Table 2 Acceptability, appropriateness and feasibility of companion of choice at birth

Women and their families

a. In general, women and their male partners, when present, appreciated the presence of a support person with them, whether that person was a doula or a student nurse.

a. McGrath & Kennell, 2008; Hemminki, 1990; Hodnett et al., 2002

b. Women had low expectation in the quality of care, they and their families reported experiencing bad treatment at the hospital.

b. Brown et al., 2007; Madi et al., 1999; Kabakian-Khasholian et al., 2015.

c. Women expressed some reservations about lay female companions from the community in the form of fear of being exposed to the companion and the consequent gossip expected in the community, therefore a worry to keep up with social expectations.

c. Al-Mandeel et al., 2013; Maimbolwa et al., 2001; Alexandre et al., 2013.

d. Lay female companions who were not related to women were viewed as an ally with no interest in the hospital system and easy to communicate with.

d. Hofmeyer et al., 1991; Campbell et al., 2007

e. Male partners presence was appreciated for providing emotional and spiritual reassurance to women and to witness the challenges of childbirth endured by women however, they were viewed as unskilled, not usually present throughout labor and less interactive compared to female companions. Women feared that their male partners could not handle the process of labour and birth. In some cultures, the presence of the male partners is not socially acceptable.

e. Kennell et al., 1991; McGrath and Kennell, 2008; Morhason-Bello et al., 2009; Scott et al., 1999; Mosallam et al., 2004; Kabakian-Khasholian et al., 2015; Qian et al., 2001; Alexandre et al., 2013.

Health care providers

a. Health care providers were found to lack the positive attitudes of providing emotional and spiritual support as labour support was not considered a professional task.

a. Hemminki et al., 1990; Morhason-Bello et al., 2009

b. Nurse and midwives sometimes were apprehensive about the presence of a support person and not quite sure about the effect on the cooperation of women with the staff or the skills of the lay person or their fear from the use of traditional medicine.

b. Banda et al., 2010; Maimbolwa et al., 2001; Cogan & Spinnato, 1988; Hemminki et al., 1990; Qian et al., 2001.

c. The presence of the lay companion was viewed positively in reducing the dependency on the overloaded staff. Providers were perceived to be friendlier in the presence of the companion.

c. Madi et al., 1999; Bruggeman et al., 2007; Maimbolwa et al., 2001

d. Health care providers should be informed of the evidence and motived by the high patient satisfaction with the implementation of this practice.

d. Bruggeman et al., 2007; Campbell et al., 2006

Other stakeholders

Community agencies including local health departments and health care providers can act as a source of information for doulas.

Campbell et al., 2007

Health system factors

a. The presence of the companion during childbirth might improve accessibility to health services in subsequent births through the reduction of the negative effects of the hospital environment in terms of reducing the feelings of being left alone, insecurity and neglect.

a. Langer et al., 1998; Maimbolwa et al., 2001; Kumbani et al., 2013

b. Identified implications on human resources include: freeing the time of nurses and midwives thus improving quality of care, organization at the ward to change shift for

b. Madi et al., 1999; Yuenyong et al., 2012; Brown et al., 2007; Maimbolwa et al., 2001; Scott et al., 1999; Gordon et al., 1999

c. nurses and midwives, the availability of the doula early during labour.

c. Langer et al., 1998; Kashanian et al., 2010; Banda et al., 2010; Kabakian-Khasholian et al., 2015, Campbell et al., 2007; Qian et al., 2001

d. Training and hiring of nurses or midwives as doulas could be considered in some settings. Clear communication and some training about the duties of the lay companion are expected in others. Retired nurses hired as companions could be desensitized to women’s needs.

d. Yuengyong et al., 2012; Brown et al., 2007; Kabakian-Khasholian et al., 2015, Maimbolwa et al. 2001; Qian et al., 2001.

e. Some implications on facilities include: availability of lounges for lay companions short breaks, privacy in labour rooms, space for companions in labour rooms.

Social and political factors

a. Changes to national, state or hospital policies against having lay companions during childbirth might be necessary.

a. Madi et al., 1999; Kabakian-Khasholian et al., 2015; Yuengyong et al., 2012; Brown et al., 2007

b. The cost of hiring a doula or the transportation need to be considered, however in general, having a lay companion or a doula is likely to result in overall reduction of costs in obstetric interventions and complications.

b. Madi et al., 1999; Campbell et al., 2007; Brown et al., 2007; Scott et al., 1999; Gordon et al., 1999

c. Sustainability is believed to result from political commitment at the state and hospital level and from raising public awareness.

c. Brown et al., 2007