of birth)?
• how might midwifery care be improved to result in better outcomes?
• how might collaboration between midwives and physicians be improved to result in better outcomes?

I think that many questions such as "Is homebirth safe?" or "Are midwives or obstetricians better caregivers for low risk women?" are questions that may never be fully answered with research. There will always be people who find a flaw in a study's design or some other way to discredit it, because most people have basic beliefs about birth that are not easily changed. There will always be people who focus (some because it is their job) on the cases where things go wrong and work their hardest to save those lives. There will also always be people who want put their primary trust in either a divine design for the process of birth or its thousands of years of improvement through natural selection (whichever is their belief, mine is these former) and who prefer to use the technology of the past hundred years or so as mostly a back-up. Most people find ways to dismiss "evidence" that does not support their basic view while accepting that which is in line with it. It is human nature.

The answer to safety in maternity care is not to convince one side that the other is "right." The answer is respectful collaboration. This is not the first time I have talked about this. In October 2010, I committed to make my blog a doctor-friendly zone, and I hope that I have held true to that promise. I believe now, as I did then, that peaceful dialogue between doulas/activists/midwives and obstetricians and other hospital providers is essential for improving our maternity care system to protect the lives and and best meet the needs of mothers and babies. I believe that hospital and out-of-hospital providers could learn a lot from each other, which I think could help improve the safety of the practice of homebirth and care in transfers, as well as improve the environment and the options available to women in hospital birth. I have started to see dialogue opening up a little more in the past months, as more physicians are creating online presences and the internet is becoming a larger platform for conversation. I'm curious also, to see where the upcoming Home Birth Summit will lead.

Homebirth Research: Another Side of the Story

Information about this has been showing up everywhere for me lately, though I have not sought it out intentionally, and I feel like I would be irresponsible not to write about it.

For a long time, I stayed away from the topic of homebirth, partly because it is such a controversial topic. I have only started writing about it recently because I am pregnant and currently am under the care of a team of homebirth midwives. My post titled "How Homebirth Benefits Babies" was the first post I wrote that "promoted" homebirth (with caveats!). It is also has been the most widely read, currently at 1,788 pageviews.

I have discovered that the evidence really is not clear on the most important point I make in that post when I talk about homebirth research. My words:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6).

It has come to my attention that the results of one of the studies I cite in that post has been called into question by the results of another study--a study that nobody in the online natural birth community appears to be talking about, even though it was published 9 months ago.

The study I cited in my post was the de Jonge study from the Netherlands, which compared outcomes of home and hospital births attended by Dutch midwives among women classified as "low risk" by the Netherlands maternity care system. De Jonge found no difference in mortality or severe morbidity in the home and hospital groups.

The Evers study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study was published in the British Medical Journal in November 2010. It compared outcomes of term births classified as "low risk" by the Dutch system attended by midwives (primary care) with outcomes of births classified as "high risk" and attended by obstetricians (secondary care). It found higher rates of perinatal mortality in the primary care group, and no difference in rates of level 3 NICU admission (the measure the study used for severe morbidity). Yes, you read that right. More low risk babies died. There were 26 delivery-related perinatal deaths out of 18,686 who began labor in primary care(a rate of 1.39/1000) and there were 10 delivery-related perinatal deaths out of 16,739 who began labor in secondary care (rate: 0.60/1000). The transfer rate from primary care to secondary care during labor was 22.9%, and 12 if the delivery-related deaths occurred in those who were transferred. The number of intrapartum stillbirths was also higher in the group that began labor in primary care. The study excluded all instances of congenial anomalies.

This study calls into question the belief that the best and safest care for low risk births is low-intervention care. From the Discussion section of the paper:

This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels. Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes. Delay can occur at three moments. Firstly, diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours. Secondly, transport can delay treatment in case of an emergency. Finally, a delay can occur because the obstetrician underestimates the problem as the referred woman is a “low risk” patient. In addition, essential information can be lost during the referral. These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted.

And this is in the Netherlands, where there is a universal standard for midwife education and there is supposedly to be a good system of transfer of care. Would having low risk women also be cared for by obstetricians be a better system for the Netherlands? That is basically what we have in the U.S., and we have a 33% cesarean rate. Cesareans increase the risk of maternal morality (see Deneux-Tharaux, 2006), though maternal mortality occurs much less frequently than perinatal morality does. Considering the increased risks associated with pregnancies and births in women with prior cesarean sections (see Kennare, 2007) , some of which impact both the mother and baby, I just don't see how this can be the optimal way to care for mothers and babies either. I'm not even going to try to answer the question of how many mothers (and any future babies they may have) should have to accept the risks of a cesarean section to save the life of one baby. It is something to think about.

The choices we have are between sets of risks. The absolute risk of a baby dying at all is low, especially if there is access to fetal monitoring and some level of emergency care (such as midwives who can perform neonatal resuscitation). When are talking about a rate of 1.39/1000, it means an individual has a 0.139% chance of it happening (and a 99.861% chance of it not happening)--and that's all primary care deaths in the Evers study, including ones who would have died no matter what kind of care they received. The risk of preventable death is presumably lower, though we don't know how much lower because there is no obstetrician-attended low-risk comparison group in the study. I don't want it to seem like I am trying to "explain away" the risk of preventable death. The statistics mean nothing when your baby is the unlucky one who dies. I believe in informed choice, and I believe you need accurate information to make informed choices.

After I wrote this post and was waiting to publish it (I usually space posts out further, but I moved this one up because I felt I needed get it out there), I saw this post from Birth Without Fear in my facebook newsfeed, and felt it applied to what I am trying to say. Like her, I am not here to advocate that you have a homebirth. I advocate that you look at the information, weigh your options, and make whatever is the best decision for you.

How Homebirth Benefits Babies

EDIT 8/28/11: Things are not always as simple as they first appear. There are multiple sides to every story. I have written a follow up post to this one that looks at another study that is relevant to the homebirth research I cite here: Homebirth Research: Another Side of the Story. It is important that you read it as well because what I talk about there has implications for everything I wrote about here.

I believe that having a good birth experience is and should be a factor in women's decision-making about where to give birth. But I don't believe it should be the primary factor, and don't believe it is for most women, including those who chose homebirth. There is no doubt that for a women who wishes to avoid medical intervention as much as possible, the experience will almost always be better in her own home where she can feel more in control of what is done to her and it is easier to relax. However, some women (myself included) would be willing to give up these advantages to themselves if it equated to better outcomes for the baby.

So, the question is, how does homebirth affect babies? Does being born at home harm them, have no effect, or help them? Theoretically, homebirth is a "more peaceful transition" and the baby "benefits from the mother's lack of trauma," but is there anything clinically measureable? What follows is my attempt to answer these questions with research. I have included citations and links to all the studies I cited so you can look at them yourself and make your own judgments about them. What I have linked to is what I read--in some cases full studies, and in others an abstract or the results cited in another article.

Clinical benefits of homebirth for the baby:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6). Babies of mothers who plan homebirths also:

• are less likely to require resuscitation at birth (2, 3, 4)
• are less likely to take longer than 1 minute to establish respiration (4)
  
• may have higher 5 minute APGAR scores (4, 6)
• are less likely to need oxygen therapy beyond 24 hours (2)
• are less likely to experience meconium aspiration (2)
• may be less likely to be admitted to the NICU (1, 3) though in one study (1) this difference disappeared when the data was controlled for risk factors
  
• are less likely to be born by cesarean, forceps or vacuum extraction (4, 5)
• are less likely to have birth trauma (2)

Why the differences?

Some possible explanations for the differences in neonatal outcomes:

• Women who plan homebirths are less likely to have obstetric interventions, including electronic fetal monitoring, augmentation of labor, assisted vaginal delivery, cesarean section, and episiotomy (2).
  
• Women who give birth at home feel more free to move and be upright during labor, which can promote progress without the use of oxytocin augmentation (7), thereby avoiding pitocin's potential side effects on the baby.
• Women who give birth at home are not under any pressure (direct or subliminal) to push in a bed. Studies show that upright birth results in a shorter pushing phase (8), higher APGAR scores, and lower arterial pCO2 with unchanged pO2, which indicates less transient cord compression (9).
• Women who give birth at home are not given any pain medications that have effects on the newborn's breathing or that increase the need for assisted delivery (10, 11). The vacuum extractor, the most common method of assisted delivery used today, is associated with slightly higher rates of neonatal cephalhaematomata and retinal haemorrhages (12)
  
• Babies born at home do not have their cords cut immediately. Academic OB/GYN has covered the research about cord clamping timing--see this post and these videos. In my experience, delaying cord clamping in most hospitals is much easier said than done, though hopefully this is changing.
  
• Babies born at home are almost never separated from their mothers. Most hospitals fail to implement immediate skin-to-skin contact as standard practice, despite the well-documented benefits for the newborn, including a positive impact on breastfeeding rates, breastfeeding duration, temperature regulation, cardio-respiratory stability, and infant crying (13).

It could be questioned whether the good outcomes were more related to midwifery practices than the place of birth. Some argue that midwives working in hospitals where there is immediate access to emergency care could get better results than they get at home. One study (2) found better outcomes for homebirths when comparing between home and hospital births with the same cohort of midwives. The difference could be attributed to different patient preferences in the two groups, such as a desire for pain medication in the hospital group. However, as I learned in my first birth, sometimes women who desire low-intervention births find that the hospital environment and protocols make this more difficult. Hospital policies often require providers to intervene in certain situations, such as slow or stalled labor, prolonged rupture of membranes, or a certain amount of time passing between full dilation and birth of the baby. Homebirth protocols are usually less restrictive, allowing more women to birth without intervention (without compromising results, if the protocols they are using are appropriate). Theoretically, women who birth at home will need intervention less often because being in a low-stress environment with minimal disturbance will promote optimal labor hormone release, resulting in less protracted labor and better natural pain control. And the research I've cited here indicates that when birth can safely occur with less intervention, better outcomes for babies result.

baby boy two hours after homebirth
(image originally uploaded by Fretwurst)

Some Caveats

Of course, it is important to recognize that we are talking about low risk birth here. Some higher risk women probably are taking an increased risk to their baby by choosing homebirth. I don't think all of them are necessarily "all about the experience" either. Most of them, I believe, are in a situation where they are certain or nearly certain to have a cesarean if they birth in a hospital, and they believe that the risks of surgery do not outweigh those of vaginal birth with their increased risk situation. However, these higher risk births would be much safer if they had immediate access to emergency care while still being able to give birth vaginally. While I am saddened by the lack of options for these women, homebirth is not meant to be a last resort for those in unusual circumstances that cause them to feel that the safest birth for them (vaginal birth in a hospital) is not an option.

It is also important to note the qualifiers "under a supportive system" and "with a qualified attendant." I believe it is very important to have a well-trained person you can trust to help you determine when intervention is truly necessary for the safety of you or your baby. The majority of homebirth research I have cited here is international. Many other countries have different requirements for midwife training than what we have in the U.S. In most of the countries where large-scale homebirth research has been done, homebirth midwifery is integrated into the maternity care system, allowing for smooth transfer in the event of an emergency. In the U.S., it is very important to ask questions about your midwife's qualifications, and be familiar your state's laws about direct entry midwifery (see Citizens for Midwifery) and requirements for licensure. Twenty-two states currently do not license direct entry midwifes. If your state is one of these, The Big Push for Midwives, is a resource that may help you get involved if you are interested. The requirements for the national direct-entry midwifery credential (Certified Professional Midwife or CPM) have been criticized for not being extensive enough, and are currently going through a revision process. It is also important to take into account the attitudes towards homebirth in hospitals in your area, as many in the U.S. are not supportive, which may interfere with transfer and care after transfer, should it become necessary.

Please review the the studies below, and, as always, consult with a qualified medical provider to help you make decisions about your care.

References:

• Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
  
• Outcomes of planned home birth with registered midwife vs. planned hospital birth with midwife or physician
• 3. Ontario study, outcomes cited in this article
• 4. A matched cohort study of planned home and hospital births in Western Australia 1981–1987
• 5. The Farm Study
• 6. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
• 7. Ambulation vs. oxytocin in protracted labor: a pilot study
• 8. The Squatting Position for the Second Stage of Labor: Effects on labor and on Maternal and Fetal Well-being
• 9. A comaparision of fetal outcome in birth chair and delivery table births
• 10. Epidural vs Parenteral Opiod Anestheia on the Progress of Labor
  
• 11. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid anesthesia: systematic review
• 12. Vacuum extraction versus forceps for assisted vaginal delivery (Cochrane Review)
  
• 13. Early skin-to-skin contact for mothers and their healthy newborn infants

Here is the link to the follow up post again: Homebirth Research: Another Side of the Story

Reality Check: The Brewer Diet is Not Evidence-Based

Many Childbirth Education methods teach that following the Brewer Pregnancy Diet will reduce the expectant mother's risk of complications, including pre-eclampsia. I have promoted the Brewer Diet myself in the past. The truth is that the Brewer Diet does not have any good research out there backing it up. Dr. Brewer's statistics from his patients are very un-scientific. It is hypocritical for people to accuse obstetricians of not following evidence by requiring intravenous fluid and continuous fetal monitoring (procedures not proven to be beneficial), and at the same time encourage pregnant women to follow a specific nutritional plan that has no randomized controlled trials backing it up. "But isn't good nutrition always a good thing?" you ask. Well, yes, but there are some specific problems with the Brewer Diet itself (many of these I learned from reading a comment response by Navelgazing Midwife on her blog post, Hypocrite in the Middle).

Drawbacks of the Brewer Diet:

• The Brewer Diet can create stress in the pregnant woman by encouraging her to agonize over all of her food decisions. I would think that stress could have the opposite intended effect by actually causing high blood pressure.
• The Brewer Diet is a lot of food. It is not natural or healthy for women to eat more than they feel hungry for. There is some concern that the caloric requirements of the Brewer Diet may grow overly large babies in women who are adequately nourished.
• The high amounts of protein in the Brewer Diet may put stress on some women's kidneys, if their kidneys are over-taxed, and women usually do not know whether or not their kidneys are over-taxed.
• There are many, many women who have followed the Brewer Diet and still gotten pre-ecampsia.
• Claiming that the Brewer Diet prevents pre-eclampsia equates to patient-blaming and making women feel like their pre-e diagnosis is their fault.

Instead of promoting a specific one-size-fits-all diet, why don't we focus on a few sound nutritional principles?


Sound Nutritional Principles for Pregnancy:

• Try eating frequent small meals during pregnancy. This may help with nausea (no guarantees, though) and will accommodate for the decreasing size of your stomach as your baby grows. Listen to your body about how much to eat.
  
• Avoid eating too many high-carb and sugary processed foods (white bread, baked treats, etc.) and opt instead for whole grains--oats, multigrain bread, brown rice, whole wheat pasta, etc.
• Include protein in your diet each day, but don't worry too much about getting a specific number of grams. Meats, eggs, dairy, beans, and nuts can all be good sources. Many beans and nuts are not complete proteins by themselves, but create a whole protein when eaten along with whole grains. (Edited to Add: Experts now recommend 60-80 g of protein for pregnant women. If you don't eat much meat and/or dairy, you may want to keep track to be sure you're getting enough.)
  
• Include a variety of colorful fruits and vegetables in your diet, especially ones where the flesh is colorful, not just the skin. Leafy greens are especially healthy--romaine lettuce, spinach, kale, etc.
• Include healthy fats and oils in your diet, but remember that a serving of fat is very small and there is some fat in other foods you are eating.
  
• Have water on hand throughout the day and drink enough that you are not getting thirsty.
  

If you are at risk for high blood sugar, have insulin issues, have been diagnosed with gestational diabetes before, or have a history of large babies, there are other considerations for you.

Continuous Labor Support Reduces Risk of Cesarean Section and Other Adverse Outcomes in Women and Newborns

The following press release comes from Childbirth Connection, it is available in PDF here.


FOR IMMEDIATE RELEASE - 11 am ET, February 16, 2011

Continuous Labor Support Reduces Risk of Cesarean Section and Other Adverse Outcomes in Women and Newborns
Type of Caregiver Can Make a Big Difference in Labor Experience

New York City — Women who labor with a dedicated support companion are less likely than women without such support to experience a series of risky birth procedures, according to a review published in the current issue of The Cochrane Library. The comprehensive study of experiences of 15,061 women who participated in 21 randomized controlled trials confirms previously known benefits for maternal health, identifies an additional benefit for newborns, and finds no downsides. The study was carried out through the prestigious Cochrane Collaboration, an independent international organization that prepares and keeps up to date rigorous systematic reviews of evidence from the best available studies.

Overall, women who received supportive care from a companion throughout labor were less likely than women without such support to have a cesarean section, to use narcotics or any other pain medication, to use regional pain medication such as epidural analgesia, to give birth with vacuum extraction or forceps, and to rate their childbirth experience poorly. Having continuous support shortened labor and increased the likelihood of having a “spontaneous” birth with neither cesarean nor vacuum extraction nor forceps. These results confirm previous research. With the inclusion of six new randomized controlled trials, the present systematic review, identified another benefit of continuous labor support: reduced likelihood of a baby with a poor “Apgar score” rating of well being five minutes after birth. The authors conclude that all women should have continuous support while giving birth.
Ellen D. Hodnett, RN, PhD, Professor and Heather M. Reisman Chair of Perinatal Nursing Research, University of Toronto, and co-authors of “Continuous Support for Women During Childbirth” limited the study to randomized controlled trials. This type of research helps ensure that study groups are similar and that results are a true reflection of the effects of the care being studied — here, continuous labor support.

“Cesarean section, vacuum extraction and forceps, and pain medications are interventions that increase the likelihood of adverse short- and longer-term effects in women and babies. Continuous labor support is an important way for women to avoid overuse and harms of these practices, and to have a positive experience at this special time,” said Carol Sakala, PhD, MSPH, Director of Programs at Childbirth Connection. Dr. Sakala is a co-author of the report.

Supportive care during labor and birth does not involve clinical care, and may include:
• helping women with physical comfort
• providing emotional support
• offering information
• helping women communicate their wishes to caregivers
• engaging women’s husbands or partners, as desired by the couple.

Impact Depends on Type of Caregiver
The study provides new knowledge about effects of continuous labor support under different conditions. A major finding is that the impact of this care appears to differ, according to the type of person providing the care. Effects were strongest when the caregiver was neither a member of the hospital staff nor a person in the woman’s social network, and was present solely to provide one-to-one supportive care, such as a doula. Compared with women who had no continuous support, women with companions who were neither on the hospital staff nor in the woman’s social network were:

• 28% less likely to have a cesarean section
• 31% less likely to use synthetic oxytocin to speed labor
• 9% less likely to use any pain medication
• 34% less like to rate their childbirth experience negatively.

When compared with no continuous support, continuous support by members of the hospital staff did not appear to reduce the likelihood of having a cesarean section or improve ratings of the childbirth experience and may have increased the likelihood of using synthetic oxytocin. These results may reflect the fact that hospital staff can experience divided loyalties, additional duties, and constraints of institutional policies when providing continuous support. Continuous support from a person in the mother’s social network (for example, her partner, husband, other relative, or friend) appeared to increase the mother’s satisfaction with her childbirth experience, but did not seem to impact her likelihood of undergoing a series of labor and birth interventions.

Background
Historically, laboring women routinely received support from female companions. However, more recently in hospitals worldwide, continuous labor support has become the exception rather than the norm. “There is concern about widespread dehumanization of women’s birth experiences,” said Dr. Hodnett. “Concern about institutional routines, high rates of intervention in healthy women and newborns, limits on women’s autonomy and control, unfamiliar personnel, and lack of privacy is leading to calls for making continuous labor support widely available to childbearing women.”

Leading options for continuous labor support in the United States include trained labor support companions known as doulas and — for satisfaction with the childbirth experience — the help of a friend or family member who is invited to be present when a woman gives birth. Childbirth Connection’s second national Listening to Mothers survey found that just 3% of women who gave birth in U.S. hospitals in 2005 experienced the most beneficial type of labor support, in the form of doula care. Although insurance coverage of doula services is limited, trained doulas are available in many communities throughout the United States. Typically, a woman (and her partner, if she has one) selects a doula during pregnancy, and they discuss the woman’s goals, preferences, and concerns. Some hospitals sponsor doula programs to increase access to continuous labor support. In addition to continuous presence during labor, birth doulas may provide some support in the days after birth.

“Hiring a doula was one of the best decisions my husband and I made during pregnancy,” said new mom Jenny McElroy. “Though we prepared by reading books, taking childbirth classes, and practicing comfort techniques, we were inexperienced with childbirth. Our doula knew exactly how to help my husband support me, help me cope with the pain, and help us stay calm and have the birth experience we wanted.”

Effective Strategy for Improving Maternity Care Quality and Value
Medicaid programs and taxpayers cover about 42% of the nation’s births, and private insurers and employers cover about half. The review authors encourage policy makers to provide coverage and hospitals to provide programs for continuous labor support. “The benefits of continuous labor support for mothers and babies are numerous, well established, and compelling, and warrant economic analyses of the relative costs and benefits,” said Maureen Corry, MPH, Executive Director of Childbirth Connection. “Medicaid programs and others seeking ways to improve maternity care quality and value and women’s experiences of care should consider continuous labor support as a key component of a high-quality, high-value maternity care system.”

Resources for Childbearing Women, Health Professionals and Policy Makers
Childbirth Connection’s website includes an in-depth evidence-based section to help childbearing women understand the benefits of continuous labor support, decide whether to have a continuous labor support companion, and arrange for such care (see www.childbirthconnection.org/laborsupport/). The professional area of the website includes a summary of results of the updated review and provides access to the full review, at www.childbirthconnection.org/laborsupportreview/.

How a Doula can Benefit You (yes, YOU)

This is a post I started a while ago and left it unfinished. When I found out about the Support Doulas Giveaway at Birth a Miracle Services, I decided to take the opportunity to finish it so I could enter. Today is the last day to enter the giveaway, so check it out if you are interested in winning some homemade natural hand cream!

What are the benefits of having a doula?
I am becoming a doula because I want more women to have all the benefits of doula support. Scientific studies have found clear benefits to having a professionally trained doula with you during childbirth. These include:

* 26% reduction in cesarean sections,
* 41% reduction in use of vacuum extraction or forceps,
* 28% reduction in need for pain medications, and
* 33% reduction in dissatisfaction with the birth experience
(Hodnett and colleagues 2004).

What benefits does having a doula offer over just having my husband as my birth support person?
It is wonderful that the "father pacing in the waiting room" has become a thing of the past, and fathers are now able to participate in the births of their children, to whatever degree they are willing and comfortable. The support that a loving, in-tune partner can provide a woman is of great value. However, it's important to recognize that the birth of your child is a highly significant experience in the life of your partner as well. Expecting the father, for whom the experience is extremely emotional, to meet all the emotional and physical needs of the laboring woman is a lot to ask. He may be worried about you and the baby and may find it difficult to watch you struggling with the obstacle of labor. He may not know or remember what he needs to do to help you. Doulas can be great for reminding or teaching the partner ways to better support the birthing mother. Having a doula also may allow the partner to take breaks if labor is long, without you having to be left without emotional and physical support.

How is a having doula different from having a female friend or family member at my birth?
Having an extra support person can be beneficial, and I recommend this if having a doula is not an option for you. A professional doula does offer unique benefits. She has more knowledge about the birth process, the medical procedures that may be offered, and pain reduction or coping techniques. She may be better equipped to support your plans than a friend or family member may not understand the choices you make. A friend or family member may also find it scary to watch you go through labor, while a doula is more objective and more familiar with labor and what is normal and not normal for women.

What is the benefit of having a doula in addition to the medical staff who will be there?
Most doctors are only able to be with their patients at the very end of labor to catch the baby. A midwife will typically spend more time with you, though in some situations, she will have to care for more than one laboring woman at once. In a hospital, you will have never met the nurses and they may also not be able to stay with you continuously. Some nurses are much better than others at support techniques, and you may not know in advance how good yours will be, though sometimes your choice of hospital plays a role. A doula is a person you choose, who you can get to know in advance, and who will be with you constantly during your labor and birth. Also, the primary responsibility of your medical care providers is to be concerned with the safety of you and your baby. A doula is primarily responsible for your emotional and comfort needs. The medical staff also has to worry about regulation by the hospital and their malpractice insurers. A doula works for you, not your doctor or hospital, and can often offer a more balanced perspective on your options.

Doulas sound great for women who are planning unmedicated birth, but I'm planning on having pain medication. Do I still need a doula?
Many women do choose to hire a doula to support them in their choice for an unmedicated birth, as such support can be difficult to find. However, having a doula can benefit all women, regardless of what kind of births they have. Most women will have to cope with some labor before they receive pain medication, and a doula's support can be beneficial to help the woman get through while she waits for it to be administered. Also, pain medication does not take away a woman's needs for emotional support and unbiased information. Even if a woman needs to have a cesarean, a doula can help keep her calm before and during the procedure and stay with her while the partner stays with the baby. A good doula will support the woman completely in whatever she chooses.

A woman's birth experience matters!
Research conducted by doula, childbirth educator, and author Penny Simkin indicates that women remember accurate details about their births 20 years later. Simkin's research also found that the most significant factor in the satisfaction rating a woman gave for her birth experience 15-20 years down the road was not the length of labor, whether there were complications, or whether or not she had pain medication, but how she was treated by those who cared for her. All women deserve the loving, continuous emotional and physical support of a knowledgeable professional while giving birth. (from Simkin, The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions, Third Edition, pg xi-xii)

Research-backed Benefits of Hypnosis for Childbirth

As explained in this article, a meta-analysis of selected studies on hypnosis for childbirth found that women who used hypnosis were:

• 51% less likely to use drugs for pain relief (38% of the hypnosis group used pain medications, compared to 74% in the control group)
• 70% less likely to have their labors augmented (11% in the hypnosis group were augmented, compared to 70% in the control group)
• 67% more likely to have a spontaneous vaginal delivery (meaning they were not induced and did not have cesareans)

The limits of this study

Despite it being a meta-analysis, the sample sizes are still quite small. As far as I can tell, the control group represents the standard population, which would include women who do not do any childbirth preparation and/or who planned to have epidurals. It would be interesting to see research comparing women using hypnosis with other methods of natural childbirth preparation, since that would provide a clearer picture of the unique benefits of hypnosis.

One reason why hypnosis is such an effective method of birth preparation: research shows women are more easily hypnotized during pregnancy.

Results Are In: Austrailan Study Supports Physiological Third Stage!

Back in June, I wrote about a theory paper by Australian researchers that I read that discussed the limits of current research literature that does not compare medically managed bith with truly "psychophysiological" birth, meaning unmedicated birth without routine interventions, in a comfortable setting with supportive care. This means that you can't compare the third stages of an actively managed hospital birth with a hospital birth where oxytonics and cord traction are not used, but other hospital factors are included--such as early cord clamping/separation of mother and baby, distractions, stressful atmosphere, IV fluids, unnatural positioning, etc, and claim that "expectant management doesn't work." The article proposed research that could be done comparing what they called "midwifery guardianship" with "active management."

I just learned today (thanks to Birth Sense) that the Australian researches who wrote the theory paper have completed a study on third stage management. The abstract is available here, and the results are very interesting! The study found that for low risk women, active management in a hospital was actually associated with a significantly higher rate of postpartum hemorrhage (11.5%) than the rate they found for midwife-led "holistic physiological care" in a freestanding birth center (1.7%). Considering that previous studies had found the risk or hemorrhage using other definitions of "expectant management" to be higher, these findings are important for determining what factors are necessary for a safe, natural third stage.