Abstract
In Ethiopia, women strongly desire continuous support during childbirth. Despite its benefits, this practice remains uncommon. The study aimed to evaluate health facility readiness and explore the preferences and experiences of women and providers to identify the factors affecting the implementation of continuous labor support in Ethiopia. This formative qualitative study utilized the COM-B model and Theoretical Domain Framework (TDF) to map barriers. Data were collected through 25 in-depth interviews and 12 facility observations, focusing on ‘role-oriented support’ to understand the physical and psychological needs of laboring women. Using purposive sampling, 25 in-depth interviews were conducted with 7 pregnant women, 5 postpartum women, 5 maternity heads, and 8 healthcare providers, along with assessments of the readiness of the 12 healthcare facilities. Data were analyzed through thematic analysis and narrative summaries, with findings mapped using behavioral models of Capability, Opportunity, and Motivation for behavior change, combined with a Theoretical Domain Framework to enhance understanding. Six primary themes were identified: (1) lack of emotional support skills among companions; (2) insufficient knowledge of support roles; (3) restrictive health facility policies; (4) cultural expectations impacting companionship; (5) undefined roles leading to inefficient support; and (6) limited responses by healthcare providers affecting labor companions. The key barriers to effective continuous support are systemic and institutional restrictions from health facilities and staff, aggravated by companions’ limited knowledge and skills. Addressing multifaceted barriers to continuous labor support requires an inclusive approach. Such systemic changes are essential for creating a supportive birthing environment that ultimately improves maternal outcomes and overall birth experience.
Introduction
Studies have consistently revealed that women significantly value and benefit from the presence of someone (herein ‘labor companion’) 1 : they trust to offer continuous support during the intrapartum period. Women who receive support from companions during the intrapartum period report feeling safe, strong, and confident.2,3
Quality maternal care during childbirth has become of the highest importance in terms of improving both maternal and infant mortality. 4 Many studies related to women’s health recommend quality care to address 3 areas of intervention: improving women’s childbirth experiences, institutional structures, and an environment that would support high-quality care. 5 Childbirth experiences are a critical component of service provision that affect individual satisfaction with emotional support, dignity, and respectful care. 6 A labor companion is a person of the woman’s choice who remains with the woman throughout childbirth, usually a partner, friend, or relative. Labor companions can support women in several key ways: fostering women’s ability to communicate with health workers, assisting women in managing their pain without drugs, standing up for the woman so that her choice is known, touching and holding her hand, and comforting her all throughout. 7
However, labor companion support is not yet a routine practice in the intrapartum period, and women give birth alone. 3 This affects women’s childbirth experience. In Ethiopia, labor companion support practices are minimal. A study performed in northwest Ethiopia showed that only 14.6% of women had experience with labor companion support, and a similar study conducted in southern Ethiopia showed that 13.8% of women had experience. 8 Another study in Ethiopia revealed that only 19.5% of health workers allowed labor companions to enter the labor ward. 6 Similarly, 82% of health workers do not allow labor companions to enter labor wards. 9 In Ethiopia, the persistent failure to fully implement continuous companion support during childbirth is a serious problem, with concrete and negative consequences for maternal and neonatal health. The consequences of poor implementation include an increased risk of mistreatment and disrespect during childbirth, negative psychological impacts, and adverse birth outcomes. 10 A 2024 meta-analysis revealed a high pooled prevalence of perinatal depression in Ethiopia (24.29%). The main factor is poor social support, which increases the likelihood of depression by more than 3 times compared to women with strong support. 11 Approximately 25% of pregnant women experience significant fear of childbirth. Lack of partner support was significantly associated with this fear, as it had a history of obstetric complications. Lack of support is associated with poorer neonatal outcomes, including lower Apgar scores at 5 min, an indicator of infant well-being immediately after birth. 12 Labor companionship is an intervention given the association between continuous support and optimized birth outcomes 1 as well as improved women’s experience of care and reduced mistreatment during childbirth.13,14 The intervention on the labor companionship model in each study included healthcare facilities that included information on (i) changing health facilities’ policies to allow for labor companionship, (ii) establishing eligibility criteria for women and companions, (iii) identifying how health workers can help women choose and train their labor companions, (iv) defining how health workers engage with women and companions, how many companions are allowed, and when they are present; and (v) developing educational tools for companions on how to support women.
Methods
Settings
The study was conducted in governmental health facilities in Addis Ababa, which provided both basic and comprehensive obstetric care. These health facilities contribute to more than 95% of the basic and comprehensive services offered in the catchment area. In Addis Ababa, each sub-city has 1 or 2 comprehensive health centers that can provide comprehensive obstetric care and an operating room (OR).
Study Design
A qualitative formative study design based on a combined behavior model of Capability, Opportunity, Motivation Behavioral Change (COM-B), and Theoretical Domains Framework (TDF). In-depth interviews (IDIs), Key Informant Interviews (KIIs), and health facility observation assessments were employed to explore the phenomenon. The data, explored through IDIs from pregnant and postpartum women and KIIs from health workers, were focused on the preferences, experiences, knowledge of companions, and challenges affecting the implementation from the stakeholders to enhance the practice of continuous labor companion support during the intrapartum period. Health facility observation assessments also attempt to identify the size of the labor ward, companion policies at health facilities, and privacy issues.
Sampling and Participant Recruitment
The sample size decision was reached following the concept of information power, where researchers need to consider the breadth of the study’s aim, sample specificity, quality of dialog during data collection, use of theory, and analysis strategy. 15 To gain a breadth of information on women’s experiences with continuous support during childbirth, purposive sampling was used to recruit women with varying characteristics, such as different modes of delivery, parity, and birth outcomes. Pregnant women who came to antenatal care, either primigravidea or multigravida, after receiving routine care, healthcare providers working at the maternity unit contacted them to ask whether they were willing to participate in the study. If a woman was willing to participate, the health workers communicated with the data collectors to contact her. Having a facility employee initiate the contact might have reinforced the institutional hierarchy, even though the researchers themselves were not employees of the specific facility being assessed.
Recruitment, consent, and interviews were conducted during the discharge process of each woman from the health facility. Healthcare providers working in maternity care, the antenatal, delivery, and postnatal wards, and healthcare administrators were contacted by the research team and invited to participate in in-depth interviews (IDIs), with consideration for a diverse group based on age, gender, and years of working experience (target per health facility: 2 to 3 midwives, 2 to 3 Integrated Emergency Surgeon officers (IESO), and 2 MCH). The IDIs were conducted in face-to-face in isolated room. The total sample size was 30 IDIs from 12 health facilities, with 2 to 3 targeted IDIs for each facility. A total of 25 participants participated and data saturation was reached. Data saturation is the point in qualitative research when new data no longer yield new insights and themes and patterns begin to recur. Originating from grounded theory, this term has become widely used. Data saturation at the most basic level refers to the identification of no new issues, topics, or ideas in data. It focused on the breadth of the collected data. In this study, we used grounded theory, which has the highest level of saturation. This occurs when no additional data are needed to fully develop the properties of a theoretical category, meaning that the theory is robust and well-grounded. Data saturation was achieved with 25 participants, meaning that the data collected no longer revealed new information or ideas from the data, and recurring themes were consistently observed, ensuring a full understanding of the topic.
Eligibility Criteria
Inclusion criteria for the study include pregnant and postpartum women attending antenatal care, both primigravida and multigravida, aged 18 to 45, with varied delivery methods and outcomes. Healthcare providers, including midwives and Maternal and Child Health heads, currently working in maternity units were also targeted, representing a range of ages and experience. The study was conducted in governmental health facilities in Addis Ababa, which offer both basic and comprehensive obstetric care, serving a diverse population without fees.
Whereas, private health facilities were excluded, as the study focused solely on public/governmental institutions, postpartum women with bad clinical birth outcomes (Stillbirth, IUFD, and Early neonatal death), Pregnant women with serious pregnancy complications (Bleeding during pregnancy, women who developed eclampsia, etc), Individuals who did not provide written informed consent were excluded and the study was limited to facilities with full functional operation theater setup and with adequate number of Cesarean section rates
Interview Guide Development
Semi-structured interview guides were developed based on the COM-B and TDF models, 16 World Health Organization (WHO) framework of health system building blocks, 17 and relevant literature. 18 Owing to the distinct responsibilities and comprehension levels of healthcare providers and women, we developed 2 separate semi-structured interview guides. The interview guides included questions on the health facility structure, health facilities’ policies on labor companionship, staff’s understanding of the benefits of continuous companion support, the client-provider relationship, and perceptions regarding continuous companion support. Moreover, the interview guides included open-ended questions and scenarios related to continuous support during childbirth at health facilities. These open-ended questions were developed based on the relevant literature reviews.2,14 The semi-structured interview guides were pilot-tested on clinical and non-clinical staff at different public health facilities.
Data Collection
After explaining the objectives of the study to the participants, written consent was obtained. In-depth interviews were then conducted in an isolated area of the health facility. The in-depth interviews (IDIs) lasted for 30 to 45 min. To ensure a smooth interview, a general conversation was initiated before the main interview questions. IDIs were collected by the first author together with research assistance. The first author is a PhD candidate and has good experience in qualitative data collection and analysis. The research assistance took the training how to collect qualitative data. Both the authors and research assistance were not employees of the health facilities. Data were collected between April and May 2024. All audio recordings were transcribed in the local language, Amharic, then translated into English and complemented with field notes and memos. The identified transcripts were stored on a password-protected computer. The in-depth interview guide was adapted from previous publications on possible factors, preferences, and experiences affecting labor companion practice. A semi-structured observational assessment tool was used to assess the health facility challenges affecting the implementation of companion practice. Health facility observation assessments were conducted by a research team member who was not an employee of the studied health facility.
Trustworthiness
The trustworthiness of this study was ensured to make the findings believable and accurate. Methodological trustworthiness was followed by employing credibility, dependability, conformability, and transferabilit
The conformability of the researchers engaged colleagues and external peers to review findings and challenge assumptions to minimize bias. Also, multiple data analyses were used to ensure findings were not the product of a single person’s interpretation, thereby increasing objectivity.
In qualitative research, conformability refers to the degree to which the findings are a consistent reflection of the participants’ responses rather than the researcher’s biases or interests.
The study combined Braun and Clarke’s 19 inductive approach with a framework approach using the COM-B and TDF models. 16 This mapping provides an external, established theoretical structure to categorize the data. By fitting the inductive themes into these pre-defined behavioral domains, the researchers reduce the risk of purely subjective or idiosyncratic interpretations, thereby enhancing objectivity. Data collectors initiated ‘general conversation’ before the main interview to build rapport and reduce the perceived hierarchy
Data Analysis
Data analysis followed a framework approach. 20 Inductive Thematic Analysis 19 was used in the initial open coding of the data to investigate a priori objectives using the TDF and COM-B models to describe the data and identify barriers and facilitators. A combined model, acknowledged as Capability, Opportunity, Motivation Behavior (COM-B), and a theoretical domain framework (TDF), was utilized. The fundamental concept of the COM-B model is to mobilize capability (capacity for behavioral change in an individual), opportunity (factors in the environment that influence individual behavior), and motivation (readiness for change) to produce actions that enhance interventions for behavioral change.21,22 The findings were then theorized as enabling and hindering factors affecting the practice, and framed in the combined behavioral mode. The COM-B and TDF combined models theorize the desired behavior to occur, which is the practice of continuous labor companion support. Capability represents the companion’s capacity (skills and knowledge) to provide emotional and physical support. Opportunity represents external factors, such as the environmental context (facility space/readiness) and social influences (cultural norms/peer support) that dictate if the support can occur. Motivation represents the internal decision-making processes, including Reflective beliefs (professional code of conduct and rights) and Automatic processes (emotions and impulses; Figure 1).
The target behavior illustrated by the combined model in the practice of continuous labor companion support. 16
Methodological Combination
During the analysis, we conceptualized findings from IDIs, KIIs, and health facility observation assessments as potentially affecting the implementation of labor companion practice in maternity care. The analysis adhered to Braun and Clarke 6 phases approach. 19
Phase 1: Familiarization with Data. Immerse in transcripts from In-Depth Interviews (IDIs) with stakeholders (pregnant women, postpartum women, health care providers and MCH head units) and notes from facility readiness assessments.
Phase 2: Generating Initial Codes (Inductive Focus)
Inductive coding: Actively code the data based on what participants say (eg, ‘no space in labor ward’,). Systematic approach: map codes onto the 14 TDF domains (eg, ‘no space’ = Environmental Context; ‘fear of infection’ = Beliefs about Consequences).
Phase 3: Searching for Themes. Grouping the codes into potential themes (eg, ‘Structural Constraints’, ‘Provider Resistance’, ‘Cultural Beliefs’).
Phase 4: Reviewing Themes. Check if the themes work in relation to the coded extracts and the entire data set, ensuring they adequately reflect the ‘barriers and facilitators’.
Phase 5: Defining and Naming Themes (Mapping to COM-B). Re-map the refined themes/codes to the COM-B components (Physical Capability, Psychological Capability, Social Opportunity, Physical Opportunity, Reflective Motivation, Automatic Motivation).
Phase 6: Writing the Report. The final report synthesizes the inductive themes (stories/perceptions) within the structured behavioral framework (COM-B/TDF) to explain why behaviors occur. Thematic Analysis using ATLAS. ti, Version 7.5.18) was used to analyze the qualitative data. The outputs may help in redesigning strategies to optimize the likelihood of successful interventions and the potential for scale-up of labor companion practice in maternity wards for positive childbirth experiences and better birth outcomes. The findings were reported based on Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. 23
Ethical Approval
This study obtained ethical approval based on Helsinki Declaration. All respondents were informed about the objectives of study and their voluntary participation was asked. Study objective and procedures was explained to each participant by the research team and was written in the information sheet. Then after participants were confirmed their voluntary for participation by putting their signature in the consent form we provide data collected using validated questionnaires, which was conducted in a convenient and isolated area. We followed the anonymity of data and there was no identifier in the questionnaires.
Findings
Overall, 25 IDIs and 12 health facility assessments were included in this analysis. From the total IDIs, 7 were from pregnant women (desire and preferences for labor companions of choice), 5 were from postpartum women (experiences, benefits, and challenges of labor companions of choice), 5 were from MCH heads, and 8 were from maternal healthcare providers from MCH units on enablers, hindrances, and ways forward for the practice of continuous labor companion support.
Socio-Demographic Characteristics of Pregnant and Postpartum Women
The participants’ ages ranged from 18 to 45 years, and almost all were married or had partners. Most of the participants were employed. Among the pregnant women, 1 in 5 was nulliparous. Approximately two-thirds of postpartum women had vaginal birth (Table 1).
Socio-Demographic Characteristics of Women Participating in the Study, Addis Ababa, Ethiopia, 2024.
Socio-Demographic Characteristics of Healthcare Providers
Data related to healthcare providers were collected from different units of maternal and child health departments to understand healthcare providers’ perspectives not only in the labor and delivery ward but also in antenatal care, postnatal care, and operation rooms (Table 2).
Socio-Demographic Characteristics of Healthcare Providers Participating in the Study, Addis Ababa, Ethiopia, 2024.
Health Facility Assessment Findings
Assessments using observational checklists from 12 health facilities revealed concerns about space, an overcrowded labor ward, and having more beds in 1 room. Results from health facilities revealed that there were restrictions vary based on the stage of labor and the gender of the companion.
The majority of facilities did not have a labor companion policy during intrapartum periods and time schedules in their health facilities. Some health professionals in health facilities allowed women’s relatives or their mothers to work.
During health facility assessments, some health workers mentioned that the practice of labor companion support in the labor ward was minimal and overlooked, despite having many benefits. A possible reason for this is that health facilities had concerns about the limited space they had in the labor ward.
However, the WHO’s recommendations on labor companions providing supportive care are that a woman should feel as comfortable as possible when receiving care and that a woman’s choices and preferences, including birthing position and emotional and psychological support, should be respected (Table 3).
Findings from 12 Health Facility Readiness Assessments for Continuous Labor Companion Support in Addis Ababa, Ethiopia, 2024.
Interviews on Labor Companions Practice and Challenges
The results of this study revealed that healthcare workers, pregnant women, and postpartum women had helpful perspectives on the practice of support during labor and childbirth.
The findings generally explored the following main themes: labor companions’ skills to provide support, pregnant and postpartum women’s knowledge of continuous companion support, social factors affecting labor companion practice, environmental factors affecting labor companion practice, benefits and risks of labor companion support, and community perception of labor companion practice based on COM-B and TDF models.
The main barriers identified in this study are summarized and framed using COM-B and TDF models with themes and sub-themes from IDIs and health facility readiness assessments in Addis Ababa, Ethiopia (Supplemental Figure 2).
Capability
It has 2 categories, physical and psychological. Physical Capability denotes a companion’s ability to offer continuous support to women during an intrapartum period. On the other hand, Psychological Capability refers to a labor companion’s knowledge of continuous support.
Physical Capability
(COM-B: Physical Capability; [TDF Domain: Skill])
The labor companion’s ability to offer psychological and social support to the woman in labor to overcome the physical, emotional, and mental challenges she faced during the intrapartum period. This is supported by the TDF domains of ‘Skill’, where the labor companion lacks the skills to provide support during the intrapartum period.
The ability to offer support during the intrapartum period varied from companion to companion. Less experienced companions had less skill than those with previous experience. As a postpartum woman explained,
My companion was my mother; she comforted me, massaged my back, and held my hand during contractions to cope with labor pain. She was telling me sweet words like, St. Mary is with you, and you will get better soon, so I gave birth without feeling more pain. (Postpartum woman, age 35, health facility 4)
Participants mentioned that they received advice from their labor companions, which was very helpful for them. Some of the information included how labor progressed, what to do during contractions, and signs of the second stage of labor.
When the pain is over, I should rest. My mother [companion] kept asking me how I was feeling, so I was explaining to her how I felt, and she was advising me what to do. (Postpartum woman, age 34, health facility 7).
Psychological Capability
(COM-B: Psychological Capability; [TDF Domain: Knowledge, Education, Awareness, and Behavioral Regulation])
Psychological Capability and the TDF components underpinning it, including ‘knowledge’, ‘education’, ‘awareness’ and ‘behavioral regulation’, were found to influence the likelihood of an individual engaging in continuous labor companion support during intrapartum care in health facilities. Failing to accept clients’ rights and support was a major factor hindering labor companion support during the intrapartum period. Most participants mentioned that they were supposed to have companions during birth. One participant mentioned that their source of information was health workers during antenatal care visits.
Health workers [Hakim] advised me that when labor starts, I should have somebody to help me (Pregnant woman, age 26, health facility 5).
Despite their knowledge regarding continuous labor companion support, some participants did not know if they would be with their companions during birth.
Health workers advised me about support from someone at antenatal care and told me that when coming to the health facility during labor, I should bring a companion. However, I didn’t know that the family companions would be with me in the labor ward [‘Mawaleja kefil’] (postpartum woman, age 27, health facility 2).
Most participants provided information on the perceived roles of companions during the intrapartum period for laborers, especially when midwives were not there to observe every activity during the intrapartum period. As a postpartum woman explained,
Companions should know the progress and should have enough evidence of how you are performing during birth. The potential companions should observe and have first
The Importance of companion support was that laboring women were advised about appropriate behavior during childbirth. Some women explained that they were advised against being troublesome, but to listen to what they were advised by health workers and their companions.
My mother told me. She instructed me to do my best for the baby to come out. She said. . . laughing. . . “My daughter—[pause] by looking in my eyes, this is your first pregnancy, all of us have had our babies through the same process, don’t think there will be something strange. My mother gave birth to 3 children through the same process.” (Postpartum woman, age 25, Health Facility 5).
Most participants mentioned that their companions were a source of good advice and encouragement. This is stated by the participant:
When I complained that I was feeling pain, my mother told me that she also went through the same process and that I just needed to be strong if I wanted to go home with a baby. I did not need to cry, though in pain. So I followed the advice and kept quiet (Postpartum woman health facility 8)
Labor companions are a source of physical support for women in labor. These comfort measures may be a means to encourage spontaneous birth and safeguard women from being exposed to long periods of painful labor. Labor companions also help women to adopt comfortable positions during labor.
Labor companions also provided physical support for laboring women. These supports comprised massaging her back and providing clean clothes and fluids to drink. This support may be used to promote spontaneous birth and ensure that women are not exposed to long periods of discomfort and painful labor. Labor companions also help women to adopt comfortable positions during labor.
During delivery, my labor companion was holding my head to raise me a little bit and assisted me to push effectively (Postpartum woman, age 34, health facility 9).
Opportunity
Refers to external factors that affect the implementation of labor companion practices during the intrapartum period.
Physical Opportunity
(COM-B: Physical Opportunity; [TDF Domain: Opportunities Provided by Environment, Like Availability of Supplies and Space, and Resources])
Maintaining privacy and confidentiality is a crucial issue because the structure and essential equipment are the main concerns in facilities.
We have one labor room that has 3 beds without separators. Sometimes we use curtains for privacy (Midwife, BSc, health facility 3). We manage almost 80–90 spontaneous vaginal delivery (SVD) every month, and sometimes it is difficult to allocate beds to the laboring mother who lives alone with her companion (Midwife, health facility 2).
Furthermore, a lack of beds in labor wards is also common. A midwife working in the maternity unit mentioned her concern about supplies.
In the majority of health facilities, labor companions’ access to the labor ward was not allowed. Because of the fear of confidentiality, as stated by Midwife. In the current practices of labor wards, women do not normally choose their labor companions.
The family, particularly mothers or partners, chooses the labor companion to be with the pregnant mother, which affects their choice and autonomy.
When you are in labor, you don’t even choose; it’s your family or partner who selects someone to come and be with you (Pregnant woman, age 34, health facility 3).
When mothers have a chance to choose labor companions, one of the criteria may be the availability of a person during labor.
I select a close friend of mine, but because of her work, she doesn’t. Present. She asked her boss for permission, but she could not. I was disturbed. But finally, I changed labor companion (Woman in postpartum, age 33, health facility 7).
Gender differences in companions are also a practical factor. Most labor companions were females because intrapartum care was assumed to be for women’s confidentiality. For this reason, men did not prefer to be labor companions.
Evidence is not well-founded to receive maternity rooms a male labor companions. This is why labor companions are females (Midwife, BSc, health facility 1).
Social Opportunity
(COM-B: Social Opportunity; [TDF Domain: Opportunities as a Result of Social Factors Such as Cultural Norms and Social Cues])
Lacking the Social Opportunity to engage in help-seeking behavior was a major barrier determined by the TDF domain of social influences. Multiple challenges have been highlighted, including social norms, group identity, and power. The labor companion is a responsible person (eg, partners, family, or close friends) who can provide support to laboring women during birth. IDIs participants mentioned the role of perceived labor companions.
However, some staff members described that managing labor companions was a major challenge to the midwife because a few labor companions occasionally become destructive and violent. When the labor companions were women who had given birth before, the support provided was easier since they had the appropriate experience to recognize the pain.
Most participants reported that healthcare workers in the labor ward allowed only female labor companions. Male labor companions are not common because of fear of the confidentiality needs of other mothers in the same room. Midwives mentioned that they felt bad when male labor companions were present, whereas mothers were undressed during childbirth.
Motivation
It is the process of decision-making behavior that implements labor companion support practice. It has 2 sub-domains.
Automatic Motivation
(COM-B: Automatic Motivation; [TDF Domain: Automatic Process, Such as Obtaining Community Feedback and Utilizing Social Accountability, Optimism, Emotion])
Automatic Motivation refers to the lack of rewards for providing respectful care in the implementation of companion support during labor. This concept is explained within TDF domains, such as obtaining community feedback and utilizing social accountability, optimism, and emotion. Companions of choice play a crucial role by providing emotional support, comforting the woman, and helping relieve labor pain.
Companions provided essential practical assistance, such as hygiene management and mobility support.
When I wanted to go to the restroom, my labor companion [mother] helped me to the restroom. She made my beds. When I wanted to eat, she prepared porridge (Postpartum woman, age 30, health facility 1).
Most of the female participants explained that their companions of choice were useful because they provided emotional support. Support included praising women for good performance, especially during the labor process. The existence of labor companions may reduce anxiety.
I was happy with my labor companion [mother-in-law]. That was my first time in the labor ward. People told me that usually women were left alone without health workers [Hakim], and they gave birth while alone in the beds. This was a distressing message for me (Postpartum woman, age 28, health facility 9).
Reflective Motivation
(COM-B: Reflective Motivation; [TDF Domain: Professional Code of Conduct, Human Rights, Capabilities, Optimism, Beliefs About Consequence and Intentions])
Reflective Motivation refers to women’s and labor companions’ limited knowledge about abilities, roles, and duties that affect the WHO’s recommendations on labor companion implementation. The motivation of healthcare providers who feel bound by their professional code of conduct and human rights principles is to allow and facilitate continuous support. Their Reflective Motivation is rooted in the belief that this is the correct professional practice and does not allow it to violate the mother’s rights.
As a midwife [she said], I know it’s her right to have someone with her. It’s part of providing dignified, respectful care (senior midwife, age 34, health facility 6).
Some healthcare providers have also stated the policies of health facilities to allow companions of choice during labor and childbirth.
The midwife working in the maternity ward mentioned the following:
The hospital policy states that the mother should be supported, and I have a duty to follow that. It’s what’s best for the patient, but the practice is very low and rare (BSc Midwife, age 28, health facility 9).
The understanding of how continuous support transforms the clinical birth experience into a more personal and humane one. Motivation is driven by the belief that birth is not just a medical event but also a life-changing human experience that should be treated with respect and sensitivity. A senior emergency officer stated the following.
Having her husband there changes the whole atmosphere. It’s less sterile and more like a family moment. We should be treating these women as people, not just as patients on a ward. The companion helps us do that (emergency officer, age 30, health facility 5).
Reflective Motivation stems from the belief that a companion improves clinical outcomes for the mother and baby. Professional education and positive experiences often influence these beliefs. The optimistic belief that allowing companions improves the overall patient experience and perception of care. Motivation is the desire to provide a positive, satisfying, and memorable birth experience for the family.
I’m hopeful that by letting partners stay, more women will have a positive birth story to share. When they have a good experience, they’re more likely to recommend our facility to others. It’s good for everyone (MCH Head and Health Facility 7).
This reflects the motivation for continuous support to reduce negative emotional outcomes such as fear, loneliness, and trauma. The motivation is to create a sense of safety and emotional security for laboring women.
I was so scared, but having him [her companion of choice] there just calmed me down. I don’t know what I would have done without him (Mother, age 27, health facility 6).
Connected to social influences, participants reflected on the impact of their experiences on their Reflective Motivation to engage or disengage in continuous support from a labor companion during childbirth. Despite their gratitude for the labor companion support that the women received, some women said that they did not obtain the desired support from labor companions.
I needed my labor companion to be near me, assisting me with turning because it was very difficult for me to turn, but she refused (Postpartum woman, age 23, health facility 8).
The participants repeatedly raised concerns. These concerns can be described as first concerns privacy issues. Some labor companions were selected by women but were not allowed to enter the labor ward because of the fear that women’s privacy during the labor process could be shared with others.
The participants understood that all women could receive emotional support from their families during childbirth. However, family members are not allowed to enter the labor ward during labor and remain outside the labor ward. Health workers mentioned the importance of companions, as they may act as communicators, eyewitnesses, and assistants with care.
Labor companions helped to smooth the relationship between mothers and health workers. This was mainly significant for mothers who could not talk with health professionals because of labor pain.
Helps ease the interaction between the mother and health professionals, whatever good health workers say, the mother is under the influence of labor pain, so there may be a misunderstanding. Therefore, some labor companions comprehend simply and help us to smooth the interaction (Female midwife, BSc, health facility 5).
Labor companions were also seen as witnesses to the mother and her parents. They might follow what occurred during labor, whether she received care or not. Labor companions could have concerns about the care that the mother received.
Since labor companions are there directly, they can follow the progress of labor and how care is offered. Labor companion rarely complains if the client does not receive care (midwife, maternity care unit head, health facility 2).
Health workers’ statements show that offering support to mothers during the intrapartum period may influence labor companions, as they are able to recognize what is happening through the intrapartum care process.
If you go together with someone [a companion], you recognize what occurs and shortly you will identify what to suppose (Midwife, BSc, health facility 6).
In conclusion, the combination of these factors leads to behavioral changes that enable continuous labor support from a woman’s chosen companion. The barriers can be categorized at different levels of skills, knowledge, social influences, beliefs, and emotions that affect the implementation of a labor companion’s ability to provide sustainable support. Addressing these themes and sub-themes through education, resources, institutional support, and awareness can increase effective labor companionship, improving maternal outcomes and satisfaction as summarized in Supplemental Figure 2.
Discussion
This qualitative study identified 6 main themes that shape the effectiveness of continuous companion support during labor and childbirth: (i) companions have limited ability to provide effective emotional support; (ii) Companions do not fully understand their support roles or decision-making responsibilities during labor; (iii) health facility policies restrict companions’ ability to offer support; (iv) cultural and social influences affect expectations and acceptance of companions; (v) unclear roles and responsibilities cause inefficient support; and (vi) healthcare systems and provider actions can limit women’s choice of companions. These findings were mapped onto the COM-B and TDF behavioral models to systematically highlight barriers to continuous companion support.
These findings should be viewed within the broader Ethiopian landscape of facility-based childbirth, where scholarship has documented significant levels of disrespect and abuse (D&A). As Tekle Bobo et al 10 highlight, the persistent failure to implement continuous support is part of an institutional culture where women are often expected to tolerate mistreatment, making the introduction of a companion a critical step toward reclaiming dignity in care
Social Opportunity: The disempowerment and shame identified in our study are symptoms of broader institutional power dynamics in Ethiopia. Studies on national childbirth experiences suggest that these power imbalances often lead to the normalization of abuse. 10 By providing Social Opportunity through the presence of a chosen companion, the birthing process can be transformed from an isolating medical event into a supported ‘family moment’ that safeguards the woman’s autonomy.
In this study the normalization of silence and endurance during labor, illustrated by accounts of women being advised ‘not to cry’ and to avoid being ‘troublesome’. When interpreted through the lens of Respectful Maternity Care (RMC), these accounts suggest a significant power asymmetry within health facilities, where compliance and endurance are socialized as ‘appropriate behavior’ to avoid conflict with healthcare providers. This culture of compliance can mask mistreatment and marginalize the woman’s support during a vulnerable life event.
These attitudes often compare companions’ roles unfavorably with those of healthcare providers. The regular presence of labor companions improves maternal and clinical outcomes, including less need for pain relief, fewer cesarean sections, shorter labor, and higher maternal satisfaction. Some participants recognized these benefits. A previous study in Ethiopia supports this finding. 9 Awareness of companion support benefits is increasing in this area. This situation offers a chance to reframe and improve community understanding and support companion roles. Integrating companions into health facilities creates challenges and opportunities for improving maternal care. Better childbirth experiences are required for women in Ethiopia. 24 Our findings support other studies that stress the influence of cultural practices on maternity care. 2
Physical Capability: Practical skills and supportive guidance at the facility, companions’ ability to provide support, and less experience in offering support. By fostering a culture that values continuous support, healthcare providers can help reduce stigma and encourage positive interactions among families and communities. Participants had positive attitudes toward integrating labor companions with the maternity care team; they believed that labor companions should be members of the maternity unit. This integration can enhance communication and foster a supportive environment for expectant mothers. By valuing the role of labor companions, healthcare providers can create a more holistic approach to maternal care, ultimately improving both physical and emotional outcomes for women during this critical time.25,26
Automatic Motivation: It refers to the lack of rewards for providing respectful care in the implementation of companion support during labor and childbirth. The identified ‘healthcare system gap’ in rewarding respectful care contributes to a lack of Automatic Motivation among staff to prioritize companionship. Previous studies in Ethiopia on evidence of D&A suggests that without social accountability mechanisms such as the companion acting as an ‘eyewitness’ to care the motivation to adhere to respectful maternity care (RMC) standards remains low10,27
This concept is explained within TDF domains, such as obtaining community feedback and utilizing social accountability, optimism, and emotion. Companions could play a vital role by providing emotional support, comforting the woman, and helping to relieve labor pain in addition to emotional support.
Companions also provide practical support such as ensuring that the woman stays hydrated and nourished, managing cleanliness by wiping wet beds, and escorting her to the restroom when needed. The practical support provided by companions not only helps to meet the physical needs of a woman but also strengthens emotional support and creates a holistic approach to care. The lack of rewards for providing respectful care indicates a healthcare system gap that could affect Automatic Motivation. The notion of social accountability is crucial here; when healthcare providers recognize the importance of companions and actively involve them in the care process, it fosters an environment in which respectful care is prioritized. 28
Engaging with the broader Ethiopian context of disrespect and abuse during childbirth reveals that the exclusion of companions is often a symptom of power imbalances within health facilities. The presence of a companion of choice acts as a social accountability mechanism, or an ‘eyewitness’, which is a critical deterrent to the disrespectful behaviors and negative psychological impacts as documented in global studies.13,14 Thus, institutionalizing labor companionship is a structural requirement for shifting the culture from 1 of ‘minimal and overlooked’ care to 1 of Respectful Maternity Care (RMC).
Maintaining companion support can also help with skin-to-skin contact immediately after birth, which is essential for starting breastfeeding. The newborn Friendly Hospital Initiatives (BFHI) recommend that newborns receive colostrum and start breastfeeding during the first hour of life, which can be achieved via prenatal care and labor companions who offer continuous support. Having a companion during labor and delivery is emphasized by the BFHI, which is in perfect harmony with continuous support and makes the experience safe and powerful for the mother. 29
Physical Opportunity: Opportunities as a result of environmental factors affecting labor companion implementation, space limitations, overcrowding, privacy issues, restrictions on timing and number of visits, labor companions not having time, labor companions not knowing how to provide support to women, and no health facility policy. Restricted physical space in maternity wards, overcrowding, and multiple beds in the same ward were major concerns regarding the low practice of continuous labor companion support during labor and childbirth.
The documented environmental challenges, such as labor wards containing 3 beds per room without separators, represent a structural design that prioritizes clinical throughput over individual privacy. This architectural constraint does more than just limit space; it serves as a tool of exclusion by making the presence of a companion particularly a male partner functionally impossible without violating the confidentiality of other laboring women. Consequently, until facility designs move away from ‘sterile’ open wards toward spaces that include infrastructure for privacy (like curtains and chairs), the physical environment will continue to dictate the denial of a woman’s human right to support. This leads to restrictions on the timing of visits and the number of visitors allowed by health providers. This is a challenge and may need to be adjusted before optimizing the practice of continuous labor companion support.
Addressing structural barriers like overcrowded wards is essential to ‘minimizing the perceived risk of violation’. As studies on the Ethiopian institutional culture suggests, spatial constraints are often used to justify the exclusion of companions, which in turn increases the risk of D&A.10,27 Therefore, environmental changes are a prerequisite for establishing an institutional culture of dignity. This study is similar to a study performed in Thailand. 2 Understanding women’s social contexts, including family dynamics, cultural expectations, and potential barriers to support, is crucial for effectively implementing continuous labor companion support. Family relationships can greatly influence a woman’s ability to have a companion during labor. However, a lack of family support or a family’s negative attitude toward companion support during childbirth may negatively affect the mother. Cultural beliefs and traditions surrounding childbirth can dictate how and by whom women are supported. In some cultures, women may feel shame or embarrassed, especially in the presence of male healthcare providers. Cultural norms can also restrict companion choices. 29
Reflective Motivation: Risks and benefits of continuous companion labor support, reflective processes, and beliefs, including professional codes of conduct, human rights, beliefs about capabilities, optimism, beliefs about consequences, and intentions. Fear of misunderstandings and lawsuits, and fear of increased workload for health workers.
While providers may fear conflict or lawsuits, the integration of companions actually addresses the ‘serious problem’ of mistreatment documented in Ethiopian studies.10,27,30 Framing labor companionship as a Reflective Motivation rooted in human rights allows providers to see the companion not as a clinical hindrance, but as a deterrent to the disrespectful behaviors that currently compromise birth outcomes in the national context.
Furthermore, the gendered expectation that intrapartum care is a female only space which often excludes male partners due to ‘confidentiality’ concerns further complicates women’s autonomy and choice. The finding that companions are valued as ‘eyewitnesses’ who ‘follow the progress of labor and how care is offered’ highlights a lack of institutional transparency. In this context, the labor companion serves as a vital social accountability mechanism, bridging the power gap between the silent patient and the clinical hierarchy to ensure that care remains dignified and respectful.
Room structures with limited space resulting in overcrowding, privacy issues, fear of infection spread, and fear of conflict between health workers and labor companions were some of the challenges addressed in the labor ward. The lack of companionship policies at health facilities may be another challenge because labor companions are subject to visitor restrictions. 6
Psychological Capability: Knowledge, education, and awareness; behavioral regulation; no previous adequate knowledge; and labor companion knowledge. Currently, the birthplace has shifted from home to health facilities where skilled health providers are present.
Although, healthcare providers acknowledge companionship as a ‘human right’, institutional staffing priorities remain heavily skewed toward clinical labor progress and medical outcomes, leaving the psychological and emotional components of care ‘overlooked’. This suggests an institutional culture where emotional support is viewed as a non-essential ‘favor’ rather than a core clinical competency. To move beyond this, health systems must reframe the labor companion as a member of the maternity care team an ‘eyewitness’ and ‘communicator’ who reduces provider workload by managing non-clinical tasks thereby aligning companionship with the practical needs of an overstretched workforce
This could change if labor companions had adequate information about the labor process, knew their roles and expectations, and knew how to offer support, aside from their physical presence. Emphasis on companions may be reduced by including them in antenatal care visits. This is because it helps them to receive information on the labor process, how to offer emotional support, and comfort measures during the intrapartum period at home and in health facilities. In addition, their participation in antenatal care may help them understand their roles and expectations in the labor ward. 31
However, the psychological and emotional components of intrapartum care have been overlooked. Therefore, introducing labor companions to the maternity care team is critical. Health facility policies on labor companions: Women and potential labor companions greatly valued companion support. 32 However, health workers recognized serious structural influences, such as limited space, lack of companion training, and the absence of a companion policy at health facilities, as challenges to implementing the WHO’s recommendations of companion choice. 3
The findings reveal that the majority of facilities lack a formal labor companion policy, which results in a failure of institutional enforcement. In the absence of explicit protocols, companions are subjected to generic, restrictive visitor policies, making their presence dependent on the individual ‘permission’ of staff rather than a standardized patient right. This institutional vacuum allows for ‘minimal and overlooked’ practice, even when providers believe in the benefits of support. Policy enforcement is therefore not just about creating guidelines, but about formalizing the companion’s role through explicit facility level protocols that define eligibility and responsibilities to minimize perceived risks of violation.
Finding from the current study is similar with a participatory studies involving health workers, information education materials for companions, and some environmental changes (chairs and curtains around beds) to address the existing barriers performed in the 3 Arabic countries were a useful approach to optimize the practice of labor companions per WHO’s recommendations. 33 Another study conducted in Kenya among public maternity units showed that mothers’ and health workers’ perceptions of labor companions revealed facilitators to labor companions and roles that companions could play. 25 This study identified social barriers, such as women’s belief that labor companions cannot help them, discomfiture when non-health workers see them during the intrapartum period, and fear that the labor companion would share what she/he saw during birth with others.
A few women believed that their partner/husband was the best choice for understanding the pain and observing the support offered at times of difficulty. This was different from previous studies in which most women chose their mothers as companions. Culture and sex may affect the choice of companions. An implementation study performed in 3 Arabic countries, Egypt, Lebanon, and Syria, used participatory engagement through engagement with hospital leaders, seminars with healthcare providers, communication materials for companions, and changes to the physical space (chairs for companions, curtains around beds, access to hot water and toilets, and disposable gowns and nametags for companions) to address these barriers, 33 which may also be useful when optimizing the practice of continuous labor companionship. Most women and companions believed a partner or husband to be the optimal companion choice, believing that witnessing pain and support during difficult times could strengthen family bonds, including the father and the baby, which was consistent with previous studies. 34 This finding is different from those of other women in India and Bangladesh; most women wanted their mothers to be companions.35,36 Having a female companion, especially a mother, could yield other benefits as she can share her own experiences of childbirth, which could serve as encouragement for women.
Effective reproductive health policy must go beyond ‘rights on paper’ by diagnosing and resolving the behavioral and structural bottlenecks identified in clinical settings. By centering the insights of healthcare providers who act as both human rights defenders and facilitators of dignified care states can implement targeted interventions: specifically, clarifying the limits of service refusal, investing in facility infrastructure for privacy, and utilizing trainings to foster an institutional culture of respect and accountability. 37
Implication for Practice
Not being able to fill the gap in the non-clinical components of care in the intrapartum period affects women ’sand their families’ childbirth satisfaction, which in turn affects service provision. To optimize the implementation of continuous labor support in Ethiopia, specific and feasible institutional changes are required. First, facilities should prioritize low-cost spatial adaptations, such as the installation of bed curtains and the provision of chairs, to address the infrastructure-related privacy barriers identified in this study. Second, targeted companion orientation should be integrated into routine ANC services, utilizing Behavioral change communication materials to provide role clarity and training in comfort measures like massage. Finally, the formulation of explicit hospital-level policies and provider training on non-clinical care are essential to move labor companionship from a rare practice to a formalized standard of Respectful Maternity Care.
Lastly, this study suggests that reorganization of the labor room and the development of behavior change communication materials are necessary to overcome structural bottlenecks. Targeted interventions must include low-cost environmental changes (chairs and curtains) to address privacy, and the integration of companions into Antenatal Care (ANC) to ensure they possess the psychological capability to function effectively within the clinical environment.
Strengths and Limitations
Collecting data immediately after birth to minimize recall bias and using different stakeholders (women, health professionals, and MCH heads) to help address different perspectives within the health facility, observational assessments were the strengths of this study.
In addition, the framing key identified enabler and hindrance factors that assist labor companions practice by using a combined behavioral model of COM-B and TDF to guide decision-making at the time of intervention and support theory-based intervention strategies was the strength of this study. All study health facilities were in urban and governmental health facilities with relatively high cesarean section rates compared to other health facilities outside the study, which could be a limitation of this study. In addition, interviews were conducted in the study health facilities, so the probability of introducing social desirability bias was high. Another limitation is that for this study, only governmental health facilities were considered, as including private health facilities in other studies might be important and could be used for compression.
The timing (during discharge) meant women were in a physically and emotionally vulnerable state, which may have led to shorter or more ‘compliant’ responses.
Conclusions
Integrating the labor companion support practice with maternity units, as explained by women and healthcare providers, benefits the improvement of services.
Health providers’ attitudes toward labor companions and their training on how to provide emotional support, information support, and comfort measures, in addition to physical presence, is a critical issue that needs to be explored to narrow the gaps in non-clinical support.
Labor companion engagement may result in maternal childbirth satisfaction and contribute to the quality of care for service provision. Conversely, challenges to the optimization of the implementation of the WHO’s recommendation on companions need to be solved to maximize the likelihood of achievement. These include structural changes to ensure privacy and companions’ policies are present. Context-based interventions must be considered to ease health workers’ concerns about labor companion misunderstandings and lawsuits from the introduction of labor companions. Health workers also need to recognize labor companions’ engagement as part of the women’s care team, minimizing the perceived risk of violation, and knowing how labor companions can be beneficial. The results will be considered when optimizing WHO’s recommendations on companion implementation strategies.
Patient and Public Involvement Statement
Stage of Involvement
Patients and members of the public were first involved in this research during the initial study design and proposal writing stages. Patient representatives were selected based on their involvement with local healthcare initiatives and their diverse backgrounds, ensuring a broad range of perspectives. The selection process involved open calls through community bulletin boards and outreach programs, aimed at including representatives from different age groups, genders, and health experiences to better reflect the community’s diversity.
Research Question and Outcomes
Two patient representatives from our local community advisory group (CAG) contributed to the development of the primary research questions, ensuring that they were aligned with patient priorities. Their input was gathered through a series of structured meetings and surveys, which enabled comprehensive discussions and collection of diverse perspectives. During these sessions, any disagreements were addressed through facilitated dialog, ensuring that all voices were heard and a consensus was reached before finalizing the questions. Additionally, they reviewed and refined the proposed outcome measures to ensure that they were relevant and meaningful from the patient’s perspective.
Study Design and Conduct
CAG members provided valuable feedback on the study protocol, specifically assessing the proposed procedures and time commitments to ensure that the burden on the participants was justifiable and clearly explained. Their input led to a revised, patient-friendly information leaflet and consent form.
Informed Consent Statement
Participants confirmed their voluntary participation by signing the consent form before we started the IDIs. We followed the anonymity of the data, and there were no identifiers in the interviews. The study objective and procedures were explained to each participant by the research team and written on the information sheet. After participants confirmed their voluntary participation by putting their signature on the consent form, we started in-depth interviews. In-depth interviews were conducted in a convenient, isolated area. All participants who volunteered to participate were requested to sign a consent form. In addition, for those who voluntarily participated in interviews, it was explained that there was no relationship between the information they provided during the interview and the healthcare they received. We followed the anonymity of the data and there were no identifiers
Supplemental Material
sj-docx-1-inq-10.1177_00469580261433850 – Supplemental material for Barriers and Facilitators of Continuous Labor Companion Support in Ethiopia: Qualitative Formative Study on Facility Readiness and Respectful Maternity Care
Supplemental material, sj-docx-1-inq-10.1177_00469580261433850 for Barriers and Facilitators of Continuous Labor Companion Support in Ethiopia: Qualitative Formative Study on Facility Readiness and Respectful Maternity Care by Gedamu Abera Zegeye, Muluemebet Abera Wordofa and Afework Mulugeta in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Supplemental Material
sj-docx-2-inq-10.1177_00469580261433850 – Supplemental material for Barriers and Facilitators of Continuous Labor Companion Support in Ethiopia: Qualitative Formative Study on Facility Readiness and Respectful Maternity Care
Supplemental material, sj-docx-2-inq-10.1177_00469580261433850 for Barriers and Facilitators of Continuous Labor Companion Support in Ethiopia: Qualitative Formative Study on Facility Readiness and Respectful Maternity Care by Gedamu Abera Zegeye, Muluemebet Abera Wordofa and Afework Mulugeta in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Supplemental Material
sj-docx-3-inq-10.1177_00469580261433850 – Supplemental material for Barriers and Facilitators of Continuous Labor Companion Support in Ethiopia: Qualitative Formative Study on Facility Readiness and Respectful Maternity Care
Supplemental material, sj-docx-3-inq-10.1177_00469580261433850 for Barriers and Facilitators of Continuous Labor Companion Support in Ethiopia: Qualitative Formative Study on Facility Readiness and Respectful Maternity Care by Gedamu Abera Zegeye, Muluemebet Abera Wordofa and Afework Mulugeta in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Acknowledgements
We thank the study participants, data collectors, facility heads, and supervisors for their vital roles in generating this research evidence. We acknowledge Jimma University, Faculty of Public Health, Department of Population and Family Health, for their assistance. We thank the Addis Ababa Health Bureau for their cooperation and support. Finally, we express our sincere gratitude to our friends and family for their unwavering support.
Ethical Considerations
Ethical clearance was obtained from the Jimma University Institutional Review Board (Ref. No: JUIH/IRB 108/22) on August 11, 2022. Formal support letters were also secured from the Addis Ababa Health Bureau (Ref. No: A/A 2077/277) on August 29, 2022. All study participants provided written informed consent after being briefed on the study objectives, risks, and benefits. Participant confidentiality was ensured through the use of unique identifiers and secure data storage.
Author Contributions
G.A.Z. and M.A.W. drafted the manuscript. A.M. helped to edit and review the manuscript. G.A.Z., M.A.W., and A.M. helped with statistical analyses, interpretation of results, and proofreading of the manuscript. All authors contributed to the discussion of the paper and have read and approved the final version of the manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Jimma University. The funders had no role in the study design or data collection. Collection and analysis, decision to publish, or preparation of the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Upon request, the corresponding author will provide the data used to support the conclusions of the study. The data were not publicly available because of the need to maintain the information and privacy of the research participants.
Supplemental Material
Supplemental material for this article is available online.