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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 15-21

Knowledge, attitude, and factors affecting implementation of birth companionship during labor among obstetricians, nurses and pregnant women at a tertiary care teaching hospital


1 College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission09-Jul-2021
Date of Decision09-Sep-2021
Date of Acceptance22-Sep-2021
Date of Web Publication25-Mar-2022

Correspondence Address:
Himanshu Vyas
Associate Professor, College of Nursing, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jphpc.jphpc_17_21

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  Abstract 


Context: Birth companions are women who have experienced the process of labor and provide continuous one-to-one support to the other women who are experiencing the process of labor and childbirth. Aim: This study aimed to assess knowledge, attitude, and factors affecting the implementation of birth companionship among obstetricians, nurses, and pregnant women. Settings and Design: Nonexperimental quantitative research approach with a descriptive design carried out at All India Institute of Medical Sciences, Jodhpur, Rajasthan. Materials and Methods: Data were collected from 25 obstetricians, 15 nurses selected by consecutive sampling technique, and 120 pregnant women selected by purposive sampling technique. Data collection tool included a structured knowledge questionnaire, an attitude Likert scale, and a checklist to assess factors affecting the implementation of birth companionship. Statistical Analysis Used: Data were entered into a master sheet and SPSS 16 version was used for the descriptive and inferential statistical analysis. Results: Most of the obstetricians (60%) and pregnant women (59.2%) had fair knowledge, whereas nurses (53%) had good knowledge regarding birth companionship. Most of the obstetricians (96%), nurses (73%), and pregnant women (81.7%) had positive attitudes regarding birth companionship. Breach of privacy of other mothers, less availability of space to accommodate birth companion, and nonavailability of ideal birth companion were the most common factors reported to affect the implementation of birth companionship by the obstetricians and nurses , whereas long distance of hospital from home and apprehension due to a known person's presence were the factors reported by pregnant women. Knowledge level and attitude level of the pregnant women had a significant association with age (P = 0.000) and parity (P = 0.042), respectively.

Keywords: Birth companionship, factors affecting implementation, nurses and pregnant women, obstetricians


How to cite this article:
Lathwal P, Vyas H, Singh P, Deviga T. Knowledge, attitude, and factors affecting implementation of birth companionship during labor among obstetricians, nurses and pregnant women at a tertiary care teaching hospital. J Public Health Prim Care 2022;3:15-21

How to cite this URL:
Lathwal P, Vyas H, Singh P, Deviga T. Knowledge, attitude, and factors affecting implementation of birth companionship during labor among obstetricians, nurses and pregnant women at a tertiary care teaching hospital. J Public Health Prim Care [serial online] 2022 [cited 2022 May 27];3:15-21. Available from: http://www.jphpc.com/text.asp?2022/3/1/15/340807




  Introduction Top


Birth companionship is the process of providing continuous one-to-one support to other women who are experiencing the process of labor and childbirth.[1],[7] The presence of a female relative during the period of labor is a low-cost intervention and it has been proved to be beneficial for those women who are experiencing labor.[1] Birth companions provide information about progress of labor and advice regarding coping techniques, comfort measures (therapeutic touch, massage, encouraging mobility, promoting fluid intake, and output), emotional support (continuous presence and reassurance and praise), instrumental support (providing assistance with needs), and advocacy (helping the woman articulate her wishes to the other).[1],[7] Birth companionship is recommended by the World Health Organization (WHO) to improve labor outcomes and women's satisfaction with care. It has also been found as an important element in the WHO vision of quality of care for pregnant women and newborns.[4]

Common components of support provided by birth companions include informational support, emotional support, comfort measures, instrumental support, and advocacy.[7] Support can be provided by different types of companions, including trained support persons such as doulas (nonhealth-care professionals who are trained to provide emotional and physical support to women before, during, and after delivery or childbirth) or by the companions chosen from a woman's social relation.[4] If this intervention of birth companionship is implemented in settings where labor wards have more than one bed per room, care must be taken to ensure that all women have their privacy and confidentiality maintained (e.g., by consistent use of dividers/curtains).[4] It is also important to respect the women's wishes, including those who deny to have a companion.[4] Birth companionship is correlated with increased satisfaction with health-care services.[12],[13] Some studies also suggest that women who have birth companions are less likely to experience mistreatment during childbirth.[2]

Basic requisites for a birth companionship are:[2],[7]

  • The birth companion has to be a female relative and most preferably she should be the one who has undergone the process of labor
  • In those hospitals where privacy protocols are followed in the labor room, husband of the pregnant women can be permitted as a birth companion
  • She should not have any history of communicable diseases
  • She should dress the clean clothes
  • She should be willing to stay with the pregnant woman throughout the process of labor
  • She should not create interference in the work of hospital staff and the treatment procedures
  • She should not provide guidance to other women in the labor room.


Globally, approximately 140 million births occur every year.[3],[5] The majority of these are vaginal births with no identified risk factors for complications, either for themselves or their babies, at the onset of labor.[8],[9] However, in those situations where complications arise during delivery period, the risk of serious morbidity and death increases for both mother and baby. Over a third of maternal death and a considerable proportion of pregnancy-related life-threatening conditions are associated with those complications which arise during labor, delivery, and immediate postpartum period, commonly as a result of hemorrhage, obstructed labor, or sepsis with antenatal or postpartum care strategies.[10],[11]

Maternal mortality ratio in the country has reduced from 130 (2014–2016) to 122 (2015–017) and infant mortality rate has reduced from 32 (2018) to 30.92 (2019).[14],[15] However, these indicators still remain unacceptably high as compared to developed countries; hence, there is a huge scope to bring about improvements in the maternal and newborn health indicators.

All mothers need persistent, continuous support, comfort, encouragement, motivation, and respect during labor and delivery. They need personalized care based on their circumstances and preferences.[17] It is estimated that approximately 46% of maternal death, over 40% of stillbirth, and 40% of neonatal deaths take place on the day of delivery.[16] The role of the companion at birth encompasses the nonclinical aspects of care during childbirth.[17] A quality improvement around in the care during intrapartum and immediate postpartum care can improve maternal and new-born outcomes. In this concern, the Ministry of Health and Family Welfare has launched a program “LaQshya” – quality improvement initiative in the labor room and maternity OT, which is aimed at improving the quality of care for both mothers and newborns during intrapartum and immediate postpartum period.[16]

In an exploratory study of the opinion of women on having support during labor out of 62 women, 43% of women in the study knew of companionship and its benefits before their birth, but only 24% had companions during labor and some misinterpreted companionship to apply to lawful partners only. Of the 75% of women who had no companions, 74% had no knowledge of companionship. These women viewed labor differently, as some attributed the following to the absence of companionship, namely long and painful labor, loneliness, panic, and feeling as though they were dying. These women felt that labor could have been better with the support of a companion and even recommended that companionship was a necessity during labor. This study revealed that companionship is lacking in the maternity units within the health-care departments even though the women are in need of this support.[6]

A very few studies have been conducted in India with respect to birth companionship. Moreover, it is necessary to bring awareness regarding birth companionship among health-care practitioners and general public. Therefore, undertaking this study will help to develop an insight regarding the knowledge and attitude toward birth companionship and will also help in exploring its factors affecting its implementation. Hence, the research will be helpful in understanding the scenario related to birth companionship in western Rajasthan.

Objectives of the study

  1. To assess knowledge regarding birth companionship among obstetricians, nurses, and pregnant women
  2. To assess attitude toward birth companionship among obstetricians, nurses, and pregnant women
  3. To identify factors affecting implementation of birth companionship among obstetricians, nurses, and pregnant women
  4. To determine the association of knowledge and attitude regarding birth companionship with selected personal variables.



  Materials and Methods Top


Design

This descriptive study employed nonexperimental quantitative research approach to accomplish the objectives of the study which was carried out at All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan.

Participants and settings

The target population includes obstetricians and nurses working in the maternity unit and pregnant women seeking antenatal care at the outpatient department (OPD), AIIMS, Jodhpur. Data were collected from 25 obstetricians, 15 nurses selected by consecutive sampling technique, and 120 pregnant women selected by purposive sampling technique. Obstetricians and nurses' sample sizes were taken as per the availability at AIIMS, Jodhpur. Pregnant women sample size was taken based on the previous studies.[20] Sample criteria consisted of two parts, i.e., inclusion and exclusion criteria. Inclusion criteria for obstetricians included who were working in the Maternity Unit of AIIMS, Jodhpur, for nurses included the registered nurses who were working in labor room of AIIMS, Jodhpur, and for pregnant women included antenatal women with the gestation period ≥37 weeks seeking antenatal care at OPD, AIIMS Jodhpur. The exclusion criteria for pregnant women included antenatal women who have never heard about birth companionship. A pilot study was conducted on approximately 12% of the total sample size of the main study, i.e., obstetricians –2, nurses –3, and pregnant women –15. Pilot study data collection was done from September 13, 2019, to September 19, 2019.

Ethical considerations

Ethical approval was obtained on August 26, 2019, from the institutional ethical committee AIIMS, Jodhpur. (Reference Number: AIIMS/IEC/2019-20/893). Written informed consent was obtained from each study subject. Confidentiality of data was maintained and the study subjects were given full autonomy to withdraw from the study at any time.

Data collection

Data collection was done from December 5, 2019, to January 7, 2020. The tools for data collection were structured and were developed by reviewing literatures, journals, opinion of experts, and consulting with guides and co-guides.

It consisted of the following sections

Section A

  • Personal variables tool which consisted of information on
  • For obstetricians and nurses: Age, gender, years of experience, qualification, any delivery conducted in the presence of a birth companion, and any training related to implementation of birth companionship
  • For pregnant women: Age, gender, educational status, occupation, income, parity, and period of gestation.


Section B

Part 1 consisted of structured knowledge questionnaire to assess the knowledge regarding birth companionship. It consisted of 20 items (for obstetricians and nurses) and 16 items (for pregnant women) based on the concept and meaning of birth companionship, doula, and benefits of birth companionship. Maximum possible score was 20 for obstetricians and nurses and 16 for pregnant women. The level of knowledge of obstetricians was interpreted as good (>66%), fair (37%–66%), and poor (≤36%). The reliability of the tool was found to be 0.71 calculated by the KR20 formula.

Part 2 consisted of a structured Likert scale to assess attitude toward birth companionship. It consisted of 5-point Likert scale and included 14 items, including positive as well as negative statements.

Maximum possible score was 70 and minimum possible score was 14. Attitude scores were interpreted as: positive attitude (>66%); neutral attitude (37%–66%); and negative attitude (≤36%). The reliability of the tool was found to be 0.73 calculated by the Cronbach alpha formula.

Part 3 consisted of a structured checklist to identify factors affecting the implementation of birth companionship during labor. It included 18 statements for obstetricians and nurses and 11 statements for pregnant women. Participants were asked about each statement whether it was a factor affecting implementation in their opinion. At last, an open-ended question was asked about other factors which might not be in the checklist. The reliability of the tool was found to be 0.73 calculated by the KR20 formula.

Factors affecting the implementation of birth companionship were identified according to the response of the participants. Interpretation of factors was done in percentage as the most common and least common contributing factor.

Paper-and-pencil technique was used to collect data from obstetricians and nurses and interview technique was used for pregnant women.

The tool was validated by seven experts from different institutes and certain modifications were done in the tool according to expert's and guide's suggestions. The content validity index was obtained after validation and the tool was found to be valid.

Statistical analysis

The statistical analysis was done by using descriptive and inferential statistics. The data were summarized as mean, frequency, percentage, and standard deviation. The Chi-square test was used to test the association.


  Results Top


Findings related to the personal variables of participants

[Table 1] shows the personal variables of obstetricians which shows that most of the obstetricians (76%) were of <30 years. Almost all (96%) obstetricians had conducted delivery in presence of birth companion.
Table 1: Frequency and percentage distribution of obstetricians in terms of personal variable data (n=25)

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[Table 2] shows the personal variables of nurses which shows most of the nurses (73%) were between 25 and 35 years of age. Ninety-three percent nurses had not undergone/attended any training/workshop related to the implementation of birth companionship.
Table 2: Frequency and percentage distribution of nurses in terms of personal variable data (n=15)

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[Table 3] shows the personal variable of pregnant women which shows that more than half of the pregnant women (59%) belonged to the age group of 20–30 years. Most of the pregnant women (42%) had heard about birth companionship from their family members.
Table 3: Frequency and percentage distribution of pregnant women in terms of personal variable data (n=120)

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Findings related to the knowledge level of participants

Results found that nurses (53%) had relatively good knowledge as compared to obstetricians (28%) and pregnant women (13%). More than half of the obstetricians (60%) and pregnant women (59%) had fair knowledge regarding birth companionship. The mean knowledge score among obstetricians, nurses, and pregnant women was 12.84 ± 3.28, 12.93 ± 2.60, and 7.59 ± 2.68, respectively, which means that the average number of obstetricians, nurses, and pregnant women had fair level of knowledge regarding birth companionship.

Findings related to the attitude of participants

Results showed that 96% of obstetricians, 73% of nurses, and 81% of pregnant women had positive attitude toward birth companionship and none of the obstetricians, nurses, and pregnant women had negative attitude toward birth companionship. The mean attitude score among obstetricians, nurses, and pregnant women was 57.96 ± 5.34, 53.20 ± 6.81, and 49.50 ± 3.49, respectively, which means that the average number of obstetricians, nurses, and pregnant women had positive level of attitude toward birth companionship.

Findings related to factors affecting implementation of participants

Findings related to factors affecting implementation of birth companionship during labor among obstetricians show that breach of privacy of other mothers was the most commonly affecting factor for the implementation of birth companionship followed by busy labor ward, overloaded work, birth companion may tend to guide other mothers also, absence of policies and guidelines regarding birth companionship, cultural difference, and less availability of space to accommodate birth companion with all mothers in labor room. Factors which were found least affecting the implementation of birth companionship were willingness of obstetrician/nurses, presence of inters/students and disagreement of hospital administration.

Findings related to factors affecting implementation of birth companionship during labor among nurses show that a breach of privacy of other mothers and not staying of the single person till whole period were the most commonly affecting factor for the implementation of birth companionship followed by less availability of space to accommodate birth companion with all mothers in labor room and nonavailability of ideal birth companion. Factors which were found least affecting the implementation of birth companionship were willingness of obstetrician/nurses, disagreement of hospital administration and interference in patient care.

Findings related to factors affecting implementation of birth companionship during labor among pregnant women show that long distance between hospital and home was the most commonly affecting factor followed by the consent of family members/relatives to be a birth companion and fear/apprehension in a known person's presence. The least affecting factors were disagreement of husband followed by disagreed hospital staff, unavailability of trustworthy companion, and uncomfortable with a birth companion.

Findings related to the association of level of knowledge among obstetricians, nurses and pregnant women with selected personal variables

Results show that all the personal variables of obstetricians and nurses did not have a significant association with their level of knowledge. The level of knowledge among pregnant women was found to have a significant association with age (exact value: 24.635; P value: 0.000) among all the personal variables.

Findings related to the association of attitude of obstetricians, nurses, and pregnant women with selected personal variables

Attitude of obstetricians was found to have a significant association with years of experience (exact value: 5.796; P value: 0.003) among all the personal variables. All the personal variables of nurses did not have a significant association with their attitude. Attitude of pregnant women was found to have a significant association with parity (exact value: 9.893; P value: 0.042) among all the personal variables.


  Discussion Top


The result of the present study showed that the majority of the obstetricians were <30 years, had ≤5 years of experience, and majority had conducted delivery in the presence of birth companion. In contrary to this, a study conducted by Senanayake et al.[18] shows that only few of the obstetricians (13.2%) were of <40 years, a very few (2.9%) had <5 years of experience, and about 58.8% of obstetricians did not allow birth companions in their unit and for nurses, in this study, majority of the nurses were between 25 and 35 years of age and had ≤5 years of experience in the maternity unit. In contrary to this, a study conducted by Spencer et al.[22] shows that most of the nurses (88%) had >5 years of experience and 95% of nurses were aged between 30 and 55 years. Most of the nurses (60%) had diploma in nursing and almost all the nurses (87%) had conducted delivery in the presence of birth companion. Most of the nurses (93%) had not undergone/attended any training/workshop related to the implementation of birth companionship. All the nurses were female in the maternity unit. Similar to this, a study conducted by Spencer et al.[22] shows that 97% of nurses were female in the maternity unit. For the pregnant women, in the present study, majority of pregnant women (59%) were between 20 and 30 years of age and graduated also. Similar to this, a study conducted by Kungwimba et al.[23] shows that 50% of women were aged between 20 and 25 years, while on the contrary, only 30% had completed their secondary school education. Most of the pregnant women (58%) were homemaker and their husbands were government employees. Similar to this, a study conducted by Kungwimba et al.[23] shows that over half of pregnant women (55%) were housewives.

There is one study conducted by Spencer et al.[22] that recommends that the importance of continuous support during childbirth should be emphasized in both the undergraduate and postgraduate midwifery curricula. Moreover in my study, nurses were found to have relatively high knowledge regarding birth companionship than obstetricians and pregnant women. It might be due to that nurses are the direct care provider to patients and now, they are more aware of any therapeutic intervention recommended by the government for the welfare of patients. Study conducted by Senanayake et al.[18] shows that there was an overall knowledge gap on evidence-based advantages of labor companionship and it also shows that <50% of the obstetricians were aware of the advantages associated with the practice such as shorter labor and lesser analgesic requirement. On the contrary, a study conducted by Ntombana et al.[19] showed that 56% of mothers did not have any knowledge of companionship and its advantages at the time of their delivery.

Comparing to all the participants, majority of the obstetricians (96%) had positive attitudes toward birth companionship followed by pregnant women (81%) and nurses (73%). It might be due to the experiences of maternal and neonatal outcomes of those who had birth companion and those did not have birth companion during labor and delivery. A study conducted by Kabakian-Khasholian et al.[20] shows that the attitudes of health-care providers involved in the intervention were positive as they perceived the presence of the companion helpful in reducing the dependency of women on the staff and it also shows that women reported positive experiences with having a companion of choice at birth across the different facility settings. The present study is also supported by the study conducted by Dodou et al.[21] that shows that women were highly satisfied with their companions accompanied during labor and delivery in terms of emotional, physical, and informational support.

And as depicted by the obstetricians and nurses, breach of privacy of other mothers and not staying of the single person till whole period were the most common factor, affecting the implementation of birth companionship, followed by busy labor ward, overloaded work, birth companion may tend to guide other mothers also, absence of policies and guidelines regarding birth companionship, cultural difference, and less availability of space to accommodate birth companion with all mothers in labor room.Factors which were found least affecting the implementation of birth companionship were willingness of obstetrician/nurses, disagreement of hospital administration and interference in patient care. Similar results were found in the study conducted by Kabakian-Khasholian et al.[20] Afulani P, et al.[6] show that allocation of resources, organization of care, facility-related constraints cultural inclinations, privacy concerns, and distrust of companion were identified as implementation barriers for birth companionship.

Moreover as reported by the pregnant women, long distance between the hospital and home was the most commonly affecting factor followed by the consent of family members/relatives to be a birth companion and fear/apprehension in a known person's presence. The least affecting factors were disagreement of husband followed by disagreed hospital staff, unavailability of trustworthy companion, and uncomfortable with a birth companion, whereas the study conducted by Afulani P, et al.[6] showed that reasons for not desiring companions by pregnant women included embarrassment and fear of gossip and abuse.

This study shows no significant association of personal variables of obstetricians and nurses with their knowledge level. Attitude level of the obstetricians had a significant association with years of experience (P = 0.003). In the present study, age and parity of the pregnant women were found to be significantly associated with knowledge and attitude scores, respectively. On the other side, a study conducted by Dodou et al.[21] showed that women's satisfaction during the delivery process was strongly associated with the welcoming environment and the presence of a companionship


  Conclusion Top


The present study points out the need to improve awareness among obstetricians, nurses, and pregnant women regarding birth companionship probably by training programs, workshops, and continuous feedback mechanisms. Factors affecting the implementation identified by this study can be worked upon to improve the acceptability of this initiative among beneficiaries and service providers. The following interventions can be used for effective implementation of birth companionship:

  • Improvement of the obstetrician's, nurse's, and pregnant women's knowledge on the birth companionship
  • Creating a plateform for obstetricians, nurses, and pregnant women to share their experiences with each other
  • Empowering women to appeal for a labor companion
  • Enlightening the public using mass/social media and to ensure privacy of all laboring mothers.


Acknowledgment

We express our gratitude to all the participants of the study and all those who contributed to this study directly or indirectly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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