It is difficult to think of any event that is more profoundly life-altering than childbirth - a process steeped in wonder and pain and, too often, fear. But giving birth does not have to be terrifying. Experience and evidence show that when women have a trusted companion at their side, they feel better, are more informed, less afraid, and have better outcomes.
And yet, in many places women are not permitted to have a companion with them in government health facilities - and that is one reason women sometimes cite for preferring to deliver at home, despite the risks in case of a complication. So, in an effort to improve the birthing experience at facilities, the Tanzanian national and local health authorities partnered with Thamini Uhai, a local Tanzanian organization affiliated with the U.S.-based public health organization Vital Strategies, on a pilot project enabling women giving birth at health facilities in Kigoma to have a female companion. The results of the pilot, published recently in the journal BMC Pregnancy and Childbirth, were overwhelmingly positive.
The 15-month pilot, conducted between October 2017 and December 2018, reaped praise not only from the laboring women, but from health center staff and the companions themselves. Companions provided emotional, informational, and practical support - comforting women with kind words, singing and prayer; offering advice and instruction; giving them fluids to drink; and perhaps most important, staying by their side. Over the course of the pilot, use of birth companions at the facilities rose from 59% in October 2017 to 83% in December 2018.
Moreover, 96% of women were very satisfied with their companion at the time of childbirth and 86% said having a companion improved their childbirth experience. Women even reported that health workers were more responsive and friendly. These results influenced the country’s ministry of health to recommend birth companionship in the National Guidelines for Gender and Respectful Care.
Having a designated companion throughout labor provides women with the moral support and attention they would otherwise lack giving birth in a health facility. According to the World Health Organization (WHO), that support reaps clinical benefits, including shorter labor and lower rates of necessary medical interventions (including caesarean sections); overall it leads to a more positive, respectful childbirth experience for the new mother, who may otherwise be left alone in an understaffed maternity ward. Based on extensive evidence, the WHO recommends the presence of birth companions for all women in labor as part of respectful, person-centered maternity care.
And while medical personnel in Kigoma may have been hesitant at first, the vast majority reported that the companions were very helpful, lightening their workload by performing non-medical tasks and improving their ability to provide quality care. As for the companions themselves, they saw their role as not only supporting the mother, but also bridging the communication gap between her and the medical staff. Another critical element was promoting accountability. As one birth companion said, her presence simply “helps the nurse remember her responsibilities when she sees you.”
The health centers that offered birth companions saw a meaningful rise in the number of deliveries over the 15-month study, as opposed to a notable drop in births at other facilities. Raising demand for births at facilities offering high-quality care is a high priority for Tanzania’s health authorities, integral to national efforts to reduce maternal mortality, which has remained stubbornly high.
Tanzania, with an estimated 11,000 maternal deaths annually, is ranked sixth worldwide for pregnancy and childbirth related deaths. The maternal mortality ratio was measured at 556 deaths per 100,000 live births in 2015 and has not significantly[i] improved for nearly a decade. Many of these deaths could be avoided if women gave birth in health centers or hospitals providing high-quality care, yet more than one-third of all pregnant women across the country choose to give birth at home.[ii]
While distance to a facility - particularly in rural areas - is certainly a major factor in determining where women choose to deliver, it is not the only one. There have been many global studies about the lack of respect and information women receive in labor and delivery wards. This disrespect is linked to the high number of home births in many countries. The presence of birth companions not only make women feel safer and cared for at a particularly vulnerable time in their lives, but it allows for greater communication and accountability, resulting in women having a more positive birth experience which will likely lead to improved relationships with the health system overall.
Quality, respectful care should be a given for all women on their path to motherhood. Yet, according to WHO, up to a third of all women giving birth in low-income countries are mistreated; they face verbal and sometimes physical abuse, and are routinely ignored. Introducing birth companions - an ally to provide emotional support and comfort and help protect women from neglect - is a low-cost, high-impact component of systems that can help ensure safe delivery. And isn’t that the best Mother’s Day gift?
Dr. Sunday Dominico is Clinical Director for Thamini Uhai.
Karen Schmidt is Senior Technical Advisory at the global health organization Vital Strategies.