Background

Birth companionship is a fundamental component of rights- and evidence-based, woman-centred care (1-3). It is firmly grounded in public health evidence, the ICM Philosophy and Model of Midwifery Care (4) and the ICM Bill of Rights for Women and Midwives (5). Birth companions complement, but never replace, the continuous care of a competent midwife who has access to established interprofessional consultation and referral mechanisms (3,6).

Birth companionship is the presence of a person or persons chosen by the woman or gender diverse person, such as a partner, family member, friend, and/ or trained birth companion (e.g. doula, community health worker, or cultural mediator), who provides continuous emotional, physical and sometimes informational support throughout labour, birth, and the postnatal period (1,2). Birth companions do not provide clinical care, nor do they make decisions on behalf of women. They may support women to communicate their preferences, wishes, and needs (1,2).

Birth companionship supports women’s rights to dignity, autonomy, and informed decision-making. Companionship is associated with improved maternal and newborn outcomes, more positive experiences of care, reduced need for pharmacological pain relief, reduced use of unnecessary medical interventions and in some settings an increased rate of spontaneous vaginal birth (1,2).

Birth companionship is particularly beneficial for women from marginalised groups and can help reduce inequities in access to quality care, contributing to reproductive justice (1,5). Additionally, when midwives and other health professionals engage with birth companions, this can improve communication and trust between women, their families, midwives and other health care professionals and can support more effective use of limited health system resources (2, 7).

Despite clear evidence and global recommendations, many women are still denied the right to choose a birth companion (8,9). Health facility norms, policies, staffing constraints, and medical intervention are too often cited as reasons to restrict this right (9,10). Restrictions may be based on place of birth, mode of birth, gestational age, or perceived risk, including caesarean birth or pregnancy loss. These restrictions are not evidence-based and can intensify during times of health-system stress, including public health or humanitarian crises (10). This undermines quality of care, equity, and women’s experiences, and can negatively affect emotional wellbeing, safety, and dignity (1).

Position

ICM affirms that every woman has the right to be supported by a birth companion of their choice throughout labour, birth, and the postnatal period. This right applies in all settings, regardless of place of birth, mode of birth, anticipated complications or health-system crises. Women also have the right to decline or change their decision regarding a birth companion at any time, without coercion, or negative impacts on their care.

Midwives are critical to advocating for and protecting women’s right to birth companionship in all places of birth, including during crisis. Midwives prioritise women’s needs and preferences and play a key role in enabling women to have a companion of their choice. They should engage with birth companions in ways that strengthen safety, communication, and women’s experiences of care (2,6).

ICM emphasises that birth companions complement, but do not replace, the continuous care provided by a midwife during labour and birth.

Recommendations

ICM urges policymakers to:

1. Recognise birth companionship as an essential component of rights- and evidence-based, women-centred care.
2. Enshrine the right to a birth companion of choice in national laws, policies, standards and preparedness plans, regardless of place of birth, mode of birth, anticipated complications or health-system crises.
3. Invest in infrastructure, midwifery models of care, and systems that enable the safe inclusion of companions in all places of birth.
4. Ensure that continuous care provided by a midwife during labour and birth is complemented but never replaced by a birth companion.
5. Invest in pre- and in-service midwifery education that prepares midwives to effectively engage with birth companions in ways that strengthen safety, communication, and women’s experiences of care.
6. Establish accountability mechanisms to ensure equitable implementation of birth companionship across all settings.

ICM urges facility managers to:

1. Facilitate that all women can be continuously supported by a birth companion of their choice during labour, all modes of birth and the postnatal period, including when there are complications.
2. Promote through health facility education and community outreach the right to birth companionship and the role of the companion to women, their birth companions, families and communities.
3. Educate all health facility staff including midwives on women’s right to birth companionship, the role of birth companions and how to effectively engage with birth companions in ways that strengthens safety, communication, and women’s experiences of care.

ICM urges midwives’ associations to:

1. Advocate for policy that recognises birth companionship as an essential component of rights- and evidence-based women-centred care.
2. Oppose and hold to account any non-evidence based restrictions on birth companionship such as those based on institutional norms.
3. Advocate for women to receive continuous care provided by a competent midwife during labour and birth that is complemented but never replaced by a birth companion, opposing substitution of midwifery care by birth companions.
4. Advocate for pre- and in-service education that maintains and strengthens midwives competencies in engaging with birth companions.
5. Build partnerships with advocacy and civil society organisations to promote and expand access to birth companionship, particularly for marginalised populations.

ICM urges individual midwives to:

1. Respect each woman’s right to choose, decline, or change her decision regarding a birth companion at any time.
2. Advocate for companionship throughout labour, all modes of birth and the postnatal period.
3. Educate women, their companions, families and communities about the right to birth companionship and the role of the companion.
4. Effectively engage with birth companions in ways that strengthens safety, communication, and women’s experiences of care.

References

1. Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. 2017;7:CD003766.
2. Bohren MA, Berger BO, Munthe-Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2019 Mar18;3(3):CD012449. doi:10.1002/14651858.CD012449.pub2 PubMed PMID: 30883666; PubMed Central PMCID: PMC6422112.
3. Bill of Rights for Women and Midwives. The Hague: International Confederation of Midwives 2025.
4. Philosophy and Model of Midwifery Care. The Hague: International Confederation of Midwives 2025.
5. World Health Organisation. Intrapartum care for a positive childbirth experience. Geneva: WHO; 2018.
6. Chaudhary P, Rech JP, Kumar G, Snyder K, Rosen A, Dinkel D. Role of doulas across the pregnancy care continuum on maternal and child health: a scoping review. npj Womens Health. 2025 Nov 7;3(1):63. doi:1038/s44294-025-00109-4
7. Wójcik-Brylska K, Pawlicka P, Tataj-Puzyna U, Szlendak B, Węgrzynowska M, Pięta B, et al. Cooperation between midwives and doulas in the context of perinatal care – a integrative review of qualitative and quantitative studies. Midwifery. 2023 Sep 1;124:103731. doi:1016/j.midw.2023.103731
8. World Health Organisation. Compendium on respectful maternal and newborn care. Geneva: WHO; 2025.
9. Obstetric Violence, Mistreatment, and Violence Against Women in Reproductive Health Services. The Hague: International Confederation of Midwives 2024.
10. World Health Organisation Regional Office for Europe. Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic. Lancet Regional Health – Europe. 2022;100268.