Kerala govt has once again shown the path when it decided to roll out the “labour companionship” program in 4 major government hospitals. As per the program, the woman is free to choose a family member as companion during labour and birth. It a wonderful step towards making labour and child birth a happy and safe process for the woman. The policy makers are very right in thinking that in view of the staff shortage and other limitations, women feel more comfortable when they have a companion with them. They have also taken into consideration that the psychological or behavioural problem that results due to fear or alienation during the birth process can also be alleviated to some extent by having a companion like husband, or close female relative. The initiative would need investment for additional infrastructure, but more so for appropriate education and awareness of the hospital staff and the public.
However, I just want to highlight some points here and hope that the policy makers would understand the importance of it:
1) Pregnancy is not only about labour and birth. It is a journey that starts from conception to after childbirth. Therefore, the companionship or the support should ideally start right from the time when the woman conceives. The fear, stress and anxiety that is manifested during labour and birth is not an isolated phenomenon, but the culmination of fear and doubts of the last 9 months. Therefore, it is necessary that pregnant women should be coached or made ready for the labour process. But everyone would agree that in an ecosystem with an epidemic staff shortage, poor doctor-patient ratio and doctor-patient consultation time, this remains a far cry.
2) Having a birth companion has been one of the major recommendations of WHO for improving birth outcomes. Many studies have shown great results, including in India.
The point to be noted here is whether support from a lay female relative is enough to get good/significant outcomes. Lot of studies worldwide including in India, have showed that the support was by personnel who had some basic training in handling such situations. A Cochrane review showed that in majority of cases the most beneficial support appears to be from a person who is not a member of women’s social network, not a hospital staff and who has some experience and informal training. In some cultures and communities, they expressed their worries of being exposed to the companion and consequent expected gossip about them not being able to keep up with the social expectations of behaviour, such as not losing control and shouting. When a lay person or a lay woman relative acts as a companion, there is a risk of reverse outcome because of our complex societal relationships and expectations, transfer of prejudices and superstition, lack of evidence based current knowledge, lack of understanding of ethics and boundaries etc. Women feel very vulnerable during labour and birth and most of them prefer a third person, who is not judgemental but educated and empathetic. Therefore, many studies worldwide have shown that the best outcome is always when the support is offered by a non-related female partner with some training and education.
3) Partner or husband as Companion: In the same Cochrane review- In some high income and low income setting, the presence of a female companion was perceived to be beneficial in addition to the presence of the husband or male partner. Even though male partners were appreciated for providing emotional and spiritual reassurance, women perceived them as lacking the skills needed for other aspects of support necessary to them as well not coping well with seeing women go through labour and birth. So, we really need to invest in programs like antenatal education for proper education and awareness for the couple and family members.
4) Fear of cross infection and hygiene: In all the studies conducted in high income or low-income countries, health providers reported concern about cross infection and interference in clinical decision when choice of female relative was given. Labour suite or ward is a sensitive area and it is very important to evaluate the health status of the companion to prevent any cross infection, which might not be a priority or possibility for hospitals. This could put the women, unborn child and staff at risk of exposure to any communicable diseases. This is another reason why Birth companions should be trained and certified so that the pregnant woman, her family and the hospital is assured that the companion is safe and trained to handle a sensitive situation.
Having said all this, there is no doubt that birth companions is the best way forward to improve outcomes in an overstretched and fatigued health ecosystem. The policy makers however, need to evaluate and analyse the benefits and risks of having a lay companion compared to a trained and certified birth companion. As I said earlier, Kerala has always been the torch bearer of new and innovative initiatives and I hope that this time too Kerala will be happy to take the first step towards a more evidence based scientific approach to birth companions.
Author- Anjali Raj.
Anjali is a childbirth educator and Lactation consultant, co-founder of ilove9months and is currently pursuing Phd in Yoga and infertility at Warwick Medical School, UK. She along with her two co-founders who have extensive experience nationally and internationally in maternal wellness and health care operations have launched “Sahodari”- India’s first trained and certified Birth Companions in Trivandrum, Kerala. Ilove9months is incubated at t-Hub, Hyderabad and Kerala Start Up Mission (KSUM), Trivandrum and funded by KSUM and Kerala State Industrial Development Corporation (KSIDC).