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Why Doesn’t Every Woman Deliver With a Birth Companion?

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

The evidence on birth companions

There is strong evidence supporting the use of birth companions as providers of emotional support during labor to improve maternal and newborn health outcomes, as well as women’s experiences with maternity care. According to the World Health Organization (WHO), birth companions can play a critical role in improving women’s birth experiences:

“During labor and childbirth, many women want to be accompanied by a spouse/partner, friend, family member or another community member. Indeed, studies have shown that having a labor companion improves outcomes for women. Initiatives to increase the number of women giving birth in health care facilities, however, do not necessarily take this into consideration; often women’s preferences are not respected.”

Two of the quality statements included in WHO’s “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities” highlight the importance of offering women the choice to have a birth companion as a critical component of respectful maternity care:

  • Every woman is offered the option to experience labor and childbirth with the companion of her choice.
  • The health facility has a written, up-to-date protocol, which is explained to women and their families, to encourage all women to have at least one person of their choice, as culturally appropriate, with them during labor, childbirth and the immediate postnatal period.

The White Ribbon Alliance has also stated that having a birth companion of her choice is every woman’s right. Studies have demonstrated that birth companions improve maternal and newborn health outcomes including greater likelihood of spontaneous vaginal delivery, shorter labor duration and higher newborn Apgar scores, mitigate the heavy workloads of maternal health care providers and in some cases reduce costs to a facility. However, despite the substantial body of evidence and advocacy efforts surrounding this issue, many women across the globe do not have birth companions.

Barriers to implementation

A recent paper published in BMC Pregnancy and Childbirth reviewed factors affecting the implementation of policies and practices that encourage the use of birth companions. Below are some of the barriers identified.

Women and their families: Some women from Ghana, Saudi Arabia and Zambia were reluctant to enlist the help of lay birth companions from their communities because of potential social implications like stigma.

Health care providers: Two studies—one from Nigeria and one from Finland—reported that health care providers had negative attitudes about the importance of emotional and spiritual support during labor. In several other studies, nurses and midwives expressed concerns that incorporating lay birth support could result in women being less cooperative with hospital staff.

Health system factors: In order to implement a policy supporting birth companions, health facilities may need to allocate resources or adjust aspects of management. Considerations include physical space for lay birth companions and privacy in labor rooms.

Social and political factors: Some national and facility-level policies forbid the presence of lay companions during labor. Additionally, hiring a doula for continuous labor support may not be financially feasible for some women.

A promising future

Aside from the barriers to implementation that the authors identified, many studies reported positive views towards birth companions from women, communities, health workers and other stakeholders. Several international organizations have expressed support for birth companions as an evidence-based practice that should be scaled-up worldwide, but challenges persist. Cross-disciplinary collaboration, support from national and facility-level policymakers and additional advocacy efforts are essential to ensure that every woman has a birth companion of her choice during labor and delivery.

Read the full, open access paper, “Companion of choice at birth: Factors affecting implementation.”

Explore other posts in the Maternal Health Task Force’s Global Maternal Health Workforce blog series and access related resources.

Learn more about respectful maternity care.

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