From policy to practice: establishing birth companion presence in labour rooms via quality improvement methods

Abstract

Background

The WHO and the Government of India recommend allowing a chosen birth companion during labour and delivery. However, implementation across public facilities remains poor. This study aimed to introduce and sustain the presence of birth companions for at least 50% of labouring women within 5 months at a tertiary-care hospital in eastern India using quality-improvement (QI) methods.

Methods

The Model for Improvement (MFI) with sequential Plan–Do–Study–Act (PDSA) cycles was applied from May to September 2022. Barriers were analysed through a fishbone diagram. Interventions included staff sensitisation, protocol development and workflow redesign. Staff attitude and respectful maternity care perception were assessed using short Likert-scale feedback forms after each cycle.

Results

At baseline, no women were accompanied by a birth companion. After five PDSA cycles, 75% of labouring women had one. Staff-perception scores for respectful care improved by 38%, and resistance to the practice declined. No breach of privacy or infection-control incidents were reported.

Conclusions

Iterative QI cycles successfully introduced the birth-companion concept in a busy public-sector hospital. Context-specific administrative and behavioural interventions enhanced acceptance among staff and patients, improving respectful-maternity-care delivery. Sustained policy support and periodic staff motivation will be essential for scale-up.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Birth companionship improves maternal and neonatal outcomes and is recommended by the WHO and the Government of India, but uptake in public hospitals remains low.

WHAT THIS STUDY ADDS

• This study shows that iterative PDSA cycles can successfully implement birth companionship in a tertiary care setting by addressing key operational barriers.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings provide a scalable model to support routine implementation and national initiatives such as LaQshya.

Introduction

Childbirth is a transformative life event that demands not only skilled medical care but also emotional and social support. A supportive environment contributes to a positive birthing experience and favourable outcomes. A ‘birth companion’—a person chosen by the woman to remain with her throughout labour and delivery—can provide reassurance, comfort, and advocacy.

The WHO and the Government of India both endorse the presence of a birth companion during labour and delivery.^1–3 Despite this, Indian hospitals often fail to operationalise the recommendation because of infrastructural constraints and provider apprehensions.

Disrespect or lack of privacy during childbirth deters women from institutional deliveries.⁴ Respectful Maternity Care (RMC), which ensures dignity, privacy, informed consent and emotional support, is now a national priority under India’s Labour Room Quality Improvement Initiative (LaQshya).^{5 6}

Context of the study setting

This initiative was conducted in a tertiary-care teaching hospital in eastern India, which manages 120–150 deliveries per month, including high-risk pregnancies and both vaginal and caesarean deliveries. The labour ward consists of two semi-private rooms with five curtained beds each, offering limited privacy. Each shift is staffed by a registrar, two postgraduate trainees, an on-call consultant obstetrician and nursing officers, resulting in a high patient-to-staff ratio. Cultural norms and infrastructural limitations meant that only female companions were permitted, and no formal standard operating procedures (SOPs) for birth companionship existed prior to this project.

Existing evidence, including a Cochrane review and Indian quality improvement (QI) projects,^7–11 shows that continuous companionship reduces caesarean rates, shortens labour and increases maternal satisfaction. However, contextual data from public hospitals in eastern India are scarce.

The SMART objective of this QI project was to establish and maintain the presence of birth companions for at least 50% of all labouring women admitted to our facility within 5 months while addressing barriers identified through staff and patient feedback.

Methods

Study setting

This QI project was conducted over 5 months (May–September 2022) in the labour-room complex of a tertiary-care teaching hospital in eastern India. The hospital handles about 120–150 deliveries monthly, including a significant proportion of high-risk pregnancies and caesarean and vaginal deliveries. The labour complex has two semi-private rooms with five curtained beds each, ensuring basic privacy. Staffing per shift includes a registrar, two postgraduate trainees and an on-call consultant obstetrician, supported by nursing officers.

Quality improvement team composition and roles

A multidisciplinary QI team was formed under the medical superintendent. Administrative coordination was led by the Deputy Medical Superintendent. Two senior consultants acted as team leaders, guiding project design, while three registrars and three postgraduate trainees coordinated data collection and execution of PDSA cycles. The senior nursing officer supervised implementation, staff training and inventory management. Nursing officers and residents collected feedback, monitored compliance and communicated observations during weekly review meetings.

Study design

The project used the Model for Improvement (MFI) framework with iterative Plan–Do–Study–Act (PDSA) cycles. A fishbone (Ishikawa) analysis identified root causes of poor adoption. The study followed the Standards for QUality Improvement Reporting Excellence (SQUIRE 2.0) guidelines for reporting QI interventions

Participants

All women admitted for childbirth during the study period were eligible. Women who consented to have a birth companion were enrolled in the intervention pathway; those declining companionship continued to receive standard obstetric care.

Each woman was permitted to nominate one companion, typically a female relative (mother, sister or other close family member). Male companions were not allowed in the shared labour-room setting owing to infrastructural limitations affecting privacy for other women and socio-cultural norms within the hospital’s catchment area. No participants requested a male companion during the study period.

Before entry into the labour room, companions received structured orientation covering infection prevention, expected conduct, maintenance of privacy and their supportive (non-clinical) role during labour.

Problem identification

Baseline assessment revealed no existing policy or infrastructure for allowing birth companions (0% compliance). Barriers identified included lack of awareness, absence of SOPs, resistance from healthcare providers, privacy concerns and limited space in shared labour rooms.

Intervention strategy

Change ideas were developed and prioritised based on the fishbone analysis (figure 1.1). Interventions were tested sequentially across five PDSA cycles, with review meetings held on the fifth of each month. Table 1 summarises the aims, measures and modifications in each cycle.

Figure 1. Fishbone diagram for comprehensive evaluation of quality improvement for the attendance of birth companion. 1.2 PDSA 1: for sensitisation of stakeholders and formation of SOP. 1.3 PDSA 2: to organise sensitisation meetings and seminars for resident doctors and staff nurses 1.4 PDSA 3: to provide sterile supplies for maintaining sterility in LR. 1.5 PDSA 4: to fix and provide ID card for birth companion for every patient for reducing overcrowding in the labour room 1.6 PDSA 5: to limit the overcrowding and interference of birth companion. LR, labour room; PDSA, Plan–Do–Study–Act; SOP, standard operating procedures.

Table 1. Model for improvement of birth companionship in the LR.

	PDSA cycle 1	PDSA cycle 2	PDSA cycle 3	PDSA cycle 4	PDSA cycle 5
What are we trying to accomplish	Develop and implement guidelines for birth companionship	Improve coordination among departmental units and enhance staff awareness to facilitate birth companionship	Ensure hygiene protocols for birth companions	Standardise identification of birth companions	Address issues related to overcrowding and the use of mobile phones by birth companions
How we know that a change is an improvement	Birth companion presence increased from 0% to 24.2%	Birth companion presence rose to 38.5%.	Birth companion presence increased to 72.3%.	Birth companion presence slightly increased to 74.3%.	Birth companion presence adjusted to 75%, indicating the need for further strategy review
What changes we make that will result in an improvement	Created Standard Operating Procedures (SOPs) for allowing birth companions. Sensitised duty staff about the new SOPs.	Conducted review meetings on the fifth of each month, organised seminars twice a month to increase awareness, discussed challenges and progress and encouraged feedback from staff to identify barriers.	Introduced usage of shoe covers, masks and caps for birth companions to maintain hygiene	Introduced unique dress codes and ID cards for birth companions for easy identification.	Implemented a policy allowing intermittent presence of birth companions without mobile phones to minimise distractions and maintain focus during labour.

Intervention strategy: Plan–Do–Study–Act cycles

Implementation of birth companionship was undertaken through five sequential PDSA cycles between May and September 2022 in accordance with LaQshya recommendations.

Plan–Do–Study–Act cycle 1 (May 2022): initial sensitisation

Healthcare workers were sensitised regarding LaQshya guidelines and the benefits of birth companionship. Notices in the local language permitting one companion were displayed, and verbal orientation was provided to staff and patients. During the study phase, approximately one-third of women had a birth companion, with an overall companionship rate of 24.2%. A written SOP for birth companionship was subsequently developed and implemented (figure 1.2).

Plan–Do–Study–Act cycle 2 (June 2022): reinforcement of staff engagement

Based on feedback from cycle 1, two departmental sensitisation sessions were conducted to improve staff awareness and reinforce infection prevention practices. Staff acceptance and knowledge improved during this phase. Monthly review meetings were initiated to support ongoing monitoring. The birth companionship rate increased to 38.5% (figure 1.3).

Plan–Do–Study–Act cycle 3 (July 2022): infection prevention measures

To address infection prevention concerns, companions were provided caps, masks and shoe covers before entering the labour room. Reusable slippers were found impractical and replaced with single-use shoe covers. Use of cap–mask–shoe cover protection was then standardised for all companions. The birth companionship rate increased to 72.3% (figure 1.4).

Plan–Do–Study–Act cycle 4 (August 2022): reducing overcrowding

Following improved infection prevention compliance, overcrowding and difficulty identifying authorised companions were observed. One fixed companion per woman was assigned, and a pink dress code with ‘SAARATHI’ identification passes was introduced. These measures improved organisation and reduced overcrowding in the labour room. The birth companionship rate increased to 74.3% (figure 1.5).

Plan–Do–Study–Act PDSA cycle 5 (September 2022): privacy during the second stage of labour

To improve privacy and reduce disruptions during the second stage of labour, only the companion of the delivering woman was permitted inside the labour area, and mobile phone use was restricted. These measures reduced disturbances and improved privacy for other women. The interventions were incorporated into routine SOPs, and the birth companionship rate increased to 75% (figure 1.6).

Data and measurement strategy

Three measurement domains were used:

• Outcome measure: the primary outcome was the monthly percentage of labouring women accompanied by a birth companion.

• Process measure: the proportion of deliveries in which staff followed the defined SOP for birth companionship, including companion orientation, dress code compliance and hygiene practices.

• Balancing measures: (a) staff-attitude scores using a five-point Likert tool on respectful-care perception and (b) patient-satisfaction scores from short anonymous feedback forms.

All data were recorded by the QI team’s resident members using structured Excel logs reviewed monthly.

Analysis

Descriptive statistics were used to assess trends in companion uptake across months. Run charts were used to visualise progress over sequential PDSA cycles, and standard run chart rules including shifts, trends, runs and astronomical points were applied to identify non-random variation in the process. Staff perception scores and patient satisfaction were analysed descriptively to monitor changes over time. No inferential statistical testing was performed, consistent with the QI focus of the project.

Ethical considerations

The project was conducted as a QI initiative within the hospital’s routine service framework after obtaining approval from Institutional Ethics Committee, All India Institute of Medical Sciences, Patna (AIIMS/PAT/IEC/2022/908). Participation in birth companionship was voluntary, and women could decline without affecting clinical care. Temporary stage-based restrictions on companion presence were implemented solely to maintain privacy in the shared labour room. Confidentiality of patient information was maintained throughout. Administrative approval was obtained for implementation.

Results

Implementation of the QI interventions resulted in a consistent rise in the number of women accompanied by birth companions across the 5-month project period. Month-wise outcome, process and balancing measures are described below and summarised in figure 2.

Figure 2. Run chart of monthly data for birth companionship. LR, labour room.

Outcome measure

At baseline, no woman had a birth companion (0%). By the end of the first month, 24.2% of women were accompanied. Rates continued to increase to 38.5% in June, 72.3% in July, 74.3% in August and 75% in September 2022. This demonstrated sustained improvement and achievement of the project’s SMART aim within 5 months.

Process measure

The total number of deliveries during the study months ranged from 66 to 83 per month. The proportion of staff adhering to the SOP for birth companionship also rose steadily, with staff compliance reaching 85% by the final cycle. Monthly staff review meetings reinforced accountability and data recording.

Balancing measures

Initially, 12.1% of women declined the presence of a companion due to embarrassment or privacy concerns. By the final cycle, only 8.1% refused. Staff feedback collected through Likert scales showed a 38% improvement in perceived respectful-care scores (from a mean 3.2 to 4.4 out of 5). No staff reported interference in clinical decision-making, and no infection-control or privacy incidents were reported during the project period.

Run chart analysis

The run chart (figure 2) was analysed using Institute for Healthcare Improvement run chart rules. The proportion of women having a birth companion increased from May (24.2%) to July (72.3%), with the improvement largely sustained through August (74.3%) and September (75.0%). Although the pattern suggests improvement following the implementation of the initial PDSA cycles, the number of consecutive data points above the median did not meet the formal criteria required to define a statistical shift. The observed improvement coincided with increased staff sensitisation and reinforcement of the standard operating procedures.

Vaginal delivery outcomes

Among women with birth companions, vaginal-delivery rates rose from 18.8% in May to 51.7% in September. This temporal trend is noteworthy because lower rates of caesarean delivery may have potential implications for maternal health and quality of maternity care. However, the study was not designed to determine whether birth companionship directly influenced the mode of delivery, and causality cannot be inferred from these data. Furthermore, clinical outcomes associated with the mode of delivery were not systematically collected as part of this QI project. Therefore, the observed change should be interpreted as an exploratory finding rather than evidence of a clinical effect of the intervention. This finding is broadly consistent with previous studies reporting associations between continuous labour support and mode of birth.^{7 9 10}

Barriers in implementing birth companion to routine practice

A short anonymous feedback form comprising five Likert-scale items (1=strongly disagree to 5=strongly agree) was used to assess staff apprehension and perception of respectful care. Mean scores improved progressively across PDSA cycles (figure 2). Several barriers limit the routine implementation of birth companion practices, including patient-related, healthcare workers-related, attendant-related and facility-related factors (online supplemental figure 1). These additions directly address the reviewer’s request for documentation of assessment tools.

Discussion

This QI initiative demonstrated that birth companionship can be successfully integrated into routine intrapartum care in a high-volume tertiary-care labour ward through gradual, context-sensitive system changes. More importantly, the project highlighted that implementation of respectful maternity care practices depends less on policy declaration alone and more on continuous engagement with frontline realities, staff concerns and local infrastructural constraints.

One of the key learnings from this project was that behaviour change among healthcare workers required sustained dialogue, repeated sensitisation and visible leadership support. Initial resistance from staff was not primarily ideological but practical, centred around concerns regarding privacy, infection control, overcrowding and disruption of workflow. Addressing these concerns through iterative PDSA cycles helped the team understand that staff acceptance improved when interventions were perceived as feasible, structured and supportive of existing workflows rather than as externally imposed mandates. This reinforces the importance of involving frontline staff early and continuously during implementation of QI initiatives.

The project also demonstrated the value of small operational modifications in achieving larger cultural change. Simple measures such as a companion identification system, defined dress code, orientation regarding expected behaviour and clear SOPs created predictability and reduced anxiety among staff. These low-cost interventions proved more practical and sustainable than attempting major infrastructural changes in the short term. The experience suggests that in resource-constrained settings, incremental workflow redesign may be more achievable and effective than infrastructure-heavy approaches.

Another important learning was the need to adapt respectful maternity care principles to local contextual realities. In our setting, shared labour rooms and limited privacy infrastructure required temporary restrictions during the second stage of labour and regulation of mobile phone use. Rather than abandoning the intervention because ideal infrastructure was unavailable, the team adopted a pragmatic approach that balanced women’s autonomy with the privacy and dignity of other patients. This highlighted that successful QI work often requires flexible adaptation rather than rigid implementation of guidelines.

The iterative nature of the PDSA methodology was central to the project’s success. Sequential testing allowed the team to identify barriers early, modify interventions in real time and build staff confidence gradually. The process reinforced that sustainable implementation is usually achieved through repeated small adjustments rather than one-time policy announcements. Continuous measurement and feedback also helped maintain momentum and accountability within the multidisciplinary team.

The observed reduction in caesarean deliveries and corresponding increase in vaginal deliveries over the project period warrants consideration. Avoiding unnecessary caesarean deliveries may reduce maternal operative risks and have implications for subsequent pregnancies. However, this temporal association should be interpreted with caution, as the project was designed to evaluate implementation of birth companionship and was not powered or designed to establish causality. Other clinical-level, patient-level, provider-level and system-level factors may have contributed to the observed trend. Therefore, the findings should not be interpreted as evidence that birth companionship independently reduces caesarean delivery rates. Future studies with larger samples and appropriate comparative designs should evaluate this association while accounting for relevant obstetric and clinical factors.

The broader clinical implications of this finding could not be assessed because important maternal and neonatal outcomes were not systematically collected. Outcomes including postpartum haemorrhage, maternal and neonatal morbidity, neonatal intensive care admission, length of hospital stay and initiation of breastfeeding were outside the scope of this QI project. Thus, we cannot determine whether the reduction in caesarean deliveries was associated with improvements in clinical outcomes or any unintended effects. Future evaluations should incorporate these outcomes alongside mode of delivery.

Patient-centred outcomes were also not assessed. Although staff perceptions of respectful care improved, patient satisfaction and women’s experiences of birth companionship were not systematically measured. Staff-reported improvements cannot necessarily be assumed to reflect improvements in patient experience. Future studies should therefore include patient-reported measures such as satisfaction, dignity, autonomy, privacy and overall experience of care.

Strengths and limitations

A major strength of this project was its pragmatic, iterative approach to implementing birth companionship in a busy public-sector tertiary-care labour ward. PDSA cycles, staff engagement, SOP reinforcement and balancing measures enabled adaptation to local operational challenges and demonstrated the feasibility of implementation in a resource-constrained setting.

Several limitations should be acknowledged. This was a single-centre QI project without a concurrent control group, limiting causal inference. Important maternal and neonatal clinical outcomes, including postpartum haemorrhage, morbidity and breastfeeding initiation, were not systematically collected. Patient satisfaction and other patient-reported outcomes were also not assessed, limiting evaluation of the intervention’s broader impact on patient experience and quality of care. Although a reduction in caesarean deliveries was observed, the study design does not allow causal conclusions regarding its relationship with birth companionship. Finally, the 5-month implementation period limits assessment of long-term sustainability.

Despite these limitations, the project demonstrates that birth companionship can be operationalised through context-sensitive, iterative QI approaches in an overcrowded public-sector setting. Future work should evaluate long-term sustainability and incorporate maternal and neonatal outcomes and patient-reported measures to better determine the clinical and patient-centred impact of birth companionship.

Conclusion

Through systematic QI efforts, the project increased the proportion of women accompanied by a birth companion from 0% to 75% over 5 months, demonstrating the feasibility of integrating birth companionship into routine intrapartum care in a public-hospital setting. The intervention also improved staff perceptions of respectful care and helped address practical barriers to implementation through iterative PDSA cycles.

The observed reduction in caesarean deliveries is a potentially important finding; however, the study was not designed to establish a causal relationship between birth companionship and mode of delivery. Furthermore, patient satisfaction and important maternal and neonatal clinical outcomes, including postpartum haemorrhage, breastfeeding initiation and other measures of maternal and neonatal morbidity, were not systematically assessed. Therefore, the broader impact of the intervention on clinical outcomes, patient experience and overall quality of care remains uncertain.

Future QI initiatives should combine implementation measures with patient-reported outcomes and clinically relevant maternal and neonatal outcomes and should evaluate the sustainability of birth companionship over longer periods. Infrastructure improvements for privacy, continued institutional support and ongoing staff engagement may further strengthen implementation. Birth companionship represents a feasible component of respectful maternity care, but its broader clinical and patient-centred impact requires further evaluation.

Data availability statement

Data are available upon reasonable request.