Which action is a priority when caring for a woman during the fourth stage of labor?

Historically and cross‐culturally, women have been attended and supported by other women during labour and birth. However, since the middle of the twentieth century, in many countries most women gave birth in hospital rather than at home, and continuous support during labour has become the exception rather than the routine. Concerns about dehumanisation of women's birth experiences (in high‐, middle‐, and low‐income countries) have led to calls for a return to continuous, one‐to‐one support by women for women during labour (Klaus 2002). Research has demonstrated that women benefit from and value the presence of a support person during labour, to provide psychological, physical, emotional, informational and practical support (Kabakian‐Khasholian 2015). This support person may act as an advocate for the woman, for example by helping to communicate her preferences to a health worker, and also provides encouragement, reassurance, and physical comfort. A support person may also help to communicate to the woman about her progress through labour, suggest coping techniques, and support her decision‐making. Two World Health Organization (WHO) guidelines recommend a companion of the woman's choice during labour and childbirth, to improve labour outcomes and women's satisfaction with services (World Health Organization 2015; World Health Organization 2016).

Common elements of continuous support during childbirth include emotional support (e.g. continuous presence, reassurance and praise), information about labour progress and advice regarding coping techniques, comfort measures (e.g. comforting touch, massage, warm baths/showers, encouraging mobility, promoting adequate fluid intake and output) and advocacy (e.g. helping the woman to articulate her wishes to others). The period of support for this intervention varies greatly across studies and contexts. For example, some doula programs may initiate support during the pregnancy, provide continuous support during labour and childbirth, and provide support through three months postpartum. Other programs focus specifically on facility‐based care, and continuous support is provided from around the time of admission through the birth. Definitions for what constitutes "continuous" support vary across trials and contexts. For example, "continuous" is defined as "no interruption" (Langer 1998), "minimum of 80% of the time" (Hodnett 2002), and "as continuously as possible" (Hofmeyr 1991) across three large trials in this review.

For the purposes of this review, we have defined continuous support as some combination of comfort measures, emotional support, provision of information, and advocacy on behalf of the woman, provided from at least early labour (before 6 cm dilation) or within one hour of hospital admission (for admission with greater than or equal to 6 cm dilation), through until at least the birth, and provided by a person whose sole responsibility is to provide support to the woman, as continuously as practical in a given context.

Two complementary theoretical explanations have been offered for the effects of labour support on childbirth outcomes. Both explanations hypothesise that labour support enhances labour physiology and mothers' feelings of control and competence, reducing reliance on medical interventions. The first theoretical explanation considers possible mechanisms when companionship during labour is used in stressful, threatening and disempowering clinical birth environments (Hofmeyr 1991). During labour, women may be uniquely vulnerable to environmental influences; modern obstetric care frequently subjects women to institutional routines, high rates of intervention, unfamiliar personnel, lack of privacy and other conditions that may be experienced as harsh. These conditions may have an adverse effect on the progress of labour and on the development of feelings of competence and confidence; this may in turn impair adjustment to parenthood and establishment of breastfeeding, and increase the risk of postpartum depression. The provision of support and companionship during labour may to some extent buffer such stressors.

The second theoretical explanation does not focus on a particular type of birth environment. Rather, it describes two pathways ‐ enhanced passage of the fetus through the pelvis and soft tissues, as well as decreased stress response ‐ by which labour support may reduce the likelihood of operative birth and subsequent complications, and enhance women's feelings of control and satisfaction with their childbirth experiences (Hodnett 2002a). Enhanced fetopelvic relationships may be accomplished by encouraging mobility and effective use of gravity, supporting women to assume their preferred positions and recommending specific positions for specific situations. Studies of the relationships among fear and anxiety, the stress response and pregnancy complications have shown that anxiety during labour is associated with high levels of the stress hormone epinephrine in the blood, which may in turn lead to abnormal fetal heart rate patterns in labour, decreased uterine contractility, a longer active labour phase with regular well‐established contractions and low Apgar scores (Lederman 1978; Lederman 1981). Furthermore, individual interventions (e.g. labour induction, epidural anaesthesia, caesarean birth) and a cascade of interventions throughout labour may disrupt hormonal physiology and introduce risks to the woman or her baby, both in the short and long term (Buckley 2015). Emotional support, information and advice, comfort measures and advocacy may reduce anxiety and fear and associated adverse effects during labour.

Continuous support has been viewed by some as a form of pain relief, specifically, as an alternative to epidural analgesia (Dickinson 2002), because of concerns about the deleterious effects of epidural analgesia, including on labour progress (Anim‐Somuah 2011). Many labour and birth interventions routinely involve, or increase the likelihood of, co‐interventions to monitor, prevent or treat adverse effects, in a "cascade of interventions". Continuous, one‐to‐one support has the potential to limit this cascade and therefore, to have a broad range of different effects, in comparison to usual care. For example, if continuous support leads to reduced use of epidural analgesia, it may in turn involve less use of electronic fetal monitoring, intravenous drips, synthetic oxytocin, drugs to combat hypotension, bladder catheterisation, vacuum extraction or forceps, episiotomy and less morbidity associated with these, and may increase mobility during labour and spontaneous birth (Caton 2002; Anim‐Somuah 2011) and impact the experience of giving birth.

A systematic review examining factors associated with women's satisfaction with the childbirth experience suggests that continuous support can make a substantial contribution to women's satisfaction. When women evaluate their experience, four factors predominate: the amount of support from caregivers, the quality of relationships with caregivers, being involved with decision‐making and having high expectations or having experiences that exceed expectations (Hodnett 2002a).

Clarification of the effects of continuous support during labour, overall and within specific circumstances, is important in light of public and social policies and programs that encourage this type of care. For example, the Congress in Uruguay passed a law in 2001 decreeing that all women have the right to companionship during labour. In several low‐ and middle‐income countries (including China, South Africa, Tanzania and Zimbabwe), the Better Births Initiative promotes labour companionship as a core element of care for improving maternal and infant health (World Health Organization 2016a). In many low‐income countries, women are not permitted to have anyone with them during labour and birth. Efforts to change policies in these settings have led to questions about the effectiveness of support from spouses/partners or other support people of the woman's own choosing, particularly in settings where the cost of paid companions (e.g. doulas) would be prohibitive.

In North America, and increasingly in many other areas of the world, the services of women with special training in labour support have become available. Most commonly known as doula (a Greek word for 'handmaiden'), this new member of the caregiver team may also be called a labour companion, birth companion, labour support specialist, labour assistant or birth assistant. A number of North American organisations offer doula training, certification and professional support; according to one estimate more than 50,000 people have received this training to date (P Simkin, personal communication). Some North American hospitals have begun to sponsor doula services. In a recent national survey of childbearing women in the United States, 6% of respondents indicated that they had used doula services during their most recent labours (Declercq 2013). Many associations for doulas have been established in high‐income countries, including DONA International, Doula UK, NCT Doula, British Doula, Childbirth International, Australian Doulas, Australian Doula College and Europoean Doula Network, among others. Doula services are usually paid for out‐of‐pocket, and therefore affordable to affluent, higher‐educated women only. However, a meta‐analysis conducted by Zhang 1996a showed that socially disadvantaged populations, such as low‐income women, could benefit more from doula support. Maternal healthcare systems in dozens of high‐ and low‐ to middle‐income countries throughout the world are developing new traditions for supportive female companionship during labour (Pascali‐Bonaro 2010).

Questions have arisen about the ability of employees (such as nurses or midwives) to provide effective labour support, in the context of modern institutional birth environments (Hodnett 1997). For example, nurses and midwives often have simultaneous responsibility for more than one labouring woman, spend a large proportion of time managing technology and keeping records, ensure adherence to institutional practices and protocols, and begin or end work shifts in the middle of women's labours. They may work in short‐staffed environments or lack labour support skills.

Companions chosen by a woman from her own network, such as spouses/partners and female relatives, usually have little experience in providing labour support and are often themselves in need of support when with a loved one during labour and birth. As they are frequently available to assume the role, often without extra cost to families or health systems, it is important to understand their effectiveness as providers of continuous labour support.

In addition to questions about the impact of the type of provider of labour support, there are other questions about the effectiveness of support, including its impact under a variety of environmental conditions, and whether its effects are mediated by when continuous support begins (early versus active labour).

There are also questions about the relative impact of different models of labour support; specifically, effects of support provided only during the intrapartum period versus effects of an extended model with support during the antenatal, intrapartum and postpartum periods.

Childbearing women, policy‐makers, payers of health services, health professionals and facilities and those who provide labour support all need evidence about the effects of continuous support, overall and under specific conditions.

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Continuous support compared to usual care (all trials) for women during childbirth