Utilization of companionship during delivery and associated factors among women who gave birth at Arba Minch town public health facilities, southern Ethiopia

Background Companionship during delivery is an important feature of compassionate and respectful maternity care. It has a positive impact on delivery and birth outcomes. In low resource countries like Ethiopia lack of companionship discourages women from accessing facility-based delivery care. Therefore, this study aimed to assess the utilization of companionship during delivery and associated factors. Methods Health facility-based cross-sectional study design was done from October to November 2019. Interviewer administered questionnaires were used to collect the data from 418 study participants. The data were entered with Epi data version 4.4 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for analysis. Binary logistic regression was done. Statistical significance was declared at P- values < 0.05 with a 95% confidence level. Results The finding of the study showed that only 13.8% of mothers utilize companionship during delivery. Variables such as having a desire to have companionship during delivery in the health facilities (AOR = 5.17, CI 95% 2.63, 10.16), having complication during the labor and delivery (AOR = 3.48, CI 95%, 1.81, 6.70), and being primipara (AOR = 2.05, CI 95% 1.09, 3.87) were the independent factors associated with companionship utilization. Conclusions The finding of the study showed that the utilization of companionship during delivery was low. Permitting women to have a companion of choice during labor and childbirth can be a cost-effective intervention to improve the quality of maternity care, facing complications during delivery, having a desire to have companionship during delivery and primiparous women were more likely to utilize companionship. To improve this low utilization of companionship institutions and care providers should provide information about companionship during antenatal care attendance. Besides, there is a need for clear guidelines to govern the practice of companions.

were the independent factors associated with companionship utilization.

Background
Providing continuous emotional and physical support during delivery is one of the important measures of quality of care in the health facility because it is one of the potential ways to advance the quality of maternity care (1).
Labor is considered as periods of developing extreme anxiety, fear, emotional disturbance, and stress in women's life. So providing continuous emotional support is vital for achieving positive outcomes by enhancing the physiological process of labor (2). Having a labor companion is likely to cope with labor induced stress and adapt to a strange environment when someone she knows is continuously assisted her, encouraging, and appreciating her efforts during delivery (3,4).
World health organization(WHO) recommends that facilitating and ensuring clear and respectful communication between health-care providers and the woman in labor, and providing continuous emotional support is advocated for all women. However, in the actual clinical setting, it not wellpracticed(5-6). Permitting and supporting the presence of a woman's companion of choice during labor and childbirth is vital to reduce mistreatment or abuse in a health facility (6) .beside it will increase women's satisfaction with their experience of childbirth and reduce the risk of medical interventions, like emergency cesarean section (7).
Companionship during delivery is one of the core components of respectful maternity care (RMC), but it is a neglected area. (8,9) A previous study showed that the low practice of labor companions was associated with the absence of guidelines, lack of infrastructure to protect privacy, overcrowding of ward and poor knowledge and negative attitudes of health-care providers (10,11). Now a day, labor companion is increasingly being included in the maternal health guidelines of many countries, however, little is known about the extent to which labor companionship is practiced especially, in most low-income countries (11,12).
In Ethiopia, companionship during delivery is not well studied. Therefore, this study is aimed to assess the utilization of companionship during childbirth and associated factors among women who give birth at Arba Minch town public health facilities, South Ethiopia.

Study setting and Study period
The study was conducted in Arbaminch town public health facilities from October to November 2019. Arbaminch town is the administrative city of the Gamo zone, southern Ethiopia, which is 454km south of Addis Ababa (the capital city of Ethiopia) and about 280 Km from Hawassa ( the capital of SNNP). The town is subdivided into 4-sub city and 11 kebeles (the smallest administrative structure in Ethiopia). The town has a total area of 5556 hectares and a total population of 112,724 among those (50.2%) of them were females. The number of health institutions in Arba Minch town is 1 governmental general hospital, 2 health centers, 33 private clinics, 12 drug store, and 2 community pharmacy

Study design
A health facility-based cross-sectional study design was carried out.

Source population
All women who gave birth at Arba Minch town public health facilities.

Study population
All women who gave birth in Arba Minch town public health facilities during the study period.

Inclusion criteria
All women who were laboring and gave birth at Arba Minch town public health facilities.

Exclusion criteria
Those women who are seriously ill and unable to communicate.

Sample size determination
The sample size was calculated using a single population proportion formula by considering the following assumptions: 95% confidence level, the margin of error (0.05), p= 44.7% (13). The required sample size after adding 10% non-response rate was 418

Sampling techniques & procedure
There is one public hospital (Arbaminch general hospital) and two public health centers (Sikela and Shecha health centers) in Arbaminch town and all were included in the study. The allocation of the sample to health facilities was made proportionally based on the number of women who give birth at each facility in the two months preceding the data collection period.
Individual study subject at each health facility was selected by systematic random sampling during the data collection period until the required sample size at each health facility was obtained The sampling interval k=2 was calculated by dividing the source population to the total sample size and this interval was used in all health facilities to select study subjects.
Therefore, the first women from each health institution were selected by lottery method. Then every other woman from each health institution was interviewed.

Operational definitions
Labor companionship: support provided to laboring women at all moments of the labor process. It may be provided by a partner, family member, or social network (14).

Utilization of companionship:
having a support person of laboring women to provide support and stay with her during labor in the health facilities.

Data quality control
The pretest was done on 5 % of the sample size (by 21 questionnaires) to ensure its consistency and validity then correction was made accordingly before the actual data collection. One day training was given for data collectors and supervisors about the methodology and questionnaires by the principal investigator. During the data collection period, Study participants were informed about the purpose of data collection and the importance of the study to generate quality data. The collected data were checked for completeness and consistencies by trained supervisors and investigators daily and immediate action was taken accordingly. After data collection, the collected data were rechecked for completeness and consistencies by the investigator.

Data processing and analysis
The collected data was checked by the principal investigator, and then data were coded, entered, Finally, the result of bivariate and multivariable logistic regression analysis was presented in a crude and adjusted odds ratio with 95% confidence intervals. P< 0.05 was considered statistically significant.

Ethical consideration
Ethical clearance was obtained from the institutional Research Ethics review board of the college of medicine and health science, Arba Minch University. Permission was obtained from the managers of each health facility. All participants were informed about the objectives of the study and that their participation was voluntary. It was also clearly stated to the participants that the information they provided was for research purposes and strictly confidential. Data were collected before discharge to home after she was stable and comfortable. Half of the respondents were from Gamo ethnic group (51.4%) followed by Gofa ethnic group 68(16.7%) ( Table 1). Majority 346(85%) of respondents perceived that allowing laboring women to have a companion during childbirth. Of the total respondent, 387(95.1%) of them had planned pregnancy ( Table 2).

Benefits of companionship during delivery
Majority of respondent 77.2% mention that having companionship during delivery can reduce loneliness followed by reducing labor pain management (figure 1)

Utilization of companionship during delivery
Of the total respondents, 56 (13.8%) of laboring mothers utilize companionship during delivery, and 351(86.2%) not utilize companionship. The main reason mentioned for not to utilize companionship during delivery was provider denial 47.9% followed by an institution not allowed 21.1% (Figure 2.)

Factors associated with having a companion during delivery
To determine the association between utilization of companionship during delivery in the health facilities with different factors, the following dependent variables were checked against outcome variables. On bivariate analysis, women's occupation, family monthly income, complication during labor and delivery, parity of woman, Comfortability of facilities to be accompanied and knowledge had significantly associated with utilization of companion during delivery in the health facilities.
After controlling the effects of confounder on multivariable analysis, having a desire to be accompanied, and complication during labor and delivery and parity have a statistically significant association with utilization of companionship during delivery. Respondents who had a desire to be accompanied during labor and delivery were 5 times more likely to accompanied by their companion than others (AOR=5.17 (2.63, 10.16). Those respondents who have had complications in the current pregnancy and labor were 3,48 times more likely to utilize their companionship than others (AOR=3.48 (181, 6.70). Besides, those respondents who gave birth for the first time (primipara) were 2.05 times more likely to have been accompanied by their companion than multiparous women (AOR= 2.05, 1.09, 3.87) ( Table .3)

DISCUSSIONS
Permitting companionship in the health facilities during labor is one of the factors speculated to influence women's decisions to seek skilled birth attendants (14).
The overall utilization of companionship during delivery in the health facilities among study participants was found to be 13.8%. The finding of this study is to lower the study finding done in Brazil by 38.1%, Kenya 67%, and South Africa (15,16,17).
This variation could be due to the cultural difference in labor companion and policy that enforce health care providers to allow labor companion and also study design difference.
The finding of this study showed that being primiparous (delivered for the first time) were two times more likely to be accompanied by their labor companion during childbirth in the health facilities than those women who were multiparous. This finding is similar to the study done in Brazil, which revealed that being primiparous (delivered for the first time) were more likely to be accompanied by their labor companion during childbirth in the health facilities than those women who were multiparous (15). This might be due to the fear of childbirth because most of the time primiparous women may face the fear of childbirth and they will be more likely accompanied by their companion and this fear of childbirth can harm a woman's psychological wellbeing and associated with adverse obstetric outcomes and postpartum mental health difficulties. Women who had obstetrics or medical complications during labor and delivery were 3.48 times more likely to be utilized, labor companion, compared to those women who had never been experiencing any complications during labor and delivery. This finding is supported by a study conducted in Tanzania; parturient women who develop complications during childbirth had significantly greater odds of having companionship during delivery than women who had normal labor and delivery (13). But in contrast, a study in Kenya (16) showed that women who had experienced complications at labor are 66% less likely to have companionship while giving birth in the health facilities. This difference may be encountered due to women with labor and delivery complication needs strict follow up by health care provider alone, to provide appropriate management without intervention, and to avoid additional stress by her family members.

Conclusion
The finding of this study showed that the utilization of companionship during delivery was low as compared to the previous study. Some of the factors associated with utilization of companionship during delivery was having a desire to companionship, being primiparous, and

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