Towards a universal implementation of labor companionship: A synthesis of the policy and facility environment of eight low-and-middle income countries Authors

Soha El Halabi^1*Andrea Barnabas Pembe²Alexandre Dumont³Ana Pilar Betrán⁴Charles Kaboré⁵Effie Kondwani Chipeta⁶Guillermo Carroli⁷Helle Mölsted Alvesson¹Hussein Kidanto⁸Jean- Paul Dossou⁹Kristi Sidney Annerstedt¹Lenka Benova¹⁰Mechthild Maria Gross¹¹Peter Waiswa¹²Pisake Lumbiganon¹³Quoc Nhu Hung Mac¹⁴Meghan A Bohren¹⁵Claudia Hanson^1,16

• ¹Department of Global Public Health, Karolinska Institutet (KI), Solna, Sweden
• ²Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
• ³IRD, Université Paris Cité, Paris, Île-de-France, France
• ⁴UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization (Switzerland), Geneva, Geneva, Switzerland
• ⁵Research Institute for Health Sciences (IRSS), Ouagadougou, Burkina Faso
• ⁶The Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
• ⁷Centro Rosarino de Estudios Perinatales, Rosario, Santa Fe, Argentina
• ⁸Aga Khan University, Dar es Salaam, Tanzania
• ⁹Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
• ¹⁰Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerp, Antwerp, Belgium
• ¹¹Midwifery Research and Education Unit, Hannover Medical School, Hanover, Lower Saxony, Germany
• ¹²Centre of Excellence for Maternal Newborn and Child Health, Department of Health Policy Planning and Management, Makerere University, Kampala, Central Region, Uganda
• ¹³Department of Obstetrics and Gynaecology, Khon Kaen University, Khon Kaen, Thailand
• ¹⁴Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
• ¹⁵Gender and Women's health, Nossal Institute for Global Health, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
• ¹⁶Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom

Background: Labor companionship, the presence of a woman's person of choice during childbirth, has benefits to both woman and baby and is recommended by the World Health Organization since 2012. However, implementation remains sub-optimal, especially in lowand-middle-income countries (LMICs). This study aimed to understand the maturity of labor companionship implementation in eight low-and-middle income countries with focus on the policy and facility environment. Methods: This was a multi-country study nested in two hospital-based implementation research studies: Action Leveraging Evidence to Reduce perinatal mortality and morbidity in Sub-Saharan Africa (ALERT) study and the QUALIty DECision-making by women and providers for appropriate use of caesarean section (QUALI-DEC) study. We included 48 hospitals from eight countries: Argentina, Burkina Faso, Thailand and Viet Nam (QUALI-DEC) and four from each of Benin, Malawi, Tanzania and Uganda (ALERT study). We used data from (i) a document review, including national policy documents and (ii) health facility readiness assessment, including physical layouts of maternity wards, all collected between December 2019 and April 2021. Our analysis included two steps, (1) a structured data abstraction with coding to pre-defined categories to analyse the national polices and available resources on a facility level which informed the (2) categorization of implementation maturity in three implementation phases modelled by the framework by Bergh et al. and the logic model developed by Bohren et al.Results: Three of the eight countries lacked any national-level companionship policies, four had some mentioning and only one had detailed guidance on roles of labor companions and implementation guidelines. The physical outlines of maternity wards varied greatly, and lack of space was one of the main implementation barriers to all countries except Argentina. We classified Benin, Thailand and Viet Nam in the pre-implementation phase because of missing guidelines and limited implementation; Burkina Faso, Malawi, Uganda and Tanzania in the early implementation phase; and Argentina in the institutionalization phase where policies and facility resources were conducive.Successful implementation was supported by concrete and contextualized implementation guidance. To move to high implementation levels, supporting policies, guidelines and structural changes in the maternity wards are needed.