Client and provider factors associated with companionship during labor and birth in Kigoma Region, Tanzania

•Companionship in labor was more common than at the time of birth.•Key aspects of provider's work environment influenced companionship.•Work hours, number of deliveries, and job satisfaction increased companionship.•On-site supervision decreased companionship.•Client perception of labor complications increased companionship at birth. Labor and birth companionship is a key aspect of respectful maternity care. Lack of companionship deters women from accessing facility-based delivery care, though formal and informal policies against companionship are common in sub-Saharan African countries. To identify client and provider factors associated with labor and birth companionship Cross-sectional evaluation among delivery clients and providers in 61 health facilities in Kigoma Region, Tanzania, April–July 2016. Multilevel, mixed effects logistic regression analyses were conducted on linked data from providers (n = 249) and delivery clients (n = 935). Outcome variables were Companion in labor and Companion at the time of birth. Less than half of women reported having a labor companion (44.7%) and 12% reported having a birth companion. Among providers, 26.1% and 10.0% reported allowing a labor and birth companion, respectively. Clients had significantly greater odds of having a labor companion if their provider reported the following traits: working more than 55 hours/week (aOR 2.46, 95% CI 1.23–4.97), feeling very satisfied with their job (aOR 3.66, 95% CI 1.36–9.85), and allowing women to have a labor companion (aOR 3.73, 95% CI 1.58–8.81). Clients had significantly lower odds of having a labor companion if their provider reported having an on-site supervisor (aOR 0.48, 95% CI 0.24–0.95). Clients had significantly greater odds of having a birth companion if they self-reported labor complications (aOR 2.82, 95% CI 1.02–7.81) and had a labor companion (aOR 44.74, 95% CI 11.99–166.91). Clients had significantly greater odds of having a birth companion if their provider attended more than 10 deliveries in the last month (aOR 3.43, 95% CI 1.08–10.96) compared to fewer deliveries. These results suggest that health providers are the gatekeepers of companionship, and the work environment influences providers’ allowance of companionship. Facilities where providers experience staff shortages and high workload may be particularly responsive to programmatic interventions that aim to increase staff acceptance of birth companionship.