{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:47:06Z","timestamp":1790815626265,"version":"4.1.0"},"reference-count":63,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T00:00:00Z","timestamp":1753833600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MR\/T003375\/1"],"award-info":[{"award-number":["MR\/T003375\/1"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>There is limited evidence on how companionship affects women\u2019s experiences of mistreatment during childbirth and their mental health. We assessed the characteristics of birth companionship during intrapartum care and examine its associations with women\u2019s experiences of mistreatment and symptoms of postpartum anxiety and depression. We analysed cross-sectional data from 314 women who gave birth at six public health facilities in rural Sindh, Pakistan. These women were interviewed at 42 days postpartum about their childbirth experiences and symptoms of anxiety and depression. Multivariable regression models and Path analysis were used for data analysis. Most women (83.1%) had a full-time companion in the labor room, with in-laws (44.6%) being the most common. Higher levels of companion support were associated with lower levels of mistreatment, particularly regarding non-confidential care, lack of supportive care, and ineffective communication. Women receiving low companion support were 2.86 (95% CI 1.52 \u2013 5.39) times more likely to experience postpartum anxiety and depression compared to those receiving high support. Informational support emerged as the strongest protective factor against both mistreatment and symptoms of postpartum anxiety and depression. Path analysis revealed that both the overall measure of companion support and informational support had direct and indirect effects on postpartum anxiety and depression, mediated by experiences of mistreatment during childbirth. In contrast, emotional support demonstrated only an indirect effect through mistreatment, while instrumental support showed only a direct effect on postpartum anxiety and depression symptoms. Birth companionship, especially informational support, plays a crucial role in reducing mistreatment during childbirth and improving maternal mental health outcomes. These findings underscore the need for supportive policies and health system interventions that actively encourage the engagement of companions from a woman\u2019s personal network during labour and childbirth. Future research should explore strategies to optimise the role of birth companions in promoting respectful care and maternal well-being.<\/jats:p>","DOI":"10.1371\/journal.pgph.0004030","type":"journal-article","created":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T17:32:28Z","timestamp":1753896748000},"page":"e0004030","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":7,"title":["The role of birth companionship in women\u2019s experiences of mistreatment during childbirth and postpartum anxiety and depression: An analysis of a cross-sectional 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Cold Spring Harbor Laboratory"},{"key":"pgph.0004030.ref052","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1111\/apa.14540","article-title":"Implementation of a labour companionship model in three public hospitals in Arab middle-income countries","author":"T Kabakian-Khasholian","year":"2018","journal-title":"Acta Paediatr"},{"issue":"1","key":"pgph.0004030.ref053","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1186\/s12884-020-03124-2","article-title":"Prevalence and predictors of perceived disrespectful maternity care in postpartum Iranian women: a cross-sectional study","volume":"20","author":"K Hajizadeh","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"issue":"4","key":"pgph.0004030.ref054","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0194906","article-title":"What matters to women during childbirth: A systematic qualitative review","volume":"13","author":"S Downe","year":"2018","journal-title":"PLoS One"},{"issue":"3","key":"pgph.0004030.ref055","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1089\/cyber.2012.0297","article-title":"Understanding the different types of social support offered by audience to A-list diary-like and informative bloggers","volume":"16","author":"H-C Ko","year":"2013","journal-title":"Cyberpsychol Behav Soc Netw"},{"issue":"1","key":"pgph.0004030.ref056","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1007\/BF00903305","article-title":"Locus of control as a stress moderator: the role of control perceptions and social support","volume":"10","author":"IN Sandler","year":"1982","journal-title":"Am J Community Psychol"},{"issue":"2","key":"pgph.0004030.ref057","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1177\/0020764015612119","article-title":"Relationships among depression during pregnancy, social support and health locus of control among Iranian pregnant women","volume":"62","author":"M Moshki","year":"2016","journal-title":"Int J Soc Psychiatry"},{"issue":"11","key":"pgph.0004030.ref058","doi-asserted-by":"crossref","first-page":"1264","DOI":"10.1016\/j.midw.2012.11.010","article-title":"Impact on perceived postnatal support, maternal anxiety and symptoms of depression in new mothers in Nepal when their husbands provide continuous support during labour","volume":"29","author":"S Sapkota","year":"2013","journal-title":"Midwifery"},{"issue":"11","key":"pgph.0004030.ref059","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1001\/jama.288.11.1373","article-title":"Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial","volume":"288","author":"ED Hodnett","year":"2002","journal-title":"JAMA"},{"issue":"3","key":"pgph.0004030.ref060","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1891\/1058-1243.24.3.145","article-title":"Executive Summary of Hormonal Physiology of Childbearing: Evidence 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