At a time when many laboring women are overtaken by a number of interventions—each procedure leading to other interventions used solely to monitor, prevent, or treat side effects—continuous labor support is a jewel of a care practice that has major, well-established benefits and no known downsides. These benefits appear to help protect women from being swept away in a cascade of interventions.

The first systematic review of effects of continuous labor support was published 15 years ago in the landmark book, Effective Care in Pregnancy and Childbirth, in which just two studies were included (Keirse, Enkin, & Lumley, 1989). With the establishment of the Cochrane Collaboration in 1993, the original review continued to be updated as a Cochrane Review. Recently, this review was reconstructed and expanded (Hodnett, Gates, Hofmeyr, & Sakala, 2004) in order to reflect the considerable strides made in clarifying evidence-based maternity care, documenting benefits of continuous labor support, and fostering access to continuous labor support. The new review summarizes experiences of nearly 13,000 women who participated in 15 studies. As noted in the Lamaze care practice paper, the new Cochrane Review on effects of continuous labor support clarifies that, when compared to labor support from hospital staff, stronger and more positive effects were evident when the person providing continuous support was not a regular member of the hospital staff and came into the facility exclusively to provide support to the laboring woman. Compared to women who did not have continuous labor support, those who received focused support from an outsider experienced impressive benefits with respect to several important outcomes. Women who received focused labor support were

At present, childbearing women face unprecedented challenges, including their increasing vulnerability to surgical birth. Dialogue among professionals and in the media is normalizing casual use of cesarean section and the concept of cesarean on demand. Major shifts in standards of practice are taking place. The cesarean rate in the U.S. is higher than ever, and rising. Pregnant women have limited resources for making sense of this situation and protecting themselves.

Providers of continuous labor support cannot take on the full burden of intervening in these trends, which are fueled by serious underlying problems. However, this type of care can offer an invaluable helping hand to women giving birth in today's daunting environment, making it possible for them to experience a physiologic rather than medically managed birth, avoid adverse consequences of several major maternity interventions, and have increased satisfaction with this profoundly important life experience.

In an ominous environment where pregnant women are being encouraged to choose cesarean section to avoid the supposed hazards of vaginal birth, continuous labor support offers women increased likelihood of having a spontaneous vaginal birth without the considerable risks of both surgery and instrumental birth. The drawbacks of epidural analgesia (Lieberman & O'Donoghue, 2002; Mayberry, Clemmens, & De, 2002) and opioids (Bricker & Lavender, 2002) during labor are increasingly recognized. In our pain-fearing society, continuous labor support offers women the gift of less likelihood of using pain medications and less likelihood of being dissatisfied.

In considering the explanation for these striking effects, authors of the current Cochrane Review proposed that continuous labor support enhances normal labor physiology and mothers' feelings of control and competence and, further, reduces reliance on external management with medical interventions (Hodnett et al., 2004). This approach is simple, powerful, and at the heart of the goals presented by Lamaze International in its six care practice papers that support normal birth.

The best research evidence suggests that hospital-based providers face challenges in providing effective labor support, even within focused interventions that enhance their provision of labor support (Hodnett et al., 2004). Possible limitations include the following situations for hospital staff: numerous competing responsibilities and a diffuse sense of the caregiver's role and identity across many functions, schedules tied to work shifts rather than to women's labor, divided loyalties, and inadequate training for supportive care.

Women's partners also may not be in an optimal position to take the lead in providing continuous labor support. They have needs of their own at this time and often have no previous experience with labor or labor support. As noted in Lamaze International's care practice paper on continuous labor support, an ideal situation for couples is the presence of a guide who can help a woman's partner provide effective support, according to the wishes of the couple, and step in as needed. Studies included in the current Cochrane Review did not expressly examine the effectiveness of women's partners as providers of labor support. However, the review did find that continuous support appeared to have a greater effect in hospital settings that did not permit partners or other companions of choice and where the laboring women may have been especially isolated, in comparison with settings that did permit companions of choice (Hodnett et al., 2004).

The leading support options for women are arranging for a doula or inviting a friend or family member to commit to being present throughout labor. Unfortunately, current research does not compare the impact of these different models. Through these options, virtually all childbearing women could have access to continuous labor support.

Doulas of North America (DONA), the oldest and largest doula organization in North America, encourages “a doula for every woman who wants one.” Many doulas work with at least some clients who may not be able to pay a full or even partial fee. In addition to hospital-based programs and reimbursement by some health insurers—as noted in Lamaze International's care practice paper on continuous labor support—a large number of women training to be doulas and working toward certification also offer opportunities for donated or low-cost services in many communities.

The notion of a friend or family member providing labor support is intriguing. Some studies found that women with no previous training or only modest training provided effective labor support. Penny Simkin (2001) has written an outstanding guide for individuals (including partners) who commit to supporting a friend or relative at this special time. These providers of support might also grow in confidence, enthusiasm, and effectiveness if such groups as Lamaze International and DONA, or local doula trainers, offered workshops that address their particular needs.

In 2000, the Maternity Center Association^* (MCA) created an ongoing “Labor Support Initiative” to build awareness of and increase access to continuous labor support resources (http://www.maternitywise.org/prof/laborsupport/index.html). MCA's labor support resources complement Lamaze International's care practice paper on the same topic. For example, MCA's Maternity Wise™ Web site features a special section, titled “How Do I Get the Labor Support I Need?” (http://www.maternitywise.org/mw/topics/laborsupport/), which advises expectant mothers on how to find the answers they need to this important question. The section includes information that

MCA also offers a printed brochure, “Women Supporting Women during Childbirth,” that covers a similar range of topics for consumers (for ordering information, contact MCA at 212-777-5000 or log on to www.maternitywise.org/bookstore/). For health-care providers seeking information on labor support, MCA's Web site provides access to the full—and very long—Cochrane Review, Continuous Support for Women During Childbirth, available at no cost as a downloadable PDF file (http://www.maternitywise.org/pdfs/continuous_support.pdf). Highlights of this review are summarized on another page of MCA's Web site (http://www.maternitywise.org/prof/laborsupport/review.html). Finally, a full report on the results of MCA's landmark Listening to Mothers survey (Declercq, Sakala, Corry, Applebaum, & Risher, 2002) is available on the organization's Web site (www.maternitywise.org/listeningtomothers/) and provides invaluable information at the national level on the use of labor support.