Perceptions and experiences of labour companionship: a qualitative evidence synthesis

18 Mar 2019

What is the aim of this synthesis?

The aim of this Cochrane qualitative evidence synthesis was to explore how women, families, and health workers experience women going through labour and childbirth with a support person ('labour companion'). A labour companion may be the woman’s partner, family member, trained supporter (doula), or nurse/midwife. We collected and analysed all relevant qualitative studies to answer this question.

This qualitative evidence synthesis links to another Cochrane Review by Bohren and colleagues from 2017 that assesses the effect of continuous support for women during childbirth. Continuous support improves health and well‐being for women and babies but factors affecting successful implementation are not well understood.

Key messages

Labour companions provide women with information, practical, and emotional support, and can speak up in support of women. Companions can help women have a positive birth experience and need to be compassionate and trustworthy. However, not all women who want a labour companion have one, especially in lower‐resource settings.

What was studied in this synthesis?

We use the term 'labour companionship' to describe support provided to women during labour and childbirth. In high‐income countries, women are often accompanied by family members or a doula. But in health facilities in low‐ and middle‐income countries, women may not be allowed to have any support person, and may go through labour and childbirth alone.

Bohren's review from 2017 shows that supporting women during childbirth has positive effects on women's experiences and on their health. We sought to understand how women, partners, and healthcare providers felt about labour companionship, and what factors might influence women's access to labour companionship.

What are the main findings?

We found 51 studies, mostly from high‐income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE‐CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.

Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non‐pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.

Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision‐making.

Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign‐born women in high‐income settings may appreciate support from community‐based doulas to receive culturally‐competent care (low confidence).

Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).

We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren’s review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship.

How up‐to‐date is this synthesis?

We searched for studies published before 9 September 2018.

Maternal and child health