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RESEARCH ARTICLE Open Access
Companion of choice at birth: factorsaffecting implementationTamar Kabakian-Khasholian1* and Anayda Portela2
Abstract
Background: Two recent recommendations made by the World Health Organization confirm the benefits ofcompanion of choice at birth on labour outcomes; however institutional practices and policies do not alwayssupport its implementation in different settings around the world. We conducted a review to determine factorsthat affect implementation of this intervention considering the perspectives and experiences of differentstakeholders and other institutional, systemic barriers and facilitators.
Methods: Forty one published studies were included in this review. Thirty one publications were identified from a2013 Cochrane review on the effectiveness of companion of choice at birth. We also reviewed 10 qualitative studiesconducted alongside the trials or other interventions on labour and birth companionship identified through electronicsearches. The SURE (Supporting the Use of Research Evidence) framework was used to guide the thematic analysis ofimplementation factors.
Results: Women and their families expressed appreciation for the continuous presence of a person to provide supportduring childbirth. Health care providers were concerned about the role of the companion and possible interferencewith activities in the labour ward. Allocation of resources, organization of care, facility-related constraints and culturalinclinations were identified as implementation barriers.
Conclusion: Prior to introducing companion of choice at birth, understanding providers’ attitudes and sensitizing themto the evidence is necessary. The commitment of the management of health care facilities is also required to changepolicies, including allocation of appropriate physical space that respects women’s privacy. Implementation research todevelop models for different contexts which could be scaled up would be useful, including documentation of factorsthat affected implementation and how they were addressed. Future research should also focus on documenting thecosts related to implementation, and on measuring the impact of companion of choice at birth on care-seekingbehavior for subsequent births.
Keywords: Companion of choice at birth, Continuous support during childbirth, Labour companionship, Lay companion,Doula, Implementation
BackgroundCompanion of choice at birth is defined as the continuouspresence of a support person during labour and birth [1].The intervention has been recommended by the WorldHealth Organization (WHO) to improve labour outcomesand women’s satisfaction with care [2, 3]. It has also beenidentified as a key element in the WHO vision of qualityof care for pregnant women and newborns [4]. Differentnames have been given to the intervention including
continuous support during childbirth, companion ofchoice at birth, labour companion, emotional supportduring birth. We will refer to this intervention herein ascompanion of choice at birth.Evidence for companion of choice at birth emanates
from a Cochrane systematic review conducted in 2013 [1]showing that companion of choice at birth increases thelikelihood of vaginal births, therefore reduces the need forcaesarean sections and the use of forceps or vacuum dur-ing vaginal births. In addition, it reduces the need to usepain medications during labour, it shortens the duration* Correspondence: [email protected]
1Health Promotion and Community Health Department, Faculty of HealthSciences, American University of Beirut, Beirut, LebanonFull list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 DOI 10.1186/s12884-017-1447-9
of labour and improves women’s satisfaction with care. Italso improves Apgar scores of the newborns.The Cochrane systematic review included 22 trials
involving more than 15,000 women. The trials were con-ducted in low, middle and high-income countries withconsiderable variation in hospital settings. The form ofcare evaluated was continuous presence and support dur-ing labour or labour and birth. The control group received“usual care” as defined by the study investigators that didnot involve continuous support during labour or duringlabour and birth.In the research conducted, the support person varied
from a nurse or midwife of the hospital staff to a doula,a woman not related to the labouring woman and not ahospital staff but employed through the trial to accom-pany labouring women, to a companion of choice identi-fied by the pregnant woman from her social network.The most beneficial form of support appears to be froma person who is not a member of the woman’s socialnetwork, is not hospital staff and who has some experi-ence or has received some informal training. However,in the absence of such a person, the support from aperson of choice from among the woman’s family orfriends improves women’s satisfaction with care [1].Institutional routines and policies, providers’ attitudes
as well as the physical environments of hospitals do notalways support the implementation of the intervention.Given the multiple dimensions of this intervention in-cluding variation in the delivery of the interventionaccording to the context and the provider of thesupport, there is a need for greater understanding of thefactors that influence successful implementation andsustainability of the intervention. These factors includethe perspectives, experiences, knowledge and skills ofdifferent stakeholders involved in implementation, aswell as relevant decision making processes, and barriersand facilitators within and outside of the health facility.This paper aims at a) describing stakeholder per-
spectives and experiences with the intervention; b)identifying the barriers and facilitating factors to im-plementation; and c) describing those implementationfactors which could be linked to programmes who re-ported on increased women’s satisfaction.
MethodsThis is a literature review of factors influencing imple-mentation of companions of choice at birth. It is basedon information describing the implementation of theintervention derived from trials identified through theCochrane review [1], qualitative research conductedalongside any of these trials, or studies describing healthcare providers’ attitudes towards the provision of sup-port during childbirth.
This review included 41 publications. We assessed allthe studies identified in the Cochrane review in 2013 [1]for reported information on implementation factors.These also included studies that were excluded from theCochrane review [1]. We included 31 studies in our re-view through this process:22 published articles [5–26]included in the meta-analysis of the Cochrane Review[1]and 9 excluded from it [27–35]. We excluded one ofthe trials included in the Cochrane review [1] because itwas not published in English [36]. In addition, we con-ducted electronic searches on Pubmed and Medline toidentify qualitative studies describing the experiences ofstakeholders with the implementation of companion ofchoice at birth published through March 2015. We alsosearched the bibliographies of the published trials toidentify qualitative studies on implementation factors orfeasibility of the intervention published alongside thetrials. We identified an additional 10 studies in thiscategory [37–46].No quality assessment of studies was done for this re-
view, considering that we were interested in identifyingpublications reporting on implementation factors thatwere not directly related to validity of the outcomesassessed in the trials.The first author extracted data from the publications
included in this review, and used the SURE (Supportingthe Use of Research Evidence) framework [47] to guidethe extraction and categorization of information onimplementation factors into meaningful themes. Aresearch assistant verified the coding and abstracting ofthe data. Thematic analysis was used to identify factorsthat influence implementation of the intervention as wellas different stakeholder perspectives and experiences of theintervention and contextual characteristics. To capture in-formation about the context of the implementation in thereviewed studies, we retrieved information from the dis-cussion sections. The variation in settings in these studiesbetween high, middle and low income countries allowedfor some comparison of factors in the different contexts.
ResultsThe characteristics of the studies included in this ana-lysis are presented in Table 1. Among all the reviewedstudies, only eight aimed at reporting on implementationfactors for the introduction of a companion of choice atbirth in a hospital [13, 23, 27, 32, 43–46]. The remainingstudies in this review aimed at reporting the effective-ness of the practice.All identified implementation factors are presented
in Table 2.
Stakeholders’ perspectivesStudies mainly reported on the experiences and perspec-tives of women and health care providers. Receiving
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 2 of 13
Table
1Tableof
characteristicsof
includ
edstud
iesforcompanion
ofchoice
atbirth
Stud
yStud
yde
sign
Setting
Descriptio
nof
Interven
tion
Specificstud
you
tcom
esconsidered
inthisreview
1Alexand
eret
al.,2014
Mixed
-metho
dsstud
yGhana
Nointerven
tion
Wom
en’sview
sabou
tsocialsupp
ort
durin
gchildbirth
2Al-M
ande
elet
al.,2013
Prospe
ctivecoho
rtstud
yKing
dom
ofSaud
iArabia
Nointerven
tion
Wom
en’spreferen
cesand
attitud
estowards
companion
sdu
ringchildbirth
3Band
aet
al.,2010
Pre-po
stinterven
tion
survey
Malaw
iSupp
ortdu
ringlabo
urby
laycompanion
sarriving
attheho
spitalw
ithlabo
uringwom
enwas
introd
uced
intheho
spital.
Wom
en’sexpe
riences
4Breartet
al.,1992
RCT
Belgium,France,Greece
Perm
anen
tpresen
ceof
amidwife
comparedto
varyingde
greesof
presen
ce.Fathe
rswereallowed
tobe
presen
t
5Brug
germ
anet
al.,2007
RCT
Brazil
Supp
ortwas
‘presenceof
achosen
companion
durin
glabo
urandde
livery’.C
ompanion
sreceived
verbalandwritteninform
ationto
orient
ontheir
role.In47.6%
ofthesamplethewom
an’s
companion
was
herpartne
r,for29.5%
itwas
her
mothe
r.Thecontrolg
roup
received
care
whe
rea
companion
durin
glabo
urandbirthwas
not
perm
itted
.
Satisfactionwith
labo
urandde
livery
6Brow
net
al.,2007
RCT
SouthAfrica
Hospitalsin
theinterven
tiongrou
pweregiven
training
andaccess
totheWHOReprod
uctive
Health
Library.Amultid
imen
sion
aled
ucational
packagewas
implem
entedat
theinterven
tion
hospitalsover
2mon
ths
7Cam
pbelletal.,2006
RCT
USA
Con
tinuo
ussupp
ortby
anadditio
nalsup
port
person
(dou
lagrou
p),w
ascomparedwith
wom
enwho
didno
thave
thisadditio
nalsup
portpe
rson
(con
trol
grou
p).The
doulagrou
phadtw
otw
o-ho
urorientationsessions
abou
tlabo
ursupp
ort.Con
trol
grou
phadsupp
ortpe
opleof
theirow
nchoo
sing
.
8Cam
pbelletal.,2007
RCT
USA
Sametrialasabovebu
tthissecond
aryanalysis
focusedon
maternalp
erceptions
ofinfant,self
andsupp
ortfro
mothe
rsat
6–8weeks
postpartum
.
Satisfactionwith
care
9Cam
pero
etal.,1998
Qualitativepo
stpartum
interviews
Mexico
Mothe
rsreceivepsycho
socialsupp
ortfro
mado
ula,
comparedwith
wom
enwith
outado
ula,who
gave
birthfollowingno
rmalho
spitalrou
tine.In
the
form
ergrou
p,do
ulas
wereincorporated
into
the
labo
urandde
liveryroom
sandintrod
uced
toph
ysicians
andnu
rses,and
theirrespon
sibilitiesin
accompanyingthepreg
nant
wom
enwereexplaine
dto
hospitalstaff.
Mothe
r’sview
oftheirexpe
rience
10Cog
anet
al.,1988
RCT
USA
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 3 of 13
Table
1Tableof
characteristicsof
includ
edstud
iesforcompanion
ofchoice
atbirth(Con
tinued)
Supp
ortprovided
byaLamazechildbirthprep
aration
instructor.Sup
portinclud
edcontinuo
uspresen
ce,
actin
gas
aliaison
with
hospitalstaff,providing
inform
ation,andteaching
relaxatio
nandbreathing
measuresto
thewom
anandapresen
tfamily
mem
ber.Usualcare:intermitten
tnu
rsingcare.Fam
ilymem
berswereallowed
tobe
presen
t.
11Dickinson
etal.,2002
RCT
Australia
Group
1–con
tinuo
usph
ysicalandem
otional
supp
ortby
midwifery
staff,andwom
enwere
encouraged
managetheirlabo
urwith
theassistance
ofamidwife
with
theintentionof
avoiding
epidural
analge
sia.Group
2–con
tinuo
usmidwifery
supp
ort
was
notprovided
andwom
enwereen
couraged
tohave
epiduralanalge
siaas
theirprim
arymetho
dof
pain
reliefin
labo
urThewom
enin
each
ofthetw
ogrou
pswereat
liberty
tochoo
sean
alternativeform
ofanalge
siaat
anytim
e.
12Dickinson
etal.,2003
RCTandpo
stsurvey
Australia
Sameinterven
tionandcontrolg
roup
asabovebu
tpo
stsurvey
cond
ucted6mon
thspo
stpartum
The
wom
enin
both
grou
pswereat
liberty
tochoo
sean
alternativeform
ofanalge
siaat
anytim
e.
Maternalsatisfactionof
childbirth
13El-Nem
eret
l,2006
Qualitative
Egypt
Nointerven
tion
Wom
en’sexpe
riences
ofho
spital
care
14Gagno
net
al.,1997
RCT
Canada
Interven
tiongrou
p:1-to-1
care
consistin
gof
anu
rse
durin
glabo
urandbirthwho
provided
emotional
supp
ort,ph
ysicalcomfort,and
instructionfor
relaxatio
nandcoping
techniqu
es.C
arewas
provided
byon
-calln
urseswho
werehiredspecifically
forthe
stud
yandhadreceived
a30-h
training
prog
ram
and
quarterly
refre
sher
worksho
ps.Traininginclud
edcriticalreviewsof
theliteratureconcerning
theeffects
oftheintrapartum
med
icalandnu
rsingpractices,as
wellasdiscussion
sof
stress
andpain
managem
ent
techniqu
es.C
ontrol
grou
preceived
usualn
ursing
care
bytheregu
larun
itstaff,consistin
gof
interm
itten
tsupp
ortandmon
itorin
g.
15Gagno
net
al.,1999
Second
aryanalysisof
RCT
Canada
Sameinterven
tionandcontrolg
roup
sas
above
16Gordo
net
al.,1999
RCT
USA
Supp
ortprovided
byatraine
ddo
ula.Thecontrol
grou
preceived
“usualcare”which
didno
tinclud
ethesupp
ortof
ado
ula.Thepartne
rwas
presen
tin
80%
ofallb
irthinclud
edin
thestud
y.
Mothe
rs’evaluations
oftheir
expe
riences
17Hem
minkiet
al.,1990
RCT
Finland
Repo
rtson
apilotstud
ywith
supp
ortprovided
bylaywom
anto
labo
uringwom
enarrivingto
one
hospitalw
ithou
ttheirmalepartne
rs.Rep
ortsalso
onthreetrialstesting1:1supp
ortby
midwifery
stud
ents
Mothe
rs’evaluations
oftheir
expe
riences
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 4 of 13
Table
1Tableof
characteristicsof
includ
edstud
iesforcompanion
ofchoice
atbirth(Con
tinued)
from
enrolm
entun
tiltransfer
tothepo
stpartum
ward.
Themidwifery
stud
entsvolunteered,
wereno
tspecially
traine
din
supp
ortandrespon
sibleforthe
othe
rroutineintrapartum
care.The
controlg
roup
was
‘cared
foraccordingto
theno
rmalroutineof
the
midwife
andby
amed
icalstud
ent,ifs(he
)was
ondu
ty’.Over70%
offatherswerepresen
t.
18Hod
nettet
al.,1989
RCT,stratifiedby
type
ofpren
atalclasses(Lam
azevs
gene
ral)
Canada
Supp
ortprovided
byacommun
ity‘lay’midwife
ormidwifery
appren
ticeandinclud
edph
ysicalcomfort
measures,continuo
uspresen
ce,information,
emotionalsup
port,and
advocacy.The
controlg
roup
received
usualh
ospitalcarewhich
includ
esthe
interm
itten
tpresen
ceof
anu
rse.Allbu
t1wom
analso
hadhu
sbands
orpartne
rspresen
tdu
ringlabo
ur.
Supp
ortbe
ganin
early
labo
urat
homeor
inho
spital
andcontinuedthroug
hde
livery.
Wom
en’spe
rceivedcontrold
uring
childbirth
19Hod
nettet
al.,2002
Multi-centre
RCTwith
prog
nostic
stratificationforp
arity
andho
spital
Canada,USA
Con
tinuo
ussupp
ortfro
mstafflabo
urandde
livery
nurses
who
hadvolunteeredandreceived
a2-day
training
worksho
pin
labo
ursupp
ort.Thenu
rses
with
training
werepartof
theregu
larstaffingcomplem
ent
oftheun
it.Con
trol
grou
preceived
interm
itten
tsupp
ortfro
manu
rsewho
hadno
treceived
labo
ursupp
ort
training
Birthexpe
rienceandfuture
preferen
cesforlabo
ursupp
ort
20Hofmeyret
al.,1991
RCT
SouthAfrica
Supp
ortby
carefully
traine
d,volunteerlaywom
en,
forat
leastseveralh
ours(sup
portersno
texpe
cted
toremainafterdark).Con
trol
grou
preceived
interm
itten
tcare
onabu
syward.
Husband
s/family
mem
berswere
notpe
rmitted
Mothe
rs’p
erceptions
oflabo
ur
21Kabakian-Khasholianet
al.,2015
Qualitative
Egypt,Lebano
n,Syria
Nointerven
tion
Wom
en’sandhe
alth
care
providers
percep
tions
abou
tlabo
urcompanion
ship
22Kashanianet
al.,2010
RCT
Iran
Supp
ortprovided
byan
expe
rienced
midwife
inan
isolated
room
.Midwife-ledsupp
ortinclud
edclose
physicalproxim
ity,tou
ch,and
eyecontactwith
the
labo
uringwom
en,and
teaching
,reassurance,and
encouragem
ent.Themidwife
remaine
dwith
the
wom
anthroug
hout
labo
urandde
livery,andapplied
warm
orcold
packsto
thewom
an’sback,abd
omen
,or
othe
rpartsof
thebo
dy,aswellaspe
rform
ing
massage
accordingto
each
wom
an’srequ
est.
Con
trol
grou
pinclud
edwom
enadmitted
tothe
labo
urward(whe
re5–7wom
enlabo
urin
thesame
room
),didno
treceivecontinuo
ussupp
ort,and
followed
the
routineorde
rsof
theward.
They
didno
thave
aprivateroom
,did
notreceiveon
e-to-one
care,w
ere
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 5 of 13
Table
1Tableof
characteristicsof
includ
edstud
iesforcompanion
ofchoice
atbirth(Con
tinued)
notpe
rmitted
food
,and
didno
treceiveed
ucation
andexplanationabou
tthelabo
urprocess.Theon
lype
rson
sallowed
inthede
liveryroom
werenu
rses,
midwives,and
doctors.’
23Kenn
elet
al.,1991
RCT+retrospe
ctiveno
n-rand
omcontrolg
roup
USA
Con
tinuo
ussupp
ortprovided
byatraine
ddo
ula
durin
glabo
urandbirth.Observedgrou
preceived
theroutineinterm
itten
tpresen
ceof
anu
rseand
continuo
uspresen
ceof
an‘inconspicuou
sob
server’
who
‘kep
tarecord
ofstaffcontact,
interactionandproced
ures’.Theob
server
was
away
from
thebe
dsideandne
verspoketo
thelabo
uring
wom
an.A
retrospe
ctiveno
n-rand
omcontrolg
roup
was
used
.
24Klauset
al.,1986
RCT
Guatemala
Con
tinuo
usem
otionaland
physicalsupp
ortby
alay
doulawith
noob
stetric
training
.Con
trol
grou
p:usualh
ospitalrou
tines
(described
asno
consistent
supp
ort)
25Ko
pplin
etal.,2000
RCT
Chile
Psycho
socialsupp
ortdu
ringlabo
urfro
macompanion
chosen
bythepregnant
wom
an.The
companion
swere
trainedby
trialstaffto
provideem
otionalsup
port,
prom
oteph
ysicalcomfortandencourageprog
ressof
labo
ur,w
ithou
tinterferingwith
theactivities
ofthe
obstetricians
ormidwives.Theywerewith
thelabo
uring
wom
ancontinuo
uslyfro
madmissionto
delivery.Wom
enwereencouraged
topick
acompanion
who
had
experienced
avaginalbirth.Co
ntrolgroup
didno
thave
companion
.Bothgrou
pslabo
ured
inaroom
with
otherw
omen
where
curtains
werepu
lledforp
rivacy
Expe
riencewith
childbirth
26Ku
mbani
etal.,2013
Qualitative
Malaw
iNointerven
tion
Wom
en’spe
rcep
tionof
perin
atalcare
27Lang
eret
al.,1998
RCT
Mexico
Con
tinuo
ussupp
ortfro
m1of
10retired
nurses
who
hadreceived
doulatraining
throug
hout
labo
ur,b
irth,
andtheim
med
iate
postpartum
perio
d.Supp
ortinclud
edem
otionalsup
port,information,
physicalcomfortmeasures,socialcommun
ication,
ensurin
gim
med
iate
contactbe
tweenmothe
rand
baby
afterbirth,andofferin
gadvice
abou
tbreastfeed
ingdu
ringasing
lebriefsessionpo
stnatal.
Con
trol
grou
p:wom
enreceived
‘routinecare’.
Satisfaction
28Lind
owet
al.,1998
RCT
SouthAfrica
Theinterven
tiongrou
preceived
oxytocin
followed
byroutinemon
itorin
gby
labo
urwardmidwives
inadditio
nto
thepresen
ceof
asupp
ortpe
rson
for1h.
Thesupp
ortpe
rson
swerefro
mam
ongtheho
spital
cleaning
stafffro
mthesameracialandlingu
istic
grou
pas
thewom
an.The
yprovided
encouragem
ent.
Thecontrolg
roup
received
oxytocin
androutine
mon
itorin
gof
labo
urwardmidwives.
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 6 of 13
Table
1Tableof
characteristicsof
includ
edstud
iesforcompanion
ofchoice
atbirth(Con
tinued)
29Madietal.,1999
RCT
Botswana
Con
tinuo
uspresen
ceof
afemalerelative(usuallyhe
rmothe
r)in
additio
nto
usualh
ospitalcare
Con
trol
grou
p:usualh
ospitalcare,which
involved
staff:patient
ratio
sof
1:4,andno
companion
spe
rmitted
durin
glabo
ur
30Maimbo
lwaet
al.,2001
Mixed
-metho
dsZambia
Nointerven
tion
Wom
en’sandhe
alth
care
providers
perspe
ctives
abou
tlabo
urcompanion
ship
inho
spitals.
31Manning
-Orenstein,1998
Non
-rando
mized
interven
tion
USA
Wom
enchosebe
tweenado
ulasupp
ortgrou
por
aLamazebirthprep
arationgrou
p.
32McG
rath
etal.,2008
RCT
USA
Supp
ortconsistedof
ado
ulawho
met
thecoup
leor
wom
anat
theho
spitalassoon
aspo
ssibleafter
Rand
omassign
men
t(typicallywith
inan
hour
oftheir
arrivalat
theho
spital)andremaine
dwith
them
throug
hout
labo
urandde
livery.Dou
lasupp
ort
includ
edcontinuo
usbe
dsidepresen
cedu
ringlabo
urandde
livery,althou
ghhe
rspecificactivities
were
individu
alised
tothene
edsof
thelabo
uringwom
an.
Other
supp
ortinclud
edcloseph
ysicalproxim
ity,
touch,andeyecontactwith
thelabo
uringwom
an,
andteaching
,reassurance,and
encouragem
entof
thewom
anandhe
rmalepartne
r.Alldo
ulas
completed
training
requ
iremen
tsthat
were
equivalent
totheDONAInternationald
oula
certificatio
nCon
trol
grou
p:routineob
stetric
and
nursingcare
which
includ
edthepresen
ceof
amale
partne
ror
othe
rsupp
ortpe
rson
Perceivedexpe
riencewith
thedo
ula
33McG
rath
etal.,1999
RCT
USA
TheEpiduralgrou
preceived
epiduralanalge
sia,the
controlg
roup
received
narcoticmed
icationfollowed
byep
iduralanalge
siaifne
cessary.Thedo
ulagrou
preceived
continuo
usdo
ulasupp
ortwith
narcoticor
epiduralanalge
siaifne
cessary.
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 7 of 13
Table
2Accep
tability,approp
riatene
ssandfeasibility
ofcompanion
ofchoice
atbirth
Level
Factorsaffectingim
plem
entatio
nStud
ies
Wom
enandtheirfamilies
a.In
gene
ral,wom
enandtheirmalepartne
rs,w
henpresen
t,appreciatedthepresen
ceof
asupp
ort
person
with
them
,whe
ther
that
person
was
ado
ulaor
astud
entnu
rse.
a.McG
rath
&Kenn
ell,2008;H
emminki,1990;
Hod
nettet
al.,2002
b.Wom
enhadlow
expe
ctationin
thequ
ality
ofcare,the
yandtheirfamilies
repo
rted
expe
riencing
badtreatm
entat
theho
spital.
b.Brow
net
al.,2007;M
adietal.,1999;Kabakian-
Khasho
lianet
al.,2015.
c.Wom
enexpressedsomereservations
abou
tlayfemalecompanion
sfro
mthecommun
ityin
the
form
offear
ofbe
ingexpo
sedto
thecompanion
andtheconseq
uent
gossip
expe
cted
inthe
commun
ity,the
refore
aworry
tokeep
upwith
socialexpe
ctations.
c.Al-M
ande
elet
al.,2013;M
aimbo
lwaet
al.,2001;
Alexand
reet
al.,2013.
d.Layfemalecompanion
swho
wereno
trelatedto
wom
enwereview
edas
anallywith
nointerest
intheho
spitalsystem
andeasy
tocommun
icatewith
.d.
Hofmeyer
etal.,1991;C
ampb
elletal.,2007
e.Malepartne
rspresen
cewas
appreciatedforprovidingem
otionaland
spiritualreassuranceto
wom
enandto
witn
essthechalleng
esof
childbirthen
duredby
wom
enho
wever,the
ywereview
edas
unskilled
,not
usually
presen
tthroug
hout
labo
randless
interactivecomparedto
female
companion
s.Wom
enfeared
that
theirmalepartne
rscouldno
thand
letheprocessof
labo
urand
birth.In
somecultu
res,thepresen
ceof
themalepartne
rsisno
tsociallyacceptable.
e.Kenn
elletal.,1991;M
cGrath
andKenn
ell,2008;
Morhason-Bello
etal.,2009;Scottet
al.,1999;
Mosallam
etal.,2004;Kabakian-Kh
asho
lianet
al.,
2015;Q
ianet
al.,2001;A
lexand
reet
al.,2013.
Health
care
providers
a.Health
care
providerswerefoun
dto
lack
thepo
sitiveattitud
esof
providingem
otionaland
spiritualsupp
ortas
labo
ursupp
ortwas
notconsidered
aprofession
altask.
a.Hem
minkiet
al.,1990;M
orhason-Bello
etal.,2009
b.Nurse
andmidwives
sometim
eswereappreh
ensive
abou
tthepresen
ceof
asupp
ortpe
rson
and
notqu
itesure
abou
ttheeffect
onthecoop
erationof
wom
enwith
thestaffor
theskillsof
thelay
person
ortheirfear
from
theuseof
tradition
almed
icine.
b.Band
aet
al.,2010;M
aimbo
lwaet
al.,2001;C
ogan
&Spinnato,1988;Hem
minkiet
al.,1990;
Qianet
al.,2001.
c.Thepresen
ceof
thelaycompanion
was
view
edpo
sitivelyin
redu
cing
thede
pend
ency
onthe
overloaded
staff.Providerswerepe
rceivedto
befrien
dlierin
thepresen
ceof
thecompanion
.c.Madietal.,1999;Brugg
eman
etal.,2007;
Maimbo
lwaet
al.,2001
d.Health
care
providersshou
ldbe
inform
edof
theeviden
ceandmotived
bythehigh
patient
satisfactionwith
theim
plem
entatio
nof
thispractice.
d.Brug
geman
etal.,2007;C
ampb
elletal.,2006
Other
stakeh
olde
rsCom
mun
ityagen
cies
includ
inglocalh
ealth
departmen
tsandhe
alth
care
providerscanactas
asource
ofinform
ationfordo
ulas.
Cam
pbelletal.,2007
Health
system
factors
a.Thepresen
ceof
thecompanion
durin
gchildbirthmight
improveaccessibility
tohe
alth
services
insubseq
uent
births
throug
htheredu
ctionof
thene
gativeeffectsof
theho
spitalenviro
nmen
tin
term
sof
redu
cing
thefeelings
ofbe
ingleftalon
e,insecurityandne
glect.
a.Lang
eret
al.,1998;M
aimbo
lwaet
al.,2001;
Kumbani
etal.,2013
b.Iden
tifiedim
plications
onhu
man
resourcesinclud
e:fre
eing
thetim
eof
nurses
andmidwives
thus
improvingqu
ality
ofcare,organizationat
thewardto
change
shift
for
b.Madietal.,1999;Yuenyon
get
al.,2012;
Brow
net
al.,2007;M
aimbo
lwaet
al.,2001;
Scottet
al.,1999;G
ordo
net
al.,1999
c.nu
rses
andmidwives,the
availabilityof
thedo
ulaearly
durin
glabo
ur.
c.Lang
eret
al.,1998;Kashanian
etal.,2010;
Band
aet
al.,2010;Kabakian-Kh
asho
lianet
al.,2015,
Cam
pbelletal.,2007;Q
ianet
al.,2001
d.Training
andhirin
gof
nurses
ormidwives
asdo
ulas
couldbe
considered
insomesettings.C
lear
commun
icationandsometraining
abou
tthedu
tiesof
thelaycompanion
areexpe
cted
inothe
rs.
Retired
nurses
hiredas
companion
scouldbe
desensitizedto
wom
en’sne
eds.
d.Yu
engyon
get
al.,2012;Brownet
al.,2007;Kabakian-
Khasho
lianet
al.,2015,M
aimbo
lwaet
al.2001;
Qianet
al.,2001.
e.Someim
plications
onfacilitiesinclud
e:availabilityof
loun
gesforlaycompanion
sshortbreaks,
privacyin
labo
urroom
s,spaceforcompanion
sin
labo
urroom
s.
Socialandpo
liticalfactors
a.Chang
esto
natio
nal,stateor
hospitalp
oliciesagainsthaving
laycompanion
sdu
ringchildbirth
might
bene
cessary.
a.Madietal.,1999;Kabakian-Kh
asho
lianet
al.,2015;
Yuen
gyon
get
al.,2012;Brownet
al.,2007
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 8 of 13
Table
2Accep
tability,approp
riatene
ssandfeasibility
ofcompanion
ofchoice
atbirth(Con
tinued)
b.Thecostof
hirin
gado
ulaor
thetransportatio
nne
edto
beconsidered
,how
ever
inge
neral,
having
alaycompanion
orado
ulaislikelyto
resultin
overallred
uctio
nof
costsin
obstetric
interven
tions
andcomplications.
b.Madietal.,1999;C
ampb
elletal.,2007;
Brow
net
al.,2007;Scottet
al.,1999;G
ordo
net
al.,1999
c.Sustainabilityisbe
lievedto
resultfro
mpo
liticalcommitm
entat
thestateandho
spitallevel
andfro
mraisingpu
blicaw
aren
ess.
c.Brow
net
al.,2007
Categ
oriesad
aptedfrom
:The
SURE
Collabo
ratio
n,20
11
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 9 of 13
support by a companion of choice at birth was reportedas a positive experience that was largely appreciated bywomen, and when present, by their male partners [13–15]. In three other studies, the presence of the compan-ion was experienced as a buffer to women’s and theirfamilies’ low expectations and experiences of bad treat-ment at hospitals [16, 27, 43].In some close-knit communities, where most people
knew each other, women were reserved about the pres-ence of doulas recruited from their same community orthe presence of a female family member with them dur-ing childbirth [39, 42, 45]. They expressed their worriesof being exposed to the companion and the consequentexpected gossip in the community about them not beingable to keep up with social expectations of behaviour,such as not losing control and not shouting. This is incontrast to another low-income community where layfemale companions were regarded as allies not investedin the hospital system and their presence was appreci-ated [17].In three studies conducted in high-income countries
and one from a low-income setting, the presence of a fe-male companion was perceived to be beneficial in additionto the presence of male partners. Despite the fact thatmale partners were appreciated for providing emotionaland spiritual reassurance, women perceived them as lack-ing the skills needed for other aspects of support neces-sary to them [14, 18, 32, 45] as well as not coping wellwith seeing women go through labour and birth [45]. Bothin low and high income country settings, male partnerswere found to be not consistently present throughoutlabour, they were mainly absent in early and late labourand were viewed as being less physically interactive com-pared to female companions [32, 45]. In conservative cul-tures, such as in Arab countries, in Ghana, and in China,women sometimes appreciated the presence of the malepartner to witness the challenges that women go throughduring childbirth [43–45]. In Arab cultures, the presenceof the male partners was not socially acceptable especiallyin shared labour rooms [40, 43].The attitudes of health care providers involved in the
intervention were sometimes positive as they perceivedthe presence of the companion helpful in reducing thedependency of women on the staff. This was mainly im-portant in settings with shortage of nursing and midwif-ery staff [16, 21, 39]. The presence of the companionwas noted to positively influence the behaviour of thestaff towards women [21]. Some studies reported nega-tive attitudes and some resistance in acceptance of com-panions to labour wards [13, 20, 39, 44, 46]. Nurses andmidwives reported their doubts about the role of thecompanion and expected less cooperation of womenwith the staff throughout labour and birth in the pres-ence of the companion [13, 20, 39, 44, 46]. Concerns
were reported about the use of traditional medicines bylay companions [39]. Providers also reported concernsabout companions who are not part of the hospital staff,interfering in medical decisions and about cross infec-tions in the labour and delivery ward [39, 43, 44]. Effortssuch as influencing the attitudes of health care providersby informing them about the evidence on companion ofchoice at birth and motivating them by sharing positivebirth experiences are considered to be necessary for thesuccessful implementation of this practice [21, 22].
Barriers and facilitating factors for implementationA number of health service-related barriers and facilitat-ing factors were identified in the implementation ofcompanion of choice at birth in hospital settings. Thesevaried according to resources available in the facility andto the people providing support. Whereas having a fe-male relative as a companion is considered a low costintervention that is valued in facilities with shortage ofnursing staff [16, 25, 39], the task of providing continu-ous support by nurses and midwives of the hospital wasreported to intensify the human resource shortages [39]or had implications on the organization of shifts at thelabour ward [27]. Where doulas were considered aslabour or birth companions, their arrival to the labourward early during labour was deemed necessary, for ex-ample before the woman had taken the decision to askfor an epidural [28].The presence of an accompanying person was also
found to have implications for the organization of spacein the facility. In low or middle income country hospi-tals, a lounge near the labour ward was deemed neces-sary for companions to take short breaks [25]; in othersproviding a private space or a cubicle for the dyad of thelabouring women and her companion was considered tobe important for the success of the intervention [27, 39,43, 44]. Crowding of shared labour rooms was a majorconcern in resource-constrained facilities [16, 43].In facilities with shortage of nurses or midwives, the pos-
sibility of hiring and training unemployed or retired nursesand midwives was suggested [24, 26, 45] as well as trainingof lay companions [22, 43, 45] or doulas [23]. Clear com-munication with the companion about his/her duties wasdeemed necessary to reduce the negative providers’ percep-tions about the role of the companion [43, 46].Although none of the reviewed studies reported cost
analysis, there were some discussion on expected costimplications in few of these studies. In high-incomecountries and among high-income populations, it is ex-pected that the cost of hiring a doula will be covered bywomen themselves as very few hospital-based pro-grammes offer that option [22]. In low-income settings,the involvement of family members as companions dur-ing childbirth is an inexpensive practice [16] however,
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 10 of 13
the cost of transportation for volunteer companionsneed to be considered to sustain the programme at thefacility [27]. In general, it is expected that the beneficialeffect of a companion of choice at birth would be cost-effective for healthcare insurers and for hospitals as itreduces the financial costs of obstetric interventionssuch as epidural use and cesarean sections and the timespent on complications [16, 32].
DiscussionWomen reported positive experiences with having acompanion of choice at birth across the different facilitysettings and country-income levels in the reviewed stud-ies, regardless of the person providing the support. In fa-cilities where male partners’ presence was accepted inaddition to the female companion, an added value of thefemale companion was reported. Whereas the evidenceindicates that companion of choice at birth is mostly aneffective intervention when provided by persons who arenot employed by the hospital [2], considerations shouldbe given to the acceptance of doulas or family membersin each cultural context as well as to the entailed costsfor training or transportation.We note the importance of the person providing the
support in terms of increased women’s satisfaction withthe birth experience. Only four studies reported on thisoutcome [7, 21, 23, 24]. Two studies that included layfemale relatives of labouring women as companionsreported an increased satisfaction of women duringchildbirth [21, 23]. The effectiveness of the interventionwas attributed by the authors to the fact that the com-panions were related to women therefore more in tunewith women’s needs [23] and to the positive influence oftheir presence on health care providers’ behaviours interms of sharing of information related to the care givento the labouring woman [21]. Another study showing anincrease in women’s satisfaction also reported theprovision of information as a positive factor influencingwomen’s satisfaction, however in this case the supportduring childbirth was provided by midwives [7]. Onetrial in Mexico that used retired nurses as companionsduring childbirth reported no effect on women’s satisfac-tion [24]. Retired nurses were considered to be “de-sen-sitized” to women’s needs and less empathetic than laycompanions [24].Providers’ perceived the usefulness of the companions
in facilities suffering from nurse and midwife shortage.In all of studies conducted in high or low income coun-tries, providers carried negative attitudes towards theimplementation of companion of choice at birth. Theyreported concerns about cross infection and crowding inlabour wards as well as about the expected collaborationof women and of companions with the healthcare teamand feared interferences with clinical decisions.
Other implementation barriers existed such as theallocation of resources within the facility and theorganization of care to facilitate nurses or midwives con-tinuous presence with the woman during labour andbirth. Barriers in resource constrained environmentsrelated mainly to crowding and availability of space andprivacy for women and their companions in the labourward as well as to cultural preferences of thecompanion.The implementation of this practice requires the com-
mitment of the management of health care facilities tochange institutional policies and to provide the appropri-ate physical space that respects women’s and their com-panion’s privacy. This could be informed by recentliterature on the importance of supporting the sup-porters during childbirth through observing their inter-action with the space [48]. While the evidence doesn’tindicate the necessity of providing training to the laycompanion [2], there were different approaches used inthe reviewed interventions and considerations need tobe given to various modes of orienting the companion inorder to improve the acceptance of the interventionmainly by the health care providers.Influencing the attitudes of health care providers is ne-
cessary for the successful implementation of the inter-vention. This could be achieved through sensitizationactivities including the provision of evidence-based in-formation, through minimizing system barriers such asto avoid overloading the staff and resolving issues ofspace and privacy, through affecting providers’ behav-iours and through sharing of women’s positive experi-ences with this practice to motivate their participation.The latter can be achieved through the use of effectivecommunication to clarify the role of the companion inthe labour and delivery wards.Given the improved health outcomes reported as well as
the positive experiences of women with companion ofchoice at birth reported regardless of the person providingsupport across all studies, we had expected that the use ofthis practice in hospitals would increase facility births.However, no trials reported on the effect of this practiceon this outcome. Two studies reported on women’s viewsreported that being denied of having a companion duringchildbirth can act as a reason for women opting to givebirth at home [38, 39]. The need for such specific studiesin those contexts where facility births are low would con-firm if increased quality and increased satisfaction withservices increases use of the services.Implementation factors were mostly described in the
qualitative studies identified for this review. These studieswere descriptive in nature and focused on women’s expe-riences and views [37, 38, 41, 45], few also included theperspectives of health care providers and discussed systemrelated factors important for implementation [39, 43, 46].
Kabakian-Khasholian and Portela BMC Pregnancy and Childbirth (2017) 17:265 Page 11 of 13
ConclusionMore effort should be put in documenting and reportingimplementation factors associated with interventions, bydescribing the context in terms of facility practices, pro-viders’ attitudes, community culture and challenges, eitherwithin the reporting of the intervention outcomes or inseparate publications. More importantly, future studiesshould use implementation research methods to developand test companionship models in different facility set-tings and cultures. This will inform initiatives that aim atfor scaling-up these models of care to a larger number ofhealth care settings in their region or country.Future research should also focus on measuring the
costs pertaining to the training of personnel or the laycompanion and to the changes in the physical space, aswell as on the impact of companion of choice at birthon care seeking behavior for subsequent births.
AcknowledgementsThe authors thank Hannah Bontongton and Sylvana Hassanieh for theirassistance in preparing this manuscript and Helen Smith for her guidanceand valuable comments.
FundingFunded by the World Health Organization through the work done for thedevelopment of WHO recommendations on health promotion interventionfor maternal and newborn health 2015.
Availability of data and materialsData sharing is not applicable to this article as no datasets were generatedor analysed during the current study.
Authors’ contributionsTKK carried out the analysis and drafted the manuscript. AP contributed inthe interpretation and to the writing of the manuscript. AP is a staff memberof the World Health Organization. She alone is responsible for the viewsexpressed in this article and they do not necessarily represent the decisions,policy or views of the World Health Organization. Both authors read andapproved the final manuscript.
Consent for publicationNot applicable
Ethics approval and consent to participateNot applicable
Competing interestsThe authors declare that they have no competing interests.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Author details1Health Promotion and Community Health Department, Faculty of HealthSciences, American University of Beirut, Beirut, Lebanon. 2Department ofMaternal, Newborn, Child and Adolescent Health, World Health Organization,Geneva, Switzerland.
Received: 21 December 2015 Accepted: 4 August 2017
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