The cross-sectional study included a total of 51 health care providers who were providing obstetrics and gynecology service during the study period. These were 8 obstetrics and gynecology specialists, 26 residents and 17 midwives.
The mean age of the health workers included in the study was 30 years with a SD of 3.6. Married study participants include 58.8 % of the health care providers. The longest years in obstetric practice is 15 years while the least amount of time on the health care service specifically in the delivery service is 2 years. (Table 1)
Table 1
Socio-demographic characteristics of health care providers included in the study at SPHMMC and selected catchment health centers
| Total number | Percentage |
---|
Marital Status | | |
Married | 30 | 58.8 |
Single | 21 | 41.2 |
Religion | | |
Orthodox Christian | 37 | 72.5 |
Protestant | 9 | 17.6 |
Islam | 5 | 9.8 |
Profession | | |
Midwife | 17 | 33.3 |
Obstetrics and gynecology resident | 26 | 51 |
Obstetrics and gynecology senior | 8 | 15.7 |
Knowledge, Attitude and Prevailing practice with regards to birth companions
Among the health care providers involved in the study 39.2 % were knowledgeable on benefits of birth companions.
Among the study participants 90 % has positive attitude towards involvement of birth companions while only 4 % has negative attitude.
From the health practitioners involved in the study 82.4 % didn’t allow labor companions. The reasons that were mentioned include lack of adequate space, busy labor ward, lack of partitioning among labor ward beds and doubt on the benefit of birth companions. (Table 2)
Table 2
Reasons for not allowing birth companions mentioned by health care providers involved in the study
Reasons for not allowing birth companions | Total number | Percentage |
---|
Lack of adequate space | 32 | 62.75 |
Busy labor ward | 25 | 49.02 |
Absence of partitioning at the labor ward | 12 | 23.53 |
Doubt on the benefit of birth companions | 2 | 3.92 |
Society don't agree with the practice | 3 | 5.88 |
With regards to benefits of birth companions 96.1 % of the health care providers believe that there is benefit in their involvement. The benefits mentioned were improved moral support to mothers, improved care by health workers, advantages in infant attachment, reduction of interventions, shortened length of labor, ease of communication with mothers, improved trust of health professionals, reduced home deliveries and decreased maternal stress. (Table 3)
Table 3
Benefits of birth companions mentioned by health care providers involved in the study
Benefits of birth companions | Total number of health care providers | Percentage |
---|
Moral support to mothers | 47.0 | 92.16 |
Improves care by health care providers | 16.0 | 31..37 |
Facilitate breast feeding | 28 | 54.90 |
Reduces operative deliveries | 13 | 25.49 |
Shortens duration of labor | 22 | 43.18 |
Reduces the need for augmentation | 11 | 21.57 |
Improves neonatal outcome | 9 | 17.65 |
Ease of discussion with laboring mothers | 2 | 3.92 |
Reduces home deliveries | 4 | 7.84 |
Decrease labor pain | 1.0 | 1.96 |
The health care providers who were included in the study mentioned that they have faced breach of privacy, risk of litigation/complaints, interference with routine medical care, risk of theft and worsened perception of health care providers by involving birth companions. (Table 4)
Table 4
Disadvantages of birth companions mentioned by health workers in the study
Disadvantage | Total number | Percentage |
---|
Breach of privacy | 23 | 45.09 |
Possibility of litigation | 13 | 25.49 |
Interference with routine medical care | 22 | 43.14 |
Risk of theft | 4 | 7.84 |
Worsen distrust of health professionals | 1 | 1.96 |
Health workers Perspective on involvement of birth companions: Findings from in-depth interview of health workers
In- depth interview of seven health professionals was undertaken to further understand the attitude of health care providers with regards to birth companions.
Prevailing practice while managing laboring women
The finding from the study has showed that every laboring woman that comes to the hospital goes through the emergency gynecology team. She will be evaluated initially by midwife, intern or junior resident. After that depending on the urgency of the case the most senior person from the managing team will evaluate her.
After evaluation the managing team will send baseline investigations and until bed is found the woman will be kept either inside the ER or in the corridors. And the team will prioritize among the laboring women’s in the ER and decide who will be admitted.
During a woman’s stay in the emergency she will usually be allowed to be around her family members, outside the emergency room. She will intermittently be called and evaluated. If she has any indication to be kept inside the whole time, no family member will be allowed to see her.
Once a patient is admitted to the labor ward a midwife or a resident will accept her. At the labor ward she will be evaluated and someone will be assigned to follow her. Depending on the stage of labor, condition of the laboring woman, status of the labor ward, the follow-up intensity will vary. Usually there will be intermittent follow-up of the laboring woman. There are times the woman will be left alone.
According to one resident ‘There is no one single person who will continuously be with her, a midwife, an intern or a resident will follow her but they have some tasks in between so there are a lot of times she will be left alone. If it is spontaneous labor and if she doesn’t have any risk it is only the CTG who will be with her. People will come in see the CTG and move on. There are also times we listen to the CTG while we are in the next room’.
Practice on involvement of labor companions
Health workers explained that in SPHMMC birth companions are always family members, this ranges from husband, sisters, mothers, brothers or friends and neighbors. The word doula is strange for almost all of them.
Results from the interviews show that most of the health care providers don’t allow birth companions; this applies both to labor ward and emergency room. They have explained whatever their opinion they follow the mass in not allowing birth companions. Those who allow companions described they allow them to intermittently see their loved ones and give update to the family members on how the labor is progressing and if there is a need for further intervention.
‘On principle there will not be a companion with the laboring woman ” final year resident with around six years experience in SPHMMC.
‘But I am also not different. I rarely update the family and won’t let family members inside’ one final year resident explained.
Birth companions are involved in few circumstances. Those women who have eclampsia or any condition that deserves frequent follow up are the ones who will be allowed to have companions. One of the residents explained ‘In SPHMMC there has never been a birth companions, unless the woman has ecclampsia or something like that and we want someone to restrain or hold a woman, we never allow husbands or anyone for that matter. And the reason is the setup we have, there will be two or more laboring mothers in one place and to allow attendants it will breach other women’s privacy.’
Post-partum period is the one time where majority of the women will be allowed to have companions around.
For the majority of the women who didn’t get to see anyone whoever is following them will go and get them what they need and pass messages to and from the companions since phones aren’t allowed. But there are times the companions wouldn’t hear what has happened to the laboring women.
Every one of the health care providers have different reasons for not involving birth companions. But there are reasons that are mentioned by most of the health care providers. These include need for privacy, work load, case load, set-up, knowledge and comfort of health care providers for providing care to laboring women while companions are around.
Opinion on involvement of birth companions
There is Ethiopian ministry of health’s recommendation on involvement of birth companions. It states birth companions should be allowed to be with laboring women. While asked what is their perception to this recommendation most health care providers explained though they agree with the principle they don’t think it is applicable to the set-up they work in.
‘Of course, I think involvement of birth companions is important’ a midwife with over two years experience in SPHMMC.
Benefits and difficulties they faced with involvement of labor companions
Even those who didn’t involve birth companions agreed that there is a benefit in companion involvement. The benefits they mentioned were ease of communication, relief of pain, benefit on attachment and for the mothers to attain birth positioning of choice.
The difficulties mentioned by health care providers during involvement of companions include argument with health workers, frequent nagging, risk of litigation and lack of awareness on the ongoing care the woman is getting and interference due to this.
The main cause of argument between the health care providers and the companions is the need to be with the laboring woman throughout the labor process. There were situations mentioned by health care providers that have escalated into fights.
One health care provider mentioned his experience; ‘‘once I have seen a companion who hit a midwife. This is because the health professional was telling the companion to go out, he wanted to evaluate the woman who was sharing the same room with the woman this companion was with, but he refused and it turned into a heated debate. This went on for a while and the companion hit the midwife...”
Reasons for not allowing labor companions
The main setback mentioned for involvement of birth companions is the issue of privacy. The participants mentioned that there will be multiple laboring mothers next to each other with-out proper screen. This makes allowing companion of one mother difficult. According to one health care provider “There are women who only has male companions; there are Muslim mothers who don’t want to be seen by males; so for the sake of one laboring mother we shouldn’t trespass the right of others. Even if they have female companions it is not fair to be seen by someone you don’t know.”
The other commonly mentioned problem is the existing setup. This includes the presence of laboring rooms without screens, lack of adequate space to add companions, lack of adequate couches and laboring beds. And one health worker explained his stand by saying: “with regards to birth companions I follow the mass, I don’t allow because of the setup we have”.
The case load is also one hindrance to involvement of birth companions. At SPHMMC there will be a minimum of 800 deliveries per month and the ER will be crowded with laboring mothers which makes even proper evaluation of patients challenging. The health workers mentioned that there are a lot of laboring mothers at specific time at the ER and addition of companions becomes a luxury.
Other factors include fear of litigation if any complication arouse and lack of adequate knowledge on the benefit of birth companions. There are also health care providers who mentioned they won’t feel comfortable evaluating a laboring woman with family members nearby.
There was conflicting finding with regards to the understanding on the administration stand on the issue of birth companions. There is a MOH recommendation and the institutions commitment to abide with that recommendation. But there is also institutions rule to allow companions only in the morning and late in the afternoons. The hospital has hired guards which make sure family members are allowed only on the allocated time period. This rule is implemented in the labor wards also. And the restrictions are more stringent at labor ward.