Between help and hindrance: a qualitative study on inclusion of birth companions in closed, invited and contested spaces within maternity care settings in Malawi.

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.