Companionship during labor gives comfort and reassurance to laboring women. Couples should experience this pivotal part of life together for its successful accomplishment. They bestow maternal support and ensure psychological wellbeing. However, there are some health care facilities who don’t permit the woman to bring a companion. The common barriers for not allowing companions during labor are: the utilization of traditional methods by companions, improper architectural layout, various ethnicities, and policies of hospitals. Thus, practical and realistic actions should be taken as discussed in the paper. Therefore, a laboring woman can utilize the choice of a companion during labor

Maknojia, Anul Shifa

Malik, Azwa

English

eCommons@AKU

Journal of Asian Midwives (JAM) Volume 8 Issue 2 Article 4 12-2021 Why can’t I have a choice of companion during labor? Barriers to implementation of companion presence Anul Shifa Maknojia Aga Khan University Azwa Malik Aga Khan University Follow this and additional works at: https://ecommons.aku.edu/jam  Part of the Nursing Midwifery Commons Recommended Citation Maknojia, A S, & Malik, A. Why can’t I have a choice of companion during labor? Barriers to implementation of companion presence. Journal of Asian Midwives. 2021;8(2):39–45.  Case Study Why can’t I have a choice of companion during labor? Barriers to implementation of companion presence *1Anul Shifa Maknojia, 1Azwa Malik  Abstract Companionship during labor gives comfort and reassurance to laboring women. Couples should experience this pivotal part of life together for its successful accomplishment. They bestow maternal support and ensure psychological wellbeing. However, there are some health care facilities who don’t permit the woman to bring a companion. The common barriers for not allowing companions during labor are: the utilization of traditional methods by companions, improper architectural layout, various ethnicities, and policies of hospitals. Thus, practical and realistic actions should be taken as discussed in the paper. Therefore, a laboring woman can utilize the choice of a companion during labor. Keywords: birth companion, labor, respectful maternity care, choice, family centered care.  Case During a community health nursing clinical rotation in a secondary care hospital. We were able to shadow the nurse midwives and observed a number of vaginal deliveries. The first author was assigned to care for a 34-year-old woman who was admitted with labor pains and amniotic leakage. She was 37 weeks pregnant, gravida 4, para 0+3. It was a precious pregnancy since she had had three miscarriages before and had gestational diabetes. The woman was in active labor, 6 cm dilated and experiencing strong contractions, with four contractions per 10 minutes staying for 40 seconds. She was restless and screaming with pain. She was constantly asking to call her husband or another family member but the staff refused to do so. Thinking that the presence of her husband/family will decrease the patient’s anxiety, I asked the assigned nurse: “Why it can’t be done?” The nurse replied that it is not allowed due to the hospital’s policy, even if complications exist. At that point the woman was becoming aggressive and resisting medical interventions. I  1 Nursing student, Aga Khan University School of Nursing and Midwifery *Corresponding author 39Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]Published by eCommons@AKU, 2021 perceived that as time goes by her emotional and psychological wellbeing was highly disturbed but no such involvement of her husband or family member was accomplished. Eventually, she delivered alone without her companion. I was assigned in the labor room for three days and saw similar cases repeatedly. Discussion The first author was alarmed by this non-family centered policy, leaving me feeling confused because I could not do anything. I reflected on how this experience without any family members will impact maternal and child health? It gave me a sense of sadness and futility as I cannot replace her family members, but felt some role as a health care provider by providing comfort and encouraging her to relax and breathe properly. I stayed vigilant to the conclusion of her delivery in order to monitor both physical and psychological wellbeing of the mother. I recognized that a known companion (husband, partner, or a close relative) during labor is an important for maternal support and psychological wellbeing. While reflecting upon this case study, I came across a few pros and cons of having a companion during labor; for instance, support for respectful maternity care, positive labor outcomes, support during labor emergencies, hindrance due to usage of traditional medicines/methods, the physical layout of labor suites and cultural restrictions of male companions during labor.  The World Health Organization (WHO) defines respectful maternity care (RMC) as “the care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth” [1]. The emphasis on respectful maternity care is growing day by day but there are still some health care facilities in Pakistan that don’t permit women to have a companion during labor. Many research studies have found that companionship during labor help women to feel capable and build confidence through praise, reassurance, and comfort due to continuous physical presence [2]. We agreed with the idea that companions appreciate a laboring women for their cooperation in painful processes. Furthermore, the presence of a companion during labor creates a sense of security and potentiates positive labor outcomes by reducing the risk of medical interventions such as forceps, vacuum extraction, and cesarean delivery. A combined study mentioned that one of the benefits of a companion during labor is to decrease the workload of staff and enhance processes. Researchers further explained that having a 40Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]https://ecommons.aku.edu/jam/vol8/iss2/4 companion also helps staff to timely identify and prevent serious labor related issues and remind staff to re-examine women. In case of labor emergencies, the companions can help arrange transportation and strengthen the communication by conveying the instructions to women [3]. This become a great source of help in primary and secondary care clinics.  A few studies, however, found that, although companions are helpful, but may cause adverse and some serious obstetric outcomes by using traditional herbal remedies during labor [4,5]. A research study has shown that the decision to use traditional methods is being made by grandmothers, mothers, or mother-in-law during labor which may result in serious obstetric consequences such as uterine rupture, maternal bleeding, and fetal distress. The refusal to use traditional methods by staff is often difficult and shows disrespect [6]. I concur with the opinion that companions support women during labor by communicating the messages of health care professionals and constantly reminds and encourages the women, but using traditional methods for birth and interfering in medical decisions is troublesome for both the mother and the unborn baby. The second challenge related to companion presence is the architectural outlay which limits the privacy and contributes in overcrowding of shared labor and delivery rooms [7]. Additionally, a research study in Ethiopia shows that only 13.8% of mothers had availed the facility of companionship during labor. The reasons cited in the study were congested and overpopulated ward sites due to poor infrastructure resulting in unprotected privacy of laboring women [8]. The situation has been further exacerbated by COVID-19 safety precautions. Many hospitals have restricted the presence of companions in the labor room due to the COVID-19 pandemic and its related safety precautions [9]. However, the WHO strongly recommends supporting women to have chosen companions during labor, and childbirth even during COVID-19 [10]. In this case study, the assigned nurse informed me that in a labor room of four patients their four attendants cannot be accommodated as it will result in overcrowding which will lead to compromised quality of nursing care. This, in turn, will also results in client privacy violations and altered comfort level of laboring women and staff. Moreover, the COVID-19 pandemic safe distance and cross infection precautions have also restricted companions’ presence in the labor suite.  A few countries do not allow male companions in the shared labor and delivery room due to the cultural modesty of women. A literature review of factors affecting companionship during 41Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]Published by eCommons@AKU, 2021 labor shows an example of Arab cultures that they do not permit male partners to be present in shared labor rooms leading to the issue of privacy of women due to conservative culture [11]. As every culture has different values, practices, and beliefs causes disapproval of male presence in the labor and delivery room. Compared with the setting where I was working, their goal is to promote maternal and child health without discriminating against any religion and culture. Consequently, prohibiting husbands or male partners during labor will ensure the privacy of women and respect cultural and religious sensitivities. Lastly, several hospital policies and rules limit access of a companion during labor. A research study in Japan on facilitators and barriers in the humanization of childbirth highlighted that the most important barriers identified in providing humanized birth care including continuous support were institutional rules and strategies that restricted the presence of birth companions [12]. In this case study, forbidding companions was outlined in accordance with hospital policies and guidelines. As discussed earlier, privacy and cultural backgrounds are significant obstacles to the implication of companionship during labor. Therefore, these reasons insist the stakeholders of hospitals for designing firm rules and regulations against it.  Recommendations Based on the discussion above, we feel that laboring women should be allowed a companion if she requires. To address the challenges mentioned above, the following are the recommendation:  • Including companions from the start of antenatal classes by informing their expected role in providing support would help to a great extent. Also, they should be instructed before admission to avoid interfering in medical decisions and prevent traditional methods for positive birth outcomes. • Although it is not possible to change architectural outlay, it is possible to undertake measures which may work better. For example, using dividers and curtains can address the issue of overcrowding and helps in maintaining privacy.  • If cultural backgrounds don’t allow male companions, so at least female companions including mothers, doulas might work appreciatively. • Stakeholders should review the evidence on effects of absence of companions during labor and delivery. They could try various models which may bring female companions at the 42Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]https://ecommons.aku.edu/jam/vol8/iss2/4 minimum to assist the laboring women in order to provide assistance and systemic improvement to labor and delivery.  • Concerning this pandemic, it is stated by the Ministry of National Health Services, Regulations and Coordination in Pakistan that “one attendant or companion of woman’s choice with appropriate infection prevention control should be allowed with restriction to move within specified areas of health facility to provide comfort to the pregnant woman and as a stress management support” [13]. Therefore, personal hygiene practiced by health care providers should also be followed by companions to avoid cross-infection. Additionally, they should be encouraged for frequent hand washing, mask-wearing all the time, and maintaining a 6ft distance when necessary. • Nurses should advocate for having companions during labor through research to bring change in hospital policies and practices. Moreover, she should approach leadership and management for modifications of guidelines related to a companion during labor and formulate the plan to update the COVID-19 related safety measures in regards to making its implementation possible. Conclusion In a conclusion, companions can provide comfort, love, and support throughout labor and delivery. Couples should encounter this crucial part of life together by supporting and comforting each other. It does not mean that health care providers will not support them, but rather the companion will serve as an augmentation to the woman. The major determinants which are the top challenge of not including companions during labor are traditional methods used by companions, inappropriate architectural outlay, different cultural backgrounds, and hospital policies and regulations. Therefore, sustainable measures should be taken such as educating women and companions during antepartum care, allowing female companions where husbands or male partners are not allowed due to cultural barriers, installing dividers and curtains, and amending hospital policy including the COVID-19 related safety measures could result in optimal maternal and child health.   References 1. Bohren MA, Berger BO, Munthe‐Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews. 2019 (3). 43Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]Published by eCommons@AKU, 2021 2. WHO recommendations: intrapartum care for a positive childbirth experience World Health Organization 2021 [cited 5 August 2021]. Available from: https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/ 3. Dynes MM, Binzen S, Twentyman E, Nguyen H, Lobis S, Mwakatundu N, et al. Client and provider factors associated with companionship during labor and birth in Kigoma region, Tanzania. Midwifery. 2019 Feb 1; 69:92–101. 4. Sarwal T, Sarwal Y, Tyagi S, Sarwal R. Opinion of Health Care Providers on Birth Companions in Obstetrics Department of a Tertiary Care Hospital in North India. medRxiv. 2021 Jan 1. 5. Afulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC pregnancy and childbirth. 2018 Dec;18(1):1-28. 6. Lampiao, F., Maliwichi-Nyirenda, C., Mponda, J., Tembo, L., & Clements, C. A preliminary investigation of the effects of labour inducing plant, Cissampelos mucronata, on the outcomes of pregnancy using rat models. Malawi medical journal: the journal of Medical Association of Malawi. 2018 Sep; 30(3):159–161. 7. Brüggemann OM, Ebsen ES, Oliveira ME, Gorayeb MK, Ebele RR. Reasons which lead the health services not to allow the presence of the birth companion: nurses' discourses. Texto & Contexto-Enfermagem [In English: Text Context Nursing]. 2014 Jun;23(2):270-7.  Available from, https://www.scielo.br/j/tce/a/zdk4C8b6WxWXbyjYvh9s43y/?format=pdf&lang=en 8. Beyene Getahun K, Ukke GG, Alemu BW. Utilization of companionship during delivery and associated factors among women who gave birth at Arba Minch town public health  facilities, southern Ethiopia. PloS one. 2020 Oct 2;15(10). 9. Asefa A, Semaan A, Delvaux T, Huysmans E, Galle A, Sacks E, Bohren MA, Morgan A, Sadler M, Vedam S, Benova L. The impact of COVID-19 on the provision of respectful maternity care: findings from a global survey of health workers. medRxiv. 2021 Jan 1.  10. World Health Organization [Internet]. https://www.who.int/news/item/09-09-2020-every-woman-s-right-to-a-companion-of-choice-during-childbirth. 2021 [cited 18 May 2021]. Available from: https://www.who.int/news/item/09-09-2020-every-woman-s-right-to-a-companion-of-choice-during-childbirth 44Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]https://ecommons.aku.edu/jam/vol8/iss2/4 11. Kabakian-Khasholian T, Portela A. Companion of choice at birth: factors affecting implementation. BMC pregnancy and childbirth. 2017 Dec;17(1):1-3. 12. 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. 13. Government of Pakistan. Guidelines: Sexual, Reproductive and Maternal Health Services during COVID 19. Available from:  http://www.covid.gov.pk/new_guidelines/07July2020_20200707_Interim_Guidance_for_Continuity_of_SRH_Services_2201.pdf   45Journal of Asian Midwives (JAM), Vol. 8, Iss. 2 [2021]Published by eCommons@AKU, 2021

Why can’t I have a choice of companion during labor? Barriers to implementation of companion presence

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Why can’t I have a choice of companion during labor? Barriers to implementation of companion presence

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