Nursing Support Found Not to Change C-Section Rate

Women who have a specially trained nurse at their side throughout labor appear to be just as likely to have a caesarean section as women with typical nursing care.

The finding contradicts previous studies suggesting that C-section rates--which have soared in recent years to almost 25% of all U.S. births--might be lower if women were attended by nurses providing ample social and emotional support, advice and information.

Many hospitals have adopted policies to provide such support because caesarean births are associated with higher risks of medical complications, longer hospital stays, longer recovery time and higher costs.

The new study, published last week in the Journal of the American Medical Assn., was directed by Ellen D. Hodnett, a nursing professor and researcher at the University of Toronto.

Hodnett in 1999 published an analysis of 14 studies and concluded that there were several advantages to having continuous labor support, including shorter labors, reduced use of pain medication and fewer C-sections.

However, the new study, a randomized controlled trial of almost 7,000 women in 13 U.S. and Canadian hospitals, found C-section rates of around 12.5% both for women who had specially trained labor nurses providing continuous care and for women who had nurses who were not specially trained and may not have provided continuous care.

While continuous support may be helpful, its benefits are likely “overpowered” by routine medical interventions that increase the chances of caesarean section, Hodnett said.

These interventions include the use of labor-inducing drugs (which 62% of the women in the study received), continuous electronic fetal monitoring (77%) and regional anesthesia, such as an epidural (75%).

Instead of adopting policies of one-on-one labor support, Hodnett suggested that hospitals view birth as a natural event and then monitor medical practices, such as the use of labor-inducing drugs, that increase C-section rates.

“The effectiveness of labor support may depend on the setting in which it is provided,” Hodnett said. “However, reducing U.S. and Canadian caesarean delivery rates cannot be accomplished solely through a policy of continuous nursing support.”

The study found no differences between the two groups in complications during labor, length of labor, length of hospital stay or health outcomes of the babies. However, more women in the continuous support group expressed strong satisfaction with their birth experiences.

Further studies should focus on whether doulas, women trained to be labor assistants, have more effect at lowering C-section rates, says Carol Sakala, director of programs at Maternity Center Assn., a New York City-based organization devoted to maternity care.

The nurses in the study, she noted, were part of the hospital staff and had had only two days of labor support training.

“A doula coming in from the outside and with different approaches might have a different effect,” Sakala said. “Doulas have tricks of the trade, different ways of thinking about [labor] situations.”