African hospitals struggle to let birth partners into delivery rooms
A new study of maternity wards in Malawi reveals that hospitals officially support having family members present during childbirth—a practice known to improve outcomes—but staff regularly exclude them in practice. The findings highlight how policy gaps between what's written and what happens on the ground undermine maternal care quality in resource-constrained settings.
Originaltitel: Between help and hindrance: a qualitative study on inclusion of birth companions in closed, invited and contested spaces within maternity care settings in Malawi.
Malmöiinstitutet visar att födelsekompanjonskap—stöd från närstående under förlossning—är otillräckligt integrerat i matris av låginkomstländer trots väl dokumenterade fördelar för moder och nyfödds hälsa. En kvalitativ studie på två sjukhus i Malawi (regering och trossamfund) intervjuade 65 personer: 24 föderskor, 20 ledsagare och 21 barnmorske. Observationer under 72 timmar och providerjournal avslöjade systemiska hinder. Slutsatsen: personalen bestämde när ledsagare fick närvara, rutinerna var oklara, personalbrist och överbelastade avdelningar stängde möjligheterna. Där ledsagare tillåts—"inviterade rum"—var stödet beroende av personalens godkännande och ofullständigt erkänt. I tvistemål uppstod spänning över auktoritet och ansvar när ledsagare utmanade beslut. För regionvård och MedTech är detta kritiskt: designa förlossningsvård för familjecentrerad omsorg kräver policy, utbildning och fysisk planering—inte bara goda avsikter.
BACKGROUND: Birth companionship is widely recognised as a key component of respectful maternity care, with well-documented benefits for maternal and neonatal outcomes. However, in low-resource settings like Malawi, its integration into facility-based care remains limited and uneven due to systemic, infrastructural and interpersonal challenges. The study aimed to explore how birth companionship is negotiated in closed, invited and contested spaces within maternity care settings. METHODS: This qualitative exploratory study, nested within the ALERT (Action Leveraging Evidence to Reduce Perinatal Mortality and Morbidity in sub-Saharan Africa) project, was conducted in one government and one faith-based hospital in Malawi. 65 Participants were purposively sampled: 24 postpartum women, 20 birth companions and 21 maternity care providers. Data were collected through semi-structured interviews, focused group discussions with providers and birth companions, 7-day provider diaries and 72 hours of observations involving 16 birthing mothers and 16 maternity care providers. Transcripts were uploaded into NVivo V.14 for coding and data were analysed using reflexive thematic analysis, applying Gaventa's Spaces of Power framework for interpretation. RESULTS: Findings show that companion inclusion was overlooked in maternity ward design and policy, leaving involvement unstructured and dependent on provider discretion. Provider-centred routines, lack of guidance and training, overcrowding, restricted visiting hours and inadequate facilities reinforced closed spaces and limited continuous support. In invited spaces, companions offered emotional and practical support, but participation remained conditional, poorly acknowledged and shaped by provider needs. In contested spaces, unclear roles generated tension over authority and responsibility as companions sought visibility, questioned decisions or mediated between women and providers, often risking reprimand. CONCLUSION: The integration of birth companionship in Malawi's maternity care system remains conditional and inconsistently practised. Addressing this requires clear policy frameworks, role orientation for companions, infrastructural investment and provider training. Interventions should promote well defined inclusive spaces where companions are empowered and midwives supported, thereby advancing respectful, woman-centred care.