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BIRTH 19:3 September 1992
LETTERS To the Editor: I agree wholeheartedly with Dr. Richards’s statement in his commentary, “Doulas and the Quality of Maternity Services” (1992;19(1):40-41), that the women in the Texas trial-of-labor support (1) received “appalling treatment by the standard of any industrialized country.” Although his interpretation of the results of the observer-only comparison group is interesting, it is not the only possible explanation. O’Driscoll and Meagher (2) argued that part of the benefit of active management of labor is due to the continuous presence of a professional. It may not be what the professional does that is important, but the fact that she or he is continuously present. We know relatively little about the dynamics and effects of professional support during labor, but we do know that it should not be discounted as unimportant. I was surprised by Richards’s comment that “the extra person had little or no impact” in our Toronto trial of intrapartum support (3,4), given that the women in the experimental group were less likely to require medication for pain relief, more likely to have intact perineum, and realized greater personal control than they had anticipated. Surely, cesarean section and medical complications of birth are not the only important birth outcomes! Two assumptions underlay Richards’s opinion that intrapartum support “is best provided by a woman friend, or relative, or a partner”: social and professional support differ only in terms of the provider, and one type of provider is preferable to another. On the contrary, our studies indicated that professional and social support encompass many but not all of the same activities, and more important, the activities are interpreted differently by the laboring woman. For example, instruction/ information is more reassuring when it comes from
an “expert.” Furthermore, although the continuous presence of a partner or friend is undoubtedly very important for most women, so is that of the nurse or midwife. The social contracts between the partner and woman and between the nurse and woman are quite different. Partners are not usually good nurses, or vice versa. However, support-professional, social, or whatever-is not a panacea. Richards’s central point, that mothers, babies, and families require a much higher standard of care than that provided in the Texas hospital, is an excellent one. It is a sad commentary, indeed, that the appalling conditions of a developing country can also be found in one of the world’s leading industrialized nations. Ellen Hodnett, R N , PhD University of Toronto Faculty of Nursing, and Scientist, Mt. Sinai Hospital Perinatal Nursing Research Unit 600 University Avenue, Suite #1200, Toronto, Ontario, Canada MSG 1x5
References Kennel1 J , Klaus M, McGrath S, Robertson S , Hinkley C . Continuous emotional support during labor in a US hospital: A randomized controlled trial. JAMA 1991;265:21972201. O’Driscoll K, Meagher D. Active Management uflabuur. London: WB Saunders, 1980. Hodnett ED, Osborn RW. A randomized trial of the effects of rnonitrice support: Mothers’ views two to four weeks postpartum. Birrh 1989;16(4): 177-183. Hodnett ED, Osborn RW. The effect of continuous intrapartum support on childbirth outcomes. Res Nurs Health 1989;12:28%297.
BIRTH 19:3 September 1992
LETTERS To the Editor: I agree wholeheartedly with Dr. Richards’s statement in his commentary, “Doulas and the Quality of Maternity Services” (1992;19(1):40-41), that the women in the Texas trial-of-labor support (1) received “appalling treatment by the standard of any industrialized country.” Although his interpretation of the results of the observer-only comparison group is interesting, it is not the only possible explanation. O’Driscoll and Meagher (2) argued that part of the benefit of active management of labor is due to the continuous presence of a professional. It may not be what the professional does that is important, but the fact that she or he is continuously present. We know relatively little about the dynamics and effects of professional support during labor, but we do know that it should not be discounted as unimportant. I was surprised by Richards’s comment that “the extra person had little or no impact” in our Toronto trial of intrapartum support (3,4), given that the women in the experimental group were less likely to require medication for pain relief, more likely to have intact perineum, and realized greater personal control than they had anticipated. Surely, cesarean section and medical complications of birth are not the only important birth outcomes! Two assumptions underlay Richards’s opinion that intrapartum support “is best provided by a woman friend, or relative, or a partner”: social and professional support differ only in terms of the provider, and one type of provider is preferable to another. On the contrary, our studies indicated that professional and social support encompass many but not all of the same activities, and more important, the activities are interpreted differently by the laboring woman. For example, instruction/ information is more reassuring when it comes from
an “expert.” Furthermore, although the continuous presence of a partner or friend is undoubtedly very important for most women, so is that of the nurse or midwife. The social contracts between the partner and woman and between the nurse and woman are quite different. Partners are not usually good nurses, or vice versa. However, support-professional, social, or whatever-is not a panacea. Richards’s central point, that mothers, babies, and families require a much higher standard of care than that provided in the Texas hospital, is an excellent one. It is a sad commentary, indeed, that the appalling conditions of a developing country can also be found in one of the world’s leading industrialized nations. Ellen Hodnett, R N , PhD University of Toronto Faculty of Nursing, and Scientist, Mt. Sinai Hospital Perinatal Nursing Research Unit 600 University Avenue, Suite #1200, Toronto, Ontario, Canada MSG 1x5
References Kennel1 J , Klaus M, McGrath S, Robertson S , Hinkley C . Continuous emotional support during labor in a US hospital: A randomized controlled trial. JAMA 1991;265:21972201. O’Driscoll K, Meagher D. Active Management uflabuur. London: WB Saunders, 1980. Hodnett ED, Osborn RW. A randomized trial of the effects of rnonitrice support: Mothers’ views two to four weeks postpartum. Birrh 1989;16(4): 177-183. Hodnett ED, Osborn RW. The effect of continuous intrapartum support on childbirth outcomes. Res Nurs Health 1989;12:28%297.
