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CONTINUOUS LABOR SUPPORT EFFECT ON C-SECTION RATES
Reducing Cesarean Section Rates Through Continuous Professional Labor Support:
A Research Proposal
Moira J. Lamping
School of Nursing, Liberty University
NURS 500: Research
Dr. Donna Washburn
December 12, 2021
Author Note
I have no known conflict of interest to disclose.
Correspondence concerning this paper should be addressed to Moira Lamping, PSC
824 BOX 989 FPO, AE 09623. Email: MJLamping@liberty.edu
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Reducing Cesarean Section Rates Through Continuous Professional Labor Support: A
Research Proposal
Research Question and Design
The following study proposal will explore whether continuous professional labor support
reduces overall cesarean section rates. This author hypothesizes the following: When considering
term pregnant women in spontaneous labor, there is a reduced unplanned cesarean section rate
for those that receive continuous professional labor support compared to those that do not receive
the same support.
The proposed study methodology is quantitative in nature. “Quantitative research is
empirical, meaning that it is able to be observed and measured or counted in some way” (Gray et
al., 2017, p. 95). The key variables in this hypothesis are continuous labor support and the
unplanned cesarean section rate. Continuous labor support is the independent variable or cause.
This variable will be present in the study group and absent in the control group. The cesarean
section rate is the dependent variable or effect. The population of interest are pregnant women in
spontaneous labor at term gestation. Term gestation is defined as 37-41 weeks of pregnancy.
Spontaneous labor excludes anyone being artificially induced. Artificial induction of labor is
associated with higher cesarean section rates and could skew the results of this study. In addition,
gestation periods past 41 weeks are also associated with higher complications and cesarean
section rates and therefore could also skew the results of this study. The majority of obstetricians
in the United States do not allow their patients to go past 41 weeks due to high risk of
complications and increased rates of fetal demise.
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A quantitative quasi-experimental method for this study is proposed. Quasi-experimental
research is similar to experimental research, except that it is missing one or more attributes found
in experimental research (Gray et al., 2017, p. 102). The rationale for a quasi-experimental
design for this particular study versus an experimental design is that the two groups should not
be randomly assigned due different possible delivery histories. For example, if the groups were
randomly assigned, there is a risk that the study group could have many more nulliparous women
and the control group could have more multiparous women. Those two examples already start
out with very different cesarean section rates so it would be best for the study to ensure that the
control group and experimental group have equal numbers of nulliparous and multiparous
participants. Equalizing the groups based on previous birth histories would help to see a true
effect on cesarean rates due to the manipulation of the independent variable, which here would
be professional continuous labor support.
In order to reduce the number of external variables that could influence results,
participants would be screened to have certain characteristics. These would include no history of
prior cesarean section or abdominal surgery, no high-risk health history, normal pre-pregnancy
body mass index, spontaneous labor, normal blood pressure, current singleton pregnancy, normal
fetal anatomy, and not considered a high-risk pregnancy. Having a prior cesarean section is the
leading cause of planned cesarean sections in the United States. In a study from Mascarello et al.
(2017) it was found that “among the women who underwent a cesarean section in their first
delivery (49.47%), 87.44% had a second surgical delivery.” Prior abdominal surgeries,
depending on if the uterus or abdominal muscles were heavily involved, can also increase the
risk of a cesarean section. Certain health conditions, such as cardiac issues, where there is an
increased strain on the heart during labor, may warrant having a cesarean section. Being
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overweight poses increased risks of complications during pregnancy. Gestational diabetes and
pre-eclampsia are common complications of pregnancy that increase the need for a cesarean
section. For the purpose of this study, only participants whose blood pressures remain below
140/80 and show no other signs of pregnancy induced hypertension will be considered. Only
singleton pregnancies will be included in this study, as multiples increase the potential need for a
cesarean section depending on the position of the babies. Certain fetal deformities and conditions
increase the risk or need for a cesarean section. For the purpose of this study only normally
developing fetuses will be considered. There are many reasons that a woman may be considered
as a high-risk pregnancy. Excluding the more common issues that make a pregnancy high risk or
increase the need for a cesarean section will help to reduce the number of external factors that
could influence these results.
Once potential participants are screened and some are appropriately excluded for this
study, they will be split into two groups with equal numbers of nulliparous and multiparous
women in each group. The experimental group will be provided with professional continuous
labor support from the time they are deemed in spontaneous active labor until the time of infant
delivery. The control group will not be provided any additional support and will receive standard
care. The unplanned cesarean section rates of each group will be evaluated to see if there is a
significant statistical difference between the two groups. Ideally many different locations,
settings, races, and socio-economic statuses would be included. If the outcome is beneficial,
continuous labor support could become common place in the United States of America.
Literature Review
Throughout the country there is a growing endeavor through certain Medicaid and private care
organizations to provide non-medical care to pregnant and postpartum women via doula services
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(Kozhimannil et al., 2016). “A growing and unambiguous body of literature demonstrates
medical benefits and an increase in patient satisfaction with continuous labor support to both
mother and infant and the cost savings to be gained by the use of doulas” (Ballen & Fulcher,
2006). The position paper from Doulas of North America (DONA) International by Simkin
(2012) acknowledges that women who experience continuous labor and postpartum support
show lower birth complications, lower incidence of postpartum depression and abuse, and an
increase in self-confidence, breastfeeding rates, and overall better postpartum adjustment.
Research from Bohren et al. (2017) concurs that “continuous support during labor may improve
outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration
of labor, and decreased caesarean birth, instrumental vaginal birth, use of analgesia, use of
regional analgesia, low five-minute Apgar score and negative feelings about childbirth
experiences”. Currently there is a bill in congress, H.R. 2521, that aims to provide doula services
to pregnant women receiving healthcare from the office Veteran’s Affairs due to the promising
healthcare savings that continuous labor support may offer (United States Government, 2021).
Kozhimannil et al. (2016) acknowledges that one third of all babies born in the United States are
delivered via cesarean section, and cesarean sections cost twice as much as vaginal births.
Cesarean sections are a common surgery, but they are associated with risk, both short and long
term, that can affect both the health of the mother and her infant. It would make sense that
healthcare providers in the United States would explore all options to lower costs of their
increased obstetrical care and mental health responsibilities, which includes considering
continuous professional labor support. Despite being considered one of the leaders in healthcare,
the United States, along with many other developed and developing countries, has seen cesarean
rates continue to rise. Over the past five years the United States cesarean rate has been above 30
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percent (Martin et al., 2021). For almost 30 years the international community of healthcare has
considered the ideal cesarean section rate to be ten to fifteen percent. According to the World
Health Organization and Human Reproduction Programme’s (2015) most recent statement on
cesarean section rates, this standard is due to the fact that cesarean section rates above 10 percent
at population level have not been associated with better maternal or infant outcomes. The United
Kingdom and Ireland are experiencing rises in their cesarean rates similar to the United States. A
study done by Moran et al. (2020) discovered that “the net present value of the savings
associated with a five-percentage-point change in nulliparous {cesarean section} rates and
VBAC {vaginal birth after cesarean} rates is €1.1million and £9.8million for each successive
annual cohort of 18-year-olds in Ireland and England/Wales, respectively.” If the United States
healthcare system could implement programs or policies to reduce cesarean rates, even by a few
percentage points, that could translate into millions of dollars saved over the course of each year.
One specific intervention being considered by some state Medicaid programs and private
hospitals is continuous labor support. Continuous professional labor support is associated with
overall better outcomes to include decreased cesarean rates, fewer interventions by obstetricians,
decreased use of pain medication and epidurals, shorter labors, higher infant APGAR scores, and
increased breastfeeding initiation (Kozhimannil et al., 2016, p. 21). Professional continuous labor
support includes certified doulas, nurses, or other trained hospital staff that assist the mother
throughout the labor process. This does not include spouses or family members. A study from
Stjernholm et al. (2021) out of Sweden looked at continuous labor support on cesarean section
rates and concluded that “primiparous women who received continuous labor support by a
midwife or a nurse had shorter active labor than primiparous women who received support
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according to standard clinical routines. Continuous support was followed by a high rate of
vaginal delivery and a low rate of emergency {cesarean sections}.”
Ethical Considerations
Medical and scientific research have had a very interesting, though sometimes disturbing,
history. Numerous changes have been made to the expectations, standards, and regulations that
researchers must follow when conducting studies, especially when considering the use of human
subjects. The National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research identified three ethical principles that must always be upheld. “The
principle of respect for persons holds that persons have the right to self-determination and the
freedom to participate or not participate in research. The principle of beneficence requires the
researcher to do good and avoid causing harm. The principle of justice holds that human subjects
should be treated fairly” (Gray et al., 2017, p. 321). Study participants trust researchers to look
out for their best interests. Resnik (2018, p. 88) defines trust as “relying on a person or group of
people to act or behave ethically, professionally, competently, or skillfully.” This paper aims to
explore ethical considerations that must be addressed in the previously proposed study to
determine whether continuous professional labor support reduces unplanned cesarean section
rates in women experiencing spontaneous labor at a term gestation.
Informed Consent
The subjects of this study are going to be pregnant women in spontaneous labor.
According to Gray et al. (2017, p. 327) the U.S. DHHS identified pregnant women and human
fetuses among those that are considered to have diminished autonomy. These groups have an
equal right to be represented in medical research. The studies must be shown to have a direct
benefit to mothers and infants. Recruitment of potential subjects will be done by identifying
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obstetricians that deliver at the hospital(s) of choice. The obstetricians will identify individuals
that meet requirements to enter the study. The informed consent part of this study will take place
at the obstetrician office during the routine thirty-six-week check-up. At thirty-seven weeks the
participants will be considered term and may enter the study if they go into spontaneous labor.
Obtaining consent at hospital check -in is possible, but not ideal because the participants may be
in acute pain at that time. This author’s experience with acute labor pain does not lend itself well
to informed consent as there is limited focus and difficulty remembering what was said at the
time. It should be emphasized to potential participants that routine nursing care will not be
impacted for either group. Those placed in the study group will simply be provided an additional
individual to their care team in the form of a doula, additional nurse, or hospital trained lay
person. That individual will continuously assist the mother in labor and focus on using various
non-medical techniques to maintain the mother’s comfort and help progress labor. Labor and
delivery nurses regularly have other patients, charting, and technical duties that prevents them
from being a continuous presence at the bedside of a laboring mother. All elements of informed
consent must be met. These include competence, information, voluntariness, comprehension, and
authorization (Resnik, 2018, pp. 114–116). “US federal regulations detail the types of
information that should be included in informed consent; this is essentially information that a
reasonable person needs to know to make an informed decision about initial or ongoing research
participation” (Grady, 2017, p. 26). Potential research subjects will be given a consent form
approved by the Institutional Review Board that includes all required information to be
disclosed. This document will be in the subject’s first language. Accommodations will be made
for any vision or hearing impairment. Participants should know that they may withdraw from the
study at any time and for any reason. Their standard of care will not be compromised in any way
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regardless if they follow through with the study or not. “The right to withdraw from research
participation has been an ethical requirement since it was incorporated into the Nuremberg Code
(1949)” (Resnik, 2018, p. 144).
Participant Privacy
This study does not require the researcher to know the identities of the subjects. All
medical information may be gathered from the covered entity, which in this case are the
obstetricians providing routine prenatal care for the subjects. They will apply the safe harbor
method to all records. “Safe harbor is certifying that the 18 elements for identification have been
removed or revised to ensure the individual is not identified. The covered entity has done what it
could to make the information de-identified, but has no information whether in fact, the
individuals could still be identified” (Gray et al., 2017, p. 337). The obstetricians will assign each
record with a code in order to link the medical record to its patient in question yet keep the
individuals’ identities secure from the researcher. This method will respect the right to anonymity
and maintain confidentiality. Researchers must ensure that data is protected and used in an
appropriate manner. Study group sizes should be large, and information should undergo group
analysis so that an individual cannot be identified through their own unique medical information.
IRB Process
Each medical facility will have an entity known as the Institutional Review Board (IRB).
This may also be known as the Ethical Review Board, Ethics Committee, or something similar.
“Prior to data collection, the researcher obtains permission {from the IRB} for access to the
research setting for the duration of the study. When this has been established, the researcher then
obtains permission to collect data from human subjects, including approval of the consent form”
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(Gray et al., 2017, p. 129). Grady (2017, p. 25) further explains that “when reviewing a study, an
IRB identifies possible risks and benefits and determines whether the relationship of risks to
benefits is favorable enough that the proposed study should go forward or instead be modified or
rejected.”
Risk to Benefit Assessment
The IRB will look into a proposed study and decide if the benefits outweigh the risk
enough to warrant approval. “A risk/benefit assessment can include consideration of many types
of risks and benefits, including physical, psychological, social, economic, and legal” (Grady,
2017, p. 25). This study does not have any anticipated increased physical risks. Continuous labor
support is thought to reduce the risk of cesarean section. There may be a small amount of
psychological discomfort depending on the individual and her comfort level with having another
person in the labor room. This study aims to include all social and economic ranges of
individuals and will not exclude anyone on the basis of race, sexuality, religion, or
socioeconomic status. There is no increased anticipated legal risk. The study participant is in
complete control of what they are willing to do during their labor process. The birth assistant will
not force or coerce anyone to do something they are not comfortable with. This study is
anticipated to have a large impact on reducing unplanned cesarean sections with minimal risk.
Data Collection Methodology
Study Setting
The target population for this study includes all pregnant women in the United States at
term gestation who are eligible to have a routine vaginal delivery. “A population, sometimes
called the target population, is the entire set of subjects who are of interest to the researcher. It is
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rarely possible, or even necessary, to study the entire population of interest. Rather, it is more
likely that the researcher will study a subset of the population, called a sample” (Houser, 2016, p.
375) This study is proposed to be conducted at the Women’s Hospital of Texas in Houston. The
city of Houston was chosen because it closely reflects very similar ethnic and socio-economic
demographics compared to the United States as a whole. The Women’s Hospital of Texas
delivers ten thousand babies per year and is the busiest labor and delivery center in Texas. This
high level of delivery rate will provide thorough data from a sample that closely mirrors the
larger population. For this study the patients are naturally going to be low acuity due to the
eligibility criteria discussed in the following section. Anyone with a high-risk pregnancy will be
excluded as they have a higher chance of requiring cesarean section for medical reasons. The
standard labor and delivery ward will be the area of focus.
Sample and Sampling Procedure
Obstetricians that deliver at the Women’s Hospital of Texas will be given eligibility
criteria to identify their patients that may be eligible to enter this study. Criteria includes eighteen
to thirty-five years of age, no history of prior cesarean section or abdominal surgery, no high-risk
health history, normal pre-pregnancy body mass index, spontaneous labor, normal blood
pressure, current singleton pregnancy, normal fetal anatomy, infant in vertex position at thirty-
six-week check-up (not breech or transverse), and not considered a high-risk pregnancy for any
other reasons. The study aims to include at least two thousand individuals over the course of one
year. This is a realistic goal based on the number of deliveries that take place at the Women’s
Hospital of Texas. Based on average US percentages roughly three thousand of the ten thousand
deliveries will be by cesarean section. Once any complications, high risk pregnancies, and those
not wishing to participate are excluded, the goal number should be attainable. Two thousand
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participants provide a large enough sample for it to be representative of the greater population.
“For a sample to be representative, it must be similar to the target population in as many ways as
possible” (Gray et al., 2017, p. 622). For example, individuals of Asian heritage make up just
under six percent of the US population. In a two thousand element sample, there would be an
expectation to have about one hundred and twenty Asian elements represented. A power analysis
is not required due to the high number of elements and only two groups, but it would be helpful
to show that there is sufficient power to detect differences among the population in question.
“Statisticians consider 30 subjects the minimum number for data on a single variable to approach
a normal distribution” (Gray et al., 2017, p. 649). This study will use stratified random sampling.
“Stratified random sampling is used when the researcher knows some of the variables in the
population that are critical to achieving representativeness. Variables commonly used for
stratification are age, gender, ethnicity, socioeconomic status, diagnosis, geographical region,
type of institution, type of care, care provider, and site of care” (Gray et al., 2017, p. 634).
“Stratified random sampling is a variation on the simple random sampling technique. When the
composition of a population with respect to some characteristic important to the study is known,
the population is divided into two or more strata (groups) based on that characteristic” (Boswell
& Cannon, 2018, pp. 324–325). The sample for this study will be stratified based on whether
each element has previously delivered an infant before and their race. This will ensure equal
racial representation between the study and control groups as well as equal numbers of
multiparous and nulliparous women in each group. It should be noted that “even when the
researcher has developed a rigorous sampling plan, certain segments of the population may
refuse to participate or be unable to participate in the proposed study” (Houser, 2016, p. 381).
Data Collection
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The data collection in this study is very simple and straightforward. This is a quantitative
study and it has a direct measurement. Each element either receives an unplanned cesarean
section or they successfully deliver vaginally. The percentage in each group that delivered via
cesarean section or vaginally will be calculated. The outcomes will then be compared on whether
they received continuous professional labor support and if there is a statistical significance in
delivery method and continuous labor support. For the purpose of this study, group A will be the
study group, or the group which receives continuous professional labor support intervention.
Group B will be the control group. Group B will receive standard labor and delivery care without
additional continuous professional labor support. For outcomes, the number 1 will be assigned as
a spontaneous vaginal delivery. The number 2 will be assigned as an unplanned cesarean section
delivery. The obstetricians involved in the study will provide the appropriate data to the
researcher for each element following the delivery. Only the obstetrician will be aware of the
individual’s identity and group placement. As stated above this study will run over the course of
one year with the goal of two thousand participants.
Data Analysis Methodology
Statistical Analysis
In this study, the researcher wants to know if continuous professional labor support will
influence unplanned cesarean section rates. Prior to study submission to the Institutional Review
Board and stakeholders, a professional statistician will be consulted to ensure that the proposed
study methods will provide the desired results and thoroughly confirm or negate the hypothesis.
Adjustments will be made to the data collection and analysis based on the statistician’s referral.
“The most common parametric analysis technique used in nursing studies to test for significant
differences between two independent samples is the independent samples t-test. The samples are
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independent if the study participants in one group are unrelated to or different from the
participants in the second group” (Gray et al., 2017, p. 1076). The type of statistical procedure
that is appropriate for this experimental study would be an independent samples t-test because
the researcher will be comparing the delivery outcome of two independent groups. “The
researcher compares the outcome measures of both groups when the experiment is over to see if
there is a difference. The independent T test is the statistical procedure to use in this case since
the researcher compares two sample groups. Formally stated, this is a test of the difference
between two sample groups to see if they belong to the same population after the experimental
manipulation. It is assumed that they belong to the same population at the beginning (before the
independent variable is manipulated)” (Abbott, 2016, p. 209). Obstetricians participating in the
study will provide delivery outcomes for each element. The delivery outcomes will be compared
in each group and determined whether there is any statistical significance. See below example
table of raw data outcomes.
Group Vaginal Delivery Cesarean Delivery
G1: Continuous Professional
Labor Support (experimental group)
n1=1000
832 168
G2: Standard Labor and Delivery Support
(control group)
n2=1000
688 312
“Before entering data, a codebook should be created that describes the measurement,
coding, and scoring information for each variable as described in Chapter 20. Each variable must
be labeled in the statistical software so that the variables involved in a particular analysis are
clearly designated in the output. (Gray et al., 2017, p. 993). After all data is collected it is
imperative that the researcher provide a complete description of the sample. This may include
age, race, and delivery history among other factors. Certain patterns and observations may be
noticed by giving additional information about each group that was not necessary part of the
experiment. This may lead to discovery of additional required research questions and studies.
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The reliability of measurement methods is very straight forward for this study. Each element
either delivered via cesarean section or they delivered vaginally. Going forward additional
delivery factors could be studied such as time in active labor, whether there was any medical
assistance needed for a vaginal delivery, such as vacuum or forceps. The level of significance for
this experiment will be α = 0.05 which is standard. Data will but input to statistical software for
analyzing. For this experiment the number 1 will be assigned to vaginal delivery and 0 assigned
to cesarean section. An independent samples t-test will be performed for each group and the
outcomes compared.
Strengths and Weaknesses
The strengths of this study include simplicity in measurement, a large sample, and
inclusive ethnic and socio-economic diversity. Continuous labor and delivery support have not
been widely studied in the United States. The potential outcomes could lead to some important
changes in how the US approaches standard care in the labor and delivery setting. The outcome
of this study should be very apparent assuming the two groups are made as equal as possible
with regards to racial backgrounds, parity, general health, and maternal age. Weaknesses of this
study include possible differences in the approach of continuous labor support between
providers, underlying unknown health conditions of the mother or fetus, outside stressors placed
on the mother (familial, financial, etc.), lifestyle factors, and many other variables not
anticipated. Sometimes as much as a researcher strives to make their groups as equal as possible,
there are external factors that cannot be accounted for until all of the data is gathered and
analyzed. It is possible that the researcher may see certain populations refuse to participate in the
study so that it may not be as inclusive as was hoped.
Suggestions for Further Research
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It is recommended to have replication studies done in different populations throughout
the United States. It would be interesting to see if there was a better outcome trend in one part of
the country as compared to another. The United States is composed of many different
backgrounds and ethnicities. If the initial continuous labor support efforts are promising, it
would be beneficial to study continuous labor support in women who are experiencing more
complicated pregnancies and health conditions. Studies could be conducted to see if there are
better outcomes depending on what type of labor support is received. For example, nurses vs.
doulas vs. laypeople as the continuous labor support. Does one group have a better effect on
cesarean section rates than another? This research could produce a new specialty in healthcare
and change commonplace practices in the labor and delivery world. There are many directions to
go depending on initial study outcomes. This author is also interested in looking at birth
outcomes in countries where is it commonplace to have continuous labor support. Are their
cesarean rates lower than the United States? What other practices could influence their lower
cesarean rates? Do we have overall better birth outcomes as far as the health of the infants? Does
continuous professional labor support effect APGAR scores or initiation of breastfeeding? The
research is exciting and initial studies look promising in support of continuous labor support
benefits for all women. Further studies are in need of being conducted to show the United States
healthcare system the potential cost effectiveness of reducing cesarean section rates through
professional continuous labor support.
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