WHO recommendation on companion of choice at birth

WHO recommendation on companion of choice at birth



Continuous companionship during labour and birth is recommended for improving women's satisfaction with services.

(Strong recommendation, moderate quality evidence)


The GDG also endorsed the recommendations from an existing WHO guideline, WHO recommendations for augmentation of labour.(1)

Continuous companionship during labour and birth is recommended for improving labour outcomes.

(Strong recommendation, moderate quality of evidence)


Publication history

First published: May 2015

Updated: No update planned

Assessed as up-to-date: May 2015



In 2003 the World Health Organization (WHO) published "Working with individuals, families and communities to improve maternal and newborn health", (2) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (3) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons - over and above what happens in clinical services - why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter's health promotion components(3) were translated into MNH programme language and 12 promising interventions - identified through reviews of country experiences and the literature - were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

A companion of choice to accompany a woman in the facility during labour and birth has been the subject of a recent review in the WHO recommendations for the augmentation of labour.(1) In these guidelines the intervention referred to continuous companionship during labour and birth. We adapt this terminology in this guideline. The recommendation was made looking at improved labour outcomes and is copied herein. Given the focus of these guidelines on health promotion interventions for MNH, priority was given to two other outcomes: use of skilled care for birth/birth in a facility (for the subsequent birth) and women's satisfaction with care.



The recommendation was developed using standardized operating procedures in accordance with the process described in the "WHO handbook for guideline development", guided by the GRADE approach.(4) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(5)

A systematic review was conducted on the effect of continuous companionship during labour.(6) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • Does allowing a woman to have a companion of choice to accompany her during labour and birth in the facility or in the presence of a skilled birth attendant lead to an increase in births with a skilled birth attendant/institutional births and to improvements in perceptions of quality of care?


Evidence Summary

Evidence on the effect of continuous companionship during labour was extracted from a Cochrane systematic review of 22 trials (> 1500 women).(6)

The trials were conducted in low, middle and high-income countries across the world (Australia, Belgium, Botswana, Brazil, Canada, Chile, Finland, France, Greece, Iran, Guatemala, Mexico, Nigeria, Sweden, South Africa, Thailand and the USA). Hospital routines and facilities varied considerably in the different settings. Continuous support was defined slightly differently in the different trials but mainly women were accompanied at least during the active stages of labour. The companions in different trials varied: sometimes labour companions or doulas provided support while in other trials a female relative or husband was present throughout labour.(1) Companions could be trained to provide support to women, or have little or no training.

For the outcome of subsequent birth with a skilled birth attendant or facility birth

No studies reported on this outcome. No recommendation was made.

For the outcome of satisfaction with the birth experience, the quality of the evidence was rated as moderate.

11 RCTs reported on this outcome. Women who had continuous one-to-one support during labour were less likely to have reported negative rating of or negative feelings about childbirth experience. (11 trials, n = 11,133, average RR 0.69, 95% CI 0.59 to 0.79, I² 63%, t² 0.03).63 The effectiveness of continuous support in reducing the likelihood of dissatisfaction with or negative views of the childbirth experience appeared to be stronger in settings in which epidural analgesia was not routinely available and when the provider was neither a staff member nor part of the woman's social network. The control group varied somewhat: five studies compared continuous support with intermittent support (Breart et al., 1992 Belgium; Breart et al., 1992 France; Hodnett et al., 2002; Hofmeyr et al., 1991; Kennell et al., 1991); two with routine care (not fully described) (Langer et al., 1998; Morhason-Bello et al., 2009); or no companion present (Bruggemann et al., 2007; Torres et al., 1999); and one study (Dickinson et al., 2002) stipulated no midwife and the women were encouraged to have an epidural. In the final study women were allowed to have a support person of their own choosing (Campbell et al., 2006).(7-16)


Implementation considerations

  • The GDG acknowledged that continuous psychosocial support may not necessarily reduce the need for labour augmentation but made the recommendation on the basis of other substantial benefits for women and their babies.
  • The GDG noted that countries and policy-makers are often reluctant to implement this intervention in practice in spite of the supporting evidence, which has been available for many years. The group agreed that extra efforts are needed to encourage potential implementers at various levels of health care delivery.
  • The GDG discussed the issues of privacy, cultural inclinations and resource use often raised as concerns to implementing this intervention and agreed that simple measures to allow female relatives to accompany women during labour could be used as cost-effective and culturally sensitive ways to address these concerns.
  • The evidence supports the use of any type of culturally appropriate companion, including husbands and lay professionals, such as doulas.
  • The following points were identified by the GDG from the WHO recommendations for health promotion interventions for MNH:
  • Regarding the last bullet above, continuous support from a person who is present solely to provide support, is not a member of the woman's social network and has at least a modest amount of experience/training appears to be most beneficial.
  • In comparison with having no companion during labour, support from a chosen family member or friend appears to increase women's satisfaction with their childbearing experience. Each decision should be made according to/depending on the context and should be the choice of the woman.
  • It is important to define the training, if any, that the companion should receive. While the evidence did not indicate training was necessary for the effectiveness of the interventions, the GDG noted that there are different approaches taken by different countries such as an orientation session, tutorials or instructive cards.
  • Women's birth environments should be empowering, non-stressful, respectful of privacy and communicate respect and the valuing of women's preferences for companionship. The application of this intervention requires supporting facility policies and reflection and action on privacy considerations, possible modification of physical space in the facility, sensitization and training of health workers to increase acceptance and modes to orient the companion of choice.
  • A sensitization strategy towards acceptance of the companion by the health professionals, the community and women should be concurrently implemented.
  • Women should be able to choose the companion. This has major importance and should be clearly stated. The functions of the companion should be clearly stated when they are a family member as there could be some difficulties between health professionals and the companion.


Research implications

The GDG identified that further research on the following high-priority questions is needed:

  • The GDG identified that further research on the following high-priority questions is needed:
  • Compile lessons learned from countries where this has already been implemented.
  • Establish common indicators to measure the success of the companion intervention on maternal and newborn health outcomes and on women's satisfaction with care received.
  • Measure the different costs involved including the training of personnel and the companion, the adjustment of the physical space, etc.
  • Assess the impact on care-seeking behaviour for subsequent births.


Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015)full document and evidence tables


Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

Newborn Health


Supporting systematic reviews:

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. The Cochrane database of systematic reviews. 2013;7:Cd003766.



  1. WHO recommendations for augmentation of labour. World Health Organization: Geneva. 2014.
  2. Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.
  3. The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.
  4. WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.
  5. WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.
  6. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. The Cochrane database of systematic reviews. 2013;7:Cd003766.
  7. Breart G, Garel M, Mlika-Cabanne N. Evaluation of different policies of management of labour for primiparous women. Trial B: Results of the continuous professional support trial. Evaluation in pre, peri, and post-natal care delivery systems Paris: INSERM. 1992:57-68.
  8. Hodnett ED, Lowe NK, Hannah ME, Willan AR, Stevens B, Weston JA, et al. Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial. Jama. 2002;288(11):1373-81.
  9. Hofmeyr GJ, Nikodem VC, Wolman WL, Chalmers BE, Kramer T. Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding. British journal of obstetrics and gynaecology. 1991;98(8):756-64.
  10. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital. A randomized controlled trial. Jama. 1991;265(17):2197-201.
  11. Langer A, Campero L, Garcia C, Reynoso S. Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial. British journal of obstetrics and gynaecology. 1998;105(10):1056-63.
  12. Morhason-Bello IO, Adedokun BO, Ojengbede OA, Olayemi O, Oladokun A, Fabamwo AO. Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial. The Australian & New Zealand journal of obstetrics & gynaecology. 2009;49(2):145-50.
  13. Bruggemann OM, Parpinelli MA, Osis MJD, Cecatti JG, Neto ASC. Support to woman by a companion of her choice during childbirth: a randomized controlled trial. Reproductive Health. 2007;4:5.
  14. Torres Pereyra J, Kopplin I, Peña V, Klaus M, Salinas R, Herrera M. Impacto del apoyo emocional durante el parto en la disminución de cesáreas y gratificación del proceso. Rev Chil Obstet Ginecol. 1999;64(5):405-12.
  15. Dickinson JE, Paech MJ, McDonald SJ, Evans SF. The impact of intrapartum analgesia on labour and delivery outcomes in nulliparous women. The Australian & New Zealand journal of obstetrics & gynaecology. 2002;42(1):59-66.
  16. Campbell DA, Lake MF, Falk M, Backstrand JR. A randomized control trial of continuous support in labor by a lay doula. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2006;35(4):456-64.



WHO recommendation on companion of choice at birth (2015). WHO Reproductive Health Library; Geneva: World Health Organization.