For anyone convinced of the benefits of normal birth with as few
medical interventions as possible, recent press coverage of the new NICE guidelines on caesarean section
and the birthplace study
could make you feel like packing up and going home.
Despite what some sections of the press suggest, there is robust evidence that most women still want to have a normal vaginal birth with as few medical interventions as possible. A systematic review of worldwide studies indicates that only a small minority of women would prefer a caesarean to a vaginal birth (Mazzoni et al 2011). In the most recent UK wide audit of caesarean section, maternal request was the primary indication for only 7% of caesareans (RCOG 2001
), that is about 1.6% of births. In substantial representative studies in the UK, women express a preference for birth with as little medical intervention as necessary (Green et al 2003, Garicia et al 1998
But can we, as individual students and midwives, do anything to ensure that those women who do want a normal birth are enabled to have one?
Luckily, the answer is ‘yes’. Take a look at the Cochrane systematic review of studies comparing continuous with intermittent support in labour (Hodnett et al 2011
). This reviewed 21 randomised controlled trials carried out since 1980 involving over 15,000 women. The results are clear. Women who received continuous support during labour were less likely to have a caesarean section (reduction varied between 10% and 51% in different studies), were more likely to have an unassisted vaginal birth, less likely to use analgesia and anaesthesia (reduced by between 13% and 36%), were more satisfied with their birth experience (by around 27%) and had shorter labours (between 44 and 170 minutes).
In the research that I have carried out in four UK maternity units as part of my PhD, I wanted to find out how successful we, as midwives, could be in providing the right kind of continuous support to women in labour. I and three other trained observer midwives observed 50 women in labour being cared for by NHS midwives in three consultant led units and one midwife led unit in Scotland. We recorded what we saw using a newly developed computer programme, the ‘Supportive Midwifery in Labour Instrument’ (or SMILI, pronounced ‘smiley’), which aims to measure the quantity and quality of midwifery support. We sat through 105 hours of labour and what we found was really encouraging. The quantity and quality of support that we observed was mostly very high. The midwives provided one-to-one care for all of the women in active labour and were present in the room for an average of 92% of the time. Most midwives clearly prioritised their supportive role and provided emotional support (reassurance, encouragement, positive humour, building rapport) more often than they wrote notes, checked equipment and listened to the fetal heart.
We combined the data recorded using the SMILI with postnatal questionnaires with women and clinical outcomes data. We analysed the data to see if there were statistically significant links between the support provided and the outcomes.
Our main findings were:
• The more the midwife stayed in the room, the happier the woman was with the support she received and the more likely she was to have a normal birth
• The more emotional support that the midwife gave the woman, the happier the woman was with the support she received and the more likely she was to have a normal birth
• Where emotional support was recorded less than the study average, women were twice as likely to have a forceps or ventouse delivery
• Higher levels of emotional support were associated with significantly fewer medical interventions
• Women rated the support they had received higher when the midwife gave more verbal support, was more responsive to contractions, built rapport, gave more positive information, gave tangible support (like supportive touch and massage) and supported their birth partner as well as them.
We don’t understand fully the mechanism by which support has such a positive effect on outcomes. It seems that continuous positive support reduces women’s anxiety levels, this means they don’t produce such a high level of catecholamines which can inhibit oxytocin and so inhibit effective contractions.
Midwifery shortages in England clearly have an impact on midwives’ ability to provide continuous one-to-one support to all women in active labour. This research confirms the importance of being able to provide all women with this level of support in labour. We must continue to press the government to address the midwifery shortages and employ the additional 5000 midwives needed in England.
So, don’t feel powerless to do anything about the rising rate of caesarean sections. Midwives can be powerful, what we do can make a difference. The first thing you can do is sign the RCM’s petition
for 5000 more midwives if you haven’t already and put it in on your Facebook page to get your friends to sign it too. The second thing you can do is make sure that what you do as a student midwife supports women to have as normal a birth as possible.
From this research, the most important things you can do are:
• Stay in the room
• Spend time getting to know the woman and her partner in early labour
• Show a positive attitude – smile
• Keep reassuring and encouraging the woman and her birth partner.
The detailed results of the research will be published in 2012 in peer-reviewed journals. If you are interested in improving the support that you give, look out for them (the authors are Ross-Davie M, Cheyne H and Niven C).
By Mary Ross-Davie – midwife and PhD student at the NMAHP research unit at the University of Stirling
Green JM, Coupland VA, Kitzinger JV. Great expectations: a prospective study of women’s expectations and experiences of childbirth. 2nd ed.
Hale (Cheshire): Books for Midwives Press; 1998.
Green JM, Baston HA, Easton SC, McCormick F. Greater expectations: the inter-relationship between women’s expectations and experiences of decision making, continuity, choice and control in labour, and psychological outcomes.
Summary report. Leeds (UK): Mother & Infant Research Unit, University of Leeds; 2003.
Garcia J, Redshaw M, Fitzsimons B, Keene J. First class delivery: a national survey of women’s views of maternity care.
London: Audit Commission; 1998.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011, Issue 2
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Mazzoni, A ‘Women's preference for caesarean section: a systematic review and meta-analysis of observational studies’ BJOG
, 118, 4, 391-399; 2011
Royal College of Obstetrics and Gynaecology, ‘The National Sentinel Audit of Caesarean Section’, RCOG press, London, 2001