| Finding number |
Summary of review finding |
Studies contributing to the review finding |
CERQual assessment (confidence in the findings) |
Explanation of CERQual assessment |
| Factors affecting implementation |
| Awareness‐raising among healthcare providers and women |
| 1 |
The benefits of labour companionship may not be recognised by providers, women, or their partners. |
Abushaikha 2013; Afulani 2018; Alexander 2014; Brüggemann 2014; Coley 2016; Pafs 2016
|
Moderate confidence |
Due to minor concerns regarding methodological limitations, coherence, and relevance, and moderate concerns regarding adequacy |
| 2 |
Labour companionship was sometimes viewed as non‐essential or less important compared to other aspects of care, and therefore deprioritised due to limited resources to spend on 'expendables'. |
Akhavan 2012b; Brüggemann 2014; Lagendyk 2005; Premberg 2011
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and serious concerns regarding relevance and adequacy |
| Creating an enabling environment |
| 3 |
Formal changes to existing policies regarding allowing companions on the labour ward may be necessary prior to implementing labour companionship models at a facility level. |
Abushaikha 2013; Kabakian‐Khasholian 2015
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and serious concerns regarding relevance and adequacy |
| 4 |
In settings where companions are allowed, there can be gaps between a policy or law allowing companionship, and the actual practice of allowing all women who want companionship to have a companion present. |
Brüggemann 2014; Kaye 2014
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and adequacy, and serious concerns regarding relevance |
| 5 |
Providers, women and male partners highlighted physical space constraints of the labour wards as a key barrier to labour companionship as it was perceived that privacy could not be maintained and wards would become overcrowded. |
Abushaikha 2013; Afulani 2018; Brüggemann 2014; Harte 2016; Kabakian‐Khasholian 2015; Qian 2001; Sapkota 2012; Shimpuku 2013
|
Moderate confidence |
Due to minor concerns regarding relevance and coherence, and moderate concerns regarding adequacy and methodological limitations |
| 6 |
Some providers, women and male partners were concerned that the presence of a labour companion may increase the risk of transmitting infection in the labour room. |
Abushaikha 2013; Brüggemann 2014; Kabakian‐Khasholian 2015; Qian 2001
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and relevance, and serious concerns regarding adequacy |
| Training, supervision, and integration with care team |
| 7 |
Some providers were resistant to integrate companions or doulas into maternity services, and provided several explanations for their reluctance. Providers felt that lay companions lacked purpose and boundaries, increased provider workloads, arrived unprepared, and could be in the way. |
Bondas‐Salonen 1998; Brüggemann 2014; Horstman 2017; Kabakian‐Khasholian 2015; Kaye 2014; Lagendyk 2005; Torres 2013
|
High confidence |
Due to minor concerns regarding methodological limitations, coherence and relevance, and moderate concerns regarding adequacy |
| 8 |
In most cases, male partners were not integrated into antenatal care or training sessions before birth. Where they were included in antenatal preparation, they felt that they learned comfort and support measures to assist their partners, but that these measures were often challenging to implement throughout the duration of labour and birth. |
Abushaikha 2013; Bondas‐Salonen 1998; Chandler 1997; Ledenfors 2016; Sapkota 2012; Somers‐Smith 1999
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and relevance, and serious concerns regarding adequacy |
| 9 |
In settings where lay companionship or doula care were available, providers were not well trained on how to integrate the companion as an active or important member of the woman’s support team. |
Bondas‐Salonen 1998; Brüggemann 2014; Kabakian‐Khasholian 2015; Kaye 2014; Lagendyk 2005; Torres 2013
|
Moderate confidence |
Due to minor concerns regarding methodological limitations, coherence and relevance, and moderate concerns regarding adequacy |
| 10 |
Some doulas felt that they were not well integrated into decision‐making or care co‐ordination by the healthcare providers, and were sometimes ignored by healthcare providers. |
Berg 2006; McLeish 2018; Stevens 2011; Torres 2013
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations, and serious concerns regarding relevance and adequacy |
| 11 |
Most healthcare providers believed that having a lay companion support a woman throughout labour and childbirth was beneficial to the woman and worked well when companions were integrated into the model of care. However, when lay companions were not well engaged or integrated, conflict could arise as they may be perceived as an additional burden for healthcare providers to manage their presence, and provide ongoing direction and support. |
Brüggemann 2014; Harte 2016; Kabakian‐Khasholian 2015; Khresheh 2010; Maher 2004; Qian 2001
|
Moderate confidence |
Due to minor concerns regarding coherence, and moderate concerns regarding methodological limitations, relevance, and adequacy |
| 12 |
Most midwives believed that doulas played a collaborative role in supporting women during childbirth, and were assets to the team who provided more woman‐centred, needs‐led support. However, some midwives found it difficult to engage as carers with women when doulas were present, as they felt that doulas encroached on their carer role. |
Akhavan 2012b; Lundgren 2010; McLeish 2018; Stevens 2011
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and adequacy, and serious concerns regarding relevance |
| 13 |
Lay companions received little or no training on how to support the woman during labour and childbirth, which made them feel frustrated. |
Kululanga 2012; Sapkota 2012
|
Low confidence |
Due to minor concerns regarding methodological considerations and coherence, and serious concerns regarding relevancy and adequacy |
| 14 |
Some men felt that they were actively excluded, left out, or not involved in their female partner's care. They were unsure of where they fit in to support the woman, and felt that their presence was tolerated but not necessary. |
Bäckström 2011; Chandler 1997; Kaye 2014; Kululanga 2012; Longworth 2011; Somers‐Smith 1999
|
Moderate confidence |
Due to minor concerns regarding coherence, and moderate concerns regarding methodological limitations, relevance and adequacy |
| Roles that companions play |
| Informational support |
| 15 |
Women valued the non‐pharmacological pain relief measures that companions helped to facilitate, including a soothing touch (holding hands, massage and counter pressure), breathing, and relaxation techniques. |
Campero 1998; Chapman 1990; Dodou 2014; de Souza 2010; Fathi 2017; Hunter 2012; Kabakian‐Khasholian 2015; Khresheh 2010; Lundgren 2010; McLeish 2018; Sapkota 2013; Sapkota 2012; Somers‐Smith 1999; Thorstensson 2008; Torres 2015
|
High confidence |
Due to minor concerns regarding adequacy, coherence, and relevance, and moderate concerns regarding methodological limitations |
| 16 |
Doulas played an important role in providing information to women about the process of childbirth, duration of labour, and reasons for medical interventions. They bridged communication gaps between clinical staff and women, and facilitated a more actively engaged environment where women were encouraged to ask questions. |
Akhavan 2012a; Akhavan 2012b; Berg 2006; Campero 1998; Darwin 2016; Gilliland 2011; Horstman 2017; LaMancuso 2016; McGarry 2016; McLeish 2018; Schroeder 2005; Torres 2013; Torres 2015
|
Moderate confidence |
Due to minor concerns regarding coherence and adequacy and moderate concerns regarding methodological limitations and relevance |
| 17 |
Lay companions also played a role in providing informational support to women or acting as the woman's voice during labour and childbirth. This usually took the form of acting as an intermediary by relaying, repeating, or explaining information from the healthcare provider to the woman, and from the woman to the healthcare provider. |
Alexander 2014; Bondas‐Salonen 1998; Khresheh 2010; Price 2007; Qian 2001; Sapkota 2012
|
Moderate confidence |
Due to minor concerns regarding methodological limitations, coherence and relevance, and moderate concerns regarding adequacy |
| 18 |
Companions played an important role to help facilitate communication between the woman and healthcare providers, including representing the woman's interests and speaking on her behalf when she was unable to do so. They helped to relay information between the woman and healthcare provider, such as asking questions and setting boundaries. |
Akhavan 2012b; Bondas‐Salonen 1998; Darwin 2016; Gentry 2010; Hardeman 2016; Horstman 2017; Hunter 2012; Khresheh 2010; Koumouitzes‐Douvia 2006; LaMancuso 2016; Lundgren 2010; McGarry 2016; McLeish 2018; Premberg 2011; Price 2007; Stevens 2011; Torres 2015
|
Moderate concerns |
Due to minor concerns regarding coherence and adequacy, and moderate concerns regarding methodological limitations and relevance |
| Advocacy |
| 19 |
Companions played a role to bear witness to the process of childbirth. They shared the childbirth experience with the woman by being with her, and were viewed as observers who could monitor, reflect, and report on what transpired throughout labour and childbirth, such as witnessing pain, the birth process, and the woman's transformation to motherhood. |
Afulani 2018; Alexander 2014; Bondas‐Salonen 1998; Dodou 2014; Horstman 2017; Hunter 2012; Longworth 2011; Price 2007; Sapkota 2012
|
High confidence |
Due to minor concerns regarding methodological considerations, coherence, relevance and adequacy |
| Practical support |
| 20 |
Companions provided physical support to women throughout labour and childbirth, such as giving them a massage and holding their hand. Companions encouraged and helped women to mobilise throughout labour or to change positions, such as squatting or standing, and provided physical support to go to the bathroom or adjust clothing. |
Afulani 2018; Chandler 1997; Chapman 1990; de Souza 2010; Fathi 2017; Hunter 2012; Kabakian‐Khasholian 2015; Khresheh 2010; Koumouitzes‐Douvia 2006; McLeish 2018; Premberg 2011; Price 2007; Sapkota 2012; Shimpuku 2013; Torres 2013
|
High confidence |
Due to minor concerns regarding coherence, relevance and adequacy, and moderate concerns regarding methodological limitations |
| 21 |
Companions played an important role to assist healthcare providers to care for women by observing and identifying potential issues throughout labour and childbirth. |
Akhavan 2012b; Alexander 2014; Khresheh 2010; Qian 2001; Sapkota 2012; Shimpuku 2013
|
Moderate confidence |
Due to minor concerns regarding coherence and relevance, and moderate concerns regarding methodological limitations and adequacy |
| 22 |
Some healthcare providers and doulas felt that shortcomings in maternity services could be potentially addressed by doulas or lay companions. |
Afulani 2018; Akhavan 2012b; Stevens 2011
|
Very low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations, and serious concerns regarding relevance and adequacy |
| Emotional support |
| 23 |
Women valued that companions and doulas helped to facilitate their feeling in control during labour and gave them confidence in their abilities to give birth. |
Berg 2006; Campero 1998; Chapman 1990; Darwin 2016; Dodou 2014; Fathi 2017; Gilliland 2011; Hunter 2012; Ledenfors 2016; Price 2007; Sapkota 2012
|
Moderate confidence |
Due to minor concerns regarding adequacy and coherence, and moderate concerns regarding methodological limitations and relevance |
| 24 |
Companions often provided emotional support to women through the use of praise and reassurance. They acknowledged the women's efforts and concerns, and provided reinforcement through verbal encouragement and affirmations. |
Abushaikha 2012; Alexander 2014; Bäckström 2011; Berg 2006; Bondas‐Salonen 1998; de Souza 2010; Fathi 2017; Gentry 2010; Gilliland 2011; Hardeman 2016; Harte 2016; Horstman 2017; Hunter 2012; Kabakian‐Khasholian 2015; Khresheh 2010; Koumouitzes‐Douvia 2006; Ledenfors 2016; Lundgren 2010; McGarry 2016; McLeish 2018; Premberg 2011; Price 2007; Sapkota 2012; Schroeder 2005; Somers‐Smith 1999; Thorstensson 2008; Torres 2013; Torres 2015
|
High confidence |
Due to very minor concerns regarding adequacy, minor concerns regarding coherence and relevance, and moderate concerns regarding methodological limitations |
| 25 |
The continuous physical presence of someone caring was an important role that companions played, particularly in settings where continuous midwifery care was not available or not practiced. The continuous presence of the companion signalled to the woman the availability of support when needed, and helped to pass the time throughout labour. |
Abushaikha 2012; Afulani 2018; Berg 2006; Bondas‐Salonen 1998; Campero 1998; Darwin 2016; Dodou 2014; Koumouitzes‐Douvia 2006; Lundgren 2010; McLeish 2018; Price 2007; Sapkota 2012; Somers‐Smith 1999; Stevens 2011; Thorstensson 2008; Torres 2015
|
Moderate confidence |
Due to minor concerns regarding coherence and adequacy, and moderate concerns regarding methodological limitations and relevance |
| Experiences of companionship |
| Women’s experiences |
| 26 |
Women stated different preferences for their desired companion, including their husband or male partner, sister, mother, mother‐in‐law, doula, or a combination of different people. Regardless of which person they preferred, women who wanted a labour companion present during labour and childbirth expressed the need for this person to be a caring, compassionate, and trustworthy advocate. |
Abushaikha 2012; Afulani 2018; Akhavan 2012a; Alexander 2014; Berg 2006; Bondas‐Salonen 1998; Campero 1998; Dodou 2014; Fathi 2017; Hunter 2012; Kabakian‐Khasholian 2015; Khresheh 2010; Lundgren 2010; Pafs 2016; Price 2007; Qian 2001; Sapkota 2012; Shimpuku 2013; Somers‐Smith 1999; Torres 2015
|
High confidence |
Due to very minor concerns regarding coherence, relevance and adequacy, and minor concerns regarding methodological limitations |
| 27 |
Women described the desire for a happy and healthy birth for both themselves and their babies. Support provided by doulas and companions paved the way for them to have a positive birth experience, as the support facilitated them to feel safe, strong, confident and secure. |
Abushaikha 2012; Abushaikha 2013; Akhavan 2012a; Alexander 2014; Berg 2006; Bondas‐Salonen 1998; Campero 1998; Darwin 2016; Dodou 2014; Gilliland 2011; Hunter 2012; Kabakian‐Khasholian 2015; Khresheh 2010; Koumouitzes‐Douvia 2006; Ledenfors 2016; Lundgren 2010; McGarry 2016; Price 2007; Sapkota 2012; Schroeder 2005; Torres 2015
|
High confidence |
Due to minor concerns regarding coherence, relevance, and adequacy, and moderate concerns regarding methodological limitations |
| 28 |
Immigrant, refugee, and foreign‐born women resettled in high‐income countries highlighted how community‐based doulas (e.g. someone from their ethnic/religious/cultural community trained as a doula) were an important way for them to receive culturally competent care. |
Akhavan 2012a; Hardeman 2016; LaMancuso 2016; Stevens 2011
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and relevance, and serious concerns due to adequacy |
| 29 |
Some women were concerned that their male partners would have diminished sexual attraction to them if they witnessed the birth. Likewise, some men believed that it is taboo to see a female partner give birth because of the risk of a loss of sexual interest. |
Abushaikha 2013; Afulani 2018; Kululanga 2012; Pafs 2016; Sapkota 2012
|
Moderate confidence |
Due to minor concerns regarding methodological limitations and coherence, moderate concerns regarding relevance, and serious concerns regarding adequacy |
| 30 |
Some women felt embarrassed or shy to have a male partner as a companion present throughout labour and childbirth. |
Abushaikha 2013; Afulani 2018; Alexander 2014; Sapkota 2012
|
Low confidence |
Due to minor concerns regarding methodological limitations and coherence, moderate concerns regarding relevance, and serious concerns regarding adequacy |
| 31 |
Women who did not have a companion may view the lack of support as a form of suffering, stress and fear that made their birth experience more challenging. These women detailed experiences of poor quality of care that included mistreatment, poor communication, and neglect that made them feel vulnerable and alone. |
Afulani 2018; Alexander 2014; Campero 1998; Chadwick 2014; Fathi 2017; Khresheh 2010; Pafs 2016
|
Moderate confidence |
Due to minor concerns regarding methodological limitations and coherence, and moderate concerns regarding relevance and adequacy |
| 32 |
Some women described having their male partners present as an essential part of the birth process, which facilitated bonding between the father and the baby, the couple, and as a family. |
Abushaikha 2012; Bondas‐Salonen 1998; Price 2007
|
Low confidence |
Due to minor concerns regarding methodological limitations and coherence, moderate concerns regarding relevance, and serious concerns regarding adequacy |
| 33 |
Most women who had a doula present described doulas as motherly, sisterly, or like family, suggesting a high level of relational intimacy. |
Berg 2006; Coley 2016; Hunter 2012; Koumouitzes‐Douvia 2006; McGarry 2016
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations and adequacy, and serious concerns regarding relevance |
| Male partners' experiences |
| 34 |
Male partners had three main motivations for acting as a labour companion for their female partner: curiosity, woman’s request, and peer encouragement, and were in agreement that ultimately it should be the woman’s choice about who is allowed to be present. |
Bondas‐Salonen 1998; Chapman 1990; Kululanga 2012; Longworth 2011; Pafs 2016; Sapkota 2012; Somers‐Smith 1999
|
Moderate confidence |
Due to minor concerns regarding methodological limitations, coherence, and relevance, and moderate concerns regarding adequacy |
| 35 |
Men who acted as labour companions for their female partners felt that their presence made a positive impact on themselves as individuals. |
Kululanga 2012; Sapkota 2012
|
Low confidence |
Due to minor concerns regarding methodological considerations and coherence, and serious concerns regarding relevancy and adequacy |
| 36 |
Men who acted as labour companions for their female partners felt that their presence made a positive impact on their relationship with their female partner and the new baby. |
Dodou 2014; Kululanga 2012; Sapkota 2012
|
Low confidence |
Due to minor concerns regarding methodological considerations and coherence, and serious concerns regarding relevancy and adequacy. |
| 37 |
Men who acted as labour companions for their female partners may feel scared, anxious or helpless when witnessing their partners in pain during labour and childbirth. |
Fathi 2017; Kaye 2014; Kululanga 2012; Sapkota 2012
|
Low confidence |
Due to minor concerns regarding methodological considerations and coherence, and serious concerns regarding relevancy and adequacy. |
| 38 |
Some lay companions (both male and female) were deeply impacted by witnessing a woman's pain during labour. Observing this pain caused feelings of frustration and fear, as they felt that there was nothing that they could do to help alleviate their pain. |
Abushaikha 2013; Chandler 1997; Chapman 1990; Fathi 2017; Kabakian‐Khasholian 2015; Kululanga 2012; Sapkota 2012
|
Moderate confidence |
Due to minor concerns regarding coherence and relevance, and moderate concerns regarding methodological limitations and adequacy |
| 39 |
Some male partners felt that they were not well integrated into the care team or decision‐making. These men felt that their presence was tolerated by healthcare providers, but was not a necessary role. They relied on cues from the woman and healthcare provider for when and how to give support, but were often afraid to ask questions to avoid being labelled as difficult. |
Bäckström 2011; Chandler 1997; Kaye 2014; Kululanga 2012; Longworth 2011; Somers‐Smith 1999
|
Moderate confidence |
Due to minor concerns regarding coherence, and moderate concerns regarding methodological limitations, relevance, and adequacy |
| Doulas’ experiences |
| 40 |
Doulas often met with women, and sometimes their partners, prior to the birth to establish a relationship with them. This helped to manage expectations, and mentally and physically prepare the woman and her partner for childbirth. |
Akhavan 2012b; Berg 2006; Coley 2016; Darwin 2016; Koumouitzes‐Douvia 2006; Lundgren 2010; Shlafer 2015; Stevens 2011; Torres 2015
|
Moderate confidence |
Due to minor concerns regarding coherence and adequacy, and moderate concerns regarding methodological limitations and relevance |
| 41 |
Doulas believed that one of their key responsibilities was to build rapport and mutual trust with the woman, in order to improve her birth experience. This relationship was foundational for the doulas to give effective support, and for the women to feel comfortable enough to let go. Doulas built rapport by communicating, providing practical support, comforting and relating to the woman. |
Berg 2006; Coley 2016; de Souza 2010; Gilliland 2011; Hunter 2012; Koumouitzes‐Douvia 2006; McGarry 2016; Shlafer 2015; Thorstensson 2008
|
Moderate confidence |
Due to minor concerns regarding coherence and adequacy, and moderate concerns regarding methodological limitations and relevance |
| 42 |
Doulas found that the experience of providing support to women in labour could have a positive personal impact on themselves. Some found that acting as a doula built their self‐confidence, made them feel like they were making a difference, and provided a sense of fulfilment. |
Hardeman 2016; Hunter 2012; McGarry 2016; Thorstensson 2008
|
Low confidence |
Due to minor concerns regarding coherence, moderate concerns regarding methodological limitations, and serious concerns regarding relevance and adequacy |
