For many years now, midwives have been voicing concerns about the dehumanisation of women's birth experiences. This, in turn, has led to calls for a return to continuous, one‐to‐one support for women during labour (Bohren et al. 2017).
Yet, whilst many midwives instinctively agree with this concept, the term one-to-one care lacks a clear definition and its multiple meanings make policy development and consistently high-quality research difficult to achieve (Sosa, Crozier & Robinson 2012).
So, what exactly does one-to-one care involve and why is it so important in labour?
One of the greatest challenges in evaluating the effectiveness of one-to-one care is defining when it starts and finishes.
For example, many doula programs begin support during pregnancy, provide continuous support during labour and birth, and may provide follow-up care for several months postpartum. In hospital settings, however, continuous support is usually defined as care from the point of admission through to delivery.
Bohren et al. (2017) also suggest that greater clarity is needed in the definition of the term ‘continuous’, pointing out that it could mean anything from ‘no interruption’, to ‘as continuously as possible.’
Defining what is included in one-to-one care is also subject to variability, but typically includes:
(Bohren et al. 2017)
The positive effects of continuous, one-to-one support during labour are well documented (Clack 2021), with benefits ranging from an improved birthing experience for the mother, to long-term benefits for the whole family, as the quality of the birthing experience can influence the mother’s mental and emotional wellbeing for years to come.
Bohren et al. (2017) suggest that women who receive continuous support during labour are more likely to:
They are also less likely to:
It’s broadly recognised that continuous support enhances the progress of labour and improves the mother’s feelings of control and competence, reducing the need for medical interventions - but how can these effects be explained?
One theory proposed by Bohren et al. (2017) suggests that the continuous presence of a trusted companion may help to shield the woman from the stressful environment and routines of the delivery room. Another theory suggests that by reducing stress levels during labour, the need for medical intervention becomes much less likely.
Continuous support is also considered by some to be an additional form of pain relief and may lead to fewer interventions in labour. A recent literature search (Knape, Schnepp, Krahl & zu Sayn-Wittgenstein 2013) also suggests that emotional support delivered by one key carer who the mother has trust in seems to be effective for decreasing overall intervention rates during labour.
In addition to higher rates of spontaneous vaginal birth, less need for analgesia and greater overall satisfaction, one-to-one care also appears to shorten the duration of labour and have a favourable effect on the baby, with fewer infants displaying low five-minute Apgar scores if their mothers have received continuous one-to-one care.
Yet, Hodnett et al. (2013) make the point that not all one-to-one care is equal in its effectiveness. For example, they discovered that continuous support was most effective when the provider was neither part of the hospital staff, nor the woman's social network, and in settings in which epidural analgesia was not routinely available.
To date, there seems to be relatively little high-quality research on the long-term benefits of one-to-one care in labour. As Bohren et al. (2017) suggest, further studies into post-partum benefits and long-term outcomes are needed to complete the picture. They suggest that research in the following areas would be particularly helpful:
In other words, it seems that there are many more benefits yet to be discovered that extend beyond the critical period of labour itself.
One research project that does stand out, however, is the COSMOS trial (McLachlan et al. 2008), which compared standard maternity care with one-to-one midwifery support. During the trial, it was shown that assigning an individual midwife to a woman throughout their pregnancy, birth and early postnatal period resulted in some valuable benefits, notably:
Based on these findings, the report recommended the adoption of caseload midwifery describing the one midwife, one mother policy as the gold standard of care. Interestingly, midwives benefited too, with much lower rates of burnout and greater job satisfaction.
All too often, modern maternity care means women are required to experience institutional routines that may negatively impact birth outcomes and satisfaction levels.
Yet, moving away from custom and tradition and implementing change, however convincing the research is, can pose challenges for the maternity team in terms of staffing levels and allocation of resources. The one midwife to one woman ratio is an ideal goal to aim for and should be available for all women in labour (Sosa, Crozier and Stockl 2018), but further questions have yet to be answered about the role of the doula, or even if the continued presence of a supportive friend can achieve the same beneficial results.
It may be that future research can help answer these questions by clarifying what happens during labour between the woman and the range of people who support her one-to-one (Sosa, Crozier and Robinson 2012).
What has been proven beyond doubt is that continuous one-to-one support during labour has clinically meaningful benefits for both women and their babies, with no known associated harms (Hodnett et al. 2013).
What is needed now is a further exploration into how continuous support can be provided in different contexts, as well as an evaluation of potential long-term benefits that extend beyond the delivery room.
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