THE EXPERIENCE OF WOMEN AND THEIR COACHES WITH CHILDBIRTH IN A PUBLIC MATERNITY HOSPITAL¹

Abstracts

Qualitative study using oral history to identify the experiences of women and their coaches during the childbirth process in a public maternity hospital from Paraná State, Brazil between October/2012 and May/2013 including 11 women and 11 coaches. Data were collected using semi-structured interviews, which were recorded, transcribed, retextualized and thematically analyzed. The topic "experiences during accompanied childbirth" shows that women chose their husbands so they would feel safe, supported and reassured. The topic "work of professionals from the perspective of women and their coaches" shows that the professionals respected the women's choices, their preparation and pain-relief procedures. The topic "contradictions experienced during labor" indicates that the participants experienced restricted access to their coaches, in addition to organizational and behavioral aspects. The conclusion is that the participation of coaches in the current childbirth care model has advanced, however, some barriers still exist hindering the full implementation of humanized childbirth care.

Humanization of assistance; Parturition; Women's health

Estudo qualitativo na história oral temática com objetivo de conhecer a experiência de mulheres e de seus acompanhantes no processo de parto, realizado em uma maternidade pública do Paraná entre outubro/2012 e maio/2013, com 11 mulheres e 11 acompanhantes. Os dados foram coletados por meio de entrevistas semiestruturadas, gravadas, transcritas, retextualizadas e analisadas tematicamente. No tema "experiências no processo de parto acompanhado", destacou-se que os maridos foram escolhidos pelas mulheres por motivos de segurança, apoio e tranquilidade. No tema "a atuação dos profissionais na visão das mulheres e dos acompanhantes", aparecem o respeito às escolhas da mulher, o preparo e as medidas para alívio da dor. No tema "as contradições na vivência do parto", surgem a restrição ao acesso do acompanhante e aspectos organizacionais e comportamentais. Conclui-se que a participação do acompanhante no modelo de assistência ao parto vigente apresenta avanços, contudo, encontra barreiras para que se realize plenamente no modelo do parto humanizado.

Humanização da assistência; Parto; Saúde da mulher

Estudio cualitativo basado en historia oral con objetivo del conocer la experiencia de mujeres y sus acompañantes en la labor de parto, en una maternidad pública de Paraná entre octubre/2012 y mayo/2013, con 11 mujeres y 11 acompañantes. Los datos fueron colectados en entrevistas semiestructuradas, grabadas, transcritas y retextualizadas y analizadas temáticamente. El tema "experiencias en el trabajo de parto acompañado" se destacó la elección a sus esposos por aportar seguridad, apoyo y tranquilidad. La "actuación de los profesionales desde la perspectiva de las mujeres y de sus acompañantes", aparece la libre decisión de la mujer, el preparo y medidas de alivio del dolor. En "las contradicciones en la vivencia del parto" surge la restricción del acompañante al acceso, aspectos organizacionales y comportamentales. Concluyese que la participación del acompañante según el modelo de asistencia actual presenta avanzos, sin embargo se encuentran barreras para que realizar completamente el modelo del parto humanizado.

Humanización de la atención; Parto; Salud de la mujer

INTRODUCTION

The presence of a coach during labor, delivery and immediately post-delivery is mandatory in services provided by the Brazilian Health Service (SUS), either within its public network or through private providers linked to the system, while the patient is entitled to select a coach of her choice.

This obligation is set out in Federal law n. 11,108/2005 (the so-called Coach Law), which has promoted significant changes in the Organic Health Law (Law n. 8,080/1990) that establishes conditions for the promotion, protection and recovery of health, as well as the organization and functioning of services provided by SUS.¹

The benefits of having a coach during labor and childbirth have been widely reported in Brazilian and international studies. The importance for a woman having a coach during labor and childbirth is highlighted in a study conducted in the maternity department of a hospital in the state of São Paulo, Brazil, which reports that women who received the support of a coach of their choice were more satisfied overall with the experience of labor and delivery when compared to a group of women who did not have the support of a close companion at the time.²

The fathers also reported the benefits of supporting women during the birth of their children, reinforcing that they were able to comfort and reassure them. Unique feelings and emotions were also reported, which is believed to strengthen bonds between fathers and children.³

In a study conducted in the maternity department of a hospital in the interior of Bahia, Brazil in 2008, women reported that their coaches provided encouragement and made them feel safe. The same study showed that women reported a fear of being alone at the time of the birth of their children and women reported that the presence of a coach was beneficial by making the delivery less stressful.⁴

Isolating women in labor rooms and distancing them from their family members has been reported by women as a situation that triggers fear, which together with anxiety from being in a strange environment and negative attitudes on the part of some health providers, can change the physiology involved in labor due to the possibility of increasing substances that inhibit the synthesis of oxytocin and endogenous endorphins, essential for cervical effacement and dilatation.⁴ International studies show that childbirths in which women received continuous support during labor required less medication to relieve pain and fewer C-sections and episiotomies, while the infants obtained higher Apgar scores.⁵

The coach is someone chosen by the women - be they the spouse, partner, relative or someone close - and does not require any prior technical preparation because the individual is only a person with whom the mother will share her fears, a person who will minimize her anxiety and reassure her when facing the difficulties inherent to labor and childbirth.⁶

Nevertheless, some of the coaches' actions can actually benefit women during labor. Hence, there are training programs to prepare the couple both physically and psychologically for the labor, enabling the development of skills that facilitate gestation and birth, helping the mother overcome discomfort and difficulties and become more confident.⁷

Despite the benefits listed in the literature and the legal obligation to provide them, coaches are not fully accepted in Brazilian public maternity hospitals. The reasons for denying this right include lack of adequate environment and sensitization on the part of healthcare providers.² Some facilities in the state of Paraná, Brazil allow coaches, but with restrictions.

Based on these considerations, the University Extension Project "Preparedness for accompanied childbirth" was created as a strategy to establish partnerships with health providers within the facility in which the study was conducted so that the presence of a coach is allowed, together with training and the involvement of students.

The project includes workshops that address topics related to the humanization of labor, non-pharmacological methods to relieve pain during labor, the Coach Law, the role of coaches, and myths and taboos concerning normal delivery.

This study's aim was to better understand the experiences of mothers and their coaches and identify institutional limitations and potential elements regarding the topic. Maternal health is recognized as one of the main problems in the world and may be improved with the inclusion of a coach during labor and childbirth. This assertion is in agreement with one of the eight Millennium Objectives (improve maternal health) established by the United Nations to be achieved by all countries by 2015.

According to what was previously discussed, this study raised the following questions: 1) How are coaches included in the labor and childbirth?; 2) What are the experiences of women and their coaches with labor? The study's aim was to learn about the experience of women and their coaches in labor and childbirth.

METHOD

Qualitative study using thematic oral histories, a method based on the social experiences of people and groups that seek to capture current issues. This method was chosen because we sought to address the experiences of women and their coaches during labor.⁸

The study was conducted in the maternity department of a university public hospital linked to the nursing and medical programs at the Universidade Federal do Paraná (UFPR), in the city of Curitiba, PR, Brazil.

In oral history, the study's community is established, which in this case was composed of a group of pregnant women and their coaches who participated in the workshops promoted by the university extension project "Preparation for accompanied childbirth," conducted within the maternity department. The sample (colônia) was composed of pregnant women and their coaches invited during the workshops to participate in the study. At the event, they received clarification concerning the study's objectives and those interested in taking part in the study left their contact information. The collaborators were 11 women and their respective coaches (11), who were willing, after childbirth, to remain in the study to its end.

Inclusion criteria were: pregnant women and coaches who attended the workshops promoted by the extension project "Preparation for accompanied childbirth"; women who had the presence of a coach during labor and childbirth; and vaginal deliveries. Exclusion criteria were: couples whose babies were stillbirths or with Apgar scores below seven.

The collaborators were clarified about the possibility of dropping out from the study at any point and signed two copies of Free and Informed Consent Forms. The study complied with guidelines concerning ethical aspects established in Resolution 196/96. The study was submitted to and approved by the Institutional Review Board at the College of Nursing at Universidade de São Paulo, protocol n. 595.516-0.

Data were collected through open interviews with the guiding question "Tell me about your experience of having accompanied labor and childbirth;" other related questions were asked according to the need for them based on the responses to the guiding question. Interviews were held between October 2012 and March 2013. An interview in oral history comprises three stages. The first two stages included preparation of the interview and its application, while analysis was conducted in the third stage.⁸ When preparing the interview, the researcher visited the obstetrical center weekly to locate those who had previously showed interest in participating in the study, based on the likely date of delivery. This search was conducted in the Newborns Records book with the mothers' full names. Information such as when the infant was born, type of childbirth and Apgar score was collected. After confirming whether the women met the inclusion criteria, they were contacted by phone in order to schedule the date and place of interview. One-time interviews were conducted up to 40 days after birth at the participants' homes. The interviews lasted 15 minutes on average with each participant, mother and coach; the entire meeting took approximately one hour.

The third stage was dedicated to data analysis and included verbatim transcriptions (including questions and interruptions captured during recording), textualization and re-textualization. The transcription of interviews is the first treatment given to the reports; textualization is the phase in which the questions and comments on the part of the interviewer are eliminated; and re-textualization is the stage in which the text is recreated and presented to the collaborators through e-mail. The participants could either approve or reject any excerpts that did not accurately convey what they meant. Afterwards, a final version was presented in a second visit, the occasion in which they signed a Permission Letter.⁸

The re-textualized texts were interpreted after exhaustive readings and organized in topics that are related to the humanization of labor and childbirth. The letter "W" was used to present the excerpts concerning the women's reports and "C" for those of their coaches, followed by a number representing the sequence in which the interviews were held (e.g., W1, W2 for women and C1, C2 for the coaches).

In the presentation of results, we briefly characterize the participants and then present the topics that emerged from their reports. The reports were organized into three themes, namely: Experiences with the accompanied childbirth process; The work of health providers from the perspective of women and coaches; and Contradictions experienced during labor.

RESULTS

Characterization of the participants

The women were 17 to 41 years old; four were married and seven were single but lived in a consensus union; one mother was a homemaker; two were students and the remaining had varied occupations. Most (seven) were experiencing their first pregnancy; two were in their second pregnancy (one had a prior miscarriage); one was in her third pregnancy, and one was in her fourth pregnancy (two prior miscarriages and a C-section).

Most of the coaches (nine) were husbands or partners. One participant chose her sister and another chose her mother to be a coach. The coaches were aged from 21 to 44 years old. Most coaches were salespersons and one was unemployed at the time of the interview. All the coaches were participating in labor/childbirth for the first time.

Experiences with the accompanied childbirth process

Here we present the process through which women chose their coaches and why they chose these individuals,, the role played by the coaches during labor, and how they assess their experiences during the accompanied childbirth.

The coaches women chose and why

Most women chose their husbands/partners to be their coaches. In the two exceptions in which the women chose a mother or sister, they explained their husbands did not participate in the process because of the impossibility of being absent from work and their difficulty dealing with blood and pain, so that the couple concluded the husband would not have the emotional situation to help her at the time. The reason women wished to have a coach during labor and childbirth was the need to feel safe, have support and for reassurance.

[...] having someone to accompany you is reassuring, especially when it's the child's father. Someone you want close by when the baby comes. Being able to count on that person you have a relationship with is more reassuring, it's different when you have someone you are close to for this occasion [...] (W5).

The role of the coach during labor

In regard to the role played by coaches during labor, they mentioned: being reassuring, being present, encouraging, giving aid, entertaining, and supporting. Curiously, the way one coach found to reassure the woman was to speed up the clock so she would think it was near to the time expected for the birth according to the doctor's estimates. The coaches deemed it important to reassure the woman and talk to her during the process to encourage them to push when necessary. They said that, at this point, the women can become disoriented and need support.

In general, the women did not want their coaches to leave them, even for a few moments. The affection, support and help, and the massages their coaches gave them were perceived by the women during the experience as actions that facilitated the process, and stood out as such. Emotional support helped them to have the strength to continue.

[...] I'd say I was going to fetch a glass of water and she'd say no, asking me to stay and I had to ask somebody else for the water[...] (C3).

[...] He'd reassure me saying that the baby would come soon[...] (W5).

[...] He helped me with massage, exercise, with everything[...] (W3).

Assessment of their experience with the accompanied childbirth

In regard to how the women and coaches qualified their experiences, both sets of participants said that being alone would not help in the process, highlighting the importance of having their partners and the fathers of their children in their first experience; they also highlighted trust, safety, strengthening of family and relationship bonds, the fact they felt valued, and all the good feelings experienced at the time of birth.

[...] being present during labor strengthened our relationship because it is a very unique experience. I guess that this is one of the highest levels of intimacy you can share with someone, because it's like trusting someone very deeply [...] (C7).

The participants considered that if the women stayed by themselves they would face more difficulty during the process, would have less confidence in themselves to face the challenge and greater difficulty bearing the pain of contractions. The participants wanted to help in any way and even felt powerless at times. In the end, they realized that simply being there was a way of providing help:

[...] if I was by myself, I wouldn't be as strong as I was to keep going [...] (W3).

[...] I felt I was taking part in it, even if only a little bit, despite the feeling of not being able to do anything. It was really good being there, together, trying, just being there. I think it helped a lot [...] (C4).

The women and coaches mentioned the establishment of bonds with the child and strengthening of family ties as a positive experience. They said that the presence of the father conveys more affection to the baby. The parents highlighted that they were curious about what happens in a normal delivery and reported the experience was very interesting.

[...] I think it was important to have the father together with us. It seems that when the child is born, there's even more love[...] (W10).

[...] this fact ended up bringing us even closer together; and it helps the man, who does not directly experience a pregnancy, to gain more knowledge about the child that is coming [...] (W2).

The presence of husbands/partners during labor made the women feel valued and strengthened the couples' relationships because these men showed interest and showed solidarity with them in a time of fragility.

Finally, women and coaches reported feelings such as gratitude, relief, and an "inexplicable feeling".

Work of the professionals from the perspective of women andcoaches

This topic presents a positive assessment of care delivery and participation in workshops and guidance received in the labor process.

Positive assessment of care delivery

This topic reports the work of the staff involved in labor and childbirth, including physicians, nurses, support personnel, residents, and those responsible for admitting the women. Aspects such as attention, mood, establishment of bonds, availability, support of breastfeeding, and childcare were reported.

The women and coaches reported that the professionals in general were attentive, were in a good mood during the process and also in the rooming in, were willing and helped whenever needed. There were cases in which the bond established with the professionals went beyond hospital care and was extended to social networks on the Internet (particularly Facebook) and even visits at home.

The women considered the support received from the professionals to initiate breastfeeding and childcare to be important. They mentioned that if they had not received such guidance, they would have had difficulties and possibly would have even given up breastfeeding.

[...] The support provided by the health workers regarding breastfeeding was very important because the baby would not latch on. I found the fact that the nurses were those who taught childcare and how to breastfeed to be interesting [...] (W2).

Participation in the workshop and guidance

This item refers to the importance of the workshops promoted by the project, teaching provided, measures taken to relieve pain during labor and alternative positions. It also presents the women's search for the SUS to have a humanized birth.

Participation in the workshop "Preparation for accompanied childbirth" was important for the couple to identify when it was time to go to the hospital. The coaches felt much better prepared to help during labor and delivery.

[...] participation in the workshops provided us with much more knowledge about what we should do [...] (W4).

Most of the practices provided during the training program were allowed and encouraged by the professionals responsible for providing care during labor. The participants were instructed to use massage and other methods to relieve pain, such as walking, exercising using the obstetric ball, and using the shower and bathtub to reduce pain caused by contractions. Changing positions during labor was another aspect addressed, as well as the use of alternative positions for labor such as squatting, on all fours and in the bathtub.

Some of the women who had a private health plan opted for the public service in order to have their delivery following the principles of humanization.

[...] we decided to receive public care and have a humanized-care birth [...] (W3).

The contradictions experienced during labor

This topic addresses barriers to the access of coaches, interventions implemented by professionals, difficulties regarding the service organization, and some negative feelings that hindered the process.

Access to coaches

Restricted access in the initial consultation, which includes assessing the stage of labor and admitting the woman, was one of the barriers experienced by the coaches.

Another difficulty was restricting the presence of coaches at some points in time within the obstetrical center under the justification that pre-childbirth areas are collective and coaches would restrict the privacy of these women. Hence, sometimes, the coaches were asked to remain in the attached corridor, while the women underwent obstetric assessments and vaginal examinations.

[...] there was a time when I needed some exams and he stayed outside the obstetrical center, but after that we stayed together all the time... he would stay outside in the corridor only when I needed to undergo vaginal examination [...] (W3).

The presence of a male coach was not allowed in the rooming in section during the night; only female coaches were allowed to stay.

Interventions performed by professionals

The reports included some interventions performed by the professionals during labor/childbirth. We believe the participants were able to understand these interventions because they had participated in the workshops "Preparation for accompanied labor". Among these interventions they mentioned sere when the woman's water broke, the administration of saline solution, and episiotomy without proper clarification or the patient's prior consent, and inadequate vaginal exams. Additionally, most of the time, the women walked to the delivery room while in the expulsive stage and the births were performed on the gynecological table.

[...] So, we went to the room walking when the back pain relieved a little... I had the baby in the delivery room, on the gynecological table [...] (W7).

Failures in service organization

The study's participants reported there was equipment that required maintenance and communication problems with the staff as well as inappropriate signalization of some areas, especially the place where personal belongings are kept.

Feelings

The coaches also reported some emotional reactions that hindered them from experiencing labor in a fully positive manner. These reactions included a feeling of not being able to help, pain, fear and nervousness. These feelings occurred due to the stress of the moment. Strong pain accruing from the contractions led the coaches to consider giving up. Fear and nervousness were attributed to an unknown situation they faced and some health problem, such as varicose veins in the vaginal area.

[...] It was difficult for me because I felt powerlessness from the beginning to the end, seeing her suffering - and it seemed to be a horrible pain - and not being able to do anything other than try to reassure her and tell her to do the procedures to speed up[...] (C7).

DISCUSSION

In this study, nine women choose their husbands/partners as coaches, while one chose her mother and another chose her sister. Choosing a coach is a personal decision that involves cultural and social aspects. This person can be a friend, mother, sister, sister-in-law, mother-in-law or, most usually, the partner or husband, but normally it is a family member.^4,9

It is believed that the child's father is the ideal coach because his participation can contribute to establishing and strengthening family bonds.¹⁰ The woman is an active protagonist of the delivery process and she has the prerogative to chose whether she wants a coach and who this coach will be.¹¹

The reasons reported in this study for choosing a coach include: feeling safe, having support, and being reassured, which is in agreement with the reasons reported in the literature.¹²

The actions performed by the coaches that stood out in this study were: reassurance, being present, and encouragement, in addition to physical and emotional support. The role of a coach may only consist of being physically present or supporting the labor process.

In regard to physical contact, holding hands, massaging and helping the mother when changing positions were considered very supportive.^12-13 In the emotional aspect, women emphasized care actions provided by the coachs.¹⁴

The women and their coaches assessed the experience of going through labor together. When they needed to stay by themselves they experienced fear, abandonment and loneliness.^10-12 Having a coach was reassuring and comforting when experiencing labor. The women felt valued, which strengthened family bonds and each couple's relationship. These findings corroborate the results of other studies that also mentioned that women feel valued and family ties are strengthened.^9,14 Birth was reported by the participants as being a unique, magical and inexplicable moment, surrounded by great emotion from seeing the child being born and being able to provide support.

The support of professionals was an important factor at this time of fragility experienced by both women and coaches. The work of healthcare providers goes beyond theoretical knowledge and technical procedures. The performance of the obstetric nurse helps to encourage normal delivery and to integrate the coach and family, enabling the woman to play her role, respecting her human and reproductive rights.

Having participated in the project workshop "Preparation for accompanied labor" was also a facilitating element in experiencing the labor process. Prenatal training encourages modification of attitudes and promote greater self-confidence and ability to question professional routines.⁵

Contradictions and barriers the participants experienced included: difficult access for coaches and poor care provided by some of the workers, whose performance within the humanized care model was inadequate.

Despite the Coach Law, some healthcare workers and the institutional rules themselves establish restrictions to accompanied labor. These restrictions were verified on various occasions, a consequence of preconceptions against the possibility of having an active coach during labor, which can be considered a type of institutional violation.^11,15 A pregnant woman and her coach often are at the mercy of the facility's internal criteria, such as when the staff is changing shifts and when the women need to be examined by the obstetrician/resident.^11,16

Physical area and hospital routine are often the explanations provided for why the women must stay isolated in the pre-childbirth room and childbirth room, echoing what happened in the United States years ago when aseptic rules were used to ban family members from pre-childbirth rooms.^4,17 A relationship of power is verified in regard to the communication established between the health staff and the women in labor, in which women set aside their own desires and opinions, abiding by the decisions of health workers on issues regarding their health and that of their babies, without even receiving clarification as to what is actually happening.¹⁶

Labor and childbirth are still seen by many professionals and institutions in the current model of labor and childbirth care as a pathological and invasive process. Hence, the woman is not acknowledged as the main actor in the childbirth scenario. Routine vaginal examination performed without clarification or without asking permission is a misappropriation of the female body.¹⁶ Such harsh treatment would be a way to coerce the patient to collaborate, showing professional authority.¹⁵ As a consequence of this professional behavior, some women and their coaches tend to remain silent, passively accepting the procedures in order not to disrupt the situation.¹⁴

A fact verified in the reports of some participants was that their delivery was performed on a gynecological table, a procedure that should be eliminated from the routine of maternity wards.⁶ From the perspective of humanized childbirth, women should be respected in regard to the type of childbirth and position to be adopted.¹⁸

Changing to an orthostatic position or even on all fours can favor decompression of the fetal head against the sacroiliac joint, relieving pain and helping the development of labor.⁵ Healthcare providers should not restrict but rather encourage women to seek comfortable positions; they should trust the woman's judgment, preserving the woman's autonomy to chose the best position for herself.^5,18

The women should be free to choose the best position and how to move around during labor, adopting upright postures such as standing, sitting, or walking. Walking favors the descent of the fetus, reducing labor time and lower back pain, enabling her to find a comfortable position and shortening labor.^5,18

The facility in which the study was conducted provides care through the SUS, which has gained recognition for providing humanized care, facilitating normal delivery and allowing the presence of coaches. The participants' reports show that women are choosing this maternity facility because of its institutional philosophy: humanized labor and childbirth.

The husbands reported the need to be mentally prepared to participate in the process.¹³ Coaches subject themselves to hearing cries of pain and help requests and reported feeling helpless for not being able to share the pain with the women.⁹ Women and coaches can have more autonomy in their decisions if they acquire tools and knowledge to properly respond to the care delivered.

The health service should have conditions to welcome women in the labor and childbirth process and also properly meet their demands, reconciling their choices, desires and needs.¹¹ Most actions are still centered on the physician and an excessive use of technology and interventions.^2,4

FINAL CONSIDERATIONS

The methodological approach chosen for this study enabled better understanding the meaning of the experience of women and their coaches in the process of accompanied childbirth. The objective was achieved because the reports of the study participants contributed to important conclusions regarding the labor and childbirth process, its aspect of humanization and the presence of a coach - which is one of the most important factors of humanization.

The study limitations include a reduced number of participants due to C-sections performed among women who had consented to participate in the study. Additionally, two couples quit the study but did not reveal their reasons for doing so.

The experiences and manifestations regarding the process of accompanied childbirth are in agreement with those reported by other studies from various parts of the world. Hence, the conclusion is that, despite cultural differences, feelings concerning labor and childbirth are similar. Additionally, the participants reported that the interaction with professionals responsible for providing care to the women and their coaches was positive in general, stating their needs and desires were respected during the process.

Despite overall satisfaction, some difficulties occurred in the process, which shows a need to improve the service as a whole. Among the difficulties experienced were some gaps in regard to what is recommended by the WHO and the Ministry of Health.

In regard to the organizational aspects, there were reports concerning inefficient communication and poor information provided to the women and their coaches, in addition to malfunctioning equipment. The behavioral aspect of some professionals involved in the process is explained by the fact that the model is in a process of transition and still retains a technocratic and biomedical bias, centered on the physician with interventions that are often unnecessary.

There is a need to overcome this model, which will require public investment in the qualification of professionals, especially obstetric nurses and obstetricians, and experimentation in and monitoring of other modalities in which coaches are included in the process, ensuring the principles of humanization are satisfied, good practices occur, and the propagation of safe labor and childbirth.

This study provides scientific evidence of the importance of having a coach during labor and childbirth. In Brazil, there is considerable gap between recommended practices, widely disseminated in academic and scientific spheres, and what actually takes place in maternity departments. Nonetheless, a positive factor is that pregnant women are seeking this facility, and the entire network linked to the SUS, because they want to experience humanized labor. The existence of this search is a good indication that women are, even if slowly, regaining an awareness concerning the importance of normal humanized and accompanied childbirth.

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• ¹
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• ¹³
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  » www.elsevier.com/midw
• ¹⁴
  Frutuoso LD, Brüggemann OM. Conhecimento sobre a lei 11.108/2005 e a experiência dos acompanhantes junto à mulher no centro obstétrico. Texto Contexto Enferm [online]. 2013 [cited 2014 Ago 10]; 22(4):909-17. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-07072013000400006&script=sci_abstract&tlng=pt
  » http://www.scielo.br/scielo.php?pid=S0104-07072013000400006&script=sci_abstract&tlng=pt
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  Aguiar JM, D'Oliveira AFPL, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saúde Publica [online]. 2013 [cited 2014 Ago 10]; 9(11). Disponível em: http://dx.doi.org/10.1590/0102-311X00074912.
  » http://dx.doi.org/10.1590/0102-311X00074912
• ¹⁶
  Dornfeld D, Pedro ENR. Communication as a safety and protection factor in childbirth. Rev Eletr Enf [online]. 2011 [cited 2014 Jun 09]; 13(2). Available from: http://www.fen.ufg.br/revista/v13/n2/v13n2a05.htm.
  » http://www.fen.ufg.br/revista/v13/n2/v13n2a05.htm
• ¹⁷
  Leavitt JW. Make room for daddy: the journey from waiting room to birthing room. The University of North Carolina Press; 2009.
• ¹⁸
  Wei CY, Gualda DMR, Santos-Junior HPO. Movimentação e dieta durante o trabalho de parto: a percepção de um grupo de puerpéras. Texto Contexto Enferm. 2011; 20(4):717-25.

• 1
  Article originating in dissertation - Childbirth experiences of women and their companions at a public maternity hospital, presents Programa Interunidades de Doutoramento, Escola de Enfermagem de Ribeirão Preto (EERP), Universidade de São Paulo (USP), in 2014.

Publication Dates

• Publication in this collection
  2016

History

• Received
  04 Dec 2014
• Accepted
  17 Aug 2015