Professor Ellen Hodnett of the Faculty of Nursing said these results call into question the usefulness of guidelines in Canada, the U.S. and the United Kingdom which recommend such continuous care. "To me, the clear message is if you are serious about wanting to reduce or at least not increase your caesarean delivery rates, don't count on one-to-one support by nurses as the only answer," says Hodnett who is also cross-appointed to the Department of Public Health Sciences, Mount Sinai Hospital and the Centre for Research in Women's Health (CRWH), a partnership of U of T and Sunnybrook and Women's College Health Sciences Centre. The study is published in the Sept. 18 issue of the Journal of the American Medical Association.
Hodnett and other researchers at U of T, The Hospital for Sick Children, Mount Sinai, Sunnybrook and Women's College, McMaster University, Ohio State University and Duke University followed 6,915 pregnant women at 13 hospitals across Canada and the U.S. Approximately half received continuous care from nurses specially trained in techniques to ease labour pain and anxiety. The rest received usual care in which a nurse checked their progress periodically and offered advice but was not present on a continual basis. Researchers found caesarean rates were almost identical between the two groups (12.5 per cent in the continuous care group and 12.6 per cent in the usual care group).
The findings do not mean such one-to-one, continuous care is not beneficial, says Hodnett, the Heather M. Reisman Chair in Perinatal Nursing Research at U of T and Mount Sinai. In fact, the majority of women in the study expressed a preference for that level of care. However, relying on a single intervention is not sufficient to reduce caesarean rates. "We need widespread changes to routine hospital practices and to caregivers' attitudes about childbirth," says Hodnett, suggesting that one helpful step could be regular, multidisciplinary meetings of doctors, nurses, midwives and women from the community to review their hospital's practices.
Prior to this trial, Hodnett's systematic review of 14 other studies of continuous support had found that this support helped in significantly reducing the likelihood of caesarean delivery. National practice guidelines in North America and the United Kingdom reflect this finding. The different findings in the 2002 study may be attributed to the different routines in the settings in which the studies were conducted.
Most of the earlier trials were conducted in hospitals in countries with fewer routine medical interventions during labour. The 2002 study focused strictly on pregnant women in Canada and the U.S. where such interventions are more common. According to Hodnett, the most plausible explanation for the 2002 study results is that the benefits of continuous labour support are overpowered in North American, high-intervention labour wards. Caesareans, considered major surgery, are associated with longer recovery times and a greater risk of complications for mother and baby.
The trial received funding from the U.S.-based National Institutes of Health, National Institute for Nursing Research. Other U of T researchers involved in the study are professors Mary Hannah of obstetrics and gynaecology and the CRWH's Maternal, Infant and Reproductive Health Research Unit, Bonnie Stevens of nursing and The Hospital for Sick Children and Arne Ohlsson of paediatrics and Mount Sinai Hospital, as well as trial co-ordinator Julie Weston and PhD student Robyn Stremler of nursing and Terri Myhr of the CRWH research facilitation office.
The University of Toronto, Canada's leading research university with 58,000 students, is celebrating its 175th anniversary in 2002. On March 15, 1827, King's College - precursor to the University of Toronto - was granted its royal charter by King George IV. The university now comprises 31 divisions, colleges and faculties on three campuses, including 14 professional faculties, numerous research centres and Canada's largest university library system - the fifth largest research library in North America.
CONTACT:
Professor Ellen Hodnett
Faculty of Nursing
416-946-8676
ellen.hodnett@utoronto.ca
Jessica Whiteside
U of T Public Affairs
416-978-5948
jessica.whiteside@utoronto.ca
Journal
JAMA