Making birth companionship work in rural district hospitals: experiences of a health worker–led intervention in South Africa

Abstract Birth companionship is an essential component of high-quality maternal care, associated with better clinical outcomes and improved childbirth experiences. Despite policy support, implementation in low-and-middle income countries, remains limited. STAR (Strengthening Teamwork and Respect) was a health worker-led participatory learning and action intervention implemented in nine rural hospital maternity units in KwaZulu-Natal, South Africa. Through structured reflection, STAR teams identified locally driven change projects to improve maternity care; seven hospital teams chose to support birth companionship and were included in this study. This was a mixed-methods study. Quantitative cross-sectional surveys were conducted among postpartum women, at baseline and after STAR implementation, to assess access to birth companions. Semi-structured in-depth interviews with maternity unit health workers (HWs) explored attitudes and experiences of birth companionship before and after implementation of change projects. Embedded within the study methods was a continuous process evaluation to document implementation in each facility. We found that more women were allowed a birth companion after implementation of birth companionship (37% vs 12%), and at endline most women (64%) stated they would choose to have a companion for a future delivery. At baseline, most HWs were apprehensive about birth companions, citing understaffing, limited space, inadequate privacy, and concerns about cultural acceptability. STAR teams developed standard operating procedures for birth companions and promoted birth companions in antenatal clinics. Each STAR team designed context-specific strategies, including guidelines for companions, rearrangements in labour ward to improve privacy, name badges and registers for companions and, in some cases, providing accommodation. Following implementation, HWs reported positive experiences, stating that companions assisted both mothers and HWs, and improved communication. Thus, participatory, HW-led approaches can facilitate implementation of policy changes in low-resource settings, including practices that have been resistant to improvement. The STAR model could provide a scalable strategy for translating evidence-based recommendations into routine practice.