Labor companionship utilization and healthcare providers perceptions in Gondar public health facilities: a mixed method study

Abstract

Background

The World Health Organization strongly recommends companion of choice for all women during health facilities delivery. It is highly significant for enhancing institutional delivery. However, little is known about extent to what labor companionship is utilized and women’s preferences.

Objective

To assess Labor companionship utilization and Healthcare Providers Perceptions in Gondar Public Health facilities 2023.

Methods

A mixed study design was conducted from December 1/2022 to January 30, 2023. We used simple random sampling techniques (lottery method) to select health facilities and systematic random sampling techniques to select study participants. Semi-structured questionnaires were employed. Data were entered into kobo collect software and analyzed by Stata version 14. Variables with p value ≤ 0.2 were entered into a multivariable logistic regression model and p-value < 0.05 were significant and reported with Adjusted odd ratio (AOR) and 95% confidence interval (CI). For qualitative data purposive sampling technique was used and face to face interview guide were employed. Data were transcribed, translated, and thematically analyzed by using open code software 4.03.

Results

The magnitude of labor companionship utilization was 11.3%( 95% CI; 8.9%, 14.3%). Urban residence (AOR = 2.26, (95% CI: 1.08, 4.7)), Primiparous (AOR = 2.3, (95% CI: 1.16, 3.6)), previous history of abortion (AOR = 2.39, (95% CI: 1.15, 4.9)) and good knowledge of women about labor companionship (AOR = 2.26 (95% CI: 1.2, 5.8)) were statistically significant. The main themes that emerged as barriers to the practice of labor companionship were narrow delivery room space, absence of a partition in delivery room, overcrowding of women in one delivery room (privacy issue), lack of awareness on community and health care provider`s on labor companionship.

Conclusion

The magnitude of labor companionship utilization is low. Urban residence, Primiparous, history of abortion, and having good knowledge on labor companionship were statistically significant. Narrow delivery room space, absence of a partition in delivery room, overcrowding of women in one delivery room(privacy issue), lack of awareness on community and health care provider`s on birth companionship were main barriers. Thus to meet international recommendations that every woman is offered a companion of her choice during labor, the need for multi-layered interventions includes creating private spaces using partitions or curtains to ensure conducive delivery rooms in ways that facilitate the presence of labor companionship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-07911-7.

Background

Labor companionship is refers to non-pharmacological aspects of care provide continuous support, encouragement, respect and continuous physical, and emotional support to a woman during childbirth by their preferred person ADDIN EN.CITE [1, 2]. It is as a core element of care for improving maternal and neonatal health outcome that every woman is offered to use her choice of companion while in labor ADDIN EN.CITE [3].

Maternal and neonatal mortality is a global challenge that requires a multidimensional strategies [4]. Globally overall 295, 000 maternal deaths occurred annually. Of these, sub-Saharan Africa alone estimated 66% of the estimated global maternal deaths [5].

World Health Organization (WHO) launched critical targets that 90% of births to should be attended by skilled birth attendant to reducing preventable maternal deaths [6]. It recommends on companions of choice during childbirth adopted to introduce policies to the health services that include representatives of maternal health care providers, facility managers and women themselves [7].

According to FIGO guideline of 2015 on mother friendly care has a written policy that encourages women to have at least one person of their choice to be with her throughout the labor process ADDIN EN.CITE [8]. In Ethiopia, government was taken different measurements to improve institutional delivery but more than 50% of all child births are not assisted by skilled personnel [9].

Previous studies shown that continuous support during childbirth have great benefit [10] and improves birth outcomes by enhancing the physiological process of labor as compared with women undergoing labor alone [10]. Beside to this, continuous support has clinically meaningful benefits, including improved maternal quality of care [11, 12], higher self-esteem, coped well during labor and encourage earlier initiation of skin-to-skin contact, and breast feeding [12].

Despite of, all those importance of child labor companionship, its practice is still a major problem in developing countries including Ethiopia and little is Known about the utilization of labor companionship [13].

In previous study conducted in northern India, 93% of health care providers were awarded on labor companionship [14] in Brazil 18.8% [15],in Britain 30% [12], in Brazil the presence of companions during labor was 70.1%, during delivery 32.7%, and during the postpartum period was 61.3% % [16], in Nepal 19% [11], in Ghana, Guinea, Nigeria and Myanmar, 50.4% [17], in Tanzania, 44.7% [18], in Nigeria 22.1% [19], in Nigeria 75% [20], in Kenya about 88% of women were accompanied by someone from their social network to the health facility, 82% of women desire companionship during labor and 37% women desire during delivery [21],in Arba-minch town, 13.8% of mothers [13], in West Shao Zone 19.5% [22], in Debre Markos town,14.6% [23].

From associated factors maternal age [21], educational status [11], marital status [21], employment status [11, 21], resident ADDIN EN.CITE [11, 21, 24], complication during pregnancy ADDIN EN.CITE [18, 25], Number of pregnancy and number of delivery ADDIN EN.CITE [25, 26], wanted pregnancy [27], presence of ANC visit and getting birth preparedness and complication readiness plan counseling during ANC visit [21], ANC visit [27], delivery place [21],Previous history of labor companionship utilization [23] were significant associated with labor companionship.

According to previous studies suggested that choice of labor companion by women were family members [17], including their mother 70%, husband 69%, sister 46% [14, 21], most women were happy when their companions were allowed to stay with them during labor [21].

There is a lack of empirical evidence on barriers to practice labor companionship post-partum women`s, health care provider`s point of view in Ethiopia including particular to this study area. Therefore, this study aimed to assess utilization, influencing factors and to explore women’s perception towards labor companionship. This is important because it provides input for improving the quality of care provided to mothers during labor and childbirth. Besides, the study will helpful for health program planners and policy makers to plan targeted intervention, change policies and allocation of resources appropriately. The conceptual framework shown (Fig. 1).

Fig. 1.

Conceptual frame work to assess Labor companionship utilization and Healthcare Providers Perceptions in Gondar Public Health facilities 2023 adapted from ADDIN EN.CITE [13, 21, 23].

Methods and materials

Study design and period

An institution-based mixed study design was conducted from December 1/2022- January 30, 2023.

Study area

The study was conducted at Gondar town selected public health facilities. Gondar town is located in the Amhara Region of Ethiopia, specifically in the Central Gondar Zone. It’s situated in the northwestern highlands of Ethiopia, north of Lake Tana and southwest of the Simien Mountains. The city is about 727 km from Addis Ababa and 120 km from Bahir Dar, the city of the Amhara region. It is at 1203’N latitude and 37,028’E. Approximately the total population lives in Gondar town were 450, 000. The average delivery services at Gondar public health facilities in one month 1600. The town has one comprehensive specialized referral hospital and eight health centers. These are: University of Gondar Comprehensive Specialized Hospital, Gebrael health center, Tseda health center, Azezo health center, Mintiwab health center, Blajig health center, Weleka health center, Poly health center, and Maraki health center.

Population

Source population

All women who gave birth in Gondar town public health facilities.

Study population

All women who gave birth in selected Gondar town public health facility during data collection period.

Eligibility criteria

Inclusion criteria

Women who gave birth in selected Gondar town public health facility during data collection period.

Exclusion criteria

Post-partum women whose labor was not attended in the selected health facility and elective cesarean section were excluded.

Sample size determination and sampling procedure

Sample size determination

First, we calculated the sample size for the first objective with single population proportion formula by taking the proportion of practice of labor companionship during labor and delivery studied in Debre Markos town is 14.6% [23]. by considering the following assumptions: the practice was 14.6%, level of confidence – 95%, and margin of error – 5%, therefore, the sample size was;

Where n= required sample size

@= Level of significant

z= Standard normal distribution curve value for 95% confidence level

P= Practice of labor companionship

d= Margin of error

Substituting the above values to the single proportion formula

 

For the second objective by taking CI; 95%, Power 80%, and odds ratio from different literature calculated by Epi-info version 7 shown below (Table 1).

Table 1.

Summary of sample size calculates the for second specific objective by Epi-info

Name of variable	CI	Power	Effect size(OR)	Minimum sample size
Having complication during the labor and delivery	95%CI	80	OR-3.48	316
Women’s desire for a labor companion	95%CI	80	OR-3.63	302

From the above sample size calculation we had taken the largest sample size i.e. 316.Then since we used a Multi-stage sampling technique, with design effect 1.5. So 316 * 1.5 = 474, adding 10% non-response rate and the finally the minimum sample size was 522. For qualitative study we conducted 8 IDI from post-partum women and two FGD from health care providers.

Sampling technique and sampling procedure

Simple random sampling techniques (lottery method) was used to select Health facilities and Systematic random sampling techniques was used to select study participates. There were One referral hospital and eight health centers found in Gondar Town Health facilities. Among these UOGCSRH, Poly health center, Azezo health center and Maraki health center were selected by lottery method. We use proportional allocation formula to select the appropriate sample in the selected health facilities. The delivery coverage per month at UOGCSRH (755), Poly health center(162), Azezo health center(121) and Maraki health center(153) women.

Where Where ni= Total sample size for each health facilities n= Final sample size, 522 Ni= Monthly total delivery in each health facilities N= Monthly total number of delivered women in all selected health facilities 1191.

The sampling procedure was by calculating a constant k=3 and we were take the average delivery services at selected public health facilities in one month 1191 with total minimum sample size 522 then k=1191/522=2.28 in every 3^rd interval. The first participant was selected by using lottery method and the rest was selected every 3 interval (Fig. 2).

Fig. 2.

Schematic presentation of sampling technique and procedure of women who gave birth at Gondar town public health facilities, North West Ethiopia, 2023

For qualitative study we used purposive sampling technique to select post-partum women.

Study variables

Dependent variable

Utilization of labor companionship.

Independent variable

Socio-demographic factors; age, marital status, education, occupation, husband education, husband occupation, and residence.

Obstetric factors; Parity, complicated pregnancy, complicated delivery, previous history of abortion, and Status of current pregnancy.

Health Service Related factors; presence of ANC visit, Informed about labor companionship, counseling on BPCRP, desire for labor companionship and knowledge on labor companionship.

Operational definition

Labor companionship; continuous support provided to laboring women in all moments of labor and delivery process by their preferred companion. It may be provided by family member, a partner, or other [7].

Utilization of companionship: - Yes if laboring women accompanied by her preferred person starting from home to provide continuous support and stay with her till a minimum to the end of first stage of labor in the health facilities, otherwise No [21].

Knowledge; Participants were asked Eight items questions measure knowledge on labor companionship.

The response of participants in each item was coded as “Good knowledge” if they answered to the items correctly and get score above the median value and “Poor knowledge” if they below the median score [28].

Data collection tools and procedures

For quantitative study a pre-tested semi-structured interview questionnaire was entered and coded to kobo collect v2022.1.2, collected by four trained midwifery with one supervisor. The questionaries’ had three parts Part -One; Socio demographic characteristics −8 items. Part -two; Obstetrics related factors-15 items. Part -Three; Knowledge related to companionship −8 items. Part -Four; Health Service Related factors-8 items. The questionaries’ were standardized; the reliability test was checked using Cronbach alpha the value was 0.8. Data were coded and entered to Kobo collect software and exported to Stata version-14 for further analysis. Variables with a p- value of ≤0.2 was entered into a multivariable logistic regression model. Variables p-value<0.05 were taken as statistical significant and AOR with 95% CI was reported. Hosmer-Lemeshow test had insignificant with p value of 0.7. In all variables this variance inflation factor was less than 10.

For qualitative study interview guide were prepared. An interview was conducted in Amharic, audio-recorded, and simultaneously transcribed verbatim and retranslated into English. A coding scheme was thematically analyzed using open code software version 4.03. The codes were categorized sub-themes and main-them were merged.

Data quality control

The questioner was pre-tested with 5% [26] of the participants at Debre Tabor referral Hospital one week prior to the actual data collection. Two day intensive training on the data collection tool, was provided for data collectors and supervisors. The questionnaires were translated to Amharic to make it understandable by the study participants and then were retranslate to English. Trust worthiness of the qualitative data was checked by; transferability, Credibility. Dependability and Conformability.

Results

Quantitative finding

Socio-demographic characteristics of respondents

A total of 522 women who gave birth were included making a response rate of 100%. Of these the mean age of women was 28±4.1 years and half (50.57%) of them with the age range of 25-29 years. More than two-third (67.64%) of respondent were lived in urban area (Table 2).

Table 2.

Socio-demographic characteristics of respondents about labor companionship utilization, Gondar town public health facilities, North West Ethiopia 2023

Variable	Frequency	Percent (%)
Age(years)
18-19	18	3.45
20-24	70	13.41
25-29	264	50.57
30-34	138	26.44
≥35	32	6.13
Residence
Rural	171	32.36
Urban	351	67.64
Marital status
Married	484	92.72
Un married(single, divorced)	38	7.28
Maternal educational level
Cannot read and write	28	5.37
Can read and write	69	13.21
Primary school(1-8)	133	25.48
Secondary school(9-12)	159	30.46
Colleague and above	133	25.48
Maternal Occupational status
House wife	326	62.46
Government employee	105	20.11
Merchant	54	10.34
Non-government employee	9	1.73
Student	28	5.36
Husband occupation (n=484)
Daily labor	14	2.89
Farmer	127	26.24
Government employee	245	50.62
Merchant	82	16.94
Non-government employee	14	2.89
Student  Other: Catholic, protestant; Unmarried: Single, widowed and separated;	2	0.42

Obstetrics characteristics of respondents

More than half of women (54.79%) were primiparous. Among multiparous women, 69(13.22%) of women had at least one previous history of abortion. Regarding to most recent previous pregnancy, 34 (14.4%) of women had complication during pregnancy. From women who had recent previous complication (47.06%) of women had preeclampsia and/or eclampsia. Among the respondent (92.79%) of women delivered by SVD for last recent previous pregnancy followed by C/S (Table 3).

Table 3.

Maternal obstetrics condition in Gondar town public health facilities, Northwest Ethiopia, 2023

Variable	Frequency	Percent (%)
Previous history of abortion
Yes	69	13.22
No	453	86.78
Type of abortion(n=69)
Spontaneous	57	82.61
Induced	12	17.39
Parity
Primi-para	286	54.79
Multi-para	236	45.21
Had Complication during most recent previous pregnancy(n=236)
Yes	34	14.4
No	202	85.6
Had labor complication in recent previous pregnancy(n=236)
Yes	21	8.9
No	215	91.1
Had labor companion in recent previous delivery(n=236)
Yes	15	6.36
No	221	93.64
Was current pregnancy planned
Yes	483	92.53
No	39	7.47
Was current pregnancy wanted
Yes	494	94.64
No	28	5.36
Had complication during Current pregnancy
Yes	84	16.09
No	438	83.91

Maternal health service related factors

Majority of women 212 (89.83%) had got ANC follow up for last recent previous pregnancy. From the respondent (17.79%) women were delivered at home (Table 4).

Table 4.

Maternal health service characteristics of the respondents in Gondar town public health facilities, Northwest Ethiopia, 2023

Variables		Frequency		Percent (%)
Had recent previous ANC follow up (n = 236)
Yes		212		89.83
No		24		10.17
Place of ANC follow up at recent previous pregnancy (n = 212)
Health center		118		55.66
Public hospital		86		40.57
Private clinic		8		3.77
Place of delivery in recent previous pregnancy (n = 236)
Home		42		17.79
Health center		86		36.45
Public hospital		108		45.76
Had ANC follow up for current pregnancy(n = 522)
Yes		477		91.37
No		45		8.63
Birth preparedness and complication readiness plan during ANC follow up
Yes		368		77.15
No		109		22.85
Information about Birth companionship
Yes		102		19.54
No		420		80.46
Women future desire
Yes		464		88.8
No		58		11.2

Knowledge of post-partum women on labor companionship utilization

From the respondent, 146(27.97%) women had good knowledge about labor companionship (Fig. 3).

Fig. 3.

Knowledge of women on labor companionship at Gondar town public health facilities, North West Ethiopia, 2023

Magnitude of labor companionship utilization

The magnitude of labor companionship utilization at Gondar town public health facilities was 11.3%(95% CI; 8.9%, 14.3%) (Fig. 4).

Fig. 4.

Magnitude of Labor companionship utilization in Gondar town public health facilities, Gondar North west Ethiopia 2023

The magnitude of labor companionship utilization was low which is assisted by qualitative findings from the women, narrate that they didn`t get labor companion with the reason of health facilities and health provider do not allowed entering birth companion to beside of laboring mother.

“….This University of Gondar hospital was not allowed. So I don’t see any family from the beginning to the end of my labor. I am suffering alone.” (IDIW-Participant-8).

Some respondents also reported that if the companioned person was health professional or if they have a relative in that area of health facility, they have to get birth companion during their labor process unless it is difficult.

“My husband is a health professional, they bring things what I need because he knows what I want” (IDIW-Participant4).

Of those a companioned women, more than two third 45(76.27%) of post-partum women were accompanied until the end of first stage of labor and 14(23.73%) were continued to accompanied till delivery (Fig. 5).

Fig. 5.

Women’s duration of accompanied in Gondar town public health facilities, Gondar North west Ethiopia; 2023

From those who utilized a labor companions, (59.3%) of post-partum women were accompanied by their mother/mother-in-law, (30.5%) by their husbands followed by sisters and family health professional. In labor ward, 98.8% of them were accompanied by their preferred companion. This quantitative finding also nourished by qualitative finding that, most of the women preferred for birth companion were their mothers because the mother supports in every activity.

“I chose my mother because; my mother loves me very much. I want her to come. My mother has given birth and she knows the situation of my birth. I will become strong when my mother near my side” (IDIW-7).

Factors associated with labor companionship utilization

A total of fifteen variables were eligible for regression analysis to identify factors associated with labor companionship utilization. On bi-variable binary logistic regression nine variables had an association with labor companionship utilization. However, after controlling confounders; residence, previous history of abortion, parity, and knowledge of women were statistically significant (Table 5).

Table 5.

Multi variable logistic regression table among women who gave birth in Gondar town public health facilities, Ethiopia; 2023

Variables	Labor companionship			COR; 95% CI	p-value	AOR;95%CI	P-value
	Yes		No
Residence
Rural	10		161	0		0
Urban	49		302	2.6(1.2,5.2)	0.008	2.26(1.08,4.7)	0.029*
Marital status
Unmarried	7		29	0		0
Married	52		434	0.53(0.2,1.2)	0.156	0.41(0.15,1.2)	0.084
Previous history of abortion
No	46		407	0		0
Yes	13		56	2.05(1.04,4.0)	0.037	2.39(1.15,4.9)	0.018*
Parity
Multi Para	20		216	0		0
Primi Para	39		247	1.7(0.9,3.2)	0.006	2.3(1.1,3.6)	0.02*
Presence of at least one ANC follow up visit for current pregnancy
No	8		48	0		0
Yes	51		415	6.9(0.8,10.5)	0.07	3.6(0.4,21)	0.239
Current pregnancy complication
No	53		385	0
Yes	6		78	0.55(0.23,1.3)	0.194	0.5(0.2,1.2)	0.154
Current delivery complication
No	41		357
Yes	18		106	1.47(0.8,2.6)	0.198	1.51(0.79,2.8)	0.212
Current mode of delivery
C/s	22		93
SVD	37		370	0.42(1.23,0.7)	0.03	2.19(0.79,6.0)	0.13
Knowledge on birth companionship
Poor knowledge		51	325	0		0
Good Knowledge		8	138	2.7(1.2,5.8)	0.011	2.26(0.9,5.8)	0.04*

*p-value < 0.05

Women who came from urban area were 2.26 times more likely to utilize a labor companion compared to women from rural area (AOR=2.26, (95% CI: 1.08, 4.7)). And those women who had previous history of abortion were 2.39 times more likely to use a labor companion compared to their counterparts (AOR=2.39, (95% CI: 1.15, 4.9)).

Being primiparous were 2.3 times more likely to use labor companion as compared to multipara women (AOR=2.3, (95% CI: 1.16, 3.6)). Women who had good knowledge on labor companionships was 2.26 times more likely to use labor companion (AOR= 2.26 (95% CI: 1.2, 5.8)) as compared to those women who had poor knowledge on labor companionship.

To explore further and in-depth understanding of the factors for labor companionship qualitatively approach were conducted. As a result, participants described as health care provider’s denial and health facilities not allowed to enter birth companion in labor ward were main factors. In qualitative finding the overarching themes, sub theme of women for the analysis of the data IDI from post-partum women and FGD from health care providers were shown (Supportive File 2.docx).

In qualitative study the finding show that all participants perceived well regarding to companionship during labor and delivery as respondent describe labor companionship is necessary for women due to various kinds of support provided by the companions to these women in physical and moral perspectives.

“It’s nice to allow Labor companion. They help me, they care for me. Even if they don’t share my pain, they share my worries, at least they see me for what I am, and I’m very happy if someone is with me” (IDIW- participant-4)

The most common reason for desiring a labor companion was to have someone readily available to attend to their needs like carrying a child, keeping mothers to clean and helps to going to the bathroom.

“……because I am nothing to do without labor companion, they help me by keeping me to clean” (IDIW- participant-5)

The other reason for desiring a labor companion was to have someone readily available to attend to their needs like providing food, soft drink, and to buy medicine.

“If Labor companion is enter, they bring water and food for eat” (IDIW- participant-8)

Participants need companion to meet their informational needs by telling them what to do, and helping them make decisions, they were not in a state to make decisions on their own during labor.

“Yes, when they are near my side, I look at them and talk to them, forgetting pain what they are saying to me” (IDIW- participant-8)

Most respondents reported that, they wanted the companion around them in order to have someone who could remind them later of what happened during labor.

“When the pain get worse, they will call doctors. If I don’t have someone, I can’t get up who will call me” (IDIW-3)

Emotional support was on the whole mentioned as a reason for desiring a companion and crucial “If there is a person and when you have a person around me, my anxiety will decrease a little”.

Most of the women preferred for birth companion were their mothers because the mother has given birth before and experienced for the situation of birth and supports in every activity resulting in the best companion in labor. “….I need my mother, she tells me to be strong, she encourages me, and she makes me bear my pain.”(IDIW- participant-2).

Most of the women narrate that the factors for labor companionship was health facilities do not allowed entering the birth companion to beside of laboring mother especially in hospital setting.

“…. University of Gondar hospital was not allowed to enter companion, I am suffering alone. I am worry alone.”(IDIW-Participant-8)

Other women narrate that health care provider do not allowed entering the supported person to beside of laboring mother.

“Because laboring mothers need someone at that time, but providers don’t let them in. They say going to get out. It is another worry for laboring mother…….” (IDIW-Participant-5)

Most of women who had to get companions during labor and delivery expressed their gratitude because they helped them through the journey and felt safe with them nearby and in contrast they felt sad when they lonely. “I am very happy when my husband was with me(IDIW-Participant-4).

The women suggest to health facility, must allowed for labor companionship and even if it is difficult to separate delivery room for each woman to protect privacy, should better to prepare partition by screen. “… If there is no room for the parents the room is covered with a curtain,” (IDIW-Participant-1).

Some of women commented to health care provider, they must give respectful and companionate care for each woman.

“I recommend that anyone, whether it is a government employee, a doctor, or a nurse, comes from the laboring mother, and they should respect the laboring mother” (IDIW-Participant-1)

Discussion

In this study the magnitude of labor companionship utilization was 11.3%, among women who had companions. The finding of this study was not stick with the WHO recommendation states that, all women must have access to have a continuous support by companion during labor and delivery [2]. Our study findings was also consistent with previous study conducted at Arbaminch 13.8% [13]. This might be due to similar study setting both studies were conducted in public health facilities, used similar sampling method and techniques [23].

In contrast, it was lower than a study south Wollo, 19.9% [28], West Shoa Zone, Central Ethiopia,19.5% [22], Nepal,19% [11], East New Britain, 30% [12], in Brazil,18.8% [15], A multi nation Survey (Ghana, Guinea, Nigeria and Myanmar),50.4% [17], Tanzania, 44.7% [18] and Kenya,82% [21].

The possible explanation for this discrepancy might be due to socio-cultural and demographic differences of study participants in terms of educational level, norms and cultures between the societies [29], differences in healthcare policy and administrative protocol at the health facilities [30], difference in sample size and study setting [21], difference in health institution set up, health administrative barriers [30]. The health policy of other countries is committed to practice labor companionship which is feasible and well accepted by health providers and government officials [18].

In our study most of women narrate that they didn`t get birth companion during labor due to health facilities related barriers including narrow delivery room, privacy and voluntariness of the health facilities to enter birth companion. This finding is supported by the study conducted in Burkina Faso [31].

In this study women who were come from urban area were 2.26 times more likely to utilize a labor companion compared to counter parts. This finding is consistent with a study conducted in Kenya [21]. This might be due to women lived in urban more likely utilize ANC [32], had high media access easily gets information on labor companionship and birth preparedness and complication readiness plan [23].

Being Primi-para were 2.3 times more likely to utilize labor companion compared to multipara women. This is in agreement by a previous study conducted in Debere markos [23], Arbaminch [13], Ghana [26]. This could be Primiparous women perceived more likely to have complication during labor [29], had no experience of the childbirth process, and fearing of their labor [33].

Those women who had previous history of abortion were 2.39 times more likely to utilize a labor companion compared to their counterparts. This is supported by a previous study conducted in Tanzania [18]. The possible explanation might be women who had previous abortion, perceives that the complication may happen again [13, 18], that enhances more utilize labor companion.

Women who had good knowledge on labor companionship was 2.26 times more likely to utilize a labor companion compared to those women who had poor knowledge on labor companionship. This is consistent with previous study in Debre Markos town [23].The possible explanation could be women recognized about the role of the labor companionship, and know about companionship utilization is a component of human right, they might be choose their preferred companion ADDIN EN.CITE [33–35].

Among those who utilized labor companion, 98.8% of them were accompanied by their preferred companion (mother). This finding was Supported by previous study in three Arab countries [32], India [14], A multi nation Survey (Ghana, Guinea, Nigeria and Myanmar) [17], Ghana, Guinea, Nigeria, Myanmar and Kenya [17, 21]. This might be mothers were experienced in supporting and provide care for the women and newborn [21, 36].

From this qualitative finding most of the women narrate that both health facilities and health provider did not allowed to enter the birth companion to beside of laboring mother especially in hospital setting. The barriers were lack of provider’s awareness, lack of community awareness, facility level (infrastructure and limited space), and privacy issue. This study is supported with study conducted in south Africa [31, 37], midwives narrates barriers to utilize companion can be classified, limited space in the labor and delivery wards, no private rooms.

In our study, 88.8% women had future desire for labor companionship utilization consistent with a study conducted in Debre Markos and Rwanda [23, 36]. This might be that mothers that have a desire to use labor companionship more likely to express their feelings to the maternal health care providers by means of their companion [33]. Most of women wanted to have a companion stay with them during labor and delivery, otherwise they feel lonely. This findings is in lined with previous study conducted in Kenya and Uganda [21, 35].

Most post-partum women who desire birth companion for reason various activities like for physical support, instrumental support, and informational support. This is highlighted similar benefits in previous study in Srilanka, Rwanda [30, 36], south Africa [37] midwives stated that companion gives some forms of support can be physical, psychological and emotional, informational and non-pharmacological pain relief by massaging the laboring woman [38]. Addressing these challenges through targeted policies can improve maternal and neonatal outcomes, reducing mortality rates by exercising labor companionship. Ultimately, these findings call implementing a more integrated and accessible health system that prioritizes labor companionship utilization to reduce maternal and neonatal mortality.

Strength and limitation of the study

Key strengths include the triangulation of qualitative research method, multicenter study and multiple data sources that helps to insights the perspectives and experiences of labor companionship based on their understanding. However, the study had the following limitations. Firstly the nature of the study design (cross-sectional) does not allow establishing temporal relationships. Secondly recall bias may have influenced mothers’ ability to accurately remember maternal and child health services received. Thirdly social desirability bias, stemming from self-reported information, may also have affected data validity. Fourthly the study conducted only in urban public health facilities, may not generalize to all public health facilities due to exclusion rural public health facilities. Finally heterogeneity may face by factors such as type of health facilities between hospital and health center that the service provision might be different.

Conclusions

In this study the magnitude of labor companionship utilization was low. Urban residence, Primiparous, previous history of abortion, and having good knowledge on labor companionship were statistically significant. Most of the women and health care providers perceived that, narrow delivery room space, absence of a partition in delivery room, overcrowding of women in one delivery room(privacy issue), lack of awareness on community and health care provider`s on birth companionship were main barriers. Thus to meet international WHO recommendations every woman is offered a companion of her choice during labor and birth, suggest the need for multi-layered interventions includes creating private spaces using partitions or curtains to ensure conducive delivery rooms in ways that facilitate the presence of labor companionship.

Recommendations

A clear written policies allowing companions during labor, enforce privacy measures like curtains should be developed in order to standardize the implementation of labor companionship, future delivery rooms should be constructed as wide as possible to accommodate the birth companions.

Additionally health care providers start to implement labor companionship for all women at all times and provide client education regarding labor companionship to all pregnant women during antenatal care and enhancing their awareness during counseling on ANC follow up.

Researchers are also encouraged to conduct prospective cohort studies for stronger evidence in labor companionship utilization by incorporating rural public health facilities and other concerning bodies; such as traditional birth attendant, their partners, community leaders, religious leaders and HEWs for generalization.

Abbreviations

ANC

Antenatal Care

AOR

Adjusted Odds Ratio

APH

Antepartum Hemorrhage

BPCR

Birth Preparedness and Complication Readiness

CI

Confidence Interval

COR

Crude Odds Ratio

CSLD

Companionship during Labor and Delivery

FDG

Focus Group Discussion

FMOH

Federal Ministry of Health

HEWs

Health Extension Workers

IDI

In-depth Interview

IDIK

In-depth Interview of Provider

IDIW

In-depth Interview of Women

IUFD

Intra Uterine Fetal Death

LMIC

Low and Middle Income Country

MCH

Maternal and Child Health

MMR

Maternal Mortality Rate

RMC

Respectful Maternity Care

SDG

Sustainable Developmental Goal

SSA

Sub-Saharan Africa

SVD

Spontaneous Vaginal Delivery

UOG

University Of Gondar

UOGCSRH

University Of Gondar Comprehensive Specialized and Referral Hospital

WHO

World Health Organization

Authors’ contributions

All authors reviewed the revised manuscript. All authors declared that no conflict of interest exist.

Funding

Not Applicable.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from school of midwifery on behalf of the institutional Ethical review board of the University of Gondar, before conducting the study. Based on Ethical clearance obtained from institutional Ethical review board of the University of Gondar letter of permission was obtained from administrative bodies of each selected health facilities then oral informed consent were obtained from all of the participants in the study. The study had advantages as baseline information for policy makers and concerned bodies and it had no negative impact on study participates. The study adhered to the Declaration of Helsinki principles S1 file. Ethical clearance.docx.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.