Labour companionship in practice : systems, perspectives and pathways to scale from eight low- and middle-income countries

<p dir="ltr">Labour companionship is defined as the presence of a person of the woman's choice to support her during labour and birth. A labour companion can be a woman's partner, her relative such as mother, sister or in-laws, a friend, or a doula. A Cochrane review by Bohren and colleagues presented clinical and nonclinical benefits to having a labour companion both to the woman and her baby, including shorter labour durations, less use of analgesia, better 5 minutes APGAR scores for the baby and better reported experiences of care. Given its benefits, labour companionship is a recommended practice, for women who want it and is mentioned in several guidelines including the World Health Organization's recommendations on positive intrapartum care. While the practice offers several benefits, its implementation, especially across low-and- middle-income countries, varies and remains suboptimal in many settings.</p><p dir="ltr">The <b>aim</b> of this thesis was to increase the understanding of the processes, factors and potential benefits that influence the integration and scalability of labour companionship practices across the macro, meso, and micro-levels of the maternity health system. This thesis was nested under two collaborative implementation projects implemented from 2020 until 2024. The ALERT project (Action Leveraging Evidence to reduce perinatal Mortality and morbidity in Sub- Saharan Africa) was implemented in 16 public and private not-for-profit hospitals in Benin, Malawi, Tanzania and Uganda and the QUALI-DEC project (QUALIty DECision making by women and providers for appropriate use of caesarean section) was implemented in 32 public and private hospitals in Argentina, Burkina Faso, Thailand and Viet Nam. This thesis included a mix of qualitative and quantitative methodologies.</p><p dir="ltr"><b>Study I</b> was a multi-country study that aimed to understand the implementation maturity of labour companionship across the eight countries before implementation. This study used data from the formative research conducted in ALERT and QUALI-DEC projects to (1) analyse the content of policy documents pertaining to labour companionship, using directed content analysis and (2) describe labour companionship practices and resources available on a facility level. Based on these results, the eight countries were classified into three phases of implementation following subject-specific models by Bohren and colleagues and Bergh and colleagues. Additionally, the physical structure of the maternity ward was illustrated to visually present labour companionship practices across the implementation phases.</p><p dir="ltr"><b>Study II</b> was a cross-sectional study conducted with 4006 women aiming to assess the associations between having a labour companion and respectful treatment as reported by women in 16 hospitals in Benin, Malawi, Uganda and Tanzania. A validated questionnaire, developed as part of the ALERT project, on respectful treatment and responsiveness was administered to all eligible women before discharge from December 2021 until March 2024. Women were eligible to participate if they had given birth at one of the 16 hospitals to a baby weighing more than 1000 grams and agreed to consent. The women were randomly approached for an interview following a randomisation factor depending on the number of women to be discharged. Linear regression with fixed effects and cluster robust standard errors were conducted to assess the associations between presence of labour companionship and respectful treatment using a factor-weighted respectful treatment score and its sub-scores: <i>maintained respect and dignity</i>, <i>privacy and confidentiality</i> and <i>no physical and verbal abuse</i>. The model was adjusted for age, parity, educational level, mode of birth and the ALERT intervention.</p><p dir="ltr"><b>Study III</b> was a qualitative study aiming to understand the interactions between maternity care providers, women and their relatives in two hospitals in Southern Tanzania. Eleven natural group discussions were conducted with 21 maternity care providers in the labour and postnatal wards at the two hospitals. Data were analysed following Braun and Clarke's reflexive thematic analysis. Three themes were developed with both semantic and latent content.</p><p dir="ltr"><b>Study IV</b> was a scalability assessment to understand the factors influencing the scalability of the QUALI-DEC intervention in Argentina, Burkina Faso, Thailand and Viet Nam. Data from the formative research conducted in the four countries were deductively analysed using the framework analysis. The analysis was guided by the scalability assessment tool developed by Zamboni and colleagues and incorporated into the QUALI-DEC intervention. The tool included 34 items covering four dimensions on the attributes of innovation, implementers, adopting organizations and socio-political context.</p><p dir="ltr"><b>Results</b> suggested that having a companion during labour or birth was associated with reduced levels of physical and verbal abuse in Benin, Malawi, Tanzania and Uganda. However, the coverage of labour companionship across these countries was low (around 39%) and women reported poor experiences of care during labour and birth.</p><p dir="ltr">Three distinct levels of implementation were identified across the eight countries: <i>pre-implementation</i> (Benin, Thailand and Viet Nam); <i>early implementation</i> (Burkina Faso, Malawi, Tanzania and Uganda); and <i>institutionalisation</i> (Argentina). These implementation levels were shaped by different processes and factors at the meso and macro-levels.</p><p dir="ltr">At the meso-level, several processes facilitated implementation and scalability, including adaptations to the intervention to better align it with users' needs. These adaptations included reviewing the educational material, introducing structural changes to the maternity ward and addressing physical constraints that limited the inclusion of companions. Organizational norms also shaped care processes, influencing the integration of labour companionship. In Tanzania, gatekeeping practices by maternity ward providers further influenced the integration of labour companions, reflecting a provider-centred model of care that may conflict with women's autonomy.</p><p dir="ltr">At the macro-level, the broader policy landscape generally portrayed labour companionship as a luxurious add-on rather than a woman's right (except in Argentina). Strict legal frameworks and the absence of clear financing mechanisms limited integration into existing maternity care systems, particularly in Thailand and Viet Nam.</p><p dir="ltr">These findings underscore that labour companionship is a dynamic process that needs to be negotiated at the macro, meso and micro-levels of the maternity care system. Its integration is shaped by institutional and systemic factors, including policy landscape, availability of adequate physical structures and an aligned organisational culture.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>El-Halabi S,</b> Pembe AB, Dumont A, Betrán AP, Kaboré C, Chipeta EK, Carroli G, Alvesson HM, Kidanto H, Dossou JP, Annerstedt KS., Beňová L, Gross MM, Waiswa P, Lumbiganon P, Mac QNH, Bohren MA, Hanson C. Towards a universal implementation of labor companionship: A synthesis of the policy and facility environment of eight low-and-middle income countries. Frontiers in health services. 2025 Jul 23;5:1550473. <a href="https://doi.org/10.3389/frhs.2025.1550473" rel="noreferrer" target="_blank">https://doi.org/10.3389/frhs.2025.1550473</a></p><p dir="ltr">II. <b>El-Halabi S,</b> Annerstedt KS, Agossou C, Al-Beity FMA, Pembe AB, Wanduru P, Kandeya B, Dossou JP, Molsted-Alvesson H, Bohren MA, Hanson C. Labour companionship and respectful treatment of women during childbirth: a cross-sectional study across 16 hospitals in Benin, Malawi, Tanzania and Uganda. BMJ Public Health. 2025 May 12;3(1):e002462. PMID: 40391249; PMCID: PMC12086892. <a href="https://doi.org/10.1136/bmjph-2024-002462">https://doi.org/10.1136/bmjph-2024-002462</a></p><p dir="ltr">III. <b>El-Halabi S,</b> Al-Beity FMA, Hanson C, Pembe AB, Alvesson HM. "Labour under lock: providers' perspectives on relatives' access to two maternity wards in Southern Tanzania". [Manuscript]</p><p dir="ltr">IV. <b>El-Halabi S,</b> Hanson C, Dumont A, Cleeve A, Alvesson HM, Kaboré C, Carroli G, Lumbiganon P, Mac QNH, Betran AP, Annerstedt KS, Bohren MA, Zamboni K. Planning for scale: analysis of adaptations and contextual factors influencing scale-up of the QUALI-DEC intervention to optimize caesarean section use. Implement Sci Commun. 2025 May 21;6(1):61. PMID: 40400046; PMCID: PMC12093684. <a href="https://doi.org/10.1186/s43058-025-00737-6" rel="noreferrer" target="_blank">https://doi.org/10.1186/s43058-025-00737-6</a></p>