Introduction

The presence of a companion (whether a partner, family member, friend or doula) to support a woman during labour and birth is a critical component of good quality maternal and newborn care [1]. Companions help by providing emotional and physical support, assisting women in managing their pain, improving communication with health providers, and advocating for the person giving birth [2]. The WHO Quality of Maternal and Newborn Care Framework highlights labour companions as an important component of quality care [3] and the World Health Organization (WHO) recommends that all women have the opportunity to be supported by a companion [4]. Companionship can be continuous throughout labour and birth or only during labour or after birth [1]. The presence of a companion can both improve the birthing experience, and lead to improved health outcomes for the woman and infant [1,5]. For example, the presence of a companion has been found to reduce the experience of pain, the need for pain relief and facilitates progress in labour. It has been shown to result in less need for intervention during labour, higher breastfeeding rates and potentially lower rates of mistreatment by health care workers [1,6]. Global research is increasingly reaffirming the value of companionship during labour and birth [7–9]. However, in many settings labour companionship is not permitted due to limited health service and health worker support for companionship, inadequate facility infrastructure to maintain privacy, lack of resources and person-centred organization of care, as well as cultures and customs that oppose the presence of companions, especially men, during labour and birth [10].

Papua New Guinea (PNG) is a lower middle income country and the most populous in the Pacific Region with an estimated population over 9 million. More than 800 languages are spoken across the country [11]. The birth rate in PNG is over two times greater than Australia (27 per 1000 people compared to 12 per 1000 people) [12]. Maternal and newborn health outcomes in PNG are poor [13], and compounded by multiple factors including an underfunded health system, chronic workforce shortages, limited medical equipment and supplies and high aid dependency [14]. In addition, the majority of the population live in rural areas, which means that access to care can be difficult, particularly for villages situated within mountainous terrain and across scattered islands. Across PNG, there are only 0.6 physicians, nurses and midwives per 1000 population [15], well below the WHO recommendation of 4.5 adequately trained health providers per 1000 for universal health coverage [16]. There are very low numbers of critical maternity provider cadres, such as midwives [17]. Skilled health providers are often concentrated in urban and peri-urban areas, with much lower numbers in rural and remote areas. Promoting and facilitating the presence of companions may support this workforce gap and provide women with greater support during labour and birth, particularly in an under-resourced and overburden health system.

The national guideline for Obstetrics and Gynaecology in Papua New Guinea [18] specifically mentions that women should have continuous companionship throughout labour, although it does not specify who the companion may be. In PNG, the term ‘wasman/wasmeri’ (guardian) is often used to refer to a partner, family member or friend who provides support and care to a person in a health facility. Wasman/Wasmeri are rarely allowed in a labour ward or with a women during labour or birth. Most health facilities in PNG do not provide meals for patients and wasman/wasmeri will bring in food and other items needed, such as, bedsheets and medicines. A study conducted in 2011 at the Port Moresby General Hospital (the national tertiary referral hospital in PNG) found that whilst women wanted support people present, there were multiple barriers to enabling this to be a reality including an unsupportive organisational culture and reluctance from maternity staff [19].

In determining whether companionship during labour and birth is a feasible intervention to improve the quality of maternal and newborn care in PNG, it is important to understand the perspectives of women and those providing maternity care. The aim of this study was to describe perspectives and experiences of women, their partners and health providers regarding labour companionship, to identify enablers and barriers and develop a framework for implementing this intervention in PNG health facilities.

Methods

Data analysis

Quantitative data analysis.

Univariate analyses were conducted using variables from facility audit and labour observation data. Variables included privacy, the presence of a companion during labour or birth and whether women were offered to have a companion present. Descriptive analyses were completed using Stata data analysis software (StataSE15) [29].

Qualitative data analysis.

Conventional content analysis was used to analyse qualitative data [30]. Content analysis was chosen as it offered a systematic and objective approach to describing a phenomena (companionship) and a process for developing a framework for companionship [30,31]. QSR NVivo software was used to manage the qualitative data [32]. The content analysis involved three phases: preparation, organising and reporting [31] (Fig 1). The first phase (Preparation) involved an inductive analysis to identify key factors associated with companionship. The inductive analysis involved reading and re-reading segments of transcripts related to companionship. Sections of text, also known as units of meaning–sentences and paragraphs–were identified.

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Fig 1. Preparation, organizing and reporting stages of content analysis.

Adapted from Elo and Kyngas³¹.

https://doi.org/10.1371/journal.pgph.0000102.g001

The second stage of the analysis (Organising) involved making sense of the data by re-reading the units of meaning, open coding, creating categories and abstraction [31]. Coding was conducted jointly by the Australian and PNG research team (AW, RS, PH, PM, DK). Transcripts were open coded and a coding framework iteratively developed and discussed between researchers; when data didn’t fit into existing codes, new codes were added. Once all relevant data was coded, coded units were examined, compared and grouped into categories. Categories were then reviewed and collapsed into similar and dissimilar categories, and higher order headings applied [31]. Categorical organising of the data occurred through a process of constant comparison between categories to interpret what units belonged together versus those that did not [33]. The abstraction process enabled generation of content-characteristic titles to name categories [31]. To assist with the abstraction process, we used the conceptual quality care framework by Austin el al [34], which builds on the Donabedian framework [35]. We used this framework given its specific relevance and application to understanding the enablers and barriers to quality maternal and newborn care. The framework enabled us to arrange the categories into interconnected inputs at the community, facility and provincial levels (structures) that lead to the delivery of high quality care (processes) and result in increased companionship during labour and birth, improved care experiences and maternal and newborn health outcomes (outcomes) [34].

The third stage of the analysis (Reporting) involved developing a conceptual framework to outline the components needed for companionship during labour and birth in East New Britain. Drawing on the interconnected components of the Austin framework [34], we reviewed and compared the categories and sub-categories of the content analysis to develop a framework which described the structures and processes required to achieve companionship as an outcome (Fig 2).

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Fig 2. Conceptual framework for enabling companionship.

https://doi.org/10.1371/journal.pgph.0000102.g002

During the data analysis process, qualitative data were also discussed at a two-day Quality Maternal and Newborn Care Workshop held in East New Britain in November 2020, attended by 35 healthcare workers, managers and community members, which provided an opportunity to member-check data collected and provide input into preliminary findings.

Results

Five facility audits, 30 labour observations and 29 interviews with women, their partners and health providers provided three different sources of information about companionship during labour and birth. Table 1 shows sociodemographic characteristics of participants. All participants were aged over 18 years.

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Table 1. Sociodemographic characteristics of interview participants.

https://doi.org/10.1371/journal.pgph.0000102.t001

Conceptual framework

Using the findings from the three data sources, we developed a conceptual framework to outline the factors needed to enable companionship during labour and birth in East New Britain, PNG (Fig 2). Our framework was informed by the Austin et al. framework [34], and we grouped categories according to the structural inputs required at the community, facility and provincial level to deliver high quality maternal and newborn care to ultimately improve the care experience and reduce maternal and newborn morbidity and mortality, and stillbirths. This enabled us to organise and present the findings in an actionable framework that may be used to drive the changes needed to enable companionship at the facility level. It is important to note that the structural inputs are not limited to the community, facility or provincial levels and indeed intersect, overlap and may operate at multiple levels.

Discussion

There are very few reported studies on the experiences of companionship during labour and birth from the perspectives of women, their partners and health providers, and this is the first study to include all perspectives in PNG. Facility audit data highlighted that most facilities were not able to provide adequate privacy and space for birthing women, reflected in the small number of women observed to have a companion present during labour or birth. Benefits of companionship described by women, partners and providers included encouragement, physical support and nourishment, better communication and advocacy, improved labour progress and assistance with workforce shortages. Multiple enablers and barriers were identified including provider attitudes towards companionship, the need for education and training on working with companions, infrastructure limitations including privacy, hospital policies, and culture and customs.

Global research examining companionship has identified multiple ways in which companions can support women during labour and birth [2], as well as the potential improvements in health outcomes that may be achieved [1]. In our study, women felt that companions could assist with caring for the baby after birth or support breastfeeding. Companionship during and after birth has been shown to increase rates of early and sustained breastfeeding [36,37], which may improve nutritional status of infants and young children, bringing about reductions in infant and child mortality [38]. Previously identified factors in other populations and regions that affect the implementation of companionship in facilities include little recognition of the benefits of companionship, lack of privacy, fear of increased infection, prohibitive policies and practice, cultural inclinations and poor integration of companions [2,10], and are consistent with our findings.

Our findings also align with previous research on companionship in other LMICs which has found that women desire companions, inadequate privacy is a significant barrier, health worker support for companionship is mixed and that companions can help reduce the impact of workforce gaps [7,39]. Previous studies have consistently identified that health providers and facilities that do not permit a support person to be present during labour and birth represent a major barrier to companionship [8,40]. A mixed-methods study in Kenya identified additional barriers, including if health providers believed that the companions main role was to assist staff with non-clinical tasks rather than support women, and if health providers did not trust companions [7].

In our study, health providers reported that education and training for staff and the women’s partner was needed to understand the benefits of companionship, and prepare partners for labour and birth. Staff needed support in learning how to integrate companions into their routine care and for partners, and partners would benefit from learning how to best support women. These findings are consistent with a qualitative synthesis into perceptions and experiences of labour companionship which identified the need for training, supervision and preparation of companions for labour and birth [2]. Integrated obstetric emergency simulation training may be an avenue through which to provide training to health providers on elements of respectful care, including companionship [41]. A study in Ghana that integrated specific components of respectful maternity care into training for management of obstetric and neonatal emergencies, found women were more likely to have a labour companion at endline (32%) compared to baseline (10%) [41]. However, training of maternity providers itself is not sufficient. An Ethiopian study that provided respectful maternity care training to providers, including an emphasis on companionship, found that whilst companionship initially improved, providers felt that companionship jeopardized women’s privacy and over time companionship was not upheld [42], further emphasizing the need for a multi-pronged intervention.

Whilst there are current initiatives to promote male involvement in maternal and newborn health in Papua New Guinea [43], it is important to note that discussions around promoting and enabling companionship are not limited to or dependent on male involvement. Whilst we found that male companions were less likely to be allowed to provide support during labour and birth than female companions, we need to move beyond ‘male involvement’ as the main intervention, instead emphasizing promotion of the women’s companion of choice as the solution. However, a larger study of nearly 700 women attending antenatal clinics in East New Britain found that male partners were present at 18% of appointments, and many expressed a desire to attend, indicating a shift towards greater involvement of men during pregnancy and childbirth [23]. A global review of companionship of choice during labour and birth found the presence of male partners was considered helpful for emotional reassurance, though they were often perceived to lack the skills necessary for other aspects of support needed which female companions were able to provide [10]. In keeping with our study findings, the review found that some women appreciated the presence of a male partner to witness the pain and challenges of childbirth experience by women [10].

Whilst this research was conducted before the COVID-19 pandemic, it is important to note that we have seen major disruptions to maternity care in PNG and elsewhere as a result of the pandemic [44]. Many of these changes to service delivery aim to minimise COVID-19 transmission and have included significant restrictions on the presence of support people during antenatal appointments, labour and birth and through to postnatal care [45,46]. As such, it is likely that endeavours to support and enhance companionship during labour and birth have been negatively impacted during the pandemic. However, companionship is a critical component of quality care with a direct impact on maternal and newborn health outcomes, and as such it is essential that women have access to a companion of choice during and after the pandemic [47].

Implications for policy and research

Companionship represents an essential element for improving the quality of maternal and newborn care in PNG. The inclusion of companionship in PNG’s national obstetric guidance documents [18] is an enabler for companionship but needs translation into facility level policies and practice. Our data suggest that companionship is a complex intervention involving multiple intersecting factors. In order to address the barriers to companionship and create an enabling environment, it is not enough to address one single factor, a multi-pronged approach is required. For example, modifying hospital infrastructure to allow better privacy for women during labour and birth is essential, but without supportive facilities and health providers that allow companionship as well as partners that want to be present, it will not be possible to achieve companionship for all women who desire it.

Enabling companionship may be an avenue through which to support efforts in PNG to increase antenatal care uptake and facility birth attendance [48]. However, further rigorous research on how companionship can be scaled up in PNG, and the subsequent impact on maternal and newborn health outcomes, is needed. Our conceptual framework has highlighted that in order to achieve an enabling environment for companionship, multiple factors need to be present and operating simultaneously including positive health worker and partner attitudes to companionship, health worker education and training, adequate hospital infrastructure, accommodating hospital policies and protocols and supportive community views on companionship.

Strengths and limitations

The small number of labour observations conducted (N = 30) provides a limited snapshot into the number of women who were able to have a support person present at labour or birth and whether they were offered a companion, in the five participating facilities in East New Britain. A previous larger study in this population reported that male partner involvement was low [23], as we found here. It is possible that the observer presence may have altered provider behavior. We were not able to explore in greater depth whether socioeconomic, age, education, employment, marital status or physical ability impacted on experiences of companionship. Previous studies have found that women who are educated, wealthy and employed are more likely to have a companion present [7,49]. We did not specifically delineate women’s desire for companionship during labour and/or birth in the labour observations. Previous research has found that women generally desire companions during labour and after birth, but less so at the time of birth [7]. It is important to examine women’s desires for companionship during labour and birth separately [7]. Lastly, the results may not be generalisable to all women, their partners and providers in PNG. However, our study provides several important findings highlight the need for future studies in other settings across PNG.

Despite these limitations, this study makes a valuable contribution to the literature regarding companionship during labour and birth in PNG. The use of multiple data sources and engagement of three key players in maternity care (women, their partners and health providers) provides comprehensive insights into perspectives and experiences of companionship in PNG. Other notable strengths include a participatory approach whereby the study concept, design and conduct was co-developed with the provincial health authority, health care providers and community members. In addition, data analysis was collaboratively conducted by researchers in Australia and Papua New Guinea. By using content analysis, we were able to build a conceptual framework for enabling companionship. Our framework has similarities to a logic model which outlines the components required for implementation of labour companionship [2], including recognition of the need for formal policies to enable companionship in facilities, structuring labour wards to allow for adequate privacy, training providers on how to integrate companions, and the need for education of companions from antenatal care onwards about how to provide emotional, practical and advocacy support for women.

Conclusion

Our study has found that women want companions present during labour and birth and many partners want to be present. However, mixed health provider attitudes to companionship and inadequate health facility infrastructure or restrictive policies present significant barriers to enabling companionship to occur. Health providers need education and training to understand the benefits of companionship and how to prepare and support companions, so that they in turn can best support women. Supporting women to have their companion of choice present during labour and birth is critical to improving women’s experiences of care, achieving person-centered health outcomes [50,51], and improving the quality of maternal and newborn care. In order to meet international recommendations that every woman is offered a companion of her choice during labour and birth [3], multi-layered, intersecting interventions are needed at community, facility and provincial levels.

Supporting information

Acknowledgments

We would like to acknowledge the women and men from the community of East New Britain, PNG for generously taking part in the study. We recognize and gratefully acknowledge the dedication and contribution by the HMHB study team in Kokopo and Melbourne, in addition to colleagues at PNG Institute for Medical Research. Our special thanks to the National Department of Health, the East New Britain Provincial Administration, the Provincial Health Authority, Catholic Health Services and participating health facilities (Nonga General Hospital, St Mary’s Vunapope, Kerevat Rural Hospital, Napapar Health Centre, Malasait Community Health Post) for enthusiastically facilitating our research team to work with them.