Key words: childbirth, labor, social support, pregnancy outcome, maternal health ... Holly N. Essex is a Doctoral Student and Kate E. Pickett is a Senior. Lecturer ...
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Mothers without Companionship During Childbirth: An Analysis within the Millennium Cohort Study Holly N. Essex, MSc, and Kate E. Pickett, PhD ABSTRACT: Background: Studies have highlighted the benefits of social support during labor but no studies focused on women who choose to be unaccompanied or who have no companion available at birth. Our goals were, first, to identify characteristics of women who are unaccompanied at birth and compare these to those who had support and, second, to establish whether or not being unaccompanied at birth is a risk marker for adverse maternal and infant health outcomes. Methods: The sample comprised 16,610 natural mother-infant pairs, excluding women with planned cesarean sections in the Millennium Cohort Study. Multivariable regression models were used to examine, first, sociodemographic, cultural, socioeconomic, and pregnancy characteristics in relation to being unaccompanied and, second, being unaccompanied at birth in relation to labor and delivery outcomes, maternal health and health-related behaviors, parenting, and infant health and development. Results: Mothers who were single (vs not single), multiparous (vs primiparous), of black or Pakistani ethnicity (vs white), from poor households (vs nonpoor), with low levels of education (vs high levels), and who did not attend antenatal classes (vs attenders) were at significantly higher risk of being unaccompanied at birth. Mothers unaccompanied at birth were more likely to have a preterm birth (vs term), an emergency cesarean section (vs spontaneous vaginal delivery) and spinal pain relief or a general anesthetic (vs no pain relief), a shorter labor, and lower satisfaction with life (vs high satisfaction) at 9 months postpartum. Their infants had significantly lower birthweight and were at higher risk of delayed gross motor development (vs normal development). Conclusions: Being unaccompanied at birth may be a useful marker of high-risk mothers and infants in need of additional support in the postpartum period and beyond. (BIRTH 35:4 December 2008)
Key words: childbirth, labor, social support, pregnancy outcome, maternal health The experience of labor can be lonely and stressful for women (1). Causes of stress and anxiety include unfamiliarity with the hospital environment and clinical staff; pain, discomfort, and worry; loss of control and the adoption of a passive role; and problems of communication (2). Few human experiences approach the intensity of stress, pain, exertion, and emotional turmoil as labor (3). Qualitative studies of women’s
memories and perceptions of birth conducted soon after, and many years later, show that the experience of childbirth is powerful and long lasting (4). When childbirth shifted from home to hospital, many traditional childbirth practices were lost or subsumed by technological interventions, and for a long time, women suffered a loss of companionship during labor (5,6). Previously, women were supported in
Holly N. Essex is a Doctoral Student and Kate E. Pickett is a Senior Lecturer in Epidemiology in the Department of Health Sciences at the University of York, United Kingdom.
Address correspondence to Holly N. Essex, MSc, Department of Health Sciences, University of York, Postgraduate Building, HYMS Building, 2nd Floor, Heslington, York YO10 5DD, UK.
Kate E. Pickett is supported by a National Institute of Health Research Career Scientist Award in the United Kingdom.
Accepted May 2, 2008 Ó 2008, Copyright the Authors Journal compilation Ó 2008, Wiley Periodicals, Inc.
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childbirth by other women (7), but currently, since the need for support and companionship has once again achieved recognition and acceptance, this role has been adopted primarily by fathers (8). In the United Kingdom, approximately 95 percent of fathers attend the birth of their baby (9). Mothers may also be accompanied by other family members, friends, doulas, or other paraprofessionals in addition to, or instead of, the father (2,10). It is therefore rare for a woman giving birth in the U.K. to be unaccompanied by supportive companions during labor and delivery (11). In such cases, the woman is reliant on hospital staff for support and companionship. U.K. clinical guidelines for intrapartum care state that women in established labor should receive one-to-one care and not be left on their own except for short periods or at their request (12), but arrangements for modern maternity care constrain the ability of midwives and others to offer such support, particularly continuity of care (2,8,13). Midwives have also reported feeling devalued by the task of providing support and feeling that their continuous presence is unnecessary (14). Many studies have highlighted the benefits, both physical and emotional, of support during labor for mother and child (1,5,15), including reduced length of labor (1,10,14,16–18); fewer cesarean sections (6,14,16,19–21); fewer instrumental deliveries by means of forceps or vacuum extraction (6,14,18,20,21); reduced need for pain medication, including epidural anesthesia (6,14,18,20–22); reduced need for medication to accelerate labor (14,16,18,21,22); and reduced need for amniotomy (21). Labor support has also been linked to increased levels of satisfaction and perceived control during the birth (1,3,6,10,18,20,22,23); accelerated recovery of the mother after birth and a shorter hospital stay (2,15,18); increased perception of the birth as a positive experience (20,23); earlier and increased bonding between mother and child (1,5,17,18); less difficulty mothering (3); decreased postpartum anxiety and depression (1,3,18); increased self-esteem (24); and an increased likelihood of developing rich and successful family relationships (25). Infants born to mothers who are supported in labor are less likely to be admitted to neonatal intensive care (16,18); have a higher 5-minute Apgar score (6,26); and are more likely to be breastfed (1,3,6,10,18). To our knowledge, no research studies have focused on women lacking any support from family, friends, or others during labor. Mothers who are unsupported at birth may differ from those who are supported and being unaccompanied may be a marker for women at higher risk for experiencing problems in labor and delivery and with parenting. Our study had two aims: first, to examine the characteristics of women giving
birth without support and, second, to ascertain whether or not giving birth unsupported is associated with adverse outcomes for mothers and infants.
Methods The Sample The data for this study come from the Millennium Cohort Study, which is a large-scale survey of babies born in the four countries of the U.K. The first sweep of the study was carried out during 2001 to 2002 and contains information about 18,819 babies in 18,553 families, collected from the parents when the babies were approximately 9 months old (11). It recorded the circumstances of pregnancy and birth, the first few months of the baby’s life, and also the socioeconomic background into which the baby had been born. Information about the Millennium Cohort Study is available at the Web site: http://www.cls.ioe.ac.uk/. The sampling framework for the MCS was first stratified by ward, with an oversampling of wards with high proportions of ethnic minorities (based on census estimates), wards with high levels of child poverty, and wards in the three smaller countries of the U.K. Within selected wards, all children born within the relevant time period were eligible for the study and were identified through the Child Benefit register, which is an almost complete census. The Child Benefit is a universal provision, payable (usually to the mother) from the child’s date of birth. Child Benefit claims cover almost all the child population except those ineligible due to recent or temporary immigrant status. The information center did not, however, release the addresses for all births known to them. They were obliged to exclude a small number of socalled sensitive cases. Health visitors were asked to forward names of other eligible babies (27). The response rate was 72 percent; nonrespondents were more likely to be without a fixed residence, living in ethnic minority areas in England or living in a nondisadvantaged ward in Northern Ireland (28). Detailed information about the sampling strategy is reported elsewhere (29). Data were collected through face-to-face Computer Assisted Personal Interviews and a Computer Aided Self-completion Interview. Interviews lasted for approximately 1 hour 40 minutes, with approximately 30 minutes of this period being self-completed (30). Questions covered a range of topics, including household structure; parenting; family; pregnancy, labor, and delivery; baby’s health and development; parent’s health and psychosocial adjustment; and parental employment and education (28). Mothers were not excluded on the
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Table 1. Characteristics of Mothers in the Millennium Cohort Study Who Were Unaccompanied at Birth and Mothers Who Had a Companion During Childbirth
Characteristics Sociodemographic factors Age (yr) Marital status Married Cohabiting Single Parity Primiparous Multiparous Cultural factors Ethnicity White Indian Pakistani Bangladeshi Black Mixed and other Religion None Christian Hindu Jew Muslim/Islam Sikh Buddhist Other non-Christian First language English spoken at home Other languages Socioeconomic factors Type of ward Advantaged Disadvantaged Ethnic Educationa None Overseas qualification NVQ level 1 NVQ level 2 NVQ level 3 NVQ level 4 NVQ level 5 Household income Less than £10,400 pa More than £10,400 pa Obstetric factors Planned pregnancy Planned Unplanned Feelings about pregnancy Unhappy Happy or unconcerned Antenatal care Antenatal care, plus classes
Accompanied at Birth (n = 15,745) 94.79% Mean (SD) or No. (%) 29 (6)
Unaccompanied at Birth (n = 821) 4.94% Mean (SD) or No. (%) 30 (6)
p
