Continuous Support for Women During Childbirth

Abstract

Continuous support and care during childbirth is an essential element of obstetric nursing care that should not be neglected. The practice has been shown to have positive implications for the patient population. The implications include increased vaginal deliveries, reduction in the number of cesarean deliveries, lesser negative attitudes among its stakeholders, and a reduction in the duration of labor. However, experts also consider the practice a clinical problem that needs to be addressed to facilitate its effectiveness. This article describes some of the suggested guidelines and recommendations by experts on how continuous support of women can be structured to give better patient outcomes.

Section 1

Description of the Clinical Problem

Continuous support for women during childbirth encompasses the act of caring, advocacy, nurturing, and supportive behaviors. Despite the enormous benefits of the practice, continuous care has been shown to have implications for the patients (both mothers and infants), nurses, and the population/country. Nurses face a complexity of various tasks and challenges during their practice. Some of these challenges result from poorly designed and obsolete clinical guidelines regarding the provision of continuous care during childbirth. Additionally, interactions among those involved in the provision of continuous care such as nurses, patients, family, housekeeping staff, lab personnel, nursing managers, neonatologists, anesthesia physicians, and obstetricians reveal frustrations that emanate from their direct or indirect participation in the continuous care. Moreover, Hodnett, Gates, Hofmeyr, and Sakala (2005) assert that continuous support can have diversified implications through the causation of short-term and long-term psychosocial and physiological effects to participants involved.

Implications of Continuous Care to Patient

Hodnett et al. (2005) assert that women who received continuous support were more likely to elicit spontaneous vaginal birth. They were less likely to be provided with intrapartum analgesia or report their dissatisfaction in care. Moreover, these women experienced a relatively shorter duration of labor. As a result, they were less likely to have cesarean deliveries and regional analgesia. Continuous care during childbirth reduces the need for use of pain-relieving medication due to the relatively shorter labor durations. Pain medications are purported to have negative side effects on both the mother and the child. For instance, pethidine, which is one of the most popular pain-relieving medications indicated during labor, has been ascribed to have potential fetal, neonatal, and maternal side effects based on randomized controlled studies. The side effects of the neonate include depressed respiration, lack of responsiveness to sounds and lights, drowsiness, lassitude, impaired suckling reflex, and depressed reflexes. Moreover, pethidine has been closely associated with inhibition of breastfeeding, thus affecting the nutritional health of the baby. To the mother, pethidine causes nausea and vomiting, dysphoria, dizziness, and drowsiness (Munro & Jokinen, 2012). Therefore, the provision of continuous support protects the mother and the neonate from adverse effects of pain medications.

Synthetic oxytocin is also another commonly used drug during childbirth. Despite its wide use, this hormonal drug is mainly used for the induction of labor. The drug has been shown to have several side effects on the mother and the child. One of the common side effects is the development of breastfeeding difficulties due to its effect on hormonal balance. Moreover, oxytocin has been purported to have neuropsychological defects in neonatal development to babies of the exposed mothers (Odent, 2013). Hence, by reducing the duration of labor because of continuous care, the side effects of oxytocin that emanate from a long duration of exposure are eminently reduced.

Implications of Continuous Care to Nurses

Continuous care during childbirth confers an array of implications for the nurses concerning the division of loyalties, additional duties, constraints of institutional support, and self-selection among others. These factors limit the effectiveness of the nurses in providing quality support for their patients. The childbirth environment has a huge influence on nurses. For example, the program has multiple demands from the nurses themselves. It exposes them to very stressful and exhausting work environments. Particularly, in the second stage of labor, the nurse is required to multitask and/or pay attention to a multiplicity of things while at the same time documenting the occurrences.

Another implication that arises from the provision of continuous care is the disruption that results from the interaction between nurses and other healthcare team members, for instance, physicians. Besides, the demands for documentation of non-intuitive electronic health records lead to suboptimal outcomes. These disruptions interfere with the nurses’ work to the extent of preventing them from achieving their intended outcomes. In addition, technology has also been implicated as an ingredient of complexity to continuous care due to its paradoxical increase in human error and its potential for causing side effects (Glenn, Stocker-Schnieder, McCune, McClelland, & King, 2014).

Implications for Continuous Care to Population/Country

One of the implications of continuous care during childbirth to the population is the provision of poor quality services because of the additional workload for the nurses. The poor quality is a risk to patient safety. Strong evidence is available indicating a positive correlation between heavy nurse workload and patient outcomes. Overworked and stressed nurses are highly likely to provide suboptimal care services to patients (Carayon & Gürses, 2005). Research evidence strongly indicates that the greatest benefit of continuous care is attained when a provider that is not an employee of the healthcare organization confers it. However, this benefit occurs on the condition that the support begins at an early stage of labor and that epidural analgesia is avoided (Hodnett et al., 2005).

Section 2

Guideline Recommendations

Continuous support during labor should include guidelines for fetal monitoring during labor and delivery. To enhance the provision of this service, nurses among other hospital personnel should be educated on a periodic basis to reinforce their competency in providing continuous care. Electronic monitoring should be performed for at least 20 minutes until fetal wellbeing has been established. Patients who present in labor should be monitored either continuously or periodically. The study by Hodnett et al. (2005) indicates that an intermittent approach to monitoring fetal heart rate is closely linked to the increased rate of neonatal mortality and cerebral palsy. Moreover, electronic fetal monitoring has been documented to have higher rates of spontaneous vaginal birth. In case of multiple gestations, the healthcare provider or nurse should use a monitor that is capable of recording more than one fetal heart rate. This process can be reinforced with ultrasound and abdominal palpitation that allow the location of placement monitors to guarantee success in the process (NNEPQIN, 2012).

It is recommended that the healthcare organization should instill a culture of patient safety by engaging its healthcare workers in team building and self-evaluation exercises. Implementation of these two interventions has been shown to increase a sense of safety attitude and job satisfaction while at the same time improving patient outcomes (NNEPQIN, 2012). Nevertheless, teamwork in an organizational setting should be structured in a way that enhances patient safety, as opposed to disruptive interactions. Disruptive interactions refer to exchanges that interfere with individuals’ work while reducing their ability to achieve the intended patient outcomes. Glenn et al. (2014) suggest a need to address the shortages of nurses as a mitigation intervention for disruptive interactions with an expected overall increase in patient safety and outcomes. An increase in the number of nurses who provide continuous care allows nurses to focus on the demands of other healthcare professionals.

Regarding distraction via the documentation of essential information, information systems should be accurately designed in a way that positively influences patient safety and outcomes. The design should reduce the time spent by nurses in dealing with electronic records, thus allowing them to invest more quality time in their patient. Additionally, the organizations should continuously review their information systems to ensure minimal errors within the system.

Hospitals should encourage and permit women to be accompanied by a companion of their choice during childbirth. Nonetheless, the companion does not necessarily have to be a staff member. To facilitate this process, hospitals should implement programs that offer continuous support of women while in labor. In fact, concerted evidence indicates that continuous support of women during labor by midwives and nurses may not necessarily reduce the high rates of caesarean deliveries unless supplemented with other changes to the existing policies and/or routines. Surprisingly, non-staff members offer more benefits to women in labor compared to staff members. This claim supports the hypothesis of the need to eliminate barriers that emanate from the implications of continuous services by nurses such as lack of education, workloads due to inadequate staff, and lack of institutional support among others (Hodnett et al., 2005).

Efforts should be ascribed towards ensuring that women’s labor environments are non-stressful, affordable, private, respectful, and that they not allow risky routine interventions. One of the recommendations is the incorporation of companionship between nurses or healthcare providers and the laboring mothers. Furthermore, camaraderie should be accompanied with the avoidance of unproven interventions during labor such as supine position, routine starvation, and routine episiotomy. These interventions can be enhanced through the provision of educational materials regarding the subject of care during labor such as the Better Births Initiative video that is available in the World Health Organization library platform.

Concerning the ongoing research on continuous care to women during childbirth, clinical trials should be structured in a recommendable manner. For instance, attention should be paid to the outcomes on morbidity such as fecal and urinary incontinence, pain during intercourse, and depression and prolonged perineal pain to better inform care providers about the most effective models that relate to their practice settings (Hodnett et al., 2005). Barriers to the implementation of these guidelines such as the physical environment where the cost of building is increased to accommodate more childbearing women in single rooms, an increase in the number of staff members, and meeting the costs of additional people should be eliminated.

Section 3

Guideline Evaluation

Scope and Purpose

The overall objective of the guidelines is specific to the issue of providing continuous care to women during childbirth. Fetal monitoring, education of participants, and effective communication are specific in addressing the issue of patient safety and outcomes through the enhancement of teamwork, reduction of medical errors, and facilitation of the decision-making process. However, the guidelines do not specifically describe how electronic documentation can facilitate the provision of quality support and care for the patients. The guidelines also are specific concerning their application by the target population that includes nurses, patients, other healthcare providers, and the patient’s family. They describe the parties’ involvement during instruction implementation.

Stakeholder Involvement

The guidelines strongly describe how nurses, patients, other healthcare providers, and partners/companions are involved in the implementation of the guidelines. For instance, the guidelines describe the importance of partners or companions in influencing positive patient outcomes through the provision of psychosocial support. Nurses are also required to incorporate companionship, apply electronic documentation, communicate effectively, and/or ensure patient safety during their involvement in providing continuous support for women during childbirth (McDonald, 2013). However, the guidelines do not vividly describe the involvement and/or engagement of the patients in the implementation of the guidelines, thus making them passive participants.

The guidelines incorporate the preferences and views of the patients, nurses, and other staff members who are involved in the provision of a one-on-one care. For instance, many patients are described as preferring a companion to accompany them to the delivery room. They cite loneliness, emotional, and physical support as the main motivational factors. Additionally, patients claim that they prefer nurses who can communicate effectively, as opposed to those who have a solid technical background while lacking proper communication tactics. However, the guidelines fail to involve the views and preferences of the companions. This situation reveals a weakness because the companions may be unwilling to participate in continuous care during childbirth and instead cause anxiety and emotional imbalance to the patient. The target users of the guideline include patients, nurses, companions, and partners whose participation and involvement in the implementation of the guidelines is recommended.

Rigor and Development

Details of the guidelines were obtained from electronic databases such as PubMed, reviewed journal articles, and authoritative sites such as NNEPQIN. The information was searched using key words from the topic ‘continuous care during childbirth’. The articles were dated between 2000 and 2016. However, the sources were not easy to find or decipher. Therefore, they required one to critically evaluate their relevance in addressing the clinical problem. Nevertheless, adequate information regarding the recommended guidelines is replicable to the tackled research topic. The main criteria for selecting the guidelines were clearly defined. Selection of the guidelines was based on primary and secondary outcomes of patients who were exposed to continuous care together with those who had not gotten such exposure to continuous care.

The clinical guidelines possess a great deal of strengths and weaknesses concerning their implementation and applicability. With respect to strengths, the guidelines comprehensively describe their implications for practice, nursing research, the patients, and the nurses. For instance, the implementation of the guidelines by nurses, companions, patients, and hospitals favor women since they are likely to be less affected with analgesia. Besides having more service satisfaction and reduced caesarean deliveries, they also have a shorter duration of labor. All guidelines are found to be consistent with respect to improving clinical outcomes of the patients and in mitigating or eliminating negative implications for the target population. Finally, the guidelines can be deduced as applicable to addressing the clinical problem of the implications of continuous care during delivery. However, they do not directly involve or engage the patient in their implementation. As a result, they face the risk of patient resistance to care. Most of the methods recommended in implementing the guidelines are well described. For example, the guidelines describe the why, when, and how companionship can be applied to optimize patient outcomes.

The guidelines have greatly focused on the benefits, but with little consideration of the risks and/or side effects that may be accrued during their implementation. Nonetheless, there is low level of risk in relation to the biasness of the study. The recommendations are strongly linked to supporting evidence as illustrated by Hodnett et al. (2005) with special focus on primary and secondary outcomes of continuous care.

The guidelines are mainly obtained from externally reviewed journal articles prior to their publication. This criterion reinforces their authenticity in terms of applicability, feasibility, gathering feedback, and evidence dissemination. Moreover, external reviewers have been heavily involved and their views clearly described at the end of the article, ‘Continuous Support for Women during Childbirth (Review)” by Hodnett et al. (2005).

A procedure for updating the guidelines has also been provided through clinical trials with recommendation to pay particular attention to patient outcomes that are regarded as under-researched, but are responsible for significant morbidity such as fecal and urinary incontinence, depression, and prolonged perineal pain (Hodnett et al., 2005). The guidelines tackle different options that facilitate the implementation of continuous care during childbirth from education, companionship, electronic fetal monitoring, electronic documentation, and effective communication to progressive clinical trials that are more focused on neglected patient outcomes.

Applicability

The guidelines clearly describe facilitators and barriers to their application. For instance, patient safety is facilitated by the participants’ education and effective communication between the nurse, other healthcare providers, and the patient. The main barrier that is identifiable from the guidelines and that is clearly stated is biasness during blinding and selection of reporting style. Fortunately, the guidelines illustrate the authors’ judgments in curbing these barriers to achieve the overall objective. The courses of action are supported with a list of references, thus indicating and confirming their authenticity and accuracy. Moreover, additional materials such as results for randomized control trials have been provided. Hodnett et al. (2005) have amply described the potential implications of applying the guidelines to clinical practice, patient outcomes, and clinical research. The procedures present monitoring criteria through clinical outcomes with specific emphasis on patient outcomes that have been under researched, but still cause significant morbidity, depression, prolonged perineal pain, and urinary incontinence.

Editorial Independence

The expressed views are independent from influence by the authors. This observation can be deduced from the fact that the selection criteria were completely randomized while the study was blinded. Moreover, Hodnett et al. (2005) assert that in case there was a possibility of biasness in the recorded data, the outcomes obtained from the clinical trials would not have been included. Overall, the provided guidelines are of high quality. Therefore, their application by all stakeholders who are involved in providing continuous support for women during childbirth is recommendable.

Section 4

Implication of Guideline Implementation to Nursing Care and Patient Outcomes

Electronic Fetal Monitoring offers the continuous care providers with information regarding the fetus’ wellbeing, thus providing a tracing that assures the safety of the infant during and after birth. Additionally, Electronic Fetal Monitoring paves way for the setting of protocols where nurses are required to use this tool frequently. However, there exists a dilemma since this form of approach contradicts the minimalistic practice of majority of the midwives who believe that a woman should be allowed to labor as long as the baby and her are okay. As a result, few nurses may be willing to completely integrate this guideline fully into their practice (Ward, 2001).

Patient safety is central to the educational background of nursing care provider. Therefore, through the incorporation of proper education of the nurses and nursing students, incidents such as medication errors, lack of proper communication, lack of teamwork, and inadequacy in the decision-making process can be mitigated or eliminated. Medication errors encompass inaccuracies that are witnessed during patient identification. Such errors are directly linked to ineffective communication among the caregivers. To avoid this issue, all medications to the patients during childbirth should be accurately and fully reconciled. This role can be facilitated through nursing education that has been shown to reduce the incidents of adverse drug reactions because of medication errors.

Lack of effective communication among the caregivers is one of the causes of undesirable childbirth cases. According to Currie and Hughes (2008), effective, clear, timely, accurate, and complete communication improve patient safety. Effective communication involving listening, politeness, and kindness among other attributes has also been shown to positively influence patient satisfaction. Patients appreciate this factor more than the technical or capability aspect of the care providers because effective communication during labor boosted the self-esteem of the patients. On the other hand, lack or poor communication backed up by negative attitude, unfriendliness, and impatience was a major cause of patient dissatisfaction and avoidance of continuous care during childbirth (Srivastava, Avan, Rajbangshi, & Bhattacharyya, 2015). Moreover, effective communication between the nurse and other healthcare providers reduces medication errors. It also assists in giving correct and accurate diagnosis and treatment of the patient. This role is facilitated through an effective information systems technology that allows easy access to essential patients’ information regarding their medical status.

The presence of a companion of choice such as a partner during childbirth is paramount to a positive outcome for most women. However, in spite of most women in support of having a companion during labor, some preferred not to have a companion in the delivery room. Those in support cite solitude, expressive support, and physical support as the main motivational factors (Iravani, Zarean, Janghorbani, & Bahrami, 2015).Ntombana, Sindiwe, and Ntombodidi (2014) found out that women who had companions of their choice during childbirth were more comfortable, experienced reduced pain, and/or had a shorter duration of labor. Conclusively, the application of companionship in continuous care provides psychosocial benefits to the patients and nurses, thus implying a less stressful process of labor for both participants.

The implementation of proper systems of information as a priority in continuous support for women during childbirth improves patient safety and outcomes. Due to the high cost and high-risk environments of labor units, data transmission delays and failures can have dire consequences if not dealt with. As a result, hospitals have integrated an electronic health record system that facilitates accurate clinical workflow in the delivery units. Contrary to the belief that electronic record systems reduce direct patient-nurse care, EHRs improve the practice of continuous care by reducing time wastage in locating essential information, thus allowing nurses to focus more on caring the patient. Nevertheless, besides the integration of an electronic documentation system, a system should be available within the organization to provide room for the improvement of quality and accuracy of the collected and recorded perinatal information. Moreover, the design of the system should accurately address the needs of care during childbirth regarding the collection of data, storage of data, and retrieval of the stored data. The shift to an electronic record system will provide an opportunity to improve the comprehensiveness and quality of clinical documentation during labor with the overall effect of improved patient outcomes (Campbell, Li, Mori, Osterweil, & Guise, 2008).

Effective communication is complementary to teamwork among the participants and other healthcare service providers, regardless of hierarchy. Through teamwork, adverse effects and medication errors can be averted. Evaluation of research data illustrates a consistency in the correlation between lack of teamwork and reporting of medication errors and poor patient outcomes. Moreover, reports from the JACHO indicate that majority of perinatal and maternal injuries and deaths can be averted by enhancing teamwork among the stakeholders involved in providing continuous support during labor (Marzolf, 2012). An increase in the number of nurses will proportionately amplify the ability of some of the understaffed institutions to provide continuous support for patients during childbirth.

Reference List

Campbell, E., Li, H., Mori, T., Osterweil, P., & Guise, J. (2008). The impact of health information technology on work process and patient care in labor and delivery.

Carayon, P., & Gürses, A. (2005). A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units. Intensive and Critical Care Nursing, 21(5), 284-301.

Currie, L., & Hughes, R. G. (2008). Patient safety and quality: An evidence-based handbook for nurses. London: Routledge.

Glenn, L., Stocker-Schnieder, J., McCune, R., McClelland, M., & King, D. (2014). Caring nurse practice in the intrapartum setting: nurses’ perspectives on complexity, relationships and safety. Journal of Advanced Nursing, 70(9), 2019-2030.

Hodnett, E., Gates, S., Hofmeyr, G., & Sakala, C. (2005). Continuous support for women during childbirth. Birth, 32(1), 72-72.

Iravani, M., Zarean, E., Janghorbani, M., & Bahrami, M. (2015). Women’s needs and expectations during normal labor and delivery. Journal of Education and Health Promotion, 4(1), 6-6.

McDonald, S. (2013). Women who receive continuous support during labor have reduced risk of caesarean, instrumental delivery or need for analgesia compared to usual care. Evidence-based Nursing, 16(2), 40-41.

Marzolf, S. (2012). Teamwork approach in labor and delivery: Method to improve maternal and neo natal outcomes at Orotta Maternity Hospital Washington, DC: University of Washington.

Munro, J., & Jokinen, M. (2012). Evidence-based guidelines for midwifery-led care in Labor. Web.

NNEPQIN. (2012). Guideline for fetal monitoring in labor and delivery. Web.

Ntombana, R., Sindiwe, J., & Ntombodidi, T. (2014). Opinions of laboring women about companionship in labor wards. African Journal of Midwifery and Women’s Health, 8(3), 123-127.

Odent, M. (2013). Synthetic oxytocin and breastfeeding: Reasons for testing an hypothesis. Medical Hypotheses, 81(5), 889-891.

Srivastava, A., Avan, B., Rajbangshi, P., & Bhattacharyya, S. (2015). Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy & Childbirth, 15(1), 1-2.

Ward, J. (2001). Institute of midwifery, women and health. Web.

Appendix: Agree Ii Instrument

Scope and Purpose

• The overall objective(s) of the guideline is (are) specifically described

I strongly agree that the overall objective of the guidelines is specific to the issue of provision of continuous care for women during childbirth. Fetal monitoring, education of participants, effective communication are all specific in addressing the issue of patient safety and outcomes through enhancement of teamwork, reduction of medical errors, and facilitation of decision making process. However, the guidelines do not specifically describe how electronic documentation can better facilitate the provision of quality support and care for the patients.

• The clinical question(s) covered by the guideline is (are) specifically described.

Comments:I strongly disagree that the clinical questions covered by the guidelines are specifically described

• The patients to whom the guideline is meant to apply are specifically described.

I strongly agree (4) that the patients to whom the guidelines are meant to apply are specifically described in regards their benefits with specific emphasis to patient safety and patient outcomes

Stakeholder Involvement

• The guideline development group includes individuals from all the relevant professional groups.

The guidelines strongly describe how nurses, patients, other healthcare providers and partners/companions are involved in implementation of the guidelines. For instance, the guidelines describe the importance of partners or companions in influencing positive outcomes of the patients through providing psychosocial support. The nurses are also required to incorporate companionship, apply electronic documentation, communicate effectively, and ensure patient safety during their involvement in providing continuous support for women during childbirth. However, the guidelines do not vividly describe the involvement and/or engagement of the patients in the implementation of the guidelines making them passive participants.

• The patients’ views and preferences have been sought

I strongly agree (4) that the guidelines incorporate the preferences and views of the patients, nurses and other staff involved in the provision of one-to-one care. For instance, the most patients are described as preferring a companion to accompany them to the delivery room citing loneliness, emotional and physical support as the main motivational factors.

• The target users of the guideline are clearly defined

I strongly agree (4) that the target users of the guideline including patients, nurses, companions, and partners are clearly defined in their involvement in implementation of the guidelines is recommended.

Rigour of Development

• Systematic methods were used to search for evidence

I strongly agree (4) that systematic methods were used to search for evidence through using electronic databases such as PubMed and authorized sites such as WHO.

• The criteria for selecting the evidence are clearly described

I agree (3) criteria for selecting the guidelines are clearly defined. Selection of guidelines was based on primary and secondary outcomes of patients exposed to continuous care and those not exposed to continuous care.

• The strengths and limitations of the body of evidence are clearly described

I agree (3) that strengths and limitations of the body of evidence are clearly described. The clinical guidelines possess a great deal of strengths and weaknesses concerning their implementation and applicability.

• The methods used for formulating the recommendations are clearly described.

I strongly agree that the researchers clearly describe the methods they used in formulating their recommendations.

• The health benefits, side effects and risks have been considered in formulating the recommendations

I agree (3) that the health benefits, side effects and risks have been considered in formulating the recommendations. The guidelines have greatly focused on the benefits, but with little consideration of the risks and/or side effects that may be accrued during their implementation

Agree Appraisal Instrument

• There is an explicit link between the recommendations and the supporting evidence.

I strongly agree (4) that there is an explicit link between the recommendations and the supporting evidence

• The guideline has been externally reviewed by experts prior to its publication

I strongly agree (4) that the guidelines have been externally reviewed having been highlighted at the end of the article.

• A procedure for updating the guideline is provided.

I strongly agree that a procedure for updating the guidelines has been provided through recommendation of continuous clinical trials that particularly focused on patient outcomes.

Clarity and Presentation

• The recommendations are specific and unambiguous

I strongly agree (4) that the recommendations are specific in addressing the clinical problem of continuous.

• The different options for management of the condition are clearly presented

I strongly agree (4) different options of management of the condition are clearly presented and include companionship, effective communication, increased patient safety, policy formulation, effective information systems and teamwork among the healthcare workers.

• Key recommendations are easily identifiable.

I strongly agree that the recommendations can easily be identified from the guidelines and/or effectively applied in clinical practice

• The guideline is supported with tools for application

I agree (3) that the guidelines are supported with tools for application such as electronic health record systems, provision for education among the stakeholders and effective communication.

Applicability

• The potential organizational barriers in applying the recommendations have been discussed.

I strongly agree (4) that the guidelines are applicable in regards to describing the facilitators and barriers to their implementation and describe how such barriers can be curbed.

• The potential cost implications of applying the recommendations have been considered

I disagree (2) the cost implications of applying the recommendations have been considered.

• The guideline presents key review criteria for monitoring and/or audit purposes.

I agree (3) that the guidelines present key review criteria for monitoring and/or audit through performing frequent clinical trials on neglected patient outcomes with significant morbidity in regards to perineal pain, depression, urinary incontinence, among other conditions.

Editorial Independence

• The guideline is editorially independent from the funding body

I agree that the guidelines are editorially independent from the funding body because the clinical trials were based on randomized controlled blinded studies to ensure minimal risk to biasness in terms of the views of the funding body

• Conflicts of interest of guideline development members have been recorded.

I disagree (2) that the conflict of interest of guideline developmental members have been recorded.

Further Comments

• The Overall Quality of the Guideline

Overall, the guidelines provided are of high quality and would therefore recommend their application by all stakeholders involved in providing continuous support for women during childbirth.

Overall Assessment

Would you recommend these guidelines for use in practice?

• Yes
• Recommend
• (with provisos or alterations)
• With provisions
• Would not recommend
• Unsure