270 BIRTH 24:4 December 1997

LEclTERS

One-to-one Nurse Support in Labor

To the Editor: Gagnon and associates are to be congratulated on con- ducting and publishing a trial of one-to-one nursing support of women in labor that is unquestionably nega- tive (Birth 1997;24(2):71-77). Their conclusion that a ‘‘beneficial trend” with respect to one-to-one nursing in reducing oxytocin augmentation of labor is unsup- ported by their data. One can understand their apparent disappointment in the lack of effect of the intervention, but they really should not be surprised, given the condi- tions under which the trial was conducted.

The trial setting is a tertiary care center with a tertiary care orientation, and like many such centers, also has a substantial secondary care role where women at no apparent risk will be nursed beside those who carry substantial risk. In this situation, the likelihood exists that appropriate care for high-risk women can spill over into the care of low-risk women, leading to less than optimal outcomes for the latter (1,2). A previ- ous trial conducted in this setting, in which a birth room was evaluated compared with conventional care, ran into similar problems because of the lack of physi- cal separation between the nursing staffs caring for the experimental and control groups (3). With the passage of time considerable narrowing between the style of care took place from one setting to another, and we can expect the same thing to have happened here, even though a “separate” nursing staff cared for the experimental and control groups. The overall physical setting was the same.

To understand if the experimental nurses had an opportunity to modify the care so as to affect the outcomes of interest, one would need to present overall cesarean section rates for the setting and the rates for the population of women who would be eligible for the trial. In this way it is possible to get a sense of the total environment. This is important because in some tertiary care settings with low intervention rates for the entire population, one-to-one nursing might make a further inroad into the intervention rates. To obtain a sense of the overall study setting, one would like to know not only rates for cesareans but also for epidurals and continuous electronic fetal monitoring, frequency of admission of women who are not in labor, and cervical dilation on admission to hospital for over- all study populations. Information on the philosophy of care would also be helpful.

At a British Columbia women’s hospital, one-to- one care is the standard, but the cesarean section rate for women who would be eligible for this trial was well over 20 percent at the time that we began a project specifically designed to reduce the rate through a pro-

cess of continuous quality improvement. Four principal areas were addressed that are pertinent to Gagnon et al’s study, and these were specifically targeted within a structured institutional approach:

1. Keeping women out of hospital who are not in active labor

2. Reserving electronic fetal monitoring for women requiring this procedure

3. Tightly controlling conditions for “low-risk’’ inductions

4. Providing a range of pain management strategies for women to allow for epidural anesthesia if needed later (ideally after 5 cm)

Major inroads occurred within a few months in all of the target areas, including cesarean section.

This type of continuous quality improvement proj- ect in tertiary care environments has a much greater chance of success than placing nurses in the difficult role of trying to change a system that is deeply locked in institutional inertia. The culture governing appro- priate and inappropriate nursing behavior that mitigates against change has been well described in Hodnett’s accompanying commentary.

At the 1997 Doulas of North America International Conference we were privileged to hear the first nega- tive trial of doula care (4). That trial bears striking similarity to the study by Gagnon et al. The doulas were former (now retired) obstetric nurses who were hired specifically for labor support. Epidural anesthesia was virtually obligatory. Women came under the care of the “doulas” too late in the process to have a chance of success. In other words, this was not truly doula care.

Negative trials such as these are extremely im- portant because they show clearly that interventions cannot work unless the conditions for their potential effect are propitious.

Michaet C. Klein, MD, CCFP Professor of Family Practice and Pediatrics

University of British Columbia Head, Family Practice

BC Women S and Children S Hospitals 4500 Oak Street

Vancouver; BC V6H 3NI Canada

References

I . Klein M, Lloyd I, Redman C, et al: A comparison of low risk women booked for delivery in two different systems of care. Part I: Obstetrical procedures and newborn outcomes. Br J Obstef Gynaecol 90: 118-122, 1983.

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2. Klein M, Lloyd I, Redman C, et al: A comparison of low risk women booked for delivery in two different systems of care. Part 11: Management of labour, treatment of labour pain and associated infant outcomes. J Obstet Gynecol 90: 123-128, 1983. Klein M, Papageorgiou A, Westreich R, et al: Care in a birth room versus a conventional setting: A controlled trial. Can Med Assoc J 131:1461-1466, 1984. Garcia C. The Eighth Doula Studydocia1 Support During Birth In Mexico. 1997 Doulas of North America International Conference, Austin, Texas, June 19-22, 1997.

3 .

4.

To the Editor:

I was encouraged to see the recent report of Gagnon et al’s study of one-to-one nursing support of women in labor (Birth 1997;24(2):71-77). I applaud these re- searchers in investigating a critical arena in the effort to reduce the cesarean rate. I also appreciated Hodnett’s commentary discussing the appropriateness of nurses as providers of labor support (Birth 1997;24(2):78-80).

I would like to raise two key issues: first, to make distinctions between “nursing” and ‘‘labor sup- port”-both as forms of care and as professions, and second, to suggest that labor support skills are, in fact, clinical skills that can be applied by all caregivers.

Is the continuous presence of a nurse the same as the continuous presence of a labor support provider? Can someone giving nursing care also give the same level of emotional and physical support as a nonmedi- cal person? In my opinion, the answer is no. As the authors note, earlier studies pointed to the efficacy of support provided by those without clinical duties at the birth. This, I believe, is an essential component. Whether or not the support person has special training is another issue. First and foremost, they must have no responsibility other than to the woman and her family. This is the special distinction between a labor support provider and other birthing professionals using labor support techniques in their care.

It is important to acknowledge that a labor support profession is now emerging that is unique in its own right. I suggest that it has arisen by the presence of what Davis-Floyd describes as the technocratic model of birth. By providing simple, essential care in birth that has traditionally been given to women throughout history, this profession serves to reinstate that which was lost when birth moved into the hospitals. Today, thousands of professional labor support providers are being trained each year in the United States with na- tional certification programs, codes of ethics, and standards of care. They offer an advantage over “lay” supporters because of their expanded knowledge base and experience with birth. Yet, unlike nurses, they have no clinical duties to fulfill during the labor, which enables them to provide a true continuous presence for the birthing family.

For example, emotional support and physical com- fort are considered key factors for labor support, and are believed to be linked to many of its beneficial effects through the reduction of maternal catechola-

mine release. During the most critical times, such as a serious change in the fetal heart rate or even the moments surrounding the birth itself, however, the nurse’s responsibility requires a shift in focus to work- ing together with other caregivers to respond safely to the situation at hand. This is the appropriate application of nursing skill level and duty. However, the ability to provide direct emotional support or physical comfort measures to the woman and her family during this time becomes diminished or nonexistent.

This is not to say that nurses should not be trained in and apply the skills of labor support in caring for their clients, which is critical to changing current child- birth practices. Because nurses spend the greatest amount of time with the laboring mother, their under- standing and application of these techniques is para- mount. They also can use their appreciation of the importance of labor support by encouraging its applica- tion by family and friends, and in welcoming the pro- fessional labor support person when present. Nursing professionals who do not see this role may well be shown the way soon, as pressures to increase client satisfaction while reducing avoidable technology use are brought to bear on them by institutions striving to hold ground in the managed care market.

I was concerned in Gagnon et al’s study that the exact details of the support given by the nurses were not given in their report. It appears that no validation of the nurses’ actual care came from the laboring mothers themselves. I also question the ability of the study to address the effectiveness of labor support applied by nurses in reducing cesarean section rates when nearly one in five women had an epidural in place before receiving the support. Twenty-six percent were receiv- ing Pitocin (the number connected to intravenous lines is not given), and over 60 percent had ruptured mem- branes. All these interventions have a significant im- pact on key attributes of labor support, such as maternal mobility and the ability to assume upright positions freely. In addition, the design required that nulliparous participants be at least 4 cm dilated for admission into the study. This excluded the provision of the interven- tion-emotional and physical support-during what for many first-time mothers constitutes the longest, and often, the most frustrating portion of their labor. Yet these were not all women who stayed at home until they were 4 cm dilated. The average amount of time the participants were in the hospital was five hours before the arrival of the study nurses. This suggests to me that an important period of time passed when the cascade of interventions that often leads to an operative birth might have been delayed or prevented.

Whereas I appreciate the authors’ intentions, I do not think the study’s results should discourage us from applying labor support skills to nursing practice. In fact, I suggest that all birthing professions consider viewing the tasks of labor support as a group of clinical skills that should be taught to and applied by nurses, physicians, and midwives alike. I strongly believe that the real discussion is not who should be providing labor

272 BIRTH 24:4 December 1997

support, but rather, that it should become a standard of care within all professions, that every mother deserves continuous emotional and physical support, and that key principles such as maternal mobility, being upright, and having the freedom to reduce pain by changing positions and employing comfort measures should guide all caregivers. In the end, the delivery of this support will ideally come from several sources at each birth-from family members to a doula to nurses and to physicians and midwives. The laboring mother would be surrounded by support and find herself em- powered by the collective skills and collaboration of the entire birthing team.

Mayri Sagady, CNM, MSN Director; Labor Assistant Training Program

Association of Labor Assistants and Childbirth Educators (ALACE)

6289 Westmoreland Place Goleta. CA 9311 7

Formula Discharge Packs and Breastfeeding

To the Editor:

I read with interest the article on formula discharge packs and the effect on breastfeeding (Birth 1997;24(2):90-97). It was distressing to see the ab- stract (which is sometimes the only part of an article that is read) casually dismiss the receipt of a formula discharge pack as ‘ ‘not meriting great concern.” While the article found only a modest effect of the discharge pack on the duration of breastfeeding, clinicians should be aware that discharge packs are not supplied to help mothers breastfeed. Discharge packs are designed to create a new market to sell a product to consumers who would not normally purchase it. An exclusively breastfeeding baby never needs formula. If a mother is encouraged to supplement by the belief of her health care provider that she will breastfeed longer, we now have the nurse and physician recommending a product that will decrease a mother’s milk supply by partially replacing breast milk, increasing the baby’s risk of allergy and illness, and changing the developmental trajectory of the infant’s brain by removing the unique components of breast milk.

The real beneficiary of discharge packs is the for- mula company. It now has a customer who will buy the product for at least a year rather than not at all or

for a shorter period of time had she breastfed exclu- sively until six months. To capture this particular mar- ket, one formula company gives maternity units a publication stating, ‘ ‘Breastfeeding instruction packs can help. Breastfeeding mothers who received for- mula-containing instruction packs were more likely to supplement” (1). This type of disinformation is designed to obscure the real effect of formula supple- mentation on lactation and infant health, and encourage practitioners to advise mothers to use this product. It is not the business of formula companies to educate anyone about breastfeeding.

Why are these packs given out at all? They are not therapeutic, the coupons do little to offset the $1200 that parents will spend on formula for the next year, and mothers do not need anything that is in these bags. Discharge packs are a marketing tool to help mothers buy a less-than-optimal infant feeding product. Hospi- tals often have a contract with a formula company that requires the distribution of this pack to receive large sums of cash, free formula, services, and equipment from the formula company. The companies simply pay the health care system to do their marketing for them. All other units in a hospital buy food for their patients through the normal procurement process and bill it as part of the room and board charge. Most hospitals have policies prohibiting staff from marketing products to patients. The cardiac unit does not give its patients coupons for potato chips, sausage, and other artery- clogging products. Why do we give these gifts at all?

Researchers would do better to look at the effect of discharge packs on the sale of formula and how effective a tool this is in influencing mothers to buy formula. Clinicians could improve the health of women and infants if they abandoned the practice of marketing formula and protecting formula companies and spent more time on providing high quality breastfeeding sup- port and services.

Marsha Walkel; RN, IBCLC President, Lactation Associates

254 Conant Road Weston, MA 02193-1756

Reference

1. Ross Products Division, Abbott Laboratories. Breastfeeding: Promoting Today, Supporting Tomorrow. Columbus, Ohio: Au- thor, 1995.