CCT: continuous care trial - a randomized controlled trial of the provision of continuous care during labor by maternity care assistants in the Netherlands

Childbirth is a life-changing event for all women, resulting in various emotions. In modern society, birth often takes place in a clinical environment, which may increase feelings of loss of control and anxiety [1]. Studies show that 20% of women in high-income countries fear childbirth. These women are more likely to request an epidural or even a caesarean section [2]. Anxiety in pregnancy is associated with more interventions during birth. Randomized controlled trials have shown that women who are provided with continuous support during labor and birth need fewer medical interventions, have improved neonatal outcomes, and report a more positive childbirth experience [1]. Women benefit from informational, emotional, physical and practical support during labor [3]. A member of staff, a doula, or a lay-person from the woman’s own network may offer continuous support in the form of improved communication, the provision of coping or massage techniques, assistance with finding the right position, and help with decision-making. This kind of support has been shown to improve both women’s satisfaction with birth experience and childbirth outcomes [1, 3‐7]. Subgroup analysis in a Cochrane systematic review suggested that support was most effective when provided by someone in a (trained) doula role [1]. Both the World Health Organization and the Steering Committee for Pregnancy and Childbirth in the Netherlands have recommended the provision of continuous support during labor [1, 8], but the actual implementation of this support remains a challenge. In a pilot study conducted by the Royal Dutch Organization of Midwives, 101 of 125 participating women (80%) indicated that they wanted to receive continuous care during labor, and a reduction in both transfer to secondary care and request for pain medication was observed when this care was provided [9, 10].

In the Netherlands, midwives provide pregnancy, birth and postnatal care to healthy, low-risk women. These women can choose to give birth at home or in a hospital. Based on national guidelines [11], a risk assessment is performed for each pregnant woman during pregnancy and delivery. This risk assessment can result in transfer of care between midwife and obstetrician at any time during pregnancy or delivery. Maternity care assistants (MCAs) assist the midwife during the last part of the first stage and in the second stage of birth. For both low- and high-risk women, midwives and MCAs provide home care following hospital discharge, for the first week of the postnatal period.

Currently, the resources are not available to provide continuous care to all women during labor in routine midwifery- or obstetric-led care. In fact, continuous care is provided in less than 30% of all cases [12]. At the same time, nationwide, there has been a steep rise in the use of epidural analgesia (EA) amongst primiparous women, from 17% in 2006 to 43% in 2018. In our region, more than half of all women delivering their first baby uses EA. [12] EA is associated with transfer of care, maternal fever, an increased risk of an instrumental delivery, and admittance of the baby due to antibiotic treatment [13]. These outcomes also result in a considerable rise in costs. We hypothesize that adding MCAs to standard maternity care for the provision of continuous support during delivery will be a cost-effective intervention. We predict that any extra costs associated with providing this care will be outweighed by the savings associated with the reduction in EA use. Finally, we predict that the intervention will not decrease patient satisfaction or lead to an increase in complications.

Our study will determine whether the implementation of continuous care during labor will result in a lower use of EA - leading to fewer complications and reducing costs - without lowering women’s level of satisfaction with the birth experience.