Recently, the hospital in which I practice instituted an open visitation policy for all patients including women and girls in labor and postpartum. The patient may have as many visitors as she would like, and at any time she would like. The patient may limit the amount of visitors she has. She may also give the hospital a list of people she would prefer not to have visit her in the hospital.

This policy has been welcomed by some staff and condemned by others. Nurses are afraid that open visitation will put a burden on nursing staff and that visitors will demand nursing time, food, and other extras, taking away valuable time to be spent at the patient's bedside. Nurses also are concerned that the number of visitors at the bedside may cause dangerous barriers to the safe care of the woman and the newborn, especially in situations where quick decisions must be made and prompt movement of laboring woman or the newborn is imperative.

The evidence suggests that caregiver support for women during labor and birth not only is without risk but has tangible benefits such as decreased operative delivery rates, less need for pain medication, and greater likelihood for Apgar score of 7/10 at 1 and 5 minutes.1 Mothers who received continuous support during labor also were more satisfied with their birth experiences than those mothers who did not have a continuous support person present at the bedside.1 Taylor reviewed the Cochrane Abstract, describing randomized controlled trials of continuous support during labor and noted that in all of the trials the caregiver was female and either had given birth or was a medically trained person.1

However, evidence from the United States and other countries suggests that support and presence by those persons who are important to the laboring woman increase the satisfaction of the woman with her birth experience without introducing risk or harm to the mother or the newborn.2-4 Madi et al3 were concerned that modernization of hospital practices in Botswana has altered the traditional custom of labor support by female relatives. Their research group designed a study to see whether the traditional customs were effective and safe. Primigravidas were randomly assigned to a group without support, or to a group allowed to have the presence of a female relative during labor. The mothers who were allowed a support person had a higher frequency of vaginal births, used less analgesia, and were less likely to require pitocin augmentation.

Bondas-Salonen2 observed couples in labor in Finland and noted that even if the mother's male partner seemed distant and uncaring to the nursing staff, the mother viewed his presence as caring and present for her needs. The presence of the male partner created an experience for the woman that was expressed by her in terms of communion and strength. Kennell and McGrath5 suggest that fathers and male partners behave differently and use supportive behaviors different from those of doulas and female companions. Women tend to move closer to the laboring woman when she experiences pain while men remain stationary or even move back away from the laboring woman. However, women still appreciate the role of the father in the birthing room. Bondas-Salonen2 found that even when the laboring woman was angry with her partner, she still preferred the presence of the partner in the birthing room to that of nurses or caregivers who were not familiar to her.

Ecenroad and Zwelling4 described the movement to a family-centered care unit from a traditional maternity unit. They describe the reluctance of the nursing staff to embrace change, even though the new unit would be more family-centered and the previous model of care was more staff-centered. In a survey of patients prior to the move to a new model, the patients were found to be dissatisfied and to feel as if they had no control of their surroundings and their birth experience. Staff were described as unfriendly and bossy. Women felt that staff used the rules pertaining to visiting hours and number of visitors to control the experience of the patients.

The family encountered today is more diverse than the family of the recent past in the United States. The family we care for now may be more like the extended families of the earlier 20th century. Families may consist of female relatives only or of male partners who are not married to the woman in labor or who are not the father of the infant. Women themselves define who is important to them and who is a source of support during labor and birth. Nurses can facilitate family support and growth by recognizing the diversity of the modern family and by accepting the needs of the woman as the standard for visiting policies.

This is not to say that limits cannot be set. The role of the nurse is to provide support for the laboring woman, continually assess the mother and the fetus, and facilitate the woman's comfort as much as possible. The nurse is not at the bedside to act as a waitress, a laundress, or a gofer for the visitors. The role of the nurse can be clearly delineated for the family on admission. The family and visitors should be advised that sometimes procedure may take precedent if there is risk to the mother or to the fetus or the newborn.

Labor and birth is a hopeful and joyous occasion for families. Policies that honor the wishes of the mother for support and surroundings that make her feel safe and loved are beneficial for the mother and the infant both practically and emotionally. Nurses can strive to maintain this balance between the physical care that we provide and the respect we give to the families we serve.

Jackie Tillett, ND, CNM

Assistant Clinical Professor, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Director, Nurse-Midwifery Center, Aurora UW Medical Group, Milwaukee, Wis

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