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The Role of Childbirth Education in ACOG’s New 2017Committee Opinion - “Approaches to Limit Interventions DuringLabor and Birth”

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Penny Simkin, PT, CD(DONA), CCE

The recommendations and conclusions in the AmericanCollege of Obstetricians and Gynecologists’ (ACOG)recently published Committee Opinion, “Approaches to LimitInterventions During Labor and Birth(http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth)” (Wharton, Ecker and Wax, 2017) are very similarto the 2014 ACOG/SMFM statement, “Safe Prevention ofthe Primary Cesarean Delivery(http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery),” (Caughey, Cahill, Guise and Rouse,2014) which I applauded, with some qualifications, in acommentary 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 forchildbearing parents. The evidence-based recommendations are mostly one way, that is, centered on managementpractices 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.

5/9/2018 Science & Sensibility : Blogs : The Role of Childbirth Education in ACOG’s New 2017 Committee Opinion - “Approaches to Limit Interventi…

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Science & Sensibility covered both the new 2017 committee opinion (blog/new-acog-committee-opinion-aligns-with-lamaze-six-healthy-birth-practices) and the 2014 joint ACOG/SMFM statement (p/bl/ar/blogaid=613) in previousposts

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 theserecommendations is prenatal education. Preparation that focuses heavily on preparing the laboring person andpartner to master effective self-help and partner-assisted techniques for comfort and labor progress will increasetheir tolerance of the now-recommended longer labors. The idea that longer labors are safe and beneficial may beparticularly 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 fromexisting trials demonstrates convincingly that continuous labor support, especially in the form of a doula improveslabor and birth outcomes (Hodnett, Gates, Hofmeyr and Sakala, 2013). On the other hand, trials of childbirtheducation have shown no clear benefit. A Cochrane Review (2007, 2011), found nine such trials involving 2284women (Gagnon and Sandall, 2011). The educational content varied greatly and no consistent outcomes weremeasured across the trials. The review of trials found a lack of high-quality evidence, and so the effects of antenataleducation remain largely unknown. This review concluded that “further research is required to ensure that effectiveways of helping health professionals support pregnant women and their partners in preparing for birth and parentingare 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 toobstetric and psycho-social outcomes.” The authors recommended “well-conducted randomized controlled trials witha low risk of bias.” The irony is that many of the skills and techniques that could be included in childbirth educationare effective in reducing pain and/or enhancing labor progress (Simkin & Klein, 2016), but are not taught. If theywere, parents could contribute to improved outcomes as can doulas and care providers.

It seems to me that the best way to evaluate childbirtheducation would be to randomize two groups of expectantparents, each with a different set of learner objectives. Thecontrol group would receive “generic” childbirth educationthat emphasizes nutrition and self-care; general descriptionof stages of labor; usual hospital procedures; newborn careand feeding, etc. These classes would not include self-helpand partner-assisted measures to reduce pain and improveprogress in labor. The experimental group would emphasizeparents’ participation in specific aspects of labor: forexample, how to get to the hospital at an optimal time; thepsychological and physical shifts in labor; and, especially,rehearsal and mastery of self-help and partner-assistedcomfort measures and coping tools.

The control and experimental classes would be differentiated by their objectives and their educational plans formeeting 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 comfortmeasures; content devoted to physiological and medicalized management, etc. The objectives for the experimentalgroup should be based on known measures for lowering cesarean rates. These can easily be formulated from theConclusions and Recommendations presented in ACOG’s Committee Opinion (Wharton, et al, 2016). Many of theirrecommendations could easily incorporate a role for educated expectant parents.

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Released: February 28, 2017 01:06 AM | Updated: February 28, 2017 08:29 AMKeywords: Labor/Birth (p/bl/kw/kt=1&kw=Labor%2FBirth) | Professional Resources (p/bl/kw/kt=1&kw=Professional%20Resources) | ACOG(p/bl/kw/kt=2&kw=ACOG) | Childbirth Education (p/bl/kw/kt=2&kw=Childbirth%20Education) | Childbirth Education Research(p/bl/kw/kt=2&kw=Childbirth%20Education%20Research) | Penny Simkin (p/bl/kw/kt=2&kw=Penny%20Simkin)

Until there is scientific evidence of clinical benefit from childbirth education, we can’t expect ACOG or anyone else toendorse 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 obstetricand psycho-social outcomes—a systematic review. Systematic Reviews 1-9. Published online 28 Feb. 2015. DOI10.1186/s13643-015-0010-x

Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014). Safe Prevention of the primary cesarean delivery. AmericanCollege 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 Databaseof 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, LockwoodCJ. (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 OpinionNo. 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 andlabor support since 1968. She estimates she has prepared over 13,000 women,couples and siblings for childbirth, and has assisted hundreds of women or couplesthrough childbirth as a doula. She has produced several birth-related films and is theauthor of many books and articles on birth for both parents and professionals. Herbooks include The Labor Progress Handbook (http://www.amazon.com/The-Labor-Progress-Handbook-Interventions/dp/1444337718) (2017), with Ruth Ancheta, TheBirth Partner (http://www.amazon.com/The-Birth-Partner-Childbirth-Companions/dp/155832819X) (2013), and When Survivors Give Birth:Understanding and Healing the Effects of Early Sexual Abuse of Childbearing

Women (http://www.amazon.com/When-Survivors-Give-Birth-Understanding/dp/1594040222/ref=sr_1_1?s=books&ie=UTF8&qid=1409629008&sr=1-1&keywords=when+survivors+give+birth+by+penny+simkin+and+phyllis+klaus) (2004), with Phyllis Klaus. Pennyand her husband have four adult children and eight grandchildren and two great-grandchildren. Penny can bereached through her website (https://www.pennysimkin.com/).

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3 Comments

Further Studies

Will Lamaze be participating in a study at any stage? Would be great to see this done in all countries that Lamazehas educators in.

BMJ did a study on an independent Childbirth Education course in Australia (which was very Bias)

http://bmjopen.bmj.com/content/6/7/e010691.full

Its very clear that further studies need to be conducted on childbirth Education and the benefits on labour, birth andpostpartum.

February 28, 2017 09:46 AM by Gemma Wilson

So true!

Thank you, Penny, for this article! I did a systematic review of the evidence on childbirth education and found similarfindings to what you discuss here-- that there really isn't much evidence on the effects of childbirth education. Itwould certainly make a great topic for a well-designed trial! One of the problems with any such study, would besomething called the "provider effect." For example, researchers have found that even when women are educatedon interventions like episiotomy, their education (and desire to avoid an episiotomy) has no effect on episiotomyrates, because the provider's desires have such a powerful effect that can (in many cases) override the client'seducation and wishes.

March 2, 2017 03:44 AM by Rebecca Dekker

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Research on Childbirth Education

I love these blog posts. Thank you for contributing Penny!

However, I just wanted to mention that there is research on the effect of childbirth education on outcomes. Bradleyhas been keeping statistics since the 1960"s. I personally have keep statistical data on outcomes of my students forthe last 20 years. At almost 500 births my students have a 15% cesarean rate, and 77% unmedicated rate. I lookat other things as well, but those are the two main ones. Thanks!

March 14, 2017 08:31 AM by Amy V. Haas, BCCE

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