The image is integral to many depictions of healthcare: the nurse is at the bedside, providing the human element of care when someone is admitted to a hospital. Almost always female, traditionally holding a hand or bending over, today she is often engaged with technology, sometimes not even looking at the person in the bed.

It has been almost 40 years since Drs Klaus, Kennell, Sosa, and associates published the first article in the medical literature about the benefits of human support in labor. This publication reminded the medical world of something midwives and nurses have always known. Having someone at your side, working with you, can ease the work of labor and improve the response of mothers to their newborns. At its most basic, this is what nurses, doulas, and midwives contribute to making physiologic labor and birth a reality. Human support can decrease fear and provide reassurance in every birth, promoting a healthy partnership among the woman, her family, and the healthcare team.

In the midst of recent discussions of maternal morbidity and mortality, patient safety, and health equity, I found myself thinking about the importance of human touch for women as they give birth, and the ways in which thwart that need, whether through adherence to policies written without thought for the importance of nursing presence or through individual implicit biases about worthiness.

For most of us who work in hospital settings rather than in the home or birth center communities, the structure of work pushes back against the idea of letting women labor naturally with support. Staffing constraints pull nurses away from the bedsides of women who are experiencing normal spontaneous labors. It is considered "easier" to provide an epidural that will reduce the need for direct support. Or, the argument is made that her family can provide all the support she needs even though family members rarely have the knowledge and experience to be completely effective. Central monitors tend to pull both providers and nurses away from the bedside, as though the contractions and vital signs were all there is to the labor. Electronic medical records may indicate a delay in charting when the nurse stops to support a family first, then documents later.

Policies intended to protect those at risk of poor outcomes place technological constraints on both women and caregivers. The concept of labor and birth as an organic process, unique to each laboring woman, is hard to fit into a world where so many interventions are standards of care, where the research is picking apart risk factors and then applying them broadly, often without any sense of shared decision-making. Yes, women with medical complications may benefit from an earlier birth or from medical interventions. Yes, some women should be counseled for cesarean if their health or the fetus's health is truly at risk from labor. All too often, however, it is a one-size-fits-all approach to risk.

The institutional biases and barriers can be identified in each setting, and nurses can have an effective voice in changing the rules in ways that benefit families. But what of the internal biases we each have? I write this in humility; I cannot know how anyone who reads this has experienced birth or has worked to be with women in labor. It is not intended to be a universal reckoning. I am sure that those who have known my practice over the years could point out places where I have failed in caring.

But I hear the voice of the inner city teen who mastered physiologic labor and grinned afterward, "that wasn't as bad as they told me!" Who told her that? Why wasn't she encouraged to believe she could be as strong as she proved to be?

I think of the African American girl carrying twins who was discouraged from breastfeeding because "Those girls don't stick with it" who breastfed those 2 babies for nearly a year.

I think of the mother with HIV infection who nearly died because the care provider was reluctant to perform a needed cesarean for severe complications of late pregnancy.

I think of the women who came for care by using 2 bus routes, who were blamed for not being "on time" even though we all knew the bus schedule could not get her to the office any faster.

So here is what I know:

Start the relationship, where the woman is, not where you wish she was. Remember that she needs support, a hand to hold, praise for her success, reassurance when her imagined birth goes out the window and reality hits hard. This is true whether she is someone who looks like us or not, whether she shares one's beliefs or not.

Many of my clients have made life choices I would not have made. It is their life, not mine. But if I cannot meet her eyes, listen actively, place my hand on hers; if I cannot accept her as she is, then how could she trust me when I talk to her about labor and birth? How can she believe that when I recommend a cesarean birth, or a medication, or a transfer of care, I am making this out of respect for her needs?

It is hard to feel as rewarded by caring for someone who has lived a life that challenges our beliefs about rightness, who is not "like us." But in every birth, there is a new beginning, and that is worth fighting for. We need to see, in every pregnancy and labor, someone who wants the same outcome every pregnant woman hopes for-a good birth, a healthy child. We need to honor that with hands-on support.

-Jan M. Kriebs, MSN, CNM, FACNM

Adjunct Professor

Midwifery Institute at Jefferson

(Philadelphia University + Thomas Jefferson University)

Philadelphia, Pennsylvania