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Effectiveness of Nurses as Providers of Birth Labor Support in North American Hospitals
A Randomized Controlled Trial
Ellen D. Hodnett, RN, PhD;
Nancy K. Lowe, RN, CNM, PhD;
Mary E. Hannah, MDCM;
Andrew R. Willan, PhD;
Bonnie Stevens, RN, PhD;
Julie A. Weston, RN, MSc;
Arne Ohlsson, MD;
Amiram Gafni, PhD;
Holly A. Muir, MD;
Terri L. Myhr, MSc;
Robyn Stremler, RN, MSc(A);
for the Nursing Supportive Care in Labor Trial Group
JAMA. 2002;288:1373-1381.
Context North American cesarean delivery rates have risen dramatically since the 1960s, without concomitant improvements in perinatal or maternal health. A Cochrane Review concluded that continuous caregiver support during labor has many benefits, including reduced likelihood of cesarean delivery.
Objective To evaluate the effectiveness of nurses as providers of labor support in North American hospitals.
Design Randomized controlled trial with prognostic stratification by center and parity. Women were enrolled during a 2-year period (May 1999 to May 2001) and followed up until 6 to 8 postpartum weeks.
Setting Thirteen US and Canadian hospitals with annual cesarean delivery rates of at least 15%.
Participants A total of 6915 women who had a live singleton fetus or twins, were 34 weeks' gestation or more, and were in established labor at randomization.
Intervention Patients were randomly assigned to receive usual care (n = 3461) or continuous labor support by a specially trained nurse (n = 3454) during labor.
Main Outcome Measures The primary outcome measure was cesarean delivery rate. Other outcomes included intrapartum events and indicators of maternal and neonatal morbidity, both immediately after birth and in the first 6 to 8 postpartum weeks.
Results Data were received for all 6915 women and their infants (n = 6949). The rates of cesarean delivery were almost identical in the 2 groups (12.5% in the continuous labor support group and 12.6% in the usual care group; P = .44). There were no significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. There were no significant differences in women's perceived control during childbirth or in depression, measured at 6 to 8 postpartum weeks. All comparisons of women's likes and dislikes, and their future preference for amount of nursing support, favored the continuous labor support group.
Conclusions In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth.
Author Affiliations: Faculty of Nursing (Drs Hodnett and Stevens, and Mss Weston and Stremler), Department of Obstetrics and Gynaecology (Dr Hannah), Department of Paediatrics (Dr Ohlsson), and Centre for Research in Women's Health (Maternal-Child Nursing Research Unit [Dr Hodnett and Mss Weston and Stremler], Research Facilitation Office [Ms Myhr], and Maternal, Infant, and Reproductive Health Research Unit [Dr Hannah]), University of Toronto, Toronto, Ontario; Hospital for Sick Children (Dr Stevens), Toronto, Ontario; Department of Clinical Epidemiology and Biostatistics (Drs Willan and Gafni), McMaster University, Hamilton, Ontario; College of Nursing (Dr Lowe), Ohio State University, Columbus; and Department of Anesthesiology, Duke University, Durham, NC (Dr Muir). Dr Lowe is now with the School of Nursing, Oregon Health and Sciences University, Portland. Dr Willan is now with the Program in Population Health Sciences, Hospital for Sick Children, Toronto, Ontario.
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