From global recommendations to (in)action: A scoping review of the coverage of companion of choice for women during labour and birth

Women greatly value and benefit from the presence of someone they trust to support them throughout labour and childbirth ('labour companion of choice'). Labour companionship improves maternal and perinatal outcomes, including enhancing physiological labour and birth experiences. Despite clear benefits, implementation is slow. We conducted a scoping review to assess coverage and models of labour companionship, including quantitative studies reporting coverage of labour companionship in any level health facility globally. We searched MEDLINE, CINAHL, and Global Health from 1 January 2010-14 December 2021. We extracted data on study design, labour companionship coverage, timing and type of companions allowed, and recoded data into categories for comparison across studies. We included data from a maternal health sentinel network of hospitals in Latin America, using descriptive statistics to assess coverage among 120,581 women giving birth in these sites from April 2018-April 2022. In the scoping review, we included 77 studies from 27 countries. There was wide variation in the coverage of labour companionship: almost one-third of studies reported coverage less than 40%, and one-third of studies reported coverage between 40-80%. Husbands or partners were the most frequent companion (37.7%, 29/77), followed by family member or friend (gender not specified) (32.5%, 25/77), family member or friend (female-only) (13.0%, 10/77). Across nine sentinel hospitals in five Latin American countries, there was variation in coverage, with no companion at any time ranging from 14.9%93.8%. Despite the well-known benefits and factors affecting implementation of labour companionship, more work is needed to improve equitable coverage. Concerted efforts are needed to engage with communities, health workers, health managers, and policy-makers to establish policies, address implementation barriers, and integrate data on coverage into perinatal records and quality processes to ensure that all women have access. Harmonized reporting of labour companionship would greatly enhance understanding at global level. Background Research has consistently shown that women greatly value and benefit from the presence of someone they trust to support them throughout labour and childbirth [1]. Women who have a companion of choice during labour and birth (hereafter referred to as labour companion) report that this support helps them feel safe, strong, confident, and secure [2]. Some women may prefer their husband or partner as a companion and view this as a family bonding experience; other women may prefer a female relative or friend. There is evidence that labour companionship improves maternal and perinatal outcomes, including enhancing the physiological process of labour [1]. Research has shown clinically meaningful benefits of the support, including shorter duration of labour, increased rates of spontaneous vaginal birth, decreased caesarean section and intrapartum analgesia use, and increased satisfaction with childbirth experiences [1]. Women have also reported less fear and distress during labour, and babies are less likely to have low five-minute Apgar scores [1]. Based on this evidence, a companion of choice during labour and childbirth is recommended in three World Health Organization (WHO) guideline recommendations [3-5]. Moreover, the WHO Standards for improving quality of maternal and newborn care in health facilities includes a quality statement that every woman should be offered the option to experience labour and childbirth with the companion of her choice [6], and it is considered an important intervention to improve women's experience of care. Historically, global maternal health efforts have focused on addressing high rates of mortality, morbidity, and access barriers, particularly around improving access to facility-based maternal and newborn care services. However, the last decade has seen a shift in global maternal health efforts towards improving quality of maternity care services with a new focus on improving women's and families' experiences of care, equity, respect, and dignity. Despite clear evidence of benefit, no harms, and labour companionship being a critical component of quality and respectful maternity care, many national and facility-level policies do not allow for labour companionship. For example, the 'WHO reproductive, maternal, newborn, child and adolescent health policy survey' (2018) showed that while labour companionship was recommended in national policies and guidelines in most countries in the Americas, European, and Southeast Asian regions, approximately one-third of countries in the African region, and three-quarters of countries in the Eastern Mediterranean region had no national level policies or guidelines recommending labour companionship [7, 8]. Where policies do exist, labour companionship may be limited in implementation, due in part to health manager and health worker resistance to implementation [2]. More work is urgently needed to improve understanding of the global landscape of labour companionship as a priority woman-centred maternal health intervention, as well as implementation evidence about how to best design labour companionship models that account for context, and the values and preferences of key stakeholders, including women. This scoping review aims to identify data on coverage and describe the different models of labour companionship for women giving birth in health facilities globally. Methods This study is reported per the Preferred Reporting Items for Systematic Reviews and Meta- Analyses extension for scoping reviews (PRISMA-ScR) [9] (S1 Appendix), and is registered with Open Science Foundation (Protocol ID: k69sg).