Support actions undertaken for the woman by companions in public maternity hospitals

ABSTRACT Objective: to identify the support actions undertaken for the woman during labor, birth, cesarean section and the postpartum period. Method: a transversal study, undertaken in three public maternity hospitals, with a sample of 1,147 companions. The data were collected through interviews and were analyzed using descriptive statistics. The support actions were classified in four dimensions: emotional, physical, informational and relating to intermediation. Results: the majority of interviewees were the partner/father of the baby (76.7%). In labor, birth and the postpartum period, the actions of emotional support - such as calming, encouraging and praising, were performed by more than 80.0% of the companions; informational support, by approximately 70.0%; and intermediation by fewer than 65.0% of them. In childbirth, the emphasis on physical support was observed in assisting with walking (84.4%), and in changing position (90.4%). Conclusion: the companions participate actively in the birth process, performing actions of support in the four dimensions. Emotional support is the most frequent, followed by physical and informational support, mainly during labor and birth. The results contribute to valuing the companion from the woman’s social network in the birth scenario and to the recognition of his/her role as a provider of support.


Introduction
In Brazil, the transition of the birth scenario from the home to the hospital took place at the beginning of the 20th century. This process was a determinant for consolidating the technocratic view of birth, with the physician as the central figure -besides the broad use of procedures and interventions whose efficiency was not always proven, and not even always beneficial (1)(2) .
In this scenario, the presence of the family and of people from the parturient woman's social network became unwanted, as it interfered negatively with the hospitals' policies and routines. As a result, the family's withdrawal, and the elimination of the emotional support for the woman during labor and birth, was inevitable (2) .
In the 1980s, women's discontentment with the medicalization of birth, apart from other grievances, was one of the axes of debates for female protagonism.
The women's movement in Brazil, also conducted by the feminist current, achieved visibility and obtained many victories in the health area. Indeed, after the creation of the National Program for Integrated Healthcare for Women (Programa de Assistência Integral à Saúde da Mulher), an ideological strengthening for the humanization of labor and childbirth could be observed (3)(4) . Agreeing with this movement, the recommendation of the World Health Organization (WHO) emphasizes the companion's presence as one of the good practices in obstetrics, that is, a practice which minimizes the undertaking of interventions which are not proven to be beneficial (5) .
In Brazil, in 2005, upon the approval of Federal Law N. 11,108, women gained the legal right to have a companion of their choice during labor, birth and the immediate postpartum period (6) . This legal support aims to protect women's rights, facilitating the companion's remaining present during obstetric inpatient treatment.
However, studies have identified that ignorance and failure to comply with this Law continue to be considerable (6)(7) .
The Born in Brazil Survey (Pesquisa Nascer no Brasil), which interviewed 23,940 puerpural women, analyzed relevant aspects regarding the implementation of the right to a companion in the maternity hospitals. The total absence of the companion during obstetric inpatient treatment was cited by 24.5% of women; 18.8% had a companion continuously, and 56.7% had a companion present only at certain points of the inpatient treatment.
The factors associated with the implementation of the right to a companion in the maternity hospital studied were: an appropriate environment and clear institutional rules regarding women's rights (8) .
The continuous support provided by the companion is considered to be beneficial for the woman and the newborn, as it contributes to a reduction in the number of cesarean sections, in the duration of labor and in the number of interventions during labor and birthand increases the women's level of satisfaction with the experience (9) . Such evidence, together with other studies, also indicates the importance of embracing the man in the birth scenario, contributing to the support for the woman, the transition to fatherhood and the formation of an early bond with the newborn (10)(11) .
The support actions undertaken by the birth companion may be classified in four dimensions: emotional, when the provider of support makes himself present continuously, and encourages, calms and praises the woman; physical, when he assists in the birthing pool, and changing position, in reducing pain and in massaging; informational, when he explains things to and informs the pregnant woman about what is happening; and, finally, intermediation -when he interprets and negotiates the woman's wishes with the health professionals (9) . The actions of emotional and physical support are carried out most and, consequently, are remembered by the women and their birth companions (6,10,(12)(13) .
Most studies focus on the woman's view of the benefits provided by the companion (12, [14][15][16] , mainly based on studies with qualitative approaches. However, few works have provided companions with the opportunity to report which support actions they felt comfortable undertaking, or for which they received guidance on how to provide the support actions to the woman (6,13) . In the international scenario, most studies have not described the dimensions of the support actions undertaken by the companion, whether the companion was a family member, a doula, a midwife or nurse (9) . The present study, therefore, contributes to the construction of knowledge regarding this topic at a national and international level.
In the Brazilian scenario, the maternity hospitals which comply with the Law allow the presence of the companion -this generally being a member of the woman's family or social network (8) . In many cases, however, there is an understanding that the companion is a mere spectator.
The support actions undertaken by the companion must be known in order to identify and value their real participation during the time they spend in the maternity hospital.
Besides this, in strengthening the companion as a provider of support for the woman, a fresh look could be directed on this practice so that the health professionals may allow the companion to exercise their role.
In this way, this work's objective was to identify the support actions undertaken by the companion during labor, birth, cesarean section and the postpartum period in public maternity hospitals in Grande Florianópolis, Santa Catarina, Brazil.  Each interviewer stored the files on a memory stick and updated the data migration system online so that the information would be sent to the central database.

Method
To ensure the quality of the information obtained, and minimize random or systematic errors during data collection, certain procedures were adopted: the use of a checklist with inclusion and exclusion criteria for selecting research subjects; monitoring of data collection throughout the fieldwork until the sample for each institution had been completed; and daily online assessment of the quality of the recording of the data.
In addition to this, at the end of data collection, some questions from the questionnaire were repeated via telephone contact in a sample of 5% of the companions interviewed in each maternity hospital.
The variables analyzed in the present study are: sex

Results
Of the 1147 interviewees, the majority were male (77.0%), were of adult age (93.9%), stated that they were Caucasian (53.8%), and were undertaking paid work (86.2%). Regarding educational level, the most frequent was Senior High School complete (36.8%).
Regarding the link with the woman being accompanied, the majority were the partner/father of the baby (76.7%). In Maternity Hospital A, one finds the highest frequency of adolescents (6.4%), as well as companions whose skin color was self-reported as mixed-race (45.9%). In Maternity Hospital C, the prevalence of the partner/father of the baby as the companion was higher (82.7%), and the companions had higher educational levels ( Table 1).
The percentage of companions with previous participation in the prenatal care, in the obstetric triage, in the labor and in the postpartum period was below 30.0%, and in the birth, was only 19.3%.
However, current participation in the prenatal care (61.3%) and in the triage (89.9%) rose considerably.
Only 8.6% reported having participated in a course or seminar during the pregnancy, and 23.6% were aware of the Companion's Law. In Maternity Hospital C, the proportion of interviewees with previous experience as a companion was greater ( Table 2).
During labor, actions of emotional support were more frequent -such as remaining by the woman's side and calming her, followed by actions of physical support: helping in changing position and walking. In Maternity Hospital C, some actions of physical support had a higher frequency ( Table 3).  (Table 4).
In the postpartum period, the emotional dimension was also that which received the greatest emphasis,

Discussion
The results show that, although the majority of companions had no previous experience of supporting the woman during labor, birth, cesarean section and the postpartum period, and had practically no preparation during the prenatal care, they took on the role of provider of support in the four dimensions analyzed (emotional, physical, informational and related to intermediation).
The participation of the partner/father of the baby in the role of companion was similar to that found in other studies with quantitative (8,(14)(15) and qualitative (6,10,16) approaches. The presence of the father in this scenario symbolizes -even if only partially -the family's becoming closer after the birth. International studies have revealed that in other countries, the presence of the father during the birth is accepted (17) , regardless of whether this is related or not to the provision of support, it frequently being the case that the doula or midwife takes on this task (18)(19) .
Another relevant aspect is knowledge of the Companion's Law, as this information can contribute to the woman and her companion demanding their rights from the very first moment of obstetric inpatient treatment. Although this document (6) was published in 2005, its limited publicizing has stopped it from being used as an instrument for ensuring the presence of the companion (6)(7) .
The fact that few companions participated in courses and/or seminars during the pregnancy, as well as not having previous experience, may have influenced their ignorance of their rights. However, these aspects did not impede or restrict the companion from performing his or her role as provider of support to the woman, especially in relation to the emotional dimension. Providing emotional support was also mentioned in other studies as activities which calm, encourage, transmit security and mitigate the woman's pain (6,10,17,(20)(21)(22) .
In relation to the actions of physical support in the labor, the activities of assistance in changing position, in walking and in using the birthing pool were mentioned by the majority of companions -that is, a large proportion of the interviewees helped in the woman's free movement. This practice must be encouraged during labor, as it allows the woman to adopt the position that she finds the most comfortable, should there be no clinical contraindication (23) .
The actions of support undertaken by the companion are considered to be nonpharmacological methods of relieving pain and anxiety -and can, therefore, reduce the duration of labor (23)(24)(25) . As a result, it may be inferred that the companion is contributing to implementing good practices in childbirth care, as he or she encourages and helps the parturient woman to undertake the recommended activities.
During the cesarean section, the reduction in the frequency of actions of support undertaken was notable -principally those related to information and intermediation. This finding may result from the fear and apprehension resulting from the need for the surgical procedure (22) -or from the restriction on actions that the environment itself imposes upon the layperson. As a result, the companion takes on a more passive role, due to the lack of preparation and advice, in addition to the insecurity he or she feels in relation to providing support. In some maternity hospitals, the companion  is prevented from participating in the birth during the surgical procedure due to being prohibited from doing so by the health professionals (22) . The members of the health team reinforce that this is no place for the companion, justifying the statement by indicating that he is not familiar with the medical routines and does not know how to behave (26) .

Actions of Support
The frequent participation of the companions in the postpartum period is similar to that found in another study undertaken in Santa Catarina, Brazil (27) ; however, this is not the reality found in other Brazilian maternity hospitals (8) . As a result, these women are deprived of the support of a person from their social network, who could assist in care with the baby and in movement. Few works have focused on this period: actions of emotional support, such as caressing, staying by the woman's side and calming her are mentioned most (6,13) . In the dimension of physical support, the puerperal women and the companions mainly report the importance of assisting in care with the baby and in breast-feeding (6,13,15) .
It is emphasized that, through participating actively in the breast-feeding process, the companion is supporting and encouraging the woman, causing her to feel more confident for establishing this process.

Participating in the care with the baby in the Maternity
Hospital is consistent with the current paradigm, which places the baby's father as a fundamental element for humanized birth, and promotes the man's greater involvement as a caregiver.
The actions of informational support were identified in all the periods evaluated, mainly during labor and birth. The companion may keep the woman informed during these periods regarding breathing, when to push for the baby's expulsion, regarding the progress of the labor, and what is happening in the birth (6,13,28) .
In addition to this, he can reinforce the information from the health professionals relating to the procedures being undertaken (13) . These actions of the companion's contribute to the woman feeling encouraged and, consequently, having a calmer and more pleasurable experience.

Support in terms of intermediation was mentioned
least by the companions, showing the difficulties they have in negotiating the woman's wishes with the health professionals. This may be associated with the women's and the companions' fear of suffering some sort of repression from the health professionals if they were to express wishes which could interfere in the hospital routines. This is although the presence of the companion is indicated as a practice which contributes to reducing institutional violence, as he can act as a defender of the woman and protect her against maltreatment (9,29) .
The Born in Brazil Survey indicated that women who went into labor in public services had a higher probability of suffering physical, verbal or psychological violence at the time of birth, in comparison with those who did not go into labor, or who did so in the supplementary services' maternity hospitals. However, one protective factor for mitigating this risk, regardless of having experienced labor or not, or of the modality of the service, is the presence of the companion (29) . This Intermediation support had higher prevalence in Maternity Hospital C, which presents relevant characteristics for the practice of humanization of birth, such as the Galba de Araújo Prize and the right to the presence of a companion since this was made law (13) .
It is advisable that the dialogue between the health professionals and the companion should take place starting during the pregnancy, informing him or her regarding the characteristics of the maternity hospital in which he or she will accompany the birth. It is possible,