A package of interventions to increase facility births attended by a birth companion in Ethiopia, Kenya, and Nigeria: A cluster-randomized controlled trial

BackgroundDespite the World Health Organizations recommendation of offering women the option to have a birth companion of their choice, implementation of this recommendation remains limited in low- and middle-income countries, including Ethiopia, Kenya, and Nigeria. This study assessed if a tailored set of programmatic interventions targeting common barriers to birth companionship could increase the proportion of women giving birth with a companion. MethodsIn this cluster-randomized trial,12 facilities in Ethiopia, 24 facilities across Machakos and Muranga counties in Kenya, and 24 facilities in Kano and Nasarawa states in Nigeria were randomized (3:1) to intervention and control arms (ClinicalTrials.gov NCT05565196). The intervention was introduced over a period of two months and was evaluated after 12 additional months of implementation. We enrolled women having vaginal births. Data were collected at baseline, quarterly, and one year, using a facility survey and qualitative interviews with women, birth companions, health workers, and unit managers. We used a cluster-weighted chi-square test to compare intervention and control arms with respect to the primary outcome, which was the proportion of women accompanied in the facility by a companion during labor, birth, and postnatal periods. Difference-in-difference analysis was also done. Findings1,475 women in Ethiopia, 1,496 in Machakos and 1,521 in Muranga Counties of Kenya and 1,644 in Kano and 1,249 in Nasarawa states of Nigeria were recruited. At end-line, primary outcome increased in intervention arm by 38% points (95%CI=12-66, p=0.009) in Ethiopia,15% points (95%CI=7-26, p=0.002) in Muranga, 9% points in Machakos (95%CI=-1-20, p=0.077), 51%(95%CI=9-93, p=0.018) points in Kano state, and 53% points in Nasarawa state (95%CI=11-96, 0.014). InterpretationA tailored interventions reduced barriers to women having continuous companionship in facilities during labor, birth, and the postnatal period and has potential for use in a range of facility types and settings aiming to increase client-centered intrapartum care.