As you might imagine, there is a wealth of research on pregnancy and childbirth. However, it might surprise you to learn that, despite all of this information, healthcare providers still don't have definite answers to many of the questions surrounding childbearing.
The "gold standard" of clinical research is the large double-blind study, wherein one group of participants receives the treatment being studied and one group does not. These groups are assigned randomly in order to reduce bias. Neither the people participating in the study nor the people conducting it know who is actually getting the treatment and who is not.
This type of research is very hard to conduct among pregnant women. The health and wellbeing of the baby must be considered, along with the health and wellbeing of the mother. It is especially difficult to design a "blind" study when considering holistic alternatives. For example, if researchers were doing a study on the effects of hydrotherapy on childbirth, it would be obvious to the woman in the study, her care provider, and the researchers if she were using a shower or bathtub during labor.
Care providers must depend on research that might not meet the double-blind gold standard, but that has credibility because it has been repeated several times with similar results, or because it tested the same participants before and after an intervention. They also rely on case studies, their own knowledge base of physiology and biochemistry, and on the practices of other obstetric providers.
All these types of knowledge are used to develop evidence-based practice standards, which reflect the current understanding of pregnancy and childbirth. In evidence-based practice standards, the research and other evidence supporting a particular practice is graded. A practice that was demonstrated to be effective and safe based on a large double-blind study would receive a higher grade than a practice based on a smaller study, an observational study, or on the opinion of childbirth experts. Thus, an evidence-based practice standard gives the care provider an indication of how strong the evidence about the practice is, and whether the practice is likely to be helpful, likely to be harmful, or somewhere in between. As new research is done, the suggested best practices change.
This article reflects these limitations, and you should understand that while you will not find absolute answers here, you might gain a deeper understanding of some childbearing issues.
There is considerable research that indicates that women who are fully involved in their prenatal care and birth, who are able to advocate for their wishes and for their infant's healthcare, and who feel that their wishes have been honored by their caregivers feel more satisfied with and empowered by their experiences. (1,2)
Several holistic practices and complementary therapies have been studied in pregnancy and childbirth. There is some evidence that women who use holistic therapies have increased satisfaction with their birth experience, and have lower rates of medical interventions during birth. (2) The following is a partial list of holistic practices and complementary therapies used in childbirth, along with benefits noted in the research.
The Cochrane Library is a collection of research analyses, with about one-third of its articles devoted to childbearing. In an attempt to summarize the research findings about pregnancy and childbirth, reviewers of the Cochrane Library have evaluated the evidence and come up with categories to describe childbearing practices. The categories include the following:
Some of the most controversial, yet common, practices encountered in pregnancy and childbirth are outlined below, along with research findings. We also include the likelihood of the practice being beneficial, as concluded by Enkin et al.'s review of the Cochrane Library findings. (30)
Practice: Group B Strep screening and treatment
Research findings: Antibiotic treatment in labor of women colonized with GBS appears to reduce the likelihood of the infant becoming ill with GBS sepsis.30 Risks of universal screening and treatment include antibiotic allergic reaction. The GBS infection rate among newborns has decreased with universal screening, but the rate of neonatal e-coli infection has simultaneously increased. (31)
Benefit: Clearly beneficial
Practice: Epidurals, intrathecals, or spinal anesthesia
Research findings: Most effective at providing pain relief for most women in labor. Woman remains alert and conscious. Side effects may include increased risk of cesarean section, vacuum or forceps delivery, low blood pressure, headache, backache. (30,32,33,34)
Benefit: Trade-off between beneficial and adverse effects
Practice: Pain medication (non-epidural forms)
Research findings: May provide adequate relief from pain for some women. Side effects may include a "drugged" feeling, respiratory depression in the newborn, newborn irritability. (30,35,36)
Benefit: Trade-off between beneficial and adverse effects
Practice: Lying on one's back
Research findings: May decrease oxygenation of the uterus by up to 30%, resulting in less oxygen to the baby and less effective contractions.30 May promote posterior positioning of the baby. (37)
Benefit: Likely to be harmful
Practice: Obstetric ultrasound
Research findings: May be done to resolve questions of estimated due date, the number of babies, the size, anatomy, and wellbeing of the baby, the amount of amniotic fluid, and the position of the placenta. (30) A few studies have questioned the safety of obstetric ultrasound, raising issues such as dyslexia and low birth weight, but the findings have not been repeated with larger well-designed studies. (38,39,40) Nevertheless, the U.S. Food and Drug Administration cautions against the use of ultrasound unless it is medically indicated, as does the American Institute of Ultrasound in Medicine.
Benefit: Likely to be beneficial
Practice: Continuous fetal monitoring
Research findings: The use of continuous fetal monitoring has been associated with an increase in cesarean section, forceps, and vacuum extractor rates, without any evidence of benefit to the infant. It has not been associated with a decrease in infant mortality rates, increased APGAR scores, or a decrease in problems associated with a lack of oxygen to the baby. (41,42,43,44)
Benefit: Trade-off between beneficial and adverse effects
Research findings: Women most likely to receive episiotomy are first-time mothers, those with a long pushing stage, or women whose baby's have a low heart rate at the end of labor. (48,49,50) Episiotomies are associated with increased pain after birth and more severe tears. (48)
Benefit: Likely to be harmful
Practice: Elective induction
Research findings: Elective inductions are those undertaken for the convenience of the mother and the provider, and may be done for many reasons: to take advantage of help from extended family, work schedules, living a great distance from the hospital, or general discomfort at the end of pregnancy. Especially for first-time mothers, elective inductions are associated with a higher cesarean section rate than found for women who enter labor spontaneously. (51,52,53,54) Induction has also been associated with higher use of forceps or vacuum extractor and postpartum hemorrhage. (51,55,56)
Benefit: Not evaluated
Practice: Inducing after rupture of membranes (water breaking) before labor starts
Research findings: The bag of water provides protection from infection, and therefore it has been common for women to have labor induced if the water breaks. However, most women will start to have contractions within a day of their water breaking, and the most recent research does not indicate an increased infection risk after 24 hours. Avoiding vaginal exams in the absence of active labor seems to be the best way to avoid infection. (57,58)
Benefit: Trade-off between beneficial and adverse effects
Practice: Restricting food and liquids during labor
Research findings: Initially used to reduce risk of breathing the stomach contents into the lungs if a woman vomited while under anesthesia, a real but rare risk. The work of the intestines slows during labor, as the body's resources are devoted to the contractions of the uterus, however, labor is a strenuous activity requiring calories, and fasting during labor has not been shown to guarantee an empty stomach should anesthesia become necessary. Dehydration can result from restricting fluid intake. (26,30)
Benefit: Unlikely to be beneficial
Of course, there are many other topics of interest surrounding pregnancy and childbirth, and not all can be covered here. If you are interested in reading further about childbearing research, the Childbirth Connection  website has an excellent summary of current evidence and research findings.
With the development of the Cochrane Library, the field of obstetrics was among the first to promote widespread distribution of research findings through searchable research reviews. (27) Sadly, there is some evidence that women are not receiving care that reflects our understanding of best childbirth practices. The Childbirth Connection, a 90-year-old organization devoted to promoting maternity care, has conducted recent surveys of women. The general conclusion was that holistic practices and beneficial activities that should be used by healthy women, such as walking during labor, drinking liquids, and using an upright position for pushing, were used by only a few women.
Additionally, many women reported experiencing several interventions not generally indicated for healthy women. Women also reported being disenfranchised from decision-making and feeling pressured into interventions by their caregivers. Although most of the survey participants noted that they wanted full information about risks and benefits of interventions, their level of knowledge at the time of the survey indicated that they lacked complete information. (28,29) Clearly, birthing families must ask questions of their care providers about any proposed plans, and childbirth professionals must remain alert to recommended practice changes and evidence-based practice standards.
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Brown, S.T., Douglas, C., & Flood, L.P. (2001). Women's evaluation
of intrapartum nonpharmacological pain relief methods used during
labor. Journal of Perinatal Education, 10(3), p. 1-8.
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