TO THE EDITOR: In a verbal express...

TO THE EDITOR: In a verbal expression to the editor (1) of American Family Physician, Dr Richards corresponded to a Cochrane Review (2) of caregiver support for women during childbirth that was abstracted in American Family Physician. (3) He makes several choice points about the invaluable character that fathers can play in supporting mothers during labor. However, he has several misconceptions that warrant further clarification.

Dr Richards expresse affair that the caregiver providing labor support "partly or entirely supplants the father," thus diminishing the couple's ability to share in the experience of childbirth. The Doulas of North America, a national certifying organization for labor support caregivers, states that the doula's part is to "provide physical, emotional, and informational support to women and their partners during labor and birth." (4) The doula organization adds, "the doula is there in addition to, not instead of the partner. Ideally, the doula and the partner make the full support team for the woman, complementing each other's strengths"

The doula is not intended to replace the supportive partner. Doula support can alleviate the anxiety of one as well as the other parents by helping the father and other family members support the laboring mother. Dr Richards states, "if observation studies indicate ways to train the father to better support the mother during birth, then provide this training rather than replace the father." (1) Providing this training is exactly what intrapartum caregivers do.

Dr Richards also misunderstands a certain quantity of of the details of the clinical trials included in the Cochrane review. (2) He remarks that in one half of the trials evaluated, women's partners were not allowed to be near for the delivery, raising a potential ethical dilemma of excluding fathers from their children's birth for the intentions of a study. The trials included in the review were actionsed in diverse locations, including North America, Europe Central America, and Africa. Hospital policies differ internationally, and a certain quantity of of these hospitals did not admit fathers as a matter of policy. Therefore, not admitting these fathers was standard care where these trials were escorted rather than a condition artificially induced by means of the investigators.

Dr Richards criticizes the Cochrane review (2) for not defining "continuous caregiver support." The review2 included trials that compared usual care with "continuous labour support on either a familiar or unfamiliar professional (nurse or midwife) or lay bodily substance (paid or volunteer)," providing one-to-one support. Dr Richards also annotations on the lack of blinding in the trials. Although the majority of trials were not blinded, the same trial attempted blinding, by using a "sham" doula who did not actually provide support for manage patients. (5) For many medical interventions, trials cannot be adequately blinded. However, this does not obviate the ne for careful evaluation of like interventions in the context of a randomized clinical trial. Finally, although doulas have not been documented to improve final clinical issues for mothers or infants, reductions in pain, operative vaginal deliveries, and cesarean deliveries are far from trivial clinical issues Family physicians who provide obstetric care should consider using doulas in the intrapartum care of their patients.

AMY C DENHAM, MD

University of North Carolina

Department of Family Medicine

CB# 7595 Manning Dr

Chapel Hill, NC 27599-7595

REFERENCES

(1) Richards JW Jr Fathers should provide support during childbirth [Letter] Am Fam Physician 2003;67:2071

(2) Hodnett ed Caregiver support for women during childbirth (Cochrane Review). Cochrane Database Syst Rev 2002;1:CD000199

(3) Taylor J Caregiver support for women during childbirth: does the vicinity of a labor-support person affect maternal-child outcomes? (Cochrane) Am Fam Physician 2002;66:1205-6

(4) Simkin P Way K Position paper: the doula's contribution to recent maternity care. Accessed January 29 2004 at http://www.dona.org/ ConsumerInformation.html.

(5) Kennell J Klaus M McGrath s Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital. A randomized controll trial. JAMA 1991;265:2197-201

COPYRIGHT 2004 American Academy of Family Physicians

COPYRIGHT 2004 Gale Group