key: cord-0947704-hn7ouxmj authors: Eu, Khin‐Shwe; Chung, Carmen Diana title: Impact of suspending labour companionship during the COVID‐19 pandemic on intrapartum care and delivery outcomes date: 2022-02-22 journal: Aust N Z J Obstet Gynaecol DOI: 10.1111/ajo.13490 sha: fd1cbba17c7d0921552f68feadf614f33e1dbcd7 doc_id: 947704 cord_uid: hn7ouxmj BACKGROUND: As part of infection control measures during the COVID‐19 pandemic, labour companionship was suspended intermittently at public hospitals across Hong Kong. AIMS: The aim was to assess the impact of restricting labour companionship on intrapartum care and maternal and neonatal outcomes. MATERIALS AND METHODS: This is a retrospective cohort study comparing patients admitted for vaginal delivery with and without a labour companion. Deliveries during 1 February to 20 May and 17 July to 11 September 2020 (‘alone group’) were compared to deliveries during the same periods one year earlier when companionship was unrestricted (‘accompanied group’). Outcomes were controlled for age, parity, body mass index, birth weight, education level and induction of labour. RESULTS: There were 651 and 491 deliveries in the accompanied and alone groups, respectively. Overall, physiological maternal and neonatal outcomes were not significantly different. Neonates in the alone group were more likely to have skin‐to‐skin contact delayed beyond 60 min after delivery (odds ratio 1.48, 95% confidence interval 1.45–1.51). None of these infants were exclusively breastfed at the time of discharge. CONCLUSIONS: The presence of a labour companion may encourage earlier initiation of skin‐to‐skin contact, which has been shown to improve bonding experience. However, families that have already been affected by previous restrictions can be provided some reassurance that physiological outcomes do not appear to be significantly different. In addition, interventions that encourage companion involvement, such as breathing exercises and massages, were not hindered, as midwives took on a greater role in supporting the parturient. Suspending labour companionship during The World Health Organization 1 recommends parturients to be accompanied by a person of her choice, be it her partner, friend, doula or midwife. Continuous support during labour has been found to provide psychological benefits for mothers. For example, an Iranian study found that maternal anxiety levels were reduced when husbands were present during labour. 2 Another study found that Nepalese women felt a greater sense of self-confidence and relief from emotional distress in their husbands' presence. 3 Although several studies have shown the psychological benefits of companionship, evidence regarding the effect on the physiological aspects of labour is limited and sometimes conflicting. During Childbirth 4 found that receiving continuous support during labour was associated with more successful spontaneous vaginal deliveries, shorter duration of labour and lower chance of requiring intrapartum analgesia. Newborns whose mothers received continuous support also appeared to benefit, with higher 5-min Apgar scores. However, most of the studies included in this review had limited statistical power or were classified as 'low quality' by the authors. In addition, a large number of studies included in the review examined the effects of support from doulas, which is not entirely applicable to our setting, as doulas are not commonly employed by mothers in Hong Kong. One of the few randomised controlled trials with adequate statistical power which investigated the effects of labour companionship was conducted in Brazil. 5 The study found that parturients reported increased satisfaction when provided with support from a lay companion. However, the study did not find any statistically significant difference regarding physiological outcomes. On the contrary, a similar study conducted in a Nigerian unit found that labour companionship was associated with lower caesarean section rates and shorter duration of the active phase of labour, as well as a subjectively more satisfying labour experience. 6 A point to note with the aforementioned studies is that they were conducted in a setting where the intervention group received support in addition to the usual level of support at the hospital. To our knowledge, no studies could be identified where the main intervention was restricting the choice of companionperhaps due to the ethical issues of imposing such restrictions in a randomised controlled setting. The brief periods where labour companionship was suspended across all public hospitals in Hong Kong presented the unique opportunity to perform a natural experiment 7 to assess the physiological impacts of such an intervention on mother and infant. The aim of this study was to assess the impact of suspending labour companionship on mothers and their newborns during the COVID-19 pandemic. This includes investigating the effects on intrapartum care, delivery outcomes and neonatal outcomes. This was a retrospective cohort study comparing maternal and neonatal outcomes of deliveries which occurred with and without a birth companion at our unit. Hospital policy regarding labour companionship was continually being adapted according to the local COVID-19 disease burden at the time. Due to the unpredictable nature of the pandemic, patients and hospital staff alike could not be certain if labour companionship would be allowed until the day of delivery itself. Parturients were entered into either cohort based on whether labour companionship was suspended on their delivery date as part of citywide COVID-19 infection control restrictions, thereby representing a natural experiment. 7 All patients who delivered during the periods of 1 February to 20 May 2020 and 17 July to 11 September 2020 were recruited into the cohort who delivered without labour companions ('alone group'). Visitors were not allowed to enter any hospital wards during this period and could come in contact with the mother and her newborn child only when they were discharged from in-patient care. The control group consisted of patients who delivered during the same periods one year earlier when COVID-19 restrictions were not present and labour companionship was allowed ('accompanied group'). Labouring mothers in both cohorts were provided with continuous one-to-one support from a des- During data entry, time to initiation of skin-to-skin contact was categorised into one of three groups: within 5, 5-60 and longer than 60 min. All of the maternal and fetal outcome data in our unit are documented in the patient's physical records and later entered into the electronic OBSCIS system manually. Descriptive comparison between the two groups was assessed by Student's t-test and Fisher's test for continuous and categorical variables, respectively. Furthermore, linear regression was used to analyse continuous outcomes and logistic regression for categorical outcomes while controlling for age, parity, maternal body mass index (BMI), birth weight, education level and induction of labour to account for potential differences in patient profiles between the two groups. To reduce the chance of findings being spuriously significant, P-values were additionally adjusted by the false discovery rate (FDR). A P-value <0.05 was considered significant. This study has been approved by the Institutional Review Board of the Hong Kong East Cluster Ethics Committee (reference number: HKECREC-2020-087). There were 1756 deliveries during the study period. After the exclusion criteria were applied, 1182 were included in the study population; 1142 subjects were included in the final analysis after those with incomplete data entry (n = 40) were excluded; 651 patients delivered with a labour companion present before the COVID-19 pandemic ('accompanied group'), while 491 delivered with a companion absent during the pandemic ('alone group'). In sum, 94% (n = 1069) of the study population was of Chinese ethnicity. Overall, 56% (n = 363) of the accompanied group and 54% (n = 264) of the alone group were nulliparous. Other patient demographics are presented in Table 1 . Maternal BMI was significantly higher in the alone group (P = 0.02), although the actual difference of the mean between the two groups is 0.48 kg/m 2 and is not clinically significant. Statistical modelling for maternal and neonatal outcomes is detailed in Table 2 . Overall usage of intrapartum analgesia was similar for both groups (adjusted P = 0.99). The rate of non-pharmacological analgesia usage initially appeared to be significantly higher for the alone group (P = 0.009), but this was no longer applicable after adjusting for FDR (adjusted P = 0.052). The rate of pharmacological analge- Initial regression analysis showed rates of first-degree tear (P = 0.013) and episiotomy (P = 0.014) to be significantly different, but this was no longer applicable after adjusting for FDR (adjusted P = 0.058 for both parameters). The rates of second-, third-and fourth-degree tears were similar. The length of stay after delivery was significantly shorter for the alone group by 0.23 days (95% CI 0.11-0.35, adjusted P = 0.002). Degrees of freedom = 1133. CI, confidence interval for the estimate; NICU, neonatal intensive care unit; TENS, transcutaneous electrical nerve stimulation. †Continuous variables are summarised with mean (standard deviation) and categorical variables with n (%). ‡P-value adjusted by false discovery rate. §As the outcomes are mutually exclusive for these variables, the most favourable outcome has been used as a reference group for comparison; the estimates represent the odds of an alternative outcome occurring in comparison to the reference group. 6 Suspending labour companionship during COVID-19 Rates of meconium-stained liquor (adjusted P = 0.55), Apgar score at 1 min (adjusted P = 0.99) and at 5 min of life (adjusted P = 0.29) and rate of admission to neonatal intensive care for more than 24 h (adjusted P = 0.37) were all similar among both groups. Initiation of breastfeeding within 1 h was similar for both groups (adjusted P = 1.0), as was for the proportion of neonates being exclusively breastfed at time of discharge (adjusted P = 0.26). Neonates in the alone group were more likely to have contact delayed to beyond 60 min post-delivery (OR 1.48, 95% CI 1.45-1.51, adjusted P < 0.001). For both groups, none of the infants who received delayed skin-to-skin contact beyond 60 min were exclusively breastfed at time of discharge. Overall, the intrapartum care and delivery outcomes for both mothers and newborns did not appear to be significantly affected The significant difference in post-delivery length of stay (adjusted P = 0.002) suggests that patients in the alone group were more likely to request an earlier discharge. However, it is difficult to attribute this solely to suspension of labour companionship and may instead be more due to other pandemic-related restrictions. Patients were not allowed visitors during their hospital stay -this may have led to more mothers requesting earlier discharge from hospital so that they could receive more hands-on support at home. However, the actual difference in duration between the two groups is less than a full day (0.23 days), which does not seem clinically significant enough to cause major concern. The typical length of stay in our unit is three days for vaginal and uncomplicated instrumental deliveries and five days for caesarean delivery -there was no change in policy during the pandemic. Newborn perinatal outcomes were also not affected, as reflected by the similar Apgar scores and rate of meconium-stained liquor. Admission to the neonatal intensive care unit was also similar between the two groups, although the total number of admissions was only 86 across both groups. A larger sample size may be required to properly detect the effect on this, although initial findings can provide some reassurance to parents who have already been affected by the restrictions. Studies have shown that early skin-to-skin contact is associated with better physiological neonatal outcomes, promotes exclusive breastfeeding and supports bonding. 8 Thus, as part of the general efforts to promote exclusive breastfeeding, parturients should be allowed to be accompanied by a person of their choice to have earlier initiation of skin-to-skin contact. Due to the retrospective study design, the psychological impact on mothers unexpectedly labouring alone could not be studied. Parental satisfaction with the labour process and impact on partners absent during the labour could also be further assessed. The effect size of some outcomes with small magnitudes could not be adequately assessed as they were limited by the sample size. The sample size of the study was in turn limited by the duration of time for which COVID-19 restrictions banning labour companionship were put in place and was beyond the control of the investigators. A literature review 9 found that hospital staff sometimes expressed reservations about having a lay companion present in the labour ward, quoting concerns such as possible interference with medical decisions and risk of cross-infections. Contrary to this, our study shows that having a labour companion present does not significantly affect the physiological outcomes. This is the first study of its kind based in Hong Kong that focuses on the effects of suspending labour companionship on physiological outcomes. As there are no current plans for further suspension of labour companionship in the immediate future, this may be the only opportunity to assess how such restrictions can affect the Hong Kong population. World Health Organization. WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience The effect of presence of trained husbands beside their wives during childbirth on women's anxiety Women's experience of giving birth with their husband's support in Nepal Continuous support for women during childbirth Support to woman by a companion of her choice during childbirth: a randomized controlled trial Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: A randomised controlled trial Using natural experimental studies to guide public health action: turning the evidence-based medicine paradigm on its head Systematic review confirmed the benefits of early skin-to-skin contact but highlighted lack of studies on very and extremely preterm infants Companion of choice at birth: factors affecting implementation for their suggestions on preparing the manuscript. The authors did not receive any funding for this research.