The recommendations and conclusions in the American College of Obstetricians and Gynecologists' (ACOG) recently published Committee Opinion, "Approaches to Limit Interventions During Labor and Birth" (Wharton, Ecker and Wax, 2017) are very similar to the 2014 ACOG/SMFM statement, "Safe Prevention of the Primary Cesarean Delivery," (Caughey, Cahill, Guise and Rouse, 2014) which I applauded, with some qualifications, in a commentary I wrote after ACOG's Consensus Statement was issued (Simkin, 2014). One concern that I have with both documents is the lack of inclusion of a role for childbearing parents. The evidence-based recommendations are mostly one way, that is, centered on management practices to lower cesarean rates, provided by up-to-date, benevolent care providers (please don't get me wrong; this is critical and most welcome!) and received by the patients. Such practices include, among other things, continuous labor support and reliance on less invasive interventions to improve labor progress when necessary. Science & Sensibility covered both the new 2017 committee opinion and the 2014 joint ACOG/SMFM statement in previous posts

As a doula and doula trainer myself, I'm delighted by ACOG's positive discussion of continuous labor support, namely a doula. However, a recommendation that is closely related to doula care, but absent from these recommendations is prenatal education. Preparation that focuses heavily on preparing the laboring person and partner to master effective self-help and partner-assisted techniques for comfort and labor progress will increase their tolerance of the now-recommended longer labors. The idea that longer labors are safe and beneficial may be particularly unappealing to childbearing people who know little about ways they can find comfort.

Why are doulas promoted, and childbirth education ignored? There is a very good reason: the evidence from existing trials demonstrates convincingly that continuous labor support, especially in the form of a doula improves labor and birth outcomes (Hodnett, Gates, Hofmeyr and Sakala, 2013). On the other hand, trials of childbirth education have shown no clear benefit. A Cochrane Review (2007, 2011), found nine such trials involving 2284 women (Gagnon and Sandall, 2011). The educational content varied greatly and no consistent outcomes were measured across the trials. The review of trials found a lack of high-quality evidence, and so the effects of antenatal education remain largely unknown. This review concluded that "further research is required to ensure that effective ways of helping health professionals support pregnant women and their partners in preparing for birth and parenting are investigated so that the resources used meet the needs of parents and their newborn infants.".

A 2015 systematic review (Brixval, Axelsen, Lauemoller, et al) including 17 randomized and quasi-randomized trails, concluded: "Insufficient evidence exists as to whether antenatal education in small classes is effective in regard to obstetric and psycho-social outcomes." The authors recommended "well-conducted randomized controlled trials with a low risk of bias." The irony is that many of the skills and techniques that could be included in childbirth education are effective in reducing pain and/or enhancing labor progress (Simkin & Klein, 2016), but are not taught. If they were, parents could contribute to improved outcomes as can doulas and care providers.

It seems to me that the best way to evaluate childbirth education would be to randomize two groups of expectant parents, each with a different set of learner objectives. The control group would receive "generic" childbirth education that emphasizes nutrition and self-care; general description of stages of labor; usual hospital procedures; newborn care and feeding, etc. These classes would not include self-help and partner-assisted measures to reduce pain and improve progress in labor. The experimental group would emphasize parents' participation in specific aspects of labor: for example, how to get to the hospital at an optimal time; the psychological and physical shifts in labor; and, especially, rehearsal and mastery of self-help and partner-assisted comfort measures and coping tools.

The control and experimental classes would be differentiated by their objectives and their educational plans for meeting those objectives. I think existing trials have suffered from a lack of consistency in the education provided, including the number of hours spent in class and on the various objectives; priority given to the mastery of comfort measures; content devoted to physiological and medicalized management, etc. The objectives for the experimental group should be based on known measures for lowering cesarean rates. These can easily be formulated from the Conclusions and Recommendations presented in ACOG's Committee Opinion (Wharton, et al, 2016). Many of their recommendations could easily incorporate a role for educated expectant parents.

Until there is scientific evidence of clinical benefit from childbirth education, we can't expect ACOG or anyone else to endorse it as a valid contributor to improved outcomes. I hope readers of this column who have facilities and know-how to mount a well-designed trial will be inspired to do so.

References

Brixval CS, Axelsen SF, Lauemoller SG, et al. (2015). The effect of antenatal education in small classes on obstetric and psycho-social outcomes-a systematic review. Systematic Reviews 1-9. Published online 28 Feb. 2015. DOI 10.1186/s13643-015-0010-x

Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014). Safe Prevention of the primary cesarean delivery. American College of Obstetricians and Gynecologists & Society of Maternal-Fetal Medicine. Am J Obstet Gynecol 210(3):179-193.

Gagnon AJ, Sandall J. (2011). Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD002869. DOI: 10.1002/14651858.CD002869.pub2. (Edited and conclusions reaffirmed, 2011)

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.

Simkin P, (2014). Preventing primary cesareans: Implications for laboring women, their partners, nurses, educators. and doulas. Birth 41(3): 220-22.

Simkin P, Klein M. (2016). Nonpharmacologic approaches to management of labor pain. In: UpToDate, Lockwood CJ. (Ed), UpToDate Waltham, MA (accessed on Jan. 31, 2017).

Wharton KR, Ecker JL, Wax JR. (2017). Approaches to limit intervention during labor and birth. Committee Opinion No. 687. American College of Obstetricians and Gynecologists. Obstet Gynecol 129:e20-28.

About Penny Simkin

Penny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 13,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2017), with Ruth Ancheta, The Birth Partner (2013), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren and two great-grandchildren. Penny can be reached through her website.

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