The continuous intrapartum support provided by professional nursing staff is an intervention that favored vaginal deliveries in the active phase and decreased labor time in NTSV patients, in a statistically significant manner.
The results found exceed the rate of reduction of cesarean deliveries reported by previous studies based on interventions or programs more complex, such as the QUARISMA trial (19) (Quality of Care, Obstetrics Risk Management, and Mode of Delivery) who reduced the Caesarean rate from 23.5% to 21.8% (difference 1.7%) in low-risk women, the BASNEF model (20) reports a reduction in the cesarean rate from 60% to 25.7% (difference 34.3%), being its final rate of cesarean delivery much greater than that recommended by WHO. Even the study reported by Rosenbloom JI, et al, who proposed that the rate of cesarean delivery could be lowered by avoiding the diagnosis of arrest of dilation before 6 cm, had adverse results, with an increase in cesarean deliveries from 15.8% in 2010 to 17.7% in 2014 and the intervention to reduce both the incidence of anal sphincter tears and the cesarean delivery section rate (22) reports a decrease in the cesarean delivery rate from 17.7% to 15.0%.
Previous studies of one-to-one support have been provided by a doula and husband (28), by midwives (29), female relative (30), family members and professional staff (31).
In the study conducted by McGrant (28), nulliparous women in the third trimester were enrolled at childbirth education classes, 420 met enrollment criteria, 224 women was randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout the labor and delivery.
Together with the pregnant woman and her male partner, the doula group had a cesarean delivery rate significantly lower than the control group (13.4% vs. 25.0%, p = 0.002), and fewer women in the group of doulas received epidural analgesia (64.7% versus 76.0%, p = 0.008),
In our study, the sample size was smaller and randomization was not done due to budget issues, as well as, women did not receive educational classes for childbirth, but a more significant reduction in cesarean rates was observed (1.7% compared to 29.1% p < 0.01), and low percentages of obstetric analgesia use, 13.3% (8 of 60) for the study group and 18.2% (10 of 55), for the control group, without significant difference.
In the randomized trial reported by Kashanian et al, (29), one-to-one intrapartum support was provided by a midwife; participants were nulliparous women who had not received labor education classes in the intervention group (n = 50) , continuous support was provided during delivery, the control group (n = 50) did not receive continuous support, the number of deliveries by cesarean delivery (8% versus 24%, p = 0.026) were significantly lower in the intervention group in comparison with the control group, our study was very similar in terms of sample size and education classes were not given for delivery, however, the reduction in cesarean delivery rate was higher than that reported by Kashanian.
Khresheh (30) in her nonrandomized comparative study with 226 NTSV women, reported continuous intrapartum support provided by a female relative, without nursing knowledge, or medicine, without finding statistically significant differences between groups for mode of delivery and duration of labor, contrary to the results of the present study in which the intrapartum continuous support was provided by a professional in the health area, without any previous relationship with the patient.
The objective of Wang et al (31), in their cross-sectional study was to evaluate the benefits of the continuous support provided by family members and professional hospital staff, during delivery in China, 362 nulliparous women were included, who requested for themselves to receive continuous support or one-on-one support, with vaginal delivery and 362 nulliparous women with routine maternal care in the hospital, Wang showed that the cesarean rate was significantly lower in women with supportive care compared to women with routine maternal care in the hospital (3.3% versus 24%), an absolute risk reduction of 20.7% against 27.4%
of the present study, the main result of Wang's study was that the duration of labor in the group with delivery care was significantly lower compared with that of the group with routine hospitalization (median: 1.5 h versus 3.05 h, p <0.0001). these results were much lower than those found in the present study (median: 6.7 h versus 13.4 h) and those reported by Borhen, that of 13 studies taken into account for the duration of labor, 6 had significantly lower means in the support group and an average of 6.97 h for the groups with support and an average of 8.46 h for groups without support
An important feature of this study was to focus on the active phase (3 cm to 4 cm of dilation) until delivery, since it is the longest and the contractions of the uterus increase in frequency and are more painful, Bohren mentions that the period of support is very varied, some programs of duolas begin during pregnancy and end after three months’ post-partum, other programs begin from admission and end in childbirth.
Given the critical situation of the pregnant during the active phase, another characteristic important was that the intrapartum continuous support was given only by a trained health professional (nurse with a bachelor's degree), Bohren in the randomized clinical trials that took into account, indicated a wide variety of people who provide support, from health professionals (nurses, midwives) to friends or strangers with some or no training in labor support.
Comparing the results with other studies in general, Bohren reported that in 24 trials there were a lower probability of birth by caesarean section with an average risk ratio de 0.75 (95% CI: 0.64 to 0.88) with evidence of low quality, in this study the risk ratio was lower 0.06 (95% CI: 0.01 to 0.42), with respect to labor time, Bohren indicated a decrease in the group with support with respect to the group without support with a difference of means of -0.69 hours ((IC 95: -1.04 a - 0.34) in 13 trials, with low quality evidence, in this study we reported the median = 6.7 hours in the group with support and median = 13.4 hours in the group without support, comparing the sample size of the group with support, Bohren take into account 24 trials, with low quality evidence, reporting a median for the sample size of 150.50 (Range: 20 to 3,454) for the group with support, and with 29% of trials with samples less than or equal to 58, in the present study the sample size for group with support was of 60.
It is recommended a standardization in the operational definition of the concepts to be measured, so that the results in clinical trials are more comparable, like the Robson classification system, recommended by the WHO (4), in addition, it is recommended to carry out more randomized clinical trials, with large samples, in countries with medium and low income, focused on the active phase and with support provided by a professional nurse giving priority to humanized delivery.