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Barriers for Birth Companionship: A Narrative Review

     Papa Dasari

Department of Obstetrics and Gynaecology, WCH, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

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ABSTRACT

Historically during home birth, the women in labour were always supported by the presence of a woman in the family or friends or neighbours but maternal morbidity and mortality was high. Institutionalization of deliveries has brought down mortality for the past few decades but what surfaced is “Disrespect and Abuse” which has been recognized as a barrier for utilizing the services to optimum. Recognizing this, various Organizations in most of the Nations adopted” Birth Companion Policy”. But this is not implemented especially in Public sectors in India and other developing Countries. Some of the barriers include lack of infrastructure, not respecting women’s choices, health care personal not aware of the women’s reproductive rights and existence of Govt’s policy regarding birth companions, fear of litigation., overcrowding, lack of privacy, lack of training for birth companion and lack of policies at the departmental and Institutional level etc. Removing the barriers and facilitating Birth companionship is the need of the hour to promote humanization of Child birth.

KEYWORDS

child birth, birth companion, barriers, disrespect and abuse, humanization

INTRODUCTION

Support during labour has been recognized as an important intervention to achieve good maternal and perinatal outcomes in developed as well as developing Countries. Though there are recommendations and guidelines provided by the Health and Family Welfare, Government of India, this practice is not implemented especially in Public Health Sector. This article presents some of the barriers for birth companionship reported in literature.

LITERATURE REVIEW NARRATION

 Historically during home birth, the women in labour were always supported by the presence of women in the family or friends or neighbours and the dhai (trained or untrained) who ultimately conducts delivery. In Public hospital deliveries usually no person is allowed to give one to one support and all the non-medical necessities of women were carried out by the health care workers especially nurses, doctors (in addition to providing medical care) and some ancillary health care workers. With overcrowding of public hospitals, women in labour are not able to receive adequate emotional and physical support and there is no time for health care workers to explain the whole process of labour, delivery and speak comfortable words to allay apprehension and anxiety.

Continuous support during labour was recognized as a necessity and one of the reproductive rights of the women in labour by various organizations after quality research in developing and developed world and the momentum in recent times started in US1. The benefits of birth companion was found to decrease the caesarean section rates and increase the vaginal delivery rates and positive experiences of women during Child birth by many authors2. Various organizations have endorsed the presence of birth companion and incorporated the same in to the guidelines3-8.

But this is not universally adopted and practiced in all health facilities due to some issues and research is on to recognize and overcome the barriers so as to effectively implement the Policy. A meta-synthesis of 12 studies on views of women found the support persons were female relatives, friends and husbands and sometimes Doulas. Experiences of women varied according to the nature of the companion and type of Birth companion support. Most of the women preferred female companion and emotional support was found to be inspiring 9. Cochrane review 2017 which included 26 trials from 17 countries concluded that women satisfaction was high when birth companion was a relative from family and negative experiences were less when a doula acted as a birth companion but there was lot of bias in these studies which mostly included women without any pregnancy complications10.In resource limited settings Companion - Integrated Child birth Practice is found to be a promising intervention to decrease the fears associated with Child birth in Primigravid women11.

Heather et al in a randomized controlled study to report on outcomes of having birth companion concluded that the abuse is significantly less in presence of birth companion but introduction of birth companion in to health care system was more difficult task than anticipated. They randomized 10 hospitals, 5 with childbirth companion intervention and the outcomes measured were allowing birth companionship, good obstetric care and humanity of care. They did not find any significant differences. The reasons for not allowing companionship were under resourced health care system and frequent change of staff 12.

The barriers for humanization of birth were found to be the presence of rules and regulations of not allowing birth companion during normal child birth, caesarean birth, postpartum period, common delivery room, common postpartum room, malpractice litigation etc. The type of hospitals in which women give birth is an important barrier in Japan as University-affiliated hospitals have trainees and the women are not attended by the same midwife who interacted/supported the woman during antenatal period and some of them do not allow birth companions. The other barriers women felt in this study was not allowing their parents and their older child to visit them in the hospital, and this increased their anxiety regarding their home front. The Obstetricians opined that the demand at workplace of caring for a large number of women at a time as much as one Obstetrician seeing 30 women in an hour in labour which led to dissatisfaction of laboring women13.

A recent study from North India found that Birth Companions of choice preferred by women in India were the mother (70%), husband (69%), sister (46%) or nurse (43%). Ninety five percent of Health care providers agreed that the presence of a Birth Companion during labour will be beneficial, as they would provide emotional support, boost the woman’s confidence, humanize labour (83%), reduce need for analgesia (70%) and increase spontaneous vaginal births (69%). Practice of the policy of birth companionship was only was low (59%) in these hospitals because majority of Staff nurses (62%) had reservations with only 40% of them believed Birth Companion to be beneficial. Over-crowding in labour room and privacy concerns for other women were identified as key barriers in this study14.

BARRIERS FOR HUSBAND BEING BIRTH COMPANION

In India, a qualitative study conducted in 2011 in one Public and one private hospital did not find many barriers for husband to be birth companion. The health care providers felt that there is space constraint and privacy of other women in labour gets affected as number of labour cots are more in a room. Further they felt that the husbands get sick and faint sometimes and they need prior knowledge of child birth and some training to give support for laboring woman. The women in labour felt encouraged to have husband as a birth companion and listed many advantages such as promoting contraception and receiving better attention at home and the only disadvantage they felt was that the other women’s privacy may be affected in a Government set. In Private set up there were no issues and the practice was in place for more than a decade15.

In Japan where husband is allowed as birth companion in some health facilities, the women stated that they could not afford husband to miss his work for family earning and also the facility allows the husband to be with his wife only for a short period of time which is again a dis-satisfying factor for women in labour13.

A study which explored the experiences and perceptions of husband as birth companion in low resource settings in Tanzania found 4 main areas or themes that were fulfilled by the men viz. demonstrating care, love and affection, men’s adoption with modern life style, observing women’s right and meeting socioeconomic difficulties during support. Men felt responsible for the promises they undertook while being married, providing physical and emotional support at the moment of stress and need and helping their wives recover fast and felt that birth companionship strengthens their marital relationship. The obstacles they experienced at health facility were unpleasant welcome and their lack of knowledge regarding childbirth16.

In USA the practice mostly allows companion of choice and it is a National Policy but barriers still exist of not allowing birth companion in 2 countries. Majority allow husband as birth companion and one of the barrier was midwives’ unawareness regarding legislation17.

 FACILITAING BIRTH COMPANIONSHIP

Doula Care is a trained programme of dedicated companionship in which the person is professionally certified to take care of the women in labour and postpartum18 is existent in some countries like USA. But for this the lady needs to pay and fix the Doula much prior during antenatal visit which not favourable for middle and low income countries

The effect of a trained birth companion using a manual for the same found that the birth companions performed more number of supportive actions in a better way which resulted in overall satisfaction of women and better child birth outcomes19. Hence training of birth companion is an essential component to achieve childbirth satisfaction with good maternal and fetal outcomes.

 In 2013, WHO has brought out a handbook for building skills “Counselling for maternal and Newborn health Care” which includes a structured programme for birth companions also20.

The facilitating factors for birth companionship are the provision of Labour Delivery rooms (LDR) with homely atmosphere of having family with the woman with facilities for recreation such as TV and a separate laboring room. Respecting women’s culture, beliefs in natural birth and allowing a longer hospital stay around the perinatal period13. Japan has introduced lot of initiatives for humanization of childbirth such as “Angel Plan” “Japan International C-operation Agency JICA)” and programmes such as Bureau of “International Medical Centers in Japan (IMCJ)” and aiming to reduce Caesarean section rate further13.

WHO has again re-emphasized the presence of birth companion as one of the reproductive rights of Child bearing women even in the COVID Pandemic and raising awareness regarding the issue, providing infrastructure for presence of birth companion are important facility based healthcare21.

CONCLUSION

Though benefits of having continuous maternal support during labour have been well documented with evidence of reduction in maternal morbidity and mortality there are barriers for birth companionship in developing as well as developed countries. The main barriers are rules of not allowing birth companionship not being lifted up, lack of infrastructure and negative attitudes of health care workers towards birth companion.

This calls for health education to raise awareness of the public as consumers of health care services regarding the rights of childbearing women in choosing the birth companion of choice to support her throught labour and child birth. It is also essential to make the policy makers and administrators of various Govt health care facilities to adopt the universal recommendations of WHO and Govt. of India in a phased manner.

REFERENCES

1. Klaus MH, Kennell JH, Klaus PH. The doula book: How a trained labor companion can help you have a shorter, easier, and healthier birth. Da Capo Lifelong Books; 2002 Nov 7.
2. Caughey AB, Cahill AG, Guise JM, Rouse DJ, American College of Obstetricians and Gynecologists. Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology. 2014;210(3):179-93.
3. Committee on Obstetric Practice; American College of Obstetricians and Gynecologists "Committee Opinion No. 687: Approaches to Limit Intervention during Labor and Birth". Obstetrics and Gynecology. 2017;129 (2):e20-e28. doi:10.1097/AOG.0000000000001905. PMID 28121831.
4. Leavitt R (2017-06-05). "All women should have access to doula care". New Beginnings Doula Training. Retrieved 2018-07-08.
5. "Doulas Position Statement". The Royal College of Midwives. October 2017. Archived from the original (PDF) on 27 August 2018.  https://en.wikipedia.org/wiki/Doula.
6. https://www.who.int/reproductivehealth/companion-during-labour-childbirth/en/
7. Companion of Choice during labour and childbirth for improved quality of care: evidence –to-action brief https://apps.who.int/iris/rest/bitstreams/1061373/retrieve.
8. LaQshya-NationalHealthMission
9. Lunda P, Minnie CS, Benadé P. Women's experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth. 2018 May 15;18(1):167. doi: 10.1186/s12884-018-1755-8. 
10. Bohren_MA, Hofmeyr_GJ, Sakala_C, Fukuzawa_RK, Cuthbert_A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. doi: 10.1002/14651858.CD003766.pub6
11. Munkhondya BMJ, Munkhondya TE, Chirwa E, Wang H. Efficacy of companion-integrated childbirth preparation for childbirth fear, self-efficacy, and maternal support in primigravid women in Malawi. BMC Pregnancy Childbirth. 2020 Jan 21;20(1):48. doi: 10.1186/s12884-019-2717-5. 
12. Brown H, Hofmeyr GJ, Nikodem VC, Smith H, Garner P.Promoting childbirth companions in South Africa: a randomised pilot study. BMC medicine. 2007 Dec;5(1):1-8.
13. Behruzi R, Hatem M, Fraser W, Goulet L, Ii M, Misago C. Facilitators and barriers in the humanization of childbirth practice in Japan. BMC pregnancy and childbirth. 2010 Dec;10(1):1-8.
14. SarwalT,SarwalY,TyagiS, Sarwal R. Opinion of Health Care Providers on Birth Companions in Obstetrics Department of a Tertiary Care Hospital in North India. Opinion https://www.medrxiv.org/content/10.1101/2021.06.24.21259462v1.full.
15. Kaveri M and Kumar AIK. Perceptions of Antenatal Women, Husband and Health Service Providers on Husband being Birth Companion during Childbirth: A Qualitative Study. Public H Open Acc 2017, 1(1): 000101
16. Kashaija DK, Mselle LT, Mkoka DA. Husbands’ experience and perception of supporting their wives during childbirth in Tanzania. BMC pregnancy and childbirth. 2020 Dec;20(1):1-9.
17. De Mucio B, Binfa L, Ortiz J, Portela A. Status of national policy on companion of choice at birth in Latin America and the Caribbean: Gaps and challenges. Revista Panamericana de Salud Pública. 2020 May 8;44:e19.
18. “What is a Doula?". American Pregnancy Association. 2019-04-26. Retrieved 2021-02-24.
19. Teles LM, Américo CF, Oriá MO, Vasconcelos CT, Brüggemann OM, Damasceno AK. Efficacy of an educational manual for childbirth companions: pilot study of a randomized clinical trial. Revista latino-americana de enfermagem. 2018 May 7;26. doi.org/10.1590/1518-8345.2277.2996.
20. Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. Geneva: World Health Organization; 2013. 10, SUPPORT DURING LABOUR AND CHILDBIRTH. 
21. Every woman’s right to companion of Choice during Child birth

REFERENCES

1. Klaus MH, Kennell JH, Klaus PH. The doula book: How a trained labor companion can help you have a shorter, easier, and healthier birth. Da Capo Lifelong Books; 2002 Nov 7.
2. Caughey AB, Cahill AG, Guise JM, Rouse DJ, American College of Obstetricians and Gynecologists. Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology. 2014;210(3):179-93.
3. Committee on Obstetric Practice; American College of Obstetricians and Gynecologists "Committee Opinion No. 687: Approaches to Limit Intervention during Labor and Birth". Obstetrics and Gynecology. 2017;129 (2):e20-e28. doi:10.1097/AOG.0000000000001905. PMID 28121831.
4. Leavitt R (2017-06-05). "All women should have access to doula care". New Beginnings Doula Training. Retrieved 2018-07-08.
5. "Doulas Position Statement". The Royal College of Midwives. October 2017. Archived from the original (PDF) on 27 August 2018.  https://en.wikipedia.org/wiki/Doula.
6. https://www.who.int/reproductivehealth/companion-during-labour-childbirth/en/
7. Companion of Choice during labour and childbirth for improved quality of care: evidence –to-action brief https://apps.who.int/iris/rest/bitstreams/1061373/retrieve.
8. LaQshya-NationalHealthMission
9. Lunda P, Minnie CS, Benadé P. Women's experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth. 2018 May 15;18(1):167. doi: 10.1186/s12884-018-1755-8. 
10. Bohren_MA, Hofmeyr_GJ, Sakala_C, Fukuzawa_RK, Cuthbert_A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. doi: 10.1002/14651858.CD003766.pub6
11. Munkhondya BMJ, Munkhondya TE, Chirwa E, Wang H. Efficacy of companion-integrated childbirth preparation for childbirth fear, self-efficacy, and maternal support in primigravid women in Malawi. BMC Pregnancy Childbirth. 2020 Jan 21;20(1):48. doi: 10.1186/s12884-019-2717-5. 
12. Brown H, Hofmeyr GJ, Nikodem VC, Smith H, Garner P.Promoting childbirth companions in South Africa: a randomised pilot study. BMC medicine. 2007 Dec;5(1):1-8.
13. Behruzi R, Hatem M, Fraser W, Goulet L, Ii M, Misago C. Facilitators and barriers in the humanization of childbirth practice in Japan. BMC pregnancy and childbirth. 2010 Dec;10(1):1-8.
14. SarwalT,SarwalY,TyagiS, Sarwal R. Opinion of Health Care Providers on Birth Companions in Obstetrics Department of a Tertiary Care Hospital in North India. Opinion https://www.medrxiv.org/content/10.1101/2021.06.24.21259462v1.full.
15. Kaveri M and Kumar AIK. Perceptions of Antenatal Women, Husband and Health Service Providers on Husband being Birth Companion during Childbirth: A Qualitative Study. Public H Open Acc 2017, 1(1): 000101
16. Kashaija DK, Mselle LT, Mkoka DA. Husbands’ experience and perception of supporting their wives during childbirth in Tanzania. BMC pregnancy and childbirth. 2020 Dec;20(1):1-9.
17. De Mucio B, Binfa L, Ortiz J, Portela A. Status of national policy on companion of choice at birth in Latin America and the Caribbean: Gaps and challenges. Revista Panamericana de Salud Pública. 2020 May 8;44:e19.
18. “What is a Doula?". American Pregnancy Association. 2019-04-26. Retrieved 2021-02-24.
19. Teles LM, Américo CF, Oriá MO, Vasconcelos CT, Brüggemann OM, Damasceno AK. Efficacy of an educational manual for childbirth companions: pilot study of a randomized clinical trial. Revista latino-americana de enfermagem. 2018 May 7;26. doi.org/10.1590/1518-8345.2277.2996.
20. Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. Geneva: World Health Organization; 2013. 10, SUPPORT DURING LABOUR AND CHILDBIRTH. 
21. Every woman’s right to companion of Choice during Child birth

Conflict of Interest

There is no conflict of interest to declare.

License: This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright: © 2021. The Author(s). Article is published by Carpel Press.

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