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Abstract

Background:

Labor companions often lack clarity about their support roles during childbirth. Therefore, this study aims to analyze factors influencing companions’ adherence to support roles during labor and childbirth.

Methods:

A convergent parallel mixed-methods design was used to examine factors influencing companions’ adherence to support roles from May to June 2024. Systematic random sampling selected 320 participants from the maternity ward. Data were collected via face-to-face exit interviews. Purposive sampling chose 24 labor companions for in-depth interviews. Adherence to support roles was measured using a four-point Likert scale, ranging from “not at all” to “all of the time.” Ethical approval was obtained from the IRB at Jimma University, and support letters were secured for each study facility. Written consent was obtained from all participants.

Results:

Companions’ adherence to support roles during childbirth had an overall mean score of 1.39 (95% CI: 1.29–1.49) on the four-point Likert scale. Specifically, 27.5% of companions reported not at all, and 35.63% reported only a little support, while 17.19% reported providing support all of the time. Awareness among companions was associated with increased adherence to support roles (B = 0.238, p = 0.029). Nevertheless, companions with less prior experience (first time: B = −0.377, p = 0.001; second time: B = −0.280, p = 0.031) showed significantly lower adherence to support roles. The qualitative data also explored that, unclear role definition, unwelcoming approach of healthcare providers, and social-cultural factors were associated with minimal adherence to support roles.

Conclusion:

A structured orientation session for companions is a vital recommendation to address hindering factors to their support roles. Such a session might equip them with techniques how to provide.

Keywords

Labor companions level of adherence to support roles Ethiopia

Introduction

In recent years, there has been an increased focus on the role of labor companions during labor and childbirth.¹ It has shown that companions can offer practical assistance and increase emotional support.² World Health Organization (WHO) advocates that all women recommended to have companion of their choice during childbirth.³ In this context, companions are individuals chosen by a woman to provide emotional and physical support during childbirth. These companions may include partners, friends, or family members.^3,4 While labor companions are known to improved outcomes, positive experiences, and a reduction in mistreatment during childbirth, there is indeed a significant gap in detailed information on their support roles.⁵ How companions work and the varied experiences of various companion types.⁶ Addressing these gaps through comprehensive research will be crucial for optimizing companion involvement in maternity care. Eventually, recognizing and valuing the support role of companions in labor and childbirth not only enriches the experience for those giving birth but also fosters healthier outcomes for mothers and newborns alike.⁷

In Ethiopia, utilization of companion support by women during labor and childbirth is underutilized, with studies reporting rates between 14% and 20%. This means that less than one in four women in Ethiopia have received companion support during labor and birth in health facilities.⁸ Despite the strong desire for companions’ support during childbirth, this low rate has occurred.^1,8 Ethiopian maternity guidelines recommend that healthcare providers encourage women to have their preferred companions present during childbirth and ensure that these companions have the necessary information.⁹ However, few studies have explored companions’ perceptions of their support roles during childbirth, particularly in the study area.

There is a lack of understanding regarding how companions perceive their roles and the impact of those roles on the birthing experience.⁸ No study, to our knowledge, examined the perceptions and experiences of companions of choice regarding their support roles in Ethiopia.

As a result, little is known about how these support roles are followed in Ethiopia. Additionally, this study investigates the difference between a companion’s presence and their compliance with assigned support roles. Limited quantitative and qualitative research has investigated the specific barriers encountered by labor companions across diverse cultural and socioeconomic contexts, which affect their ability to adhere to their roles. Furthermore, there has been inadequate exploration of how different types of labor companions, such as partners, mothers or mothers-in-law, and friends, experience and navigate their roles.

Objective

To determine the companion’s level of adherence to support roles and associated factors during labor and childbirth in healthcare facilities in Addis Ababa, Ethiopia.

Specific objectives

To assess the companion’s level of adherence to support roles.

To identify the factors associated with a companion’s level adherence to support roles.

To explore enabling and hindrances factors affecting companions level of adherence to support roles.

Methods

Study area

The study was conducted in government health facilities in Addis Ababa, which provides both basic and comprehensive obstetric care. These facilities are part of the larger health care system in Addis Ababa, where public health facilities play a significant role in providing maternal and child health services. The study focused on the implementation of WHO recommendations for a companion of choice during labor and delivery, specifically within facilities offering both basic and comprehensive obstetric care.

Study period

The exit interviews were conducted from May to June 2024, specifically during the discharge process after delivery.

Study design

A mixed method of the convergent parallel design type was used. In order to give us a more comprehensive and in-depth understanding of phenomena, mixed techniques incorporate aspects of both qualitative and quantitative approaches.¹⁰ With a sufficient sample size to improve generalizability, quantitative approaches enable the objective measurement of a specific reality.¹¹ However, the “why” of occurrences and how individual perspectives, environment, and meaning create various realities are not well explained by quantitative approaches.¹¹ Although qualitative approaches aid in addressing this shortcoming, their generalizability is constrained by sample size constraints. Therefore, mixed approaches were suitable to provide a comprehensive understanding of companions’ adherence to support role difficulties by balancing the shortcomings of both quantitative and qualitative methods and yielding the strengths of both.¹¹ This integration allows for a more exploration of how different factors influence adherence to support roles. By leveraging the strengths of both methodologies, researchers can uncover deeper insights that might otherwise remain obscured. This integrative approach allows researchers to capture the complexity of human experiences while still offering insights that can be applied more broadly. By combining numerical data with rich, narrative information, a more nuanced picture of the dynamics at play in support roles can emerge, ultimately facilitating better interventions and support strategies.

The quantitative methods provide data for measuring magnitude and examining statistical associations, and the qualitative data help to explain the quantitative findings and provide rich descriptions of views and beliefs about companions’ adherence to support roles. We collected data from companions who provide support for women who have recently given birth.

We collected quantitative data from companions of choice, and the qualitative data were characterized as descriptive, according to the consolidated criteria for reporting qualitative research (COREQ),¹² to provide detailed and comprehensive accounts of their experiences, opinions, or phenomena without attempting to develop a theory or test a hypothesis.

Sample size determination

Quantitative study

The sample size was calculated considering the following assumptions proportion of labor companions utilization (p) = 0.14, from a study done in Ethiopia by Beyene Getahun etal.⁸ Margin of error, considering 5%, with 95% confidence interval (CI). Then, the final total sample size by adding 10% nonresponse rate was become 320 companions.

Qualitative study

Purposive sampling was utilized to select participants from health facilities. The total sample size was 30 In-depth Interview (IDIs) from 12 health facilities, with number of targeted IDIs was 2–3 for each facility. Initially, health workers identify voluntary women and companions of choice at each unit. If participants agreed and voluntary to participate, then a person from research team approaches the participants to face-to-face exit interview. A total of 24 labor companions participated till data saturation was reached. A qualitative study successfully achieved data saturation with 24 participants (labor companions), meaning the data collected no longer revealed new information or ideas from the data and recurring themes are consistently observed ensuring a full understanding of the topic.

Dependent variables

Companions’ level of adherence to support roles. The outcome variable was described based on the WHO recommendation¹³ and other studies^14,15 on companions’ level of adherence to support roles. The companions adherence support roles includes (i) information support, (ii) emotional support, (iii) comfort measures and (iv) advocacy.^3,14,15

To measure companions’ adherence to support roles, we used a pretested questionnaire with a four-point Likert-type scale. Companions rated the frequency and quality of support provided, using the Birth Companion Support Questionnaire (BCSQ), which assesses emotional and tangible support on a Likert-type scale that measures overall labor support. BCSQ: This tool measures both emotional (e.g., reassurance) and tangible (e.g., comfort measures) support provided by a companion.¹⁶ It typically uses a four-point Likert scale to rate how often support was provided¹⁶ with four points Likert scale items ; 0 = “Not at all,” 1 = “A little,” 2 = “Most of the time,” and 3 = “All of the time.” Participants whose response “not at all” considered as low companion adherence to support roles while, those with response “All of the time” was considered as higher companions’ adherence to support roles. The mean score of the response was used to compared and predict sociodemographic and other variables.

Independent variables included sociodemographic (companion’s age, educational status, occupational status, and types of relationship), labor companions experiences (time of companion support provided, awareness of companions on continuous support, sufficient time to provide continuous support, history of companions jointly attend antenatal care, companions knowledge on benefits continuous support, and companions previous experiences), and facility factors (privacy issue, companions satisfaction with health care assistance). In multivariate analysis, we controlled for potential reporting bias by place of interview and postpartum length.

Quantitative data collection

Data were collected from randomly selected 12 governmental health facilities. Eligible companions were the identified and recruited from the selected heath facilities. We used systematic random sampling to recruit eligible companions in the postnatal ward before discharge. Twelve data collectors were trained to conduct the face-to-face exit interview in local language Amharic in private spaces in health facilities. Labor companions were included during normal postpartum in maternity ward that had gone through the labor and delivery process in the last 24 h in the health facility.

Sampling techniques

Proportional allocation

This technique ensures that the number of participants from each study health facility is in proportion to the actual number of companions that provide support to women who give birth in the health facilities, helping to create a representative sample.

Systematic random sampling

To select participants from a list of births attended in the health facilities and accompanied during labor and childbirth. Using the following assumptions, the total sample size was 320 companions, with 12 study health facilities. The average birth per day was four births per study health facility, and the average desired sample size per health facility was 27. Then, K = N/n, 112/27 = 4, kth = 4, The number of births per day ranges from 1 to 4; the randomly selected number was 3, and then the companion who provide to birthing woman on the 3rd, 7th, 11th, 14th, 17th, etc., at the study health facility was selected.

Data collection timing

Approaching companions of choice soon after birth helps ensure they are part of the target population for the study.

Inclusion and exclusion criteria

Companions of choice from selected by the birthing woman could be partners, family members and friends, companion from a woman who gave birth spontaneous vaginal delivery were included, while companion from health professionals, trained doulas and companion from a woman with the mode of delivery with cesarean section were excluded.

Qualitative data collection

Purposive sampling was utilized to select participants from health facilities. We conducted 24 IDIs with labor companions from 12 health facilities across the study area. With permission from the facility heads to conduct the study, the research assistants approached labor companions in selected facilities, briefed them about the study, and invited them to participate in the interviews. The interviewers used an interview guide with both closed and open-ended questions. Providers were asked, among other things, if women were allowed for continuous support roles, their perceptions of companion support roles, and barriers to providing it in their facilities. Interviews were conducted in Amharic in private spaces in each health facility and lasted about an hour. Labor companions experience on continuous companions support provision. The number of participants for the qualitative study was participants from quantitative participants and the intention was to explore results in a greater depth.¹⁷

Instruments and measurements

A pretested tool was used to collect data on labor companions’ experiences of support provision. The instrument has the following parts: (1) socio-demography of the participants, (2) knowledge and continuous companion support experiences, (3) perceived companions’ level of adherence to support roles using BCSQ.

Birth companion support questionnaire

It was adapted to measure the labor companions’ response on the perceived support they provide to laboring woman. The tool was pretested before it was measured using 12 items of the BCSQ with four domains: Information Support (4 items), Emotional Support (3 items), Comfort Measures (4 items), and Advocacy (3 items). They had 12 items with four-points Likert sale items and response format with anchors of “Not at All” = 0, “A Little” = 1, “Most of the time” = 2, and “All of the time” = 3(16). The tool is valid and reliable with Cranach’s alpha (0.977) in the current study.

Qualitative data

Observation

On arrival, maternity care providers select one woman with her labor companion for the day to explore details of support provided for the selected labor companion. Written consent was asked and received from each participant. The observers tried their best not to interfere with care provided to woman in labor but focused on the support actions being provided.¹⁸

Observation commenced from the point of admission till 1 h after birth for each participant with an average duration of 8 h. Observation focused on viewing the support actions provided by the birth companion. Careful observations were made looking out for the general sequence of events, supportive actions provided by the birth companion, actual interactions including physical, verbal, and nonverbal cues. To minimize the Hawthorne effect, the observer tried their best not to interfere or manipulate the care of the woman in labor but focused on the support actions being provided for the woman.

In-depth interview

Following birth, an in-depth interview was conducted the following days. The IDIs was conducted in private room at the postnatal unit before discharge. Interview was conducted to ascertain the companion’s needs and feelings with regards to offering continuous support. The interview was regarding the roles of labor companion during childbirth and expectations of labor companion.¹⁹

The interview questions were developed basing on literature regarding women’s needs of care during childbirth and the responsibility of the birth companion. Participants were asked open-ended questions such as “please tell me about your experience of support provide during labor and childbirth.”, “tell me about the types of support you provide for the mother,” “have you ever provided this type of support before,” “what would you need in order to be a good labor companion.” In addition, the interviewer probed if the companion met the desired support.

The interviews were audio recorded with participant’s permission and each interview lasted an average of 45 min.

Data quality assurances

Data were collected by trained BSc midwives in face-to-face exit interviews using questionnaires. The tool was pretested in 15 companions of choice before being used for the general study, and some correction was done based on the findings. An open-ended question used to interview companions on their adherence to offering continuous support at time of intrapartum period.

Quality control

Training on data collection and procedures was given. Data were checked for completeness, accuracy, and consistency.

Trustworthiness

For trustworthiness of data, triangulation was done by combining observation and interviews, continuous observation, peer debriefing after data collection, and detailed descriptions were done.

Data analysis

Quantitative data analysis

Data were checked for completeness, accuracy, and consistency. We use imputation which is a recommended technique for replacing missing values with several plausible values, preserving sample size and reducing bias by accounting for the uncertainty of the estimated values.

First, we conducted descriptive analysis to examine the characteristics of the participants and to assess companions’ level of adherence to support roles.

Next, we compare the means score of companions’ level of adherence to support roles using one-way ANOVA after checking the assumptions. The normality assumptions and the homogeneity of variance were checked using a Q–Q plot and Levene’s test. Accordingly, the companions’ level of adherence to support roles violated the assumption of normality and homogeneity of variance, while for nonnormally distributed variable we used the Kruskal–Wallis test analyses to compare the mean score with sociodemographic variables.

Furthermore, GLM analyses were employed to test the change difference in means score between selected variables. The Gaussian family, identity link, and unstructured correlation matrix were considered during fitting the model and controlling for the possible potential confounding factors. Beta coefficients along with 95% confidence intervals (CI) were used to report the results and variables with a p-value of <0.05 were considered statistically significant.

Qualitative data analysis

Latent content analysis was used; this enabled in-depth interpretation of the underlying meanings of the text and condensing data without losing its quality. The audio recordings were transcribed verbatim and were then de-identified. Analytical notes, thoughts, and reflections were made in this process with the aim of comprehending data collected. Data were then broken down into smaller meaning units, and each identified meaning unit was labeled with a code, as understood in relation to the objective of the study.²⁰ We coded data inductively, considering both the semantic (surface) and latent (underlying) meaning of the text, focusing on salience rather than frequency. We iteratively read and re-read the transcripts and coded line-by-line across the entire dataset; then analyzed initial codes to generate categories and identify themes.²⁰ Again reviewed transcripts until no new themes emerged. Throughout the process, we wrote analytic and reflexive memos to capture emerging ideas and examine our assumptions, preconceptions, and reactions to the data. For example, we started the study with the overall care of the healthcare facility and their satisfaction with care, then we go through types of companion support, good companion support, and challenges faced during support provide. To ensure the accuracy, dependability, and credibility of findings, we use reliable strategies include verifying source credibility, conducting thorough data cleaning, avoiding biases, maintaining detailed records of our process, and undergoing peer review. We analyzed the data with the help of Atlas.ti.7.5.18.

After separate analysis of both the quantitative and qualitative data, results were combined by connection.¹⁷ A “joint display”²¹ with quantitative data that resulted in greater and lesser scores connected to qualitative data.

Ethical consideration

The study was performed in line with the principles of the Declaration of Helsinki. The ethical approval was granted by Jimma University Institutional Review Board (IRB) with reference number: JUIH/IRB 108/22 on the data 11/08/22 and support letter for each study health facilities from Addis Ababa Health Bureau Ref.No: A/A 2077/277on the date of 23/12 /14 E.C. Study objective and procedures was elucidated to each participants from research team, and written informed consent was obtained from all participants. The interview was conducted in a convenient and isolated area. All companions who were voluntary to participate were asked to sign the consent form. For health facility observation assessments, we obtained permission from each health facilities heads as per the support letter from Addis Ababa Health Bureau. Also, for those who voluntarily participated in interview, it was explained that there was no relationship between the information they gave us during the interview time and health services they received. Anonymity of data, no identifier in the interview. Participants with no formal education, we used thumb print of the participants and signature of the witness.

Results

The sociodemographic characteristics of both the survey interview participants and IDIs respondents were presented in Table 1. A total of 320 respondents participated in the in face-to-face interview (Survey Interview) with a response rate of 98.9%.

Table 1.

Sociodemographic variables of participants on companion support roles during labor and childbirth in health facilities of Addis Ababa, Ethiopia, 2024.

Items	Survey respondents		IDIs respondents
Items	Frequency (n)	Percentage (%)	Frequency (n)	Percentage (%)
Total	320	100%	24	100%
Age in number (in years) Mean (SD)	33(6)		37(6)
Age in categorical
24–29	106	33	6	25
30–34	80	25	5	20.8
35–39	64	20	6	25.0
40 and above	70	21.9	6	25.2
Occupation
Employed	147	45.9	9	37.5
Private work	102	31.9	7	29.17
Housewife (Women companion)	71	22.2	8	33.33
Educational status
No read and write	33	10.3	2	8.3
Read and write	94	29.4	4	16.7
Elementary school	54	16.9	4	16.7
Secondary school	65	20.3	7	29.2
College and above	74	23.1	7	29.2
Gender
Male	127	39.7	10	41.7
Female	193	60.3	14	58.3
Types of relationship
Partner/husband	119	37.2	8	33.33
Mothers/mother in-law	124	38.8	11	45.83
Friends and neighbors	77	24.1	5	20.83
Timing of birth (Shift)
Daytime	138	43	13	54.2
Nighttime	182	56.9	11	45.8
Awareness about continuous support
Don’t know	107	33.4	_	_
Somewhat aware	138	43.1	14	58.3
Fully aware	75	23.4	10	41.7

The mean age of the participants was 33 with 6 years standard deviation (SD). Educational status of the participants was10% of them were can’t read and write and 23% of them were college and above.

Related to participant’s occupation, about 46% of the companions were employed and 22% of them were housewife for female companions. The IDIs participants were older and had lower education as compared to survey participants. About two-fifths of the companions were mothers (Table 1).

Companions’ response to support scale questionnaires (BCSQ)

The participants response to the BCSQ presented in Figure 1 show that, majority of the response lies between “not at all” (27.5%) and “a little” (35.63%). The mean score across all observation is approximately 1.39 with (95% CI: 1.29–1.49) lower standard error (0.05), and this shows that the sample mean is a precise estimate of the population mean. The means score of companions’ response was to the four-point Likert scale items. The value lies between the scale range of “not at all” and “a little.” This indicates inadequate level of support resulting in higher rates of nonadherence to support roles. Both the mean score and response distribution show there is low companions’ adherence to support roles (Figure 1).

Figure1.

Companions response distribution to support scale in Addis Aaba, Ethiopia.

Mean score distribution of companion’s support roles with their sociodemographic characteristics analyzed using Kruskal–Wallis test

The above table presents the results of a Kruskal–Wallis test analyzing the mean score distribution of companion support roles based on their various sociodemographic characteristics of the respondents. The Kruskal–Wallis test is a nonparametric method used to compare three or more independent groups when the dependent variable is not normally distributed.

The age group of the participants were not statistically significant, even if there was mean rank difference between the age groups (p < 0.062). There is a mean rank difference between genders, but not statistical significant. The mean rank (170.87) for males was higher than the mean rank for females (153.68) with p-value: 0.098. Related to marital status of the respondents, the mean rank (178.81) of divorced individuals had higher than individuals who were married, with mean rank of (156.12) and not statistically significant, p-value: 0.325.

Related to the occupational status of the participants, housewives had the highest mean rank (200.340), while employed individuals had the lowest mean rank (148.19) and was significant (p-value: 0.000) indicates a statistically significant difference among occupation groups. Suggesting that occupation significantly influences perceptions of companion’s support roles.

The educational status of the participants was statistically significant. Individuals with “College and above” had the highest mean rank (224.85), while those who can “Read and write” have the lowest (91.44). The mean ranks among educational status of the groups were statistically significant (p-value: 0.000). Suggesting that educational status has a strong influence on perceptions of companion support roles.

The type of companion’s relationship was statistically significant (p-value: 0.006). Friends and neighbors had the highest mean rank (187.69), while partners/husbands have the lowest mean rank (145.27). This statistically significant difference among the types of relationships suggest that the nature of the relationship significantly affects perceptions of companion support.

Individuals who provide support during the daytime had a higher mean rank (188.65) compared to those who provided during nighttime (139.15). The difference in mean rank was statistically significant (p-value: 0.001). Indicates a statistically significant difference based on the time of birth.

The mean rank among groups with fully aware individuals had the highest mean rank (176.25) as compared to those individuals not aware (153.50). But not statistical significance (p-value: 0.217).

History of companions’ not attending antenatal care jointly with the pregnant mother had a higher mean rank (171.07) as compared to those who did (140.33). This statistical significant (p-value: 0.004) values indicate a statistically significant difference in perceptions based on whether companions attended ANC jointly.

The companion’s experiences who provide three or more had higher mean rank (180.09) than those who provided first time support (157.67), but this was not statistically significant (p-value: 0.235) among experience levels (Table 2).

Table 2.

Comparing mean score distribution of companion’s adherence to support roles and sociodemographic characteristics analyzed using Kruskal–Wallis test Addis Ababa, Ethiopia.

Items	N (%)	Mean rank	Test statistics (H)	p-Value
Age in categorical
24–29	106(33)	179.27	7.35	0.062
30–34	80(25)	152.48
35–39	64(20)	156.58
40 and above	70(21.9)	144.83
Gender
Female	193(60.3)	153.68	13.57	0.098
Male	127(39.7)	170.87	13.57	0.098
Marital status
Single	58(18.1)	165.03	2.24	0.325
Married	223(69.7)	156.12
Divorces	39(12.2)	178.81
Occupation
Employed	147(45.9)	148.19	17.58	0.000
Private work	102(31.9)	150.50
Housewife (Women companion)	71(22.2)	200.34
Educational status
College and above	105(32.8)	224.60	85.25	0.000
Secondary school	91(28.4)	141.55
Elementary school	56(17.5)	134.75
Read and write	32(10.0)	91.44
No read and write	36(11.3)	123.6
Types of relationship
Friends and neighbors	77(24.1)	187.69	10.317	0.006
Mothers/mother in-law	124(38.8)	158.23
Partner/husband	119(37.2)	145.27
Time of birth
Day time	138(43)	188.65	23.29	0.000
Night time	182(56.9)	139.15	23.29	0.000
Awareness about continuous support
Not aware	107(33.4)	153.50	3.054	0.217
Somewhat aware	138(43.1)	157.37
Fully aware	75(23.4)	176.25
Companion jointly attended ANC
No	210(65.6)	171.07	8.26	0.004
Yes	110(34.4)	140.33	8.26	0.004
Companion experiences on continuous support
First time	202(63.1)	157.67	2.896	0.235
Second time	67(20.9)	154.12
Third time and above	51(15.9)	180.09
Knowledge on benefits about continuous support
Increased spontaneous vaginal delivery	82(25.6)	155.52	8.718	0.069
Increases maternal satisfaction	51(15.9)	132.21
Improve birth outcomes	68(21.3)	163.04
Reduces labor pain	69(21.6)	169.09
Increases parental bond	50(15.6)	182.22

Kruskal–Wallis pairwise comparison of the mean score of companions’ adherence to support roles and sociodemographic variables

Results from a pairwise comparisons between different groups were based on occupational status, educational status, types of relationships, and other factors. The data include test statistics, standard errors, standard test statistics, p-values, and adjusted p-values for each comparison. Below is a detailed interpretation of the table: There is no significant difference in mean scores between employed individuals and those in private work, statistical test (H = 2.311, Adj.p-value: 0.884). There is a significant difference between employed individuals and housewives, with employed individuals scoring higher, statistical test (H = −52.14, Adj.p-value = 0.000).

There was a significant difference between individuals in private work and housewives, with those in private work scoring higher, statistical test (H = −49.83, Adj.p-value = 0.0001). There was a significant difference between those who can read and write and those who attended elementary school, with the former scoring higher, statistical test (H = −42.88, Adj.p-value = 0.057). A significant difference exists between those who can read and write and those who attended secondary school, with the former scoring higher (test statistic = −66.5, Adj.p-value = 0.0001). There is a significant difference, with those who can read and write scoring significantly higher than those who cannot (test statistic = 99.01, Adj.p-value = 0.0001). A significant difference exists, with those who can read and write scoring lower than those with college education or above (test statistic: −150.06, Adj.p-value: 0.000).

No significant difference exists between elementary school and secondary school attendees (test statistic: −23.87, Adj.p-value: 1.00). A significant difference exists, with elementary school attendees scoring higher than those who cannot read or write (test statistic: 56.127, Adj.p-value: 0.052). A significant difference exists, with elementary school attendees scoring lower than those with college education or above (test statistic: −107.17, Adj.p-value: 0.000). No significant difference exists between secondary school attendees and those who cannot read or write (test statistic: 32.25, Adj.p-value: 0.967). A significant difference exists, with secondary school attendees scoring lower than those with college education or above (test statistic: −83.30, Adj.p-value: 0.000). A significant difference exists with individuals who cannot read or write scoring lower than those with college education or above (test statistic: –51.048, Adj.p-value: –0.073). No significant difference between partners and mothers in terms of scores (test statistic: –12.95, Adj.p-value: –0.800). Significant difference exists with partners scoring lower than friends (test statistic: –42.42, Adj.p-value: –0.004). Significant difference exists with mothers scoring lower than friends (test statistic: –29.46, Adj.p-value: –0.076). No specific data were provided for comparisons related to time of birth but indicate that there is a statistically significant finding for whether companions attended ANC jointly (p = 0.004; Table 3).

Table 3.

A Kruskal–Wallis test comparison of mean scores of companions’ adherence to support roles during labor and childbirth in Addis Ababa, Ethiopia, in 2024.

Variables		Test statistics (H)	p-Value	Adj.p-Value
Occupation
Employed	Private work	−2.311	0.844	1.00
Employed	Housewife	−52.14	0.000	0.000
Private work	Housewife	−49.83	0.000	0.001
Educational status
Read and write	Elementary school	−42.88	0.006	0.057
Read and write	Secondary school	−66.75	0.000	0.000
Read and write	No read and write	99.01	0.000	0.000
Read and write	College and above	−150.06	0.000	0.000
Elementary school	Secondary school	−23.87	0.154	1.00
Elementary school	No read and write	56.127	0.005	0.052
Elementary school	College and above	−107.17	0.000	0.000
Secondary school	No read and write	32.25	0.097	0.967
Secondary school	College and above	−83.30	0.000	0.000
No read and write	College and above	−51.048	0.007	0.073
Types of relationship
Partner	Mother	−12.95	0.267	0.800
Partner	Friends	−42.42	0.001	0.004
Mother	Friends	−29.46	0.029	0.076

Generalized linear model parameter estimates the predictors of companion’s level of adherence to support roles during labor and childbirth

The model aims to predict the relationships between the mean score of companions adherence to support roles and various demographic and contextual factors, such as age, gender, marital status, occupation, education level, time of birth, type of relationship, awareness on continuous support, sufficiency of time to provide support, jointly companions attending antenatal care (ANC), and others. Table 4 presents estimates for each parameter in the model, including the estimated coefficient (B), standard error (std. error), 95% Wald confidence interval (lower and upper bounds), Wald Chi-Square statistic, degrees of freedom (df), and significance (Sig.).

Table 4.

A generalized linear model (GLM) presented the relationship between predictors and a companion’s overall mean scale score for adherence to support roles during childbirth in Addis Ababa, Ethiopia, 2024.

Parameter	B	Std. error	95% Wald confidence interval		Wald chi-square	df	Sig.
Parameter	B	Std. error	Lower	Upper	Wald chi-square	df	Sig.
(Intercept)	2.787	0.2730	2.252	3.322	104.173	1	0.000
Age category
24–29	0.113	0.1141	−0.111	0.336	0.972	1	0.324
30–34	−0.004	0.1190	−0.237	0.229	0.001	1	0.973
35–39	−0.140	0.1319	−0.399	0.118	1.131	1	0.288
40 and above	0
Gender
Female	0.009	0.0813	−0.151	0.168	0.011	1	0.916
Male	0
Marital Status
Single	−0.170	0.1329	−0.431	0.090	1.642	1	0.200
Married	−0.159	0.1121	−0.379	0.061	2.004	1	0.157
Divorces	0
Occupation
Employed	−0.150	0.1160	−0.377	0.077	1.669	1	0.196
Private work	−0.102	0.1248	−0.347	0.142	0.673	1	0.412
Housewife	0
Educational Status
College and above	0.499	0.1473	0.210	0.788	11.48	1	0.0001
Secondary school	−0.367	0.1504	−0.66	−0.072	5.94	1	0.015
Elementary school	−0.673	0.1555	−0.977	−0.369	18.718	1	0.000
Read and write	−0.998	0.1424	−1.277	−0.719	49.11	1	0.000
No read and write	0	.	.	.	.	.	.
Time of Birth (Shift)
Day time	0.477	0.0810	0.318	0.636	34.663	1	0.000
Night time	0
Types of Relationship
Partner/husband	0.076	0.1065	−0.133	0.284	0.506	1	0.477
Mothers/mother in-law	0.224	0.1045	0.019	0.429	4.815	1	0.032
Friends and neighbors	0
Awareness about continuous support
Not aware	−0.166	0.1098	−0.381	0.049	2.282	1	0.131
Somewhat aware	0.255	0.0997	0.059	0.450	6.527	1	0.011
Fully aware	0
Sufficient time to provide continuous support
No	0.032	0.0894	−0.143	0.207	0.127	1	0.721
Yes	0
Companion jointly attended ANC
No	0.130	0.1008	−0.068	0.327	1.655	1	0.198
Yes	0
Companions provided Continuous support
No	0.076	0.0766	−0.074	0.226	0.993	1	0.319
Yes	0
Companion experiences on continuous support
First time	−0.377	0.1100	−0.593	−0.162	11.768	1	0.001
Second time	−0.280	0.1295	−0.534	−0.026	4.679	1	0.031
Third time and above	0

The intercept represents the expected log-odds of the mean score for companions’ adherence to support roles when all predictors are at their reference levels. It was statistically significant with estimate and significances (B = 2.787, p < 0.001).

The age categories of the respondents were shown nonsignificant results (p > 0.05). This suggests that age does not have a meaningful impact on companions’ level of adherence to support roles. Also, both gender categories do not significantly affect companion’s level of adherences to support roles (p > 0.05). This indicates no difference in the outcome based on gender in this model. In line with the age and gender of the participants, none of the marital status categories of the participants show significant effects (p > 0.05).

Similar to marital status, occupation categories do not yield significant results (p > 0.05), indicating no substantial association with companions level of adherence to support roles.

A generalized linear model (GLM) examining the effects of education level on the overall mean score of companion support roles. The dependent variable is the overall mean scale score, which likely measures performance and adherence, companions on support during labor and delivery. The intercept represents the baseline mean scale score for individuals in the reference category, which is no read & write education level. The intercept is statistically significant (p < 0.001), indicating a strong baseline level of adherence or performance (B = 1.758, p-value = 0.00).

Individuals with a college education and above had a mean scale score that was significantly higher than those in the no read & write category (B = 0.649; 95% CI: 0.35–0.948, p = 0.001). This positive effect was statistically significant, suggesting that higher education correlates with better performance and adherence. However, individuals with informal education (read and write) had a lower mean scale score compared to those in the reference group, and this difference is statistically significant (B = −0.456, 95% CI: −0.81, −0.095, p = 0.013). This indicates that informal education may negatively impact performance and adherence companion support roles relative to having no formal education. This suggests that even basic literacy without formal education leads to poorer performance/adherence outcomes. The estimate for daytime birth was positive and significant (B = 0.454, p < 0.001), indicating that being born at a day time positively influences the outcome. Both relationship types, mothers and friends as a companion of choice, show significant with positive estimate (B = 0.24, p = 0.009) and (Friends = 0.57, p = 0.000). This suggests that certain types of relationships are associated with higher log-odds of adherence to support roles. The awareness category (Somewhat aware) was significant (B = 0.238, p = 0.029), indicating that increased awareness positively influences the outcome. The category (Not aware) shows a nonsignificant result (p > 0.05). The estimate for not having sufficient time to provide continuous support is not significant (p > 0.05). The estimate for not having history of companions jointly attended antenatal care is not significant (p > 0.05). Both categories companions’ experiences (first time: B = −0.377, p = 0.001 and second time: B = −0.280, p = 0.031) show significant negative estimates. This implies that negative experiences of companions were associated with lower odds of adherence to companion support roles (Table 4).

Qualitative data analysis results

The qualitative study identified four main themes related to companions’ adherence to support roles: expected support roles of labor companions, labor companion benefits to healthcare providers in health facilities, and reason for nonadherence to companion support roles and improving adherence to the companion support role (Table 5). The studies explore how companions can provide emotional and physical support. Why the labor companions fail to fulfill these roles, and how their involvement can be optimized to enhance the childbirth experiences.

Table 5.

Themes and subthemes exploring companions’ adherence to their support roles during childbirth in Addis Ababa, Ethiopia.

Main themes	Subthemes
Expected support roles of labor companions	Emotional support (reassurance, encouragement),
	Physical support (massage, mobility, comfort measures),
	Informational support (explaining labor progress),
	Advocacy (communicating woman’s wishes to healthcare providers)
Labor companion benefits to healthcare providers	Combat staff shortages
Labor companion benefits to healthcare providers	Helping women to and from the delivery bed
Reason for nonadherence to support roles	Physical constraints
	Lack of clarity about a companion’s support role,
	Unwelcoming behavior from healthcare providers
	Cultural and socioeconomic factors
Improving adherence to support role	Training on support techniques
	Clarifying expectations
	Ensuring the companion’s own well-being and confidence

Theme one: expected support roles of labor companions

Labor companions can provide support to both for the pregnant mother and healthcare professionals in the health facilities. They can provide emotional support and practical assistance with comfort measures. In addition, help to improve communication and understanding between the woman, her family, and health professionals. Such support can lead to positive childbirth experiences for the mother and can optimize the efficiency of care provided.

The participants mentioned the support roles of labor companion very similarly: to provide emotional support, massage and support coping with pain, assisting with daily activities, and communicating with the maternal health care providers. Labor companions improved the confidence of laboring mothers.

I accompany her [the mother] from home, the labor was started at home. I told her to be strong then, she gave birth successfully without any complications to the mother and the newborn. (Women’s companion, Age 45, Her Mother, Facility 8)

They told that labor companions’ supports were eagerly present and do what was needed. Such presence and support create the mother sense of security in a new environment:

When health providers called me, I went quickly and were willing to saw what happen to the mother and closely watch what was the providers doing. (Women’s companion of choice, Age 30, Young sister of the mother, Health Facility 3)

Comfort measures/Practical support

This was important because women often felt helpless in labor, and providers were not with them all the time. Also, because providers were usually busy with other things, the presence of their companion ensured that there was someone readily available to help them if they needed help for things such as going to the bathroom room and to call the provider if they faced some problem or went into the second stage of labor:

I think it is good to have someone with her because health providers can show her the bed to go and sleep, then they may go to sit somewhere else, if something new happed, I may call the health providers to help the women. (Women companion, Age 30, Health Facility 2).

Labor companions were provided warm drinks. Frequent drinks of sweetened help to give energy and improve hydration:

Labor pain was strong pain, sometimes when she was in labor her body was shaking, though I hold her hand. She may lose energy and sometimes she tried to push but she can’t. When she took some drinks, she gained some energy. (Women’s companion, Age 42, Husband, Health Facility 8)

You may go to get things she needs, you may come and check her what the health providers say about her conditions and necessary to labor until delivery. (Women’s companion, Age 45, Mother, Health Facility 4)

Companion provided massage to woman’s back; such action enables the companions to involve in pain relief of the woman:

I rub her back when she was in a strong pain. (Women’s companion of choice, Age 34, Friend, Health Facility 7)

Mobility during labor is promoted, the engagement with the baby and pain relief by labor companions:

Labor companions said, I told her to walk. I supported her to walk around. (Women’s companion, age 48, Mother, Health Facility 10)

Companions were also needed to help run errands: like going to buy drugs and supplies that might not be available on the ward or arranging additional help if they were referred.

In addition, companions were needed after delivery to help care for the baby, including holding the baby when they needed to go to the bathroom:

I felt good because there are times the woman can be going to bath, and so me as companions [Father] will remain and give care to newborn. (Women’s companion, Age 46, Her partner, Health Facility 6)

Information and advocacy

Labor companions can bridge providers and the woman by facilitating the health providers’ instructions:

Maternal health care assess the woman. Companions tell her to get off the bed to take some drinks. (Women’s companion, Age 34, Elder sister, Health Facility 1)

Some labor companions shared their childbearing exposure with the mother for their own experiences to be strong.

For others, the companion helped meet their informational needs by telling them what to do, helping them make decisions, and advocating for their care as they felt they were not in a state to make decisions on their own during labor. Others wanted the companion around in order to have someone who could remind them later of what happened during labor:

Companions may be important to be with the mother during labor, at that particular time in case that anything happens then companions can share with the health care to know what next is to be done to the mother, because at that time, mothers are in so much pain that they cannot make any wise decision. (Women’s companion of choice, Age 50, Mother, Health Facility 9)

Emotional support

It is one of the common companion support roles mentioned and offered by the labor companions:

I was there from admission to birth and support her needs. What I understand is that when i was there she felt good and relaxed (Women’s companion, Age 34, Sister, Health Facility 5).

Theme two: labor companion benefits to healthcare providers in health facilities

Labor companions were useful not just to help the mother but also help health providers.

Providers reported companions sometimes helped them with various responsibilities, such as going to purchase supplies and drugs, calling on them to attend to the women, helping women to and from the delivery bed, holding items like a flashlight during delivery, helping them pick up delivery supplies, and cleaning up. The labor companion roles were particularly useful in the face of staff shortages, where only one provider may be on duty:

Sometimes health providers are alone and may have many women on labor and childbirth. So, after examining the women in the labor ward, health providers may go to other women in labor. Consequently, the women becomes alone and if some problems happened labor companions watch her and call health providers to come and check the progress of labor. (Note from Observation, by health workers)

In case of any eventuality, they can be asked to go may be to organize, for example, in a case of complicated delivery and you want things like gloves somebody at least you can send to get for you the things you want; so most of the times, we allow one caretaker to be around the mother who is giving birth:

There are some mothers who come without labor companions though during Antenatal Care (ANC) they encouraged to have with labor companions, but when they come without they are equally just served as others. But when they come with labor companions, especially at health facility, if they do not assist us I don’t know how we would do it, because they do assist us even wheeling the patient to the bedside post-delivery they do a lot to us especially to me when I am on duty, they do a lot. (Note from Observation, by care providers)

Theme three: reason for nonadherence to companion support roles

This study investigates why companions might not always fulfill their intended support roles.

The reasons why labor companions were sometimes not adhered to support roles include lack of support role clarity, lack of knowledge about how to best support the woman, or conflicting expectations.

Physical constraints

Most providers reported that companions were sometimes not allowed in the ward because of limited space and overcrowding; hence, privacy concerns for other women in the labor and delivery wards. Some also mentioned that the set-up of the labor wards is not conducive for companions, including limited seating, which may cause companions to use beds meant for the laboring woman:

If they are two in labor then now you see the privacy will [be a problem] . . .but if that woman is all alone there, then we will just allow, so it is more of the setup which is preventing us but we know. . .that if they want even their spouses to come to the delivery room they should be allowed but because of the setup and the environment now it is not really conducive. Privacy was the main reason given for not allowing companions during birth. (Note from Observation, by health providers)

Lack of clarity about a companion’s support role

A major barrier is the absence of clear guidelines and communication about the specific supportive roles and responsibilities of labor companions. Women may have expectations of support that are not met if the companion’s role is not well-defined or understood. The WHO’s recommendation on roles of labor companion, awareness of companions practice. Majority of companions interviewed had positive value on labor companion support but did not know about the roles of companion recognized by World Health Organization (WHO):

Labor companion told that if a laboring mother is supported psychologically, morally and physically, she will go well thought out the labor process. (Women’s companion, Age 40, Health facility1)

Unwelcoming behavior from healthcare providers

Some healthcare providers may be uncomfortable with the presence of companions during examinations or fear that companions might interfere with their work or even increase the risk of lawsuit in case of complication.

Cultural and socioeconomic factors

Cultural norms, socioeconomic status, and individual circumstance can also play in nonadherence to support roles. Whether a woman chooses to have a companion and the type of support she receives.

Theme four: improving adherence to the companion support role

The research also explores possible strategies to enhance companions’ effectiveness, such as providing training on support techniques, clarifying expectations, and ensuring the companion’s own well-being and confidence. Training was mentioned by most of labor companions, as request help them to know their expectation as companion and help to know roles of labor companions. The main content and skills for labor companions to learn during these sessions is how to offer roles of labor companions and understanding progress of labor:

Companions expected to have information about labor progress. It will be a long process so they can help with the pain while waiting for the delivery. (Observation Note, by healthcare provider)

Discussion

The purpose of this study was to examine the factors affecting companions’ adherence to support roles during childbirth using a convergent parallel mixed method. Findings from the quantitative data revealed that companions had minimal adherence to their expected support roles during childbirth. Main factors associated with this include awareness of continuous support, educational status, types of relationship with the birthing mother, time of birth, and previous support experiences. Yet, age, gender, occupation, and marital status were not statistically significant. In Ethiopia, accompanying a laboring woman from her home to a healthcare facility is a common practice.²²

Labor companions can facilitate communication and reduce healthcare providers’ workload by expressing the woman’s needs and preferences, thereby increasing care efficiency.¹⁴ This partnership allows healthcare providers to focus on clinical tasks while companions deliver emotional and informational support. Although some healthcare providers may feel less pressured by companions, others perceive their involvement as disruptive to established workflows. Additionally, the active participation of companions may be viewed by some providers as a challenge to their professional performance.²³ In this study, some companions perceived their roles as limited to nonclinical assistance, rather than providing emotional and informational support during childbirth. This is consistent with research that addresses companions’ support roles.²⁴

Many companions lack adequate information regarding their roles and the nature of support expected. This is supported by the qualitative data from this study, which explored factors hindering companions’ adherence to their support roles: unclear role definition, the unwelcoming approach of healthcare providers, and social and cultural factors.

An orientation session for the companion of choice with detailed explanations of their roles could be a solution. Such measures could help to create a more supportive and inclusive environment for companions, ultimately improving the overall experiences of women.

Minimal companion adherence to their support roles may result from inadequate preparation and differing expectations between companions and the woman.² The current study revealed that the relationship between the companion and the birthing woman was associated with greater adherence, as close relationships foster trust and a sense of control. Three-fourths of the companions in this study were family members. The finding is consistent with findings from Oman²⁵ and Tanzania.²⁶ Partners were the second most common choice in this study, suggesting potential benefits for postnatal relationships and parenting.

In this study, the quantitative data show that companions’ awareness of continuous support was significantly associated with higher adherence to support roles. This implies that a companion’s awareness influences their actual commitment to their support roles. To effectively move awareness from concept to practice, antenatal care visits could serve as a concrete means. These visits can provide companions with essential knowledge and skills, preparing them more effectively for their roles during labor and childbirth. Antenatal care visits could be expanded to include specific companion orientation sessions. These orientation sessions might cover practical techniques for providing physical and emotional support, communication skills for interacting with healthcare teams, and understanding procedures that may occur during labor and childbirth. The qualitative findings also further explore that inadequate preparation impedes effective support. Findings from Tanzania and Uganda^27–29 were consistent with the current study.

Companions’ experience may enhance the ability to perform their support roles.³⁰ As the current study revealed, companions with prior support experience demonstrated higher adherence to companion support roles.

Companions’ educational status also influenced the adherence to support roles during childbirth; companions with higher education were positively associated with adherence to their support roles.³¹ Sociodemographic variables, such as age, marital status, and occupation, did not show an association with the companion’s adherence to support roles in this study.

The increased availability of time for housewives may enhance their perception of being supportive partners, as they can engage more fully in caregiving roles.³² Age categories of the respondents showed no significant difference in adherence to support roles. This implies that age may not be a determining factor in how companions fulfill their support roles during labor and childbirth. But some studies reveal that older people may provide more effective support due to their life experiences.³³ While others state that younger companions are more likely to be engaged during labor and childbirth. The analysis showed that there was no significant difference between female and male companions. Although mothers gave birth with the help of providers, their companions were still an important part of their experience. Findings from this study showed that companions can act as a witness to poor treatment by caregivers. Due to this, the presence of a companion during labor and childbirth may help mothers have a good experience. Encouraging labor companions’ adherence to support roles improves the quality of care and positive birth outcomes for women and newborns by increasing emotional, informational, and practical support to mothers during childbirth. A minimal adherence to companion support roles is not merely a personal failure but often a systemic issue that requires institutional support.

Implications for practice

Understanding the value of companions support roles during childbirth is vital. An inclusive environment, where companions feel empowered and informed, can enhance the overall experience of childbirth process. A supportive environment where companions are viewed as vital members of the obstetric care team will ultimately lead to better outcomes for all parties involved.

Limitations and strengths of the study

The strengths of the study comprise its use of a mixed-methods approach. This approach provides a holistic understanding of the context, as well as the perspectives and experiences of companions regarding adherence to support roles. This is the first study in the area to examine the adherence level of the companion support role and the challenges faced in providing support.

The limitation of the study includes reliance on face-to-face exit interviews, which introduce the potential for social desirability bias. The findings may have limited generalizability beyond the study sample since the study was done only in public health facilities and focused on the companions’ perspective. Additionally, we used pretested scale to measure companions’ adherence to support roles than validated too. However, the alignment of these findings with other data from the study supports a degree of transferability. Despite these limitations, the study contributes valuable insights to the literature on adherence to companion support roles.

Conclusion

This study explore that, unclear role definition, unwelcoming approach of healthcare providers, and social and cultural factors were associated with minimal adherence level of companions to support roles during childbirth.

However, companions’ educational status, awareness on continuous support and prior experience of support were positively associated with adherence to support roles.

Moreover, the current study showed that companions frequently experienced anxiety-related to their role, particularly when they were unsure about how to assist effectively. This anxiety was compounded by a perceived lack of support in decision-making. The need for structured orientation session is as a critical recommendation from this finding. Such session could equip companions with essential skills and knowledge, enabling them to navigate the labor environment more effectively and advocate for the birthing woman’s needs. Without system strengthening, it will be difficult to provide person-centered maternity care. Future researches using implementation science methods to adapt companions training programs for diverse cultural contexts and promoting respectful maternity care.

Supplemental Material

sj-docx-1-smo-10.1177_20503121251391976 – Supplemental material for Analysis of factors affecting companions’ level of adherence to support roles during labor and childbirth: a mixed-methods study

Supplemental material, sj-docx-1-smo-10.1177_20503121251391976 for Analysis of factors affecting companions’ level of adherence to support roles during labor and childbirth: a mixed-methods study by Gedamu Abera Zegeye, Muluemebet Abera Wordofa and Afework Mulugeta in SAGE Open Medicine

Supplemental Material

sj-docx-2-smo-10.1177_20503121251391976 – Supplemental material for Analysis of factors affecting companions’ level of adherence to support roles during labor and childbirth: a mixed-methods study

Supplemental material, sj-docx-2-smo-10.1177_20503121251391976 for Analysis of factors affecting companions’ level of adherence to support roles during labor and childbirth: a mixed-methods study by Gedamu Abera Zegeye, Muluemebet Abera Wordofa and Afework Mulugeta in SAGE Open Medicine

Supplemental Material

sj-docx-3-smo-10.1177_20503121251391976 – Supplemental material for Analysis of factors affecting companions’ level of adherence to support roles during labor and childbirth: a mixed-methods study

Supplemental material, sj-docx-3-smo-10.1177_20503121251391976 for Analysis of factors affecting companions’ level of adherence to support roles during labor and childbirth: a mixed-methods study by Gedamu Abera Zegeye, Muluemebet Abera Wordofa and Afework Mulugeta in SAGE Open Medicine

Footnotes

Acknowledgements

We thank health workers working in the selected public health facilities of Addis Ababa City, women, labor companions who participated in in-depth interview and data collectors.

ORCID iD

Gedamu Abera Zegeye

Ethical considerations

Consent to participate

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 written informed consent was obtained from all participants. Then after participants were confirmed their voluntary for participation by putting their signature in consent form before we started Interviews. The in-depth interview was conducted in a convenient and isolated area. All participants who were voluntary to participate were requested to sign on the consent form. Also, for those who voluntarily participated in interview, it was explained that there is no relationship between the information they gave us during the interview time and health care they received. We followed the anonymity of data, and there was no identifier in interview.

Author contributions

GA and MA drafted the research plan. AM helped to edit and review the manuscript. GA, MA, and AM helped in the statistical analyses, and interpretation of results, and proof read the manuscript. All authors contributed to discussion of the paper, and read and approved the final version.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by Jimma University. The funders had no role in study design, data 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

Our data is available, if needed we can share you as possible.

Supplemental material

Supplemental material for this article is available online.

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