Women's and health providers' perceptions of companionship during labor and childbirth: a formative study for the implementation of WHO companionship model in Burkina Faso.

INTRODUCTION: A key component of achieving respectful maternal and newborn care is labor companionship. Despite important health benefits for the woman and baby, there are critical gaps in implementing labor companionship for all women globally. The paper aims to present the perceptions and experiences of pregnant women, postpartum women, and health care providers regarding companionship during labor and childbirth, and to identify barriers and facilitating factors to the implementation of labor companionship in Burkina Faso. METHODS: This is a formative study to inform the "Appropriate use of cesarean section through QUALIty DECision-making by women and providers" (QUALI-DEC) study, to design, adapt and implement a strategy to optimize the use of the cesarean section, including labor companionship. We use in-depth interviews (women, potential companions, and health workers) and health facility readiness assessments in eight hospitals across Burkina Faso. We use a thematic analysis approach for interviews, and narrative summaries to describe facility readiness assessment. RESULTS: In all, 77 qualitative interviews and eight readiness assessments are included in this analysis. The findings showed that all participants acknowledged an existing traditional companionship model, which allowed companions to support women only in the hospital waiting room and post-natal room. Despite recognizing clear benefits, participants were not familiar with companionship during labor and childbirth in the hospital as recommended by WHO. Key barriers to implementing companionship throughout labor and birth include limited space in labor and delivery wards, no private rooms for women, hospital rules preventing companionship, and social norms preventing the choice of a companion by the woman. CONCLUSION: Labor companionship was considered highly acceptable in Burkina Faso, but more work is needed to adapt to the hospital environment. Revisions to hospital policies to allow companions during labor and childbirth are needed as well as changes to provide private space for women. Training potential companions about their roles and encouraging women's rights to choose their companions may help to facilitate effective implementation.

A labor companion is a person who supports a woman throughout labor and birth, typically a woman's spouse/partner, family member, or friend. We were interested to explore if a labor companion throughout labor and birth was acceptable to women and health workers, and feasible to start doing for women in Burkina Faso. To achieve this objective, we interviewed 77 women, companions, and health workers about their beliefs and opinions about labor companions, and what might help or be a challenge to having companions. We also visited eight hospitals to understand what the labor ward looks like, and any policies about companions. We found that hospitals were allowing a 'traditional model' of companionship, allowing companions to accompany women only in the waiting and postnatal rooms (not during labor or birth). Both women and health workers believed that companionship during labor and birth would be helpful and desired, which might help to make it a reality for all women. We also identified some challenges, due to crowded labor rooms with limited privacy, and hospital rules that did not allow companionship. We found that sometimes a woman's family would choose the companion, instead of the woman herself, which may mean the woman does not want this person present. We plan to use these findings to help us to develop a program that allows any woman to have a companion present during labor and birth, in a way that ensures that she chooses the companion, and the companion can support her well.

Opportunities to improve postpartum care for mothers and infants: design of context-specific packages of postpartum interventions in rural districts in four sub-Saharan African countries.

BACKGROUND: Postpartum maternal and infant mortality is high in sub-Saharan Africa and improving postpartum care as a strategy to enhance maternal and infant health has been neglected. We describe the design and selection of suitable, context-specific interventions that have the potential to improve postpartum care. METHODS: The study is implemented in rural districts in Burkina Faso, Kenya, Malawi and Mozambique. We used the four steps 'systems thinking' approach to design and select interventions: 1) we conducted a stakeholder analysis to identify and convene stakeholders; 2) we organised stakeholders causal analysis workshops in which the local postpartum situation and challenges and possible interventions were discussed; 3) based on comprehensive needs assessment findings, inputs from the stakeholders and existing knowledge regarding good postpartum care, a list of potential interventions was designed, and; 4) the stakeholders selected and agreed upon final context-specific intervention packages to be implemented to improve postpartum care. RESULTS: Needs assessment findings showed that in all study countries maternal, newborn and child health is a national priority but specific policies for postpartum care are weak and there is very little evidence of effective postpartum care implementation. In the study districts few women received postpartum care during the first week after childbirth (25 % in Burkina Faso, 33 % in Kenya, 41 % in Malawi, 40 % in Mozambique). Based on these findings the interventions selected by stakeholders mainly focused on increasing the availability and provision of postpartum services and improving the quality of postpartum care through strengthening postpartum services and care at facility and community level. This includes the introduction of postpartum home visits, strengthening postpartum outreach services, integration of postpartum services for the mother in child immunisation clinics, distribution of postpartum care guidelines among health workers and upgrading postpartum care knowledge and skills through training. CONCLUSION: There are extensive gaps in availability and provision of postpartum care for mothers and infants. Acknowledging these gaps and involving relevant stakeholders are important to design and select sustainable, context-specific packages of interventions to improve postpartum care.