Giving birth is one of the most important events of a woman’s life. It is a sentinel event for her family. The process of giving birth must not be considered a mere biological event, but a process that is associated with many social and emotional connotations. It is a right of every woman to be supported and to receive the most up to date, evidence based care during childbirth.
Modern times have seen increasing medicalization of the management of labor [1]. It seems that emphasis is now on safety at the expense of its emotional aspects. Historically, laboring women have received support from other women of their social or family circle, a practice that has been used across cultures almost universally. These aspects have become marginalized as a result of concentrating services on safety.
Sri Lanka is no exception to this phenomenon. Successive governments over the past six decades have followed a policy of increasing access to and improving the quality of healthcare. The policies have had a heavy focus on infrastructure development and investment in skilled attendance at birth. These initiatives included encouraging women to deliver in hospitals, rather than at home. Over 99% of women now receive skilled attendance at birth [2,3,4]. Maternal death rates have been brought down from 61/100,000 live births in 1995 to 32.03/100,000 in 2014 [4].The public sector, which provides free healthcare to all Sri Lankans handles 94.6% of the births that occur in the country [4].Since its achievements in health indices are in keeping with countries that have ten times its gross domestic product, Sri Lanka is held out as model for non-industrialized nations [5].
As a corollary to these, women have had to pay the price for medicalization of birth. The vast majority of women who deliver in public sector hospitals in Sri Lanka will deliver in labor wards that are out of bounds to ‘outsiders’. In effect this means that some women will be deprived of contact with their immediate family and social circle on one of the most important days of their lives. Authors have expressed concern regarding dehumanization of the process of birth as a global issue [6].
A person who provides non-medical physical, emotional and informational support during and after labor is known as a ‘Doula’. Almost every culture has had its own version of Doulas, which had been practiced for thousands of years. Provision of continuous care during labor can be conducted either by hospital staff, a woman from outside the laboring mother’s social and family circle or by a companion of the woman’s choice from her family or social circles. In the modern obstetric practice, male partner’s involvement in labor support is frequently seen. However, some evidence shows that male companions may not confer major advantages to outcomes [7].
Non-medical support during labor has shown positive intrapartum, perinatal and neonatal outcomes [8]. A Cochrane review analyzing 22 trials involving 15,288 women from 16 countries demonstrated clear benefits on increased vaginal birth rates, fewer requirements of analgesics, shorter labors and improved maternal satisfaction. The review concluded that in view of clinical benefits to both mother and infant, all women should have continuous support throughout labor [6]. In a review, the American Journal of Obstetrics & Gynecology has classified companionship during labor as one of the most effective interventions [9].
A randomized controlled trial conducted in Sri Lanka to assess the effectiveness of a female labor companion in the local setting corroborated these positive outcomes in the local setting. Continuous support by a female companion was associated with significant maternal satisfaction with labor and better establishment of breastfeeding within first 24 h. It also showed a statistically not significant reduction in the requirement for augmentation of labor [10].
Despite such compelling evidence, women in less privileged settings are deprived of this valuable intervention. Thus, at a time of great psychological demand, women have no choice but to endure labor without contact with anyone from their immediate social circles. The World Health Organization recommends labor companionship as a low cost intervention to improve outcomes of labor [11]. In keeping with this, Sri Lankan government has made a policy to allow a labor companion [12]. However, implementation has been unsatisfactory. Ironically, in Sri Lanka, the norm in private hospitals is to allow a companion of the mother’s choice, including the male partner.
In Sri Lankan government hospitals, the labor rooms are designed to accommodate multiple labor beds that are separated by retractable curtains. Most labor wards will therefore not provide a high level of privacy, precluding the facility of allowing a male labor companion. However, at the presently available level of infrastructure, Sri Lankan labor rooms will be able to accommodate female labor companions without the requirement of significant changes.
In 2014, nearly 95% the deliveries were conducted in government hospitals that had the services of a Consultant Obstetrician [4]. Consultant Obstetricians & Gynaecologists are Board-Certified specialists who have completed 6 years of structured postgraduate training in the specialty. Board Certification is a prerequisite to holding a Consultant post in public sector hospitals in Sri Lanka. Polices on patient care at the local level are influenced heavily by the Consultant in charge. This is true for the practice of allowing a female labor companion as well. One of the main limiting factors against wider acceptance of allowing a female labor companion may be their lack of acceptance of its advantages. An initial resistance is natural for any change in the existing practice.
Given the leading role of Obstetricians play in the implementation of policy, we undertook a study to assess the knowledge, attitudes and practices with regard to female labor companionship. We invited all the Consultant Obstetricians providing care in government hospitals to participate. This would be useful in understanding the constraining and facilitating factors and would help in expanding this service.
