Pregnant Women’s Knowledge and Desire Towards Labor Companionship and its Associated Factors at Public Hospitals in South Wollo Zone, Northeast Ethiopia

Document Type : Original Research Article

Authors

1 Lecturer, Department of Midwifery, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

2 Lecturer, Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

3 Assistant professor of Pediatrics and Child Health Nursing, Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

4 Lecturer, Department of Midwifery, College of Medicine and Health Sciences, Debre Birhan University, Debre Birhan, Ethiopia

10.22038/jmrh.2022.63740.1849

Abstract

Background & aim: Companionship in labor is highly effective in encouraging facility-based delivery and has a positive effect on maternal self-control during childbirth. However, there have been few studies in Ethiopia to examine this issue. Therefore, this study assessed pregnant women’s knowledge and desire towards labor companionship and its associated factors at public hospitals in South Wollo Zone, Northeast Ethiopia.
Methods: A facility-based cross-sectional study design was employed from 1st November to 9th December, 2020. Study participants consisted of 416 pregnant women, who were selected by a systematic random sampling technique. Data were collected using structured questioners including socio-demographic characteristics, obstetric history, knowledge and desire towards companionship in labor, through face-to-face interviews.
Results: In this study, 19.5% of respondents have good knowledge while 87.3% of them have desire to have labor companion.  Diploma and higher educational level (AOR=3.23 95% CI: 1.06, 9.86), prior birth at private health-facility AOR=3.95, 95% CI: 1.08, 7.49) and having the experience of previous labor companion (AOR=2.36, 95% CI: 1.27, 4.38) were significantly associated with good knowledge. Rural residence (AOR=6.8, 95% CI: 1.40, 9.99) and history of having labor companion (AOR=5.34, 95% CI: 1.53, 9.64) were associated with desire to have companion.
Conclusion: Small percentage of pregnant women had awareness on labor companionship while a large percentage of women desire companionship during childbirth. Therefore, health care professionals should educate perinatal women about labor companions and allow them to have a support person throughout labor and delivery at a health facility to increase their awareness and desire.  

Keywords


Introduction

Every year, around 303,000 women worldwide die because of problems during pregnancy or childbirth. Developing regions account for approximately 99% (30, 2000) of the estimated global maternal death rate (1,2). Since 2000, Ethiopia has reduced maternal and child mortality by half, but a maternal mortality rate of 412 per 100,000 live births and a child mortality rate of 67 per 1,000 are still too high (3). Efforts to reduce maternal mortality and morbidity have focused on improving provision of and access to facility-based childbirth and, as a result, institutional births are increasing throughout many low- and middle-income countries (4).

Historically women have been attended to and supported by other women during labor and birth. However, in many countries, as more women are giving birth in hospital rather than at home, continuous support during labor has become the exception rather than the norm. This may contribute to the dehumanization of women's childbirth experiences (5,6). Companionship in labor is highly effective in encouraging facility-based delivery and has a positive effect on maternal confidence and self-control during labor and childbirth (7, 8).

Companionship in labor has been recommended most recently as part of World Health WHO recommendations on intrapartum care for a positive childbirth experience and is included as one of the WHO standards for improving the quality of maternal and newborn care in health facilities (9–11). It is a fact that allowing the presence of a woman's companion of choice during labor and childbirth promotes respect for the woman's autonomy, which is a very important factor to be considered while improving the quality of service delivery (12).

Evidence has shown that companionship in labor improves childbirth outcomes and the labor process, such as shorter duration of labor, increased rate of spontaneous vaginal deliveries, decreased need for analgesia and Caesarean Section, increased satisfaction with childbirth, less fear and distress, and reduced risk of low Apgar scores (8,10,13). Furthermore, the continuous presence of a loved one while in labor provides a strong emotional impact on the woman. This can be accomplished by making positive, reassuring statements and praising the women while they are in labor(10, 14).

As a study conducted in South Africa shows, women who didn't receive emotionally supportive companions during the hours of labor and delivery appeared to have less self-esteem and confidence, as well as increased anxiety and postpartum depression scores in the weeks after delivery (15). Women who didn’t have companionship during their last childbirth have a negative childbirth experience and the rate of caesarean section is also high (10). Women who did not receive social support during labor and delivery have a lower Apgar score and longer labor (10).

Despite the benefits of labor companionship, implementation of this approach is not universal yet (16–18). In Ethiopia, the utilization of companionship during childbirth was low. A study conducted at Arbaminch, Ethiopia, shows that only 13.8% of women utilize companions in labor (19).  In another study conducted in Debre Markos, Ethiopia, only 14.6% of women utilize companionship (20). Evidence shows that women’s knowledge and desire for labor companionship are associated with its implementation (16,19,20). The reason for low utilization might be attributed to Ethiopian women not seeking the presence of a companion of their choice when in healthcare facilities, or their desire for a companion being denied by the health professionals. It is necessary to respond to this question.

The desire of women to have a companion in labor and the challenges associated with the visibility of acceptance of such a desire in resource-limited health care facilities are still a major problem in many developing countries (11,21,22). Although many women have a desire to have childbirth companionship, their desires differ across the labor and delivery continuum, with most desiring companionship during labor but not at the time of delivery (23).

Knowing what women know about the benefits and rights of having a companion during labor, as well as their desire to have a companion, can help the health professional and the woman come to a mutually beneficial arrangement before labor begins. Women's awareness and desire to have a labor companion of their choice may impact where they deliver and how they use labor companions.

Previous research has identified sociodemographic factors such as age, marital status, educational level, occupational status, and family monthly income, as well as obstetric factors such as previous antenatal care follow-up, previous companion, gravidity, parity, and place of last delivery as factors associated with antenatal clients' knowledge and desire for labor companions (11,14,23–25). However, there have been few studies in Ethiopia to examine the awareness and desire of prenatal clients about a labor companion. Therefore, this study aimed to assess the knowledge and desire of pregnant women to have a labor companion and its associated factors.

Materials and Methods

A facility-based cross-sectional study design was employed from November 1 to December 9, 2020, at public hospitals in the South Wollo Zone of northeast Ethiopia. South Wollo is one of the 11 zones in the Amhara Region of Ethiopia. There are 11 public hospitals in the south Wollo zone.

The source population consisted of all pregnant women receiving antenatal care at public hospitals in the south Wollo zone. All pregnant women attending antenatal care in selected public hospitals in the South Wollo zone during the study period were included as the study population. Women who agreed to participate in the study and were expecting a vaginal birth were included, but those who had a known absolute or relative contraindication to vaginal delivery were excluded.The sample size for this study was calculated using a single population proportion formula by considering the following assumptions: 95% confidence level; the margin of error (0.05); and the proportion of pregnant women who need to have a companion during labor from a study done in Addis Ababa (53%) (26). Using the formula: n= Z2/2 x p (1-P)/d2, the final sample size was 422, after accounting for a 10% nonresponse rate. Because of resource limitations, only five hospitalswere selected using a simple random sampling technique, and proportional allocation was performed based on the hospital's average monthly case flow. To select the study participants, a systematic random sampling technique was employed. The sampling interval was determined based on the monthly average number of antenatal care visits. Accordingly, the hospital's first-quarter average monthly number of antenatal care visits in 2020 was 820 (i.e., Kth value 820/422 = 1.9 ~ 2). The initial woman was selected using the lottery method, and the next pregnant woman was selected every two intervals according to the order of antenatal care visit until the final sample size was fulfilled.

Companion in labor: refers to the person chosen by the woman to provide her with continuous support during labor and childbirth. This may be someone from the woman’s family or social networks, such as her spouse/partner, a female friend or relative, a community member (such as a female community leader, health worker, or traditional birth attendant), or a doula (i.e. a woman who has been trained in labor support but is not part of the health care facility's professional staff) (10).

Knowledge about companionship- refers to the women’s awareness of their right to have a companion in labor and the benefit of companionship in labor. It is measured by calculating the mean score of the 10 items and categorized as knowledgeable (if participants scored ≥ mean score of the correctly answered questions) or not knowledgeable (if participants scored

Desire to have a companion -refers to the woman’s need to have a supporter of her choice during labor and childbirth (14). A woman who answered “Yes” to the question” do you want to have a labor companion at the time of labor” was considered as having a desire to have a labor companion.

Face-to-face interviews with a pretested structured questionnaire were used to collect data. The questionnaire was adopted from previous similar literature (14,26) and it includes information related to socio-demographic characteristics, obstetric history, knowledge about companions in labor, and the desire to have a companion in labor and delivery. Four trained diploma midwives collected the data using the Amharic version (local language) of the questionnaire. Four BSc midwives supervised the data collection process.

The questionnaire was prepared originally in English and was translated into Amharic (the local language) and back to English by two independent persons to maintain the consistency of the questionnaire. The training was given to data collectors and supervisors. A pilot study was conducted using 5% of the questioners at Kemissie General Hospital and a necessary modification was made before the actual data collection.

The collected data were checked for completeness and consistency before analysis and entered into Epi Data version 4.6. For analysis, the data was exported to SPSS version 25 software. The exported data was categorized and summarized using descriptive statistics like frequency tables, graphs, and proportions. Then bivariate analysis was carried out to assess the crude association between the independent and outcome variables. The variables with a P-value <0.2 in bivariate analysis were entered into a multivariable logistic regression to assess the net effect by controlling confounders. The variables with p < 0.05 in multivariable logistic regression were considered as statistically significant factors for knowledge and desire of antenatal clients about labor companions. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to assess the strength of the association. Multi-Collinearity was checked among the independent variables. A Hosmer and Lemeshow goodness of model test in logistic regression was run to check the model fitness.

The study was approved by the Ethics and Research committee of Wollo University, College of Medicine and Health Sciences. A Letter of Cooperation was obtained from the South Wollo zone health office. Written consent was obtained from individual respondents. The participants’ confidentiality was secured throughout the study and information regarding the identification of the patient was recorded anonymously.

Results

A total of 416 pregnant women were interviewed successfully, making a response rate of 98.6%. Of those, 287(69%) of respondents were in the age range of 20–34 years. The great majority (96.9%) of the study participants were married.  More than half, 265 (63.7%) of the respondents were Muslim, followed by Orthodox Christians, 143 (34.4%). Regarding educational status, 150(36.1) of the study subjects had completed primary school. The majority of the respondents (65.6%) lived in urban areas. Most of the respondents (96.4%) were from the Amhara ethnicity (Table 1).

Regarding parity, more than half (58.7%) of the respondents were multiparous. More than three-quarters (85.3%) of the respondents received antenatal care in their last pregnancy and most of the respondents (84.9%) had facility delivery. Less than a quarter (19.9%) of the study participants had a companion with them during their last delivery. About fifteen percent of the respondents had a history of home delivery, and the predominant reason for home delivery was short labor duration (51%), followed by lack of transportation (21.6%). At the time of data collection, about thirty-three percent of the respondents were in the second trimester of pregnancy, followed by the third trimester (25.7%). The great majority of the study participants intend to deliver their current pregnancy at a health facility (Table 2).

The findings of this study showed that only 81 (19.5%) pregnant women had good knowledge regarding labor companions at health facilities, with a 95% confidence interval of 15.9%-23.5%. Among the 416 respondents, only 80 (19.2%) know that it is their right to have a companion of their choice during labor and childbirth while in a health facility. Regarding the benefit of having a labor companion, less than a quarter (20.2%) of the respondents believe that having a labor companion will reduce labor pain.

Thirty-six percent of respondents believed it reduces anxiety and fear in women, and 27.9% believed it reduces the likelihood of being abused and disrespected by health care professionals (Table 3).

The vast majority (87.3%) of the respondents have a desire to have their choice of a companion during labor and delivery. Only 32 (7.7%) of the respondents had been informed about labor companions from the health facility. More than three-quarters (88.5%) of the respondents believed that allowing labor companions during labor would promote the rate of facility delivery. More than half of respondents 270(64.9%) preferred their mother as a labor companion during labor and delivery, followed by their husband,138(33.2%) and the rest 8(1.9%) of respondents prefer their sisters as labor companion. The majority 284 (78.7%) of the respondents’ expectations from their labor companions is to encourage them, followed by running necessary errands 129 (33.2%) (Figure 1).

Bivariate and multivariate logistic regression analyses were done to identify factors associated with the pregnant women’s knowledge towards labor companionship at health facilities. After controlling for potential confounds in multiple logistic regression analyses, age <20, no formal education and primary education, home delivery, and having previous labor companion were found to be significant factors for pregnant women’s knowledge on labor companionship.

As a result, pregnant women with a diploma or higher educational level were 3.23 times more likely to have good knowledge of labor companions than those with no formal education (AOR =3.23, 95% CI: 1.06, 9.86). Similarly, pregnant women who had their previous child at a private health facility were 3.95 times more likely to have good knowledge than those who delivered at home (AOR=3.95, 95% CI: 1.08, 7.49). Pregnant women who had previous labor companions were 2 times more likely to have good knowledge about their right to have a labor companion and its benefits as compared to those who had not had labor companions during their previous labor and delivery (AOR=2.36, 95% CI: 1.27, 4.38) (Table4).

Bivariate and multivariate logistic regression analyses were done to identify factors that are associated with the desire of pregnant women to have their choice of labor companion at a health facility.

 After controlling for potential confounds in multiple logistic regression analyses, rural residence and having a labor companion during the last delivery were found to be significantly associated with the desire to have a labor companion.

 Pregnant women living in rural areas were 6.8 times more likely to want a labor companion

at a health facility than those living in urban areas (AOR =6.8, 95% CI: 1.40, 9.99).

Similarly, pregnant women who had labor companions during their last delivery are 5.34 times more likely than those who did not have labor companions during their last delivery to want labor companions at health institutions (AOR=5.34, 95% CI: 1.53, 9.64) (Table 5).

Discussion

Labor is a period marked by emotional upheavals, anxiety, concerns, terrible pain, and an increased risk of maternal and child mortality and morbidity (27). Over the last two decades, efforts to enhance maternal and newborn outcomes have emphasized the use of healthcare facilities for births, which have increased from 50% in 2000 to 77% in 2020 globally (28). Women who give birth in health facilities, on the other hand, will be alone with unknown health professionals and the surroundings, along with all of their anxieties and worries (29). Some women choose to deliver at home because they are afraid of being alone in an unknown setting, as opposed to the "secure and reassuring atmosphere" at home (30).  

The presence of a birth companion with a woman in labor has been shown to enhance beneficiary satisfaction and have a beneficial impact on delivery outcomes, such as shorter labor, better pain control, and fewer medical interventions (31). Despite the obvious benefits, research suggests many women were refused birth companions and were unaware of their entitlement to have a birth companion of their choosing present during labor (32–38). As a result, recognizing perinatal clients' awareness and desire for birth companionship during the labor phase is critical for cultivating a good attitude toward companionship and enhancing its implementation.

This study revealed that only 19.5% of pregnant women in South Wollo public hospitals are aware that they have the right to have a companion to support them in the labor and delivery room during childbirth in a health facility and its benefits. The finding was slightly higher than a study conducted in Addis Ababa in which only 13.6% of antenatal clients were aware of labor companions (14). This implies that women in Ethiopia have less awareness about their right to labor companionship, which may contribute to the low implementation of labor companionship in Ethiopia. On the other hand, the finding of this study contrasted sharply with the finding in a related study conducted in Malawi, where almost 85% of the respondents were aware of their rights and benefits as labor companions (22). The reason for the difference may be attributed to the difference in the study setting.

The study has identified that pregnant women who had a diploma and higher educational levels were statistically associated with better knowledge of antenatal clients' labor companions than women who had no formal education. The possible explanation could be that educated women might have more access to knowledge via the internet or reading material than uneducated women. Similarly, prior experience of delivery at private health facilities was statistically associated with good knowledge of pregnant women regarding labor companions when compared to those who delivered at home.  The reason could be that women who deliver at a health facility might get an opportunity for comprehensive counseling about the benefits of labor companionship.  Furthermore, prenatal clients who had a labor companion during their previous birth had considerably better knowledge about labor companions than those who did not have a labor companion during their previous delivery. This finding is in line with a study conducted in Addis Ababa, which found that perinatal women who had a labor companion during their previous birth were 3.39 times more likely to know about labor companions (14).

This study further showed that 87.3 percent of antenatal clients have a desire to have a companion of their choice during labor and delivery in a health facility. This finding is in line with studies conducted in Addis Ababa, Ethiopia, Mali, and Kenya, in which 86%, 83.6%, and 82% of women have a desire to have their choice of labor companion respectively (14,22,23). However, the finding is higher than that of studies conducted in Addis Ababa (53%), Nigeria (75%), Kenya (82%), and Saudi Arabia (45.3%) (23, 26,39,40). This high proportion of antenatal clients desiring a companion during labor and delivery in a facility is unsurprising because they want to preserve and institutionalize the age-old beneficial cultural practice of companionship, which, unbeknownst to many of them, has a strong, evidence-based scientific foundation in modern maternal and child health care (41).  This suggests that the quality of care provided in health facilities is still poor since it fails to address one of the world's health organizations' suggested interventions for encouraging and promoting facility-based delivery.  

This study has identified that rural residence was significantly associated with antenatal clients' desires to have a labor companion. Women who reside in rural areas are 6.8 times more likely to desire companionship during childbirth than those who live in urban areas. This finding contradicts a study conducted in Addis Ababa, in which there was no significant association seen between residence and the desire to have a labor companion (26). The reason could be due to a difference in the study period and setting in which the latter one was conducted in the capital city of the country, where most women live in urban areas. This study also found that having a history of past labor companions was linked to pregnant women's desire to have their preferred labor companion. The explanation for this might be because women who had a companion during their last delivery may have reaped the benefits of having someone to assist them throughout labor.

The study's strength was that it had no ethical issues. It may help to cover some knowledge gaps and serve as a baseline for future studies because there is a scarcity of information and studies on this topic in Ethiopia. The study design in this study had a drawback in that it could not determine cause and effect correlations.

Conclusion

According to the study, just a small percentage of pregnant women were aware of their rights to have labor companions and its advantages. This shows that women require information regarding the need for a supportive companion and their expected role before they present to a health facility in labor. Such notification will provide an opportunity for the pregnant woman to identify someone of their choice who is ready and capable of taking up the role of a companion.

On the other side, a large percentage of pregnant women want companionship during labor and while in the hospital. Antenatal women's knowledge about labor companionship at health facilities was found to be affected by their educational level, prior site of delivery, and the previous history of labor companion, and their desire for a labor partner was found to be influenced by their residence and past history of having a labor companion. Therefore, health care professionals should educate perinatal women about labor companions and allow them to have a support person with them throughout labor and delivery at a health facility to increase their awareness and desire. 

Acknowledgements

The authors would like to express their gratitude to Wollo University for their ethical permission and financial support of this study, as well as the study participants for their time and cooperation, and data collectors and supervisors for their dedication during the data collection procedure.

Conflicts of interest

Authors declared no conflicts of interest.

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