Continuous labor support from a companion of choice in Uganda: Practices, role orientation, experiences and effect on birth outcomes

Abstract

Background: With the current pace of progress in meeting the goal to end preventable maternal deaths by 2030, the world will likely fall short of this target by more than 1 million lives. Globally, up to 2.5 million lives can be saved using evidence-based care practices including utilization of the birth companion in the intrapartum care. Uganda grapples with challenges of health human resources especially midwifery care providers. Such shortages jeopardize midwives’ ability, availability, and motivation to offer support to women during childbirth. A birth companion of choice is recommended by WHO to promote non-clinical care for all women for a positive childbirth experience and improved birth outcomes. Birth companions could be leveraged to a great degree to mitigate the current health human resource crisis. Empirical evidence on the effect of labor support, and specific support practices with regards to women's care needs is weak in low-income settings. This study aimed to explore labor support practices and to evaluate the effect of role orientation of birth companions on birth outcomes, maternal satisfaction, and care experiences in Eastern Uganda. Methods Sub-study I: Exploratory descriptive qualitative design was used. Ten non-participant direct observations of normal laboring women admitted in early labor with a full-time birth companion were conducted. In-depth interviews with the women observed were conducted pre-discharge. Latent content analysis was done. Sub-study II: A stepped wedge cluster randomized trial; a pilot study among 475 participants (control n=240), intervention n= 235) from 4 clusters. Midwives in the intervention period provided an orientation session for the birth companions on supportive labor techniques. Women with a birth companion, and expecting a vaginal delivery were included. The primary outcome was the mode of delivery. Secondary outcomes were coping, anxiety, length of labor, Apgar score, need for augmentation, and maternal satisfaction. Analysis was undertaken on an “intention to treat basis”. Statistical tests, including Chi-squared tests, t-tests, and confidence intervals, were two-sided. The statistical significance was set at 5%. Sub-study III. A phenomenological descriptive study design among 12 women supported by birth companions who had received a role orientation session on admission. Follow up home based in-depth interviews were conducted within a week during the postpartum period. Colaizzi method of phenomenological analysis was used. Results Birth companion practices identified were “support actions aiding a good childbirth experience” and “support actions hindering coping with labor”. Support actions aiding a good experience reported were emotional presence, motivation, providing nourishments, messenger activities, body massage for pain relief, assisting in ambulation, and coaching. Companion fearful behaviors, disrespectful care in the form of unacknowledged needs, and hostility from birth companions were cited to hinder coping. Women’s care needs identified included: thoughtful communication, trust, anticipatory care, and birth companions to recognize non-perceptive phases of labor to allow them focus on themselves. Following orientation of birth companions on labor support techniques, anxiety scores were lower in the intervention group (p = 0.001). The proportion of women able to cope during early active labor was higher during the intervention period (P = 0.031). Women in the intervention period had 80 percent higher odds of coping (P=0.032) compared to the control period. Notable differences were observed in anxiety and coping with labor among first-time mothers, younger women (15-24), and women who received support from siblings. There were no statistically significant differences in the mode of delivery, need to augment labor, length of labor, and Apgar scores. The mean maternal satisfaction score was significantly higher in the intervention period compared to the control period (P>0.001). Maternal satisfaction scores were lowest with pain management and highest with humaneness across the study periods. Qualitative evaluation of orientation showed that women that received support from birth companions who had an orientation had higher self efficacy to give birth even in moments when they had given up on having a normal birth. Women were contented with their experience with birth companions who had received an orientation. They reported feeling loved, esteemed, respected due to birth companions’ profound care. Trust between birth companion and woman was critical and influenced response to instructions to relaxation, mobility, nutrition, and hydration. Kindness was a driver for obedience to instructions.

Conclusion: Birth companions provide emotional, physical support, and advocate for women’s needs during labor. Companion fearful behaviors and insensitiveness hinders coping with labor. Midwife-provided orientation of birth companions on labor support lowered maternal anxiety and improves coping with labor and maternal satisfaction with care. Birth companion orientation enhanced women’s self-efficacy, promoted respectful, compassionate intrapartum care and a positive birth experience. Midwife-provided orientation of birth companion is a low-cost intervention pivotal in improving women's care experience, as well as contributing to ending preventable maternal and newborn mortality in Uganda.