Why women and birthing people need to have a birth partner with them

Right now, many NHS Trusts across the country are limiting birth partners to one and in other countries, birth partners are being stopped altogether. We are starting to see the cancellation of many homebirth services and birth centres are being shut down and used to isolate women with confirmed or suspected Coronavirus. This means for many women, the only place to have their baby, with the support of medically trained staff, is on an obstetric led ward in the hospital.

I completely get it, we are in unprecedented times and yes, I understand that we need to implement new policies and rules to ensure we minimise the spread of the Coronavirus. I also totally understand that, at the moment, there isn’t much evidence to go by, making it difficult to base policies on evidence-based research. Hospitals are doing all they can to limit footfall through their corridors and protect their staff from becoming ill. Midwives, obstetricians, anaesthetists, paediatricians, maternity care assistants and all other maternity care staff are doing the very best they can under very difficult conditions and in unchartered waters. I am very grateful for all they do and appreciate that things are far from ideal right now.

As there is little evidence in terms of the impact of Covid-19 on mothers and newborn babies, what we do have available to us is the evidence related to the possible impact of some of the policies that are being put in place. To guide policy makers in individual NHS Trusts, they should look to the main regulatory bodies in the country, as well as in the world, to see what is being recommended.

The Royal College of Obstetricians and Gynaecologists (RCOG) clearly state:

“Having a trusted birth partner present throughout labour is known to make a significant difference to the safety and well-being of women in childbirth.”

Royal College of Midwives (RCM) continues to advise that women and people giving birth should still be able to have their birth partners with them.

“Women should be permitted and encouraged to have a birth partner present with them in their labour and during birth. Having a trusted birth partner present throughout labour is known to make a significant difference to the safety and well-being of women in childbirth.”

The World Health Organization (WHO) recommend birth companions in four of their guidelines World Health Organization 2012; World Health Organization 2014b; World Health Organization 2015; World Health Organization 2018.

When you consider that all these major organisations are still saying that having a birth companion is important, why is it that some NHS Trusts are making the decision to put limits on this free intervention which comes with only positive results?

What’s the proof that birth partners are important?
We have a reasonable amount of evidence around the importance of having a dedicated birth partner for women and birthing people during childbirth.  A labour companion could be the woman’s or birthing person’s partner, a family member or friend, a doula or a healthcare professional.

A Cochrane qualitative evidence synthesis carried out in 2019, which complements a previous Cochrane review published in 2017, explored the effect of continuous support for women during childbirth.  The results of these reviews concluded that if a woman/birthing person has continuous support during childbirth, which means having someone there the whole time, both mothers and babies are statistically more likely to have better outcomes.

This review analysed 51 studies from 22 countries, which showed that labour companions played numerous important roles in supporting women. Birthing partners provide informational support with regards to the process of childbirth, supporting communication between medical staff and women. They also offer practical support, encouraging women to be mobile and find comfortable positions, providing emotional support and non-pharmacological pain management in the form of massage and meditation. Often, birth partners act as advocates for the women, speaking up in support of her and her wishes. Birth partners also help women feel in control and build their confidence through praise, reassurance, and continuous physical presence.

It’s worth taking note that most of the studies in the review included the perspectives of having a male and/or female lay birth partner. Only four of the studies focused on the perspectives of healthcare providers, like midwives and nurses, being the only birth partner.

What is quite clear from all studies is that the absence of a birth partner contributed to women’s feelings of disempowerment, fear, and loneliness throughout labour and childbirth (Bohren 2015a; Shakibazadeh 2018).

Does it matter who the birth partner is?
As we have already established, having a birth partner makes a difference to women and birthing people, and a blanket ban could potentially lead to an increase in all those areas that we see statistical differences.

The Cochrane review was able to look at six outcomes and document the difference a birth partner made in these areas: use of any pain medication, use of artificial oxytocin during labour, spontaneous vaginal birth, caesarean births, the baby’s admission to special care nursery after birth, and negative birth experiences.

Two out of the six outcomes showed the best results when the support was provided by a doula – someone who was not a member of the hospital staff member and who was not part of the woman’s social network. The researchers found that overall, women or birthing people who have continuous support during childbirth experience a:

• 25% decrease in the chance of a caesarean birth; if the birth partner was a doula it was a 39% decrease
• 8% increase in the likelihood of a spontaneous vaginal birth; if the birth partner was a doula 15% increase
• 10% decrease in the use of any pain medication
• Shorter labours, on average by 41 minutes
• 38% decrease in the baby’s risk of a low five minute Apgar score
• 31% decrease in the risk of being dissatisfied with the birth experience; mothers’ risk of being dissatisfied with the birth experience was reduced with continuous support provided by a doula or someone in their social network (family or friend), but not hospital staff

These statistics are clearly showing that preventing birth partners for women could potentially give them a birth experience that is negative, increase the risk of their baby needing special care and increasing the risks of major stomach surgery.

What does the law say?
Birthrights, a UK charity that champions respectful care for women during pregnancy and childbirth by protecting human rights, explains:

“The legal position is that restricting the number of birth partners is an interference with a woman's right to a private and family life under Article 8 of the European Convention on Human Rights. NHS Trusts are permitted to limit or interfere with Article 8 rights, but only if such an interference is lawful, necessary and reasonable (proportionate).  They must also ensure that any interference with the right is not discriminatory against certain groups of people who would feel the impact of the restriction even more severely (else it could also be a breach of Article 14 of the ECHR)." 

"NHS Trusts that restrict a woman’s right to choose who will be present at her birth, for example by restricting birth partners to one, will need to be very clear that this response is proportionate to the additional threat of infection from Covid-19. They will also need to be very clear that it is an equally appropriate restriction in every single individual case.”

"Even if a Trust feels confident that its response is proportionate, we strongly advise that it should look at exceptions on a case by case basis, as a blanket policy could be open to legal challenge. Such a legal challenge could include the point that the blanket policy is not only disproportionate but is discriminating against certain groups of people who will feel the impact of that interference with their Article 8 rights much more severely.  Examples of such groups could include people with significant, existing, mental health issues, physical disabilities or more disadvantaged groups.”

What could the impact be on fathers and partners?
The birth of a baby is clearly a very important moment for both mothers and fathers. It’s not only a baby that is born, the mother and father is born too. Bearing witness to the birth of a baby impacts on attachment and bonding. We know from research that men who were supporting their female partner felt that it had a positive impact on them as individuals (Kululanga 2012; Sapkota 2012).

They also felt that supporting their partner in labour and seeing them give birth, positively impacted on their relationship, as well as in the way they bonded with their baby. When the father or partner was able to share the experience of their baby’s birth, it increased their love and respect for their partner, and they were able to connect with to the baby from the moment of birth (Dodou 2014; Kululanga 2012; Sapkota 2012).

I appreciate that it is by no means an easy time right now for policy makers, pregnant women/people and their families. We don’t know what the real impact of Coronavirus is going to be as we’re in the midst of it right now. Let’s hope that the restrictions and limitations set in place as a result of the outbreak doesn’t have more of a harmful effect in the long term, than the actual virus itself.