Violation of the rights of the companion during hospitalization for childbirth in public maternity hospitals

Vulneración de los derechos de la acompañante durante la hospitalización por parto en maternidades públicas

ABSTRACT

Objective

To estimate the prevalence of violation of the rights of the companion during the hospitalization of the woman for childbirth.

Method

Cross-sectional study conducted in public maternity hospitals in Florianopolis between 2015 and 2016, with data from individual interview with 1.145 companions. Prevalence ratio and Pearson's chi-square test were applied in the analysis.

Results

Women (92.8%), who received prenatal care (93.1%) and were unaware of the companions’ law (92.7%) suffered more violation of rights. Not having received written guidance (93.6%), not identifying the health professional (65.0%) and not being encouraged to participate in care (55.9%) were violated rights. Welcoming and communicating with the team were the care aspects that most violated the rights of the companion.

Conclusion

The high prevalence of violation of rights demonstrates the disrespect and the need to value companions of choice.

Keywords
Medical chaperones; Humanizing delivery; Right to health; Health services; Parturition; Hospitalization

RESUMEN

Objetivo

Estimar la prevalencia de violación de los derechos de lo acompañante durante la hospitalización de la mujer para el parto.

Método

Estudio transversal, realizado en maternidades públicas de Florianopolis, entre 2015 y 2016, con datos de entrevista individual con 1.145 acompañantes. La razón de prevalencia y la prueba de chi cuadrado de Pearson se aplicaron en el análisis.

Resultados

Las mujeres (92,8%), que siguieron la atención prenatal (93,1%) y desconocían la ley del acompañante (92,7%) sufrieron más violaciones de derechos. No haber recibido orientación escrita (93,6%), no identificar al profesional asistente (65,0%) y no ser alentado a participar en la atención (55,9%) fueron derechos violados. Acoger y comunicarse con el equipo fueron los aspectos de cuidado que más vulneraron los derechos del acompañante.

Conclusión

La alta prevalencia de violación de derechos demuestra la falta de respeto y la necesidad de valorar al acompañante.

Palabras clave
Chaperones médicos; Parto humanizado; Derecho a la salud; Servicios de salud; Parto; Hospitalización

RESUMO

Objetivo

Estimar a prevalência de violação de direitos do acompanhante durante a internação da mulher para o parto.

Método

Estudo transversal, conduzido em maternidades públicas de Florianópolis, entre 2015 e 2016, com dados de entrevista individual com 1.145 acompanhantes. Na análise, aplicou-se cálculo de razão de prevalência e teste qui-quadrado de Pearson.

Resultados

Mulheres (92,8%), que acompanharam o pré-natal (93,1%) e desconheciam a lei do acompanhante (92,7%) sofreram mais violação de direitos. Não ter recebido orientação escrita (93,6%), não ter identificado o profissional assistente (65,0%) e não ter sido estimulado a participar do cuidado (55,9%) foram direitos violados. O acolhimento e a comunicação com a equipe foram os aspectos assistenciais que mais infringiram direitos do acompanhante.

Conclusão

A elevada prevalência de violação de direitos demonstra o desrespeito e a necessidade de valorização do acompanhante de parto.

Palavras-chave
Acompanhantes formais em exames físicos; Parto humanizado; Direito à saúde; Serviços de saúde; Parto; Hospitalização

INTRODUCTION

The involvement of a companion of the woman’s choice during childbirth favors the physiological process and contributes to a positive and safe experience1^-2. In Brazil, with the enactment of Law no. 11,108 of 2005, women have been granted the right to a companion of their choice during the entire hospitalization for hospital delivery3. Interministerial Ordinances no 2,418 and no. 2,4284, of the same year, and the Collegiate Board of Directors Resolution - RDC no 36, of Brazilian National Health Surveillance Agency (ANVISA), of 2008, regulate the presence of a companion of the women’s choice during childbirth5. These legal and normative provisions, insofar as they determine the duties of the health services, guarantee the companions a set of rights.

Based on the laws and normative acts in force in Brazil, it can be affirmed the birth companion's rights are: to be present at all times during the care of the woman; be received in a suitable environment that provides the necessary conditions for their continuous stay; have full access to the facilities of the health institution; receive written general guidelines, with a description of their rights and duties as companions; right to privacy; access to food (main meals); get in touch with the professionals who provide assistance to the women; have access to clear and understandable information about the care and have their doubts clarified; receive guidance from health professionals on their role and be involved in the care of the women during hospitalization3^-5.

Findings from studies of companions and women in Brazilian maternity hospitals show violation and/or systematic annulment of rights6^-9. A national survey on obstetric care carried out in public and private maternity hospitals in 2011-2012 reported the absence of companions in 24.5% of deliveries and their partial presence in 81.2%, with a significant improvement in this indicator in 2016 and 20178. The few and limited investigations on the experience of companions have shown feelings of dissatisfaction and fear, associated with the hostility of the hospital environment6^,9^-10. The mismatch between legislation and institutional practices regarding the presence of companions during childbirth is attributed to lack of knowledge of their rights, precarious physical structure, maintenance of care flows and technical professional attitudes7^,9^-13.

Despite investments in the valuing of birth companions in the hospital setting, no studies were conducted on the violation of their rights in the national literature. The present study aimed to estimate the prevalence ratio of violation of the rights of companions during the hospitalization of women for childbirth.

METHOD

Cross-sectional study conducted in reference maternity hospitals for the Metropolitan Region of Florianopolis (MRF), subproject of the research “participation of companions of choice for women in prenatal care, labor and delivery in the public and supplementary health system” (CAEE 25589614.3.0000.0121), approved by the Research Ethics Committee of Universidade Federal de Santa Catarina (protocol no 541.296), funded by National Council for Scientific and Technological Development (Universal Public Notice 14/2013). All study participants signed the Free and Informed Consent Form.

The study population consisted of companions of women during labor and birth. Those who stayed with the women during labor and vaginal delivery or cesarean section were considered eligible14. Companions of women undergoing emergency or elective cesarean section who did not go into labor were excluded; of women whose deliveries took place outside the maternity ward; of women with multiple pregnancies; of women whose fetuses or newborns died; of women who died and those who did not understand the Portuguese language were excluded.

The sample size was calculated considering the total number of births in each institution in 2013 - the year before the research was planned; the presumed prevalence of satisfaction in being companions of women during labor and birth of 50%; a measure of the respect for their rights; confidence level of 95% and maximum error of 5% for each maternity unit. The minimum size of the total sample for the study was estimated at 1,002 companions. Probabilistic procedures were not applied for the selection of participants. Data were collected from March 2015 to May 2016, when 4,299 companions were identified, of which 4,004 were eligible, and of these 1,463 were accessed in the women's inpatient unit by the interviewers and were invited to participate in the study. Of these, 289 declined the invitation, mostly due to the length of the interview, and 13 were excluded because they did not meet all the inclusion criteria. The final sample consisted of 1,145 (28.7%) companions. Data were obtained through individual interviews, applied by trained interviewers. Daily review of the data ensured its quality.

Failure to comply with institutional duties provided for in national normative acts3^-5 and in Normative Instruction (IN) 001/2009 of the Santa Catarina State Health Department (SES/SC)15 that regulate the presence of a companion in hospital delivery, regarding the care aspects of ambience, welcoming and communication with the team was considered a case of violation of companions’ rights.

The description of the violation of the companion's rights regarding care aspects considered three variables: "violation of the companions’ rights regarding the ambience", "violation of the companions’ rights to welcoming" and "violation of the companions’ rights to communication with the health team", categorized into “antenatal screening”, “labor”, “vaginal delivery” and “cesarean section”, which correspond to the flow of care for the parturient women.

RDC no. 365 provides for the functioning of obstetric and neonatal care services and perceives the physical environment as a social space, which offers comfort and privacy to those involved. The variable “violation of the right regarding the ambience” described the disrespect for the rights of companions in this aspect and was constructed by three questions, repeated for each stage of the care flow: “in your opinion, the environment [stage of the care flow] was suitable to receive you?”; “In your opinion, was your privacy and that of the woman in the [stage of care flow] respected?”; “Did you stay by the side of the woman during the care and implementation of procedures in the [stage of the care flow]?” All questions had “yes” and “no” answer options. A negative answer to at least one of the questions was considered a case of violation of the companion's right to the ambience.

Welcoming is a way of operating work processes with the ability to respond to user demands. Thus, to be able to offer support to women during labor and childbirth, companions must be involved in the care, familiar with the environment and aware of the limits and expectations regarding their participation. The normative devices4^-5^,15 guide the health services to make available to companions, before or at the time of the women's admission, written information about the physical area of the maternity, the routines and their rights and duties, and to provide the main meals to these individuals and encourage their participation in care.

The construction of the variable “violation of the right to care” was based on the answers to the questions: “after hospitalization, did any professional take you to visit the physical area of the maternity hospital?”; “in the [stage of the care flow] did the health professionals provide guidance on your right to food?”; “did the health professionals provide written guidance on what you could do as a companion in the [care flow stage]?”; “Were you encouraged by health professionals to accompany the woman in the [stage of the care flow]?”. All questions had the answer options “yes” and “no”, with negative answers considered as a violation of this right.

Effective communication between professionals and companions during hospitalization ensures women's safety. The duties of professionals regarding companions are identify themselves before delivering the care, be friendly, provide clear information about conduct and procedures, clarify doubts and involve the companion in the care of the parturient4^-5. The variable “violation of the right to communicate with the team” was constructed based on the answers to the questions: “in the [stage of the care flow] did the professionals introduce themselves to you before starting the care?”; “Did the professionals provide you with information about the care during the [stage of the care flow]?”; “Did the professionals answer the questions you asked during the [care flow stage]?”, all with “yes” and “no” answers. A negative answer to at least one of the questions was considered a violation of the companion's rights.

Companion‘s satisfaction with the experience is a proxy for adverse situations experienced by them and was analyzed by the outcome “companion's satisfaction”, measured by the answers to the following questions: “how did you feel welcomed in the [stage of the care flow]?”; “how did you feel regarding guidance on your role in [stage of the care flow]?”; “how did you feel about the way they explained to you what was happening in the [care flow stage]?”; in general, how did you feel about the experience in the [care flow stage]?”. For these questions, a Likert table with five response options was used: “very dissatisfied”, “dissatisfied”, “satisfied”, “quite satisfied” and “very satisfied”. A combination of “satisfied and very satisfied” answers were considered an indication of satisfaction.

The variables birth route (vaginal delivery, cesarean section); period of the week the delivery took place (Monday and Tuesday; Wednesday and Thursday; Friday, Saturday and Sunday); delivery shift (day [7:00-19:00h], night [19:01-6:59h]) and length of time the companion of woman’s choice stayed with her during labor and childbirth (in hours) were used to describe the delivery in which the companion participated.

For the sociodemographic characterization of the sample, the variables gender (male, female); age (in years); color/race (white, black/indigenous, brown/yellow); education (in years of schooling); marital status (married/stable union, divorced/widowed, single); bond with the woman (partner/baby's father, mother/sister/friend); participated in prenatal care (yes, no); knowledge of the companion‘s law (yes, no); previous experience with childbirth (yes, no), participation in a childbirth course (yes, no); participation in a lecture on pregnancy/childbirth (yes, no).

For data analysis, Pearson's chi-square test with Yates continuity correction was used to test the associations between the variables. Confidence intervals for calculating the prevalence ratio (PR) were estimated at the 95% level. Data were analyzed using the R statistical software, version 3.3.2.

RESULTS

Most companions were male individuals (76.9%), self-declared white (53.8%); with a median age of 30 years (interquartile range=24-37); married/consensual union (79.7%) and with a median time of schooling of 10 years (interquartile range=7-11). The companions were often partners/fathers of the women's babies (76.7%), with no previous experience in accompanying childbirth (80.7%), did not participate in a preparatory course for (97%) or in lectures on pregnancy/ childbirth (92.1%), participated in the women's prenatal care (64.7%) and were unaware of the companion’s law (76.3%) (Table 1).

There was a predominance of companions of women who had vaginal births (75.1%), that occurred between Friday and Sunday (38.7%) and during the day (54.5%), who remained with the women during the entire hospitalization period ( 92.3%), with a median time of eight hours (interquartile range=4-13) (data not shown in the tables).

The percentage of violation of at least one right of the companion was 92.6% (CI: 91.1-94.1), associated with cesarean section (p<0.000). Violation of rights was higher among female companions (92.8%), who participated in prenatal care (93.1%) and who were unaware of the companion’s law (92.7%) (Table 1).

Table 1 -
Sociodemographic variables of companions and childbirth care, according to violation of their rights in public maternity hospitals in the Metropolitan Region of Florianópolis. Florianópolis, Santa Catarina, Brazil, 2015-2016

	Violation of one or more companion’s rights
Variable	Yes (%)	No (%)	Total (%)	p-value*
Gender				0.872
Male	815 (92.5)	66 (7.5)	881 (76.9)
Female	245 (92.8)	19 (7.2)	264 (23.1)
Self-declared color/race				0.324
White	570 (92.5)	46 (7.5)	616 (53.8)
Black/Brown	400 (93.5)	28 (6.5)	428 (37.4)
Yellow/indigenous	90 (89.1)	11 (10.9)	101 (8.8)
Marital status				0.070
Married/Consensual union	847 (92.8)	66 (7.2)	913 (79.7)
Single	169 (93.9)	11 (6.1)	180 (15.8)
Divorced/Widowed	44 (84.6)	8 (15.4)	52 (4.5)
Bond with the woman				0.475
Companion and baby’s father	816 (92.9)	62 (7.1)	878 (76.7)
Mother/Sister/Friend	244 (91.4)	23 (8.6)	267 (23.3)
Previous experience with childbirth				0.535
No	589 (92.9)	66(7.1)	925 (80.8)
Yes	201 (91.4)	19 (8.6)	220 (19.2)
Participation in childbirth course				1
No	1028 (92.6)	82 (7.3)	1110 (96.9)
Yes	32 (91.4)	3 (8.6)	35 (3.1)
Participation in a lecture on pregnancy/childbirth				1
No	977 (92.6)	78 (7.4)	1057 (92.1)
Yes	83 (92.2)	7 (7.8)	90 (7.9)
Birth route				0.000
Vaginal delivery	785 (91.3)	75 (8.7)	860 (75.1)
Cesarean section	271 (96.5)	10 (3.5)	285 (24.9)
Knowledge of the companion’s law				0.631
No	811 (92.7)	63 (7.2)	874 (76.3)
Yes	249 (91.9)	22 (8.1)	271 (23.7)
Participated during the prenatal period				0.502
No	369 (91.8)	33 (8.2)	402 (35.3)
Yes	685 (93.1)	51 (6.9)	736 (64.7)

• Source: Research data, 2015-2016.
• ^*p value ≤0.05

Regarding the rights, receiving written guidance on one’s role as a companion of the parturient was the most violated right, which was reported in 93.6% (CI: 92.2-95) of the interviews. In 65.0% (CI: 62.2-67.7) of the reports, health professionals did not identify themselves to the companions prior to care delivery and in 55.9% (CI: 53-58.8) the companions were not encouraged to participate in care, nor informed about their right to receive meals (37.6%, CI: 34.8-40.4) (Table 2).

In 26.9% (CI: 24.4-29.5) of the reports, the physical environment was inappropriate to receive the companions and in 14.1% (CI: 12.0-16.1) the right to privacy was disrespected. Of the 663 participants who reported having expressed doubts during care, 10.1% (CI: 7.8-12.4) said they had received clarification from health professionals (Table 2).

Table 2 -
Prevalence of violation of birth companion's rights in public maternity hospitals in the Metropolitan Region of Florianópolis. Florianópolis, Santa Catarina, Brazil, 2015-2016

	Violation of rights
Companions’ rights	n*	%	CI95%†
Receive written guidance about their role	1072	93.6	92.2-95
The professional who provided assistance to the companion identified oneself	744	65.0	62.2-67.7
Be encouraged to participate in the woman's care	640	55.9	53-58.8
Be informed about their right to be served meals during the maternity stay	431	37.6	34.8-40.4
Be received in a suitable physical environment	308	26.9	24.4-29.5
Have their privacy and the women’s privacy respected	161	14.1	12.0-16.1
Get their doubts about the service clarified	67‡	10.1	7.8-12.4
Remaining with the parturient women during hospitalization	88	7.7	6.1-9.2
Be informed on the progress of the labor	64	5.6	4.3-6.9

• Source: Research data, 2015-2016.
• ^*Prevalence; ^†95% Confidence Interval_;^‡Prevalence, percentage and CI were calculated considering N=663, total participants who requested clarification of doubts.

The highest prevalence of violation of the rights of companions at all times during the hospitalization of women for childbirth was related to the welcoming. During antenatal screening, when companions make the first contact with the service, the prevalence of violated rights was 71.5% (CI: 66.2-76.7). Birth was the moment when companions were least respected, and disrespect for companions‘ rights was greater in cesarean section (98.9%, CI: 97.8-100.1) than in vaginal delivery (98.1%, CI: 97, 5-99) (Table 3).

Communication with the health team during the entire hospitalization period was responsible for more than 30% of the violations of the companions’ rights, being lower during antenatal screening (33.7%, CI: 28.2-39.2) and higher during delivery, and in cesarean section (60%, CI: 54.3-65.7) disrespect for the rights of companions was greater than in vaginal delivery (49.4, CI: 46.1-52.8). The prevalence of violation of the rights of companions increased as the parturition process evolved (Table 3).

Ambience was the aspect with the lowest prevalence of violation of the rights of companions. Comparison of welcoming and communication with the team showed that antenatal screening was the period of hospitalization with the highest prevalence of violation of the companions' rights (18.3%, CI: 16.0-20.5). (18.3%, CI: 16.0-20.5). A greater number of violations of the rights of companions were recorded in cesarean sections (17.2%, CI: 12.8-21.6) compared to vaginal delivery (13.1%, CI: 10.9-15, 4) (Table 3).

Table 3 -
Prevalence of violation of the companion‘s rights in the welcoming, in communication with the team and in the ambience, according to the hospitalization stage Metropolitan Region of Florianópolis. Florianópolis, Santa Catarina, Brazil, 2015-2016

	Violation of rights
Care process aspects	n	%	CI95%*
Welcoming
Antenatal screening	819	71.5	66.2-76.7
Labor	1100	96.1	94.9-97.2
Vaginal delivery†	845	98.1	97.5-99
Cesarean section‡	282	98.9	97.8-100.1
Communication with the team
Antenatal screening	386	33.7	28.2-39.2
Labor	402	35.1	32.3-37.8
Vaginal delivery †	425	49.4	46.1-52.8
Cesarean section ‡	171	60.0	54.3-65.7
Ambience
Antenatal screening	209	18.3	16.0-20.5
Labor	191	16.7	14.5-18.8
Vaginal delivery †	113	13.1	10.9-15.4
Cesarean section ‡	49	17.2	12.8-21.6

• Source: Research Data, 2015-2016.
• ^*
  95% Confidence Interval
• ; ^†Number of vaginal deliveries in the sample = 860; ^‡Number of cesarean sections in the sample = 285.

The companions' degree of dissatisfaction with the experience ranged from 4.5% at birth via vaginal delivery to 11.8% during antenatal screening. Guidance on their role in the care sectors for women in labor and delivery was the aspect that most displeased the companions, except for birth by cesarean section, which was the worst rated item in the explanations about the care provided (Table 4).

Antenatal screening was the stage of the care flow that the companions were most dissatisfied with regarding guidance on their roles as women's companions (41.2%) and on encouraging them to participate in care (36%). Dissatisfaction with the explanations about the care provided was lower during labor (25.9%) than in the other stages of the care flow (Table 4).

Of the participants who participated in vaginal deliveries (N=860), 31.9% said they were dissatisfied with the guidance received about their role during childbirth, 28% were dissatisfied with the encouragement to participate in care and 26.5% with the explanations received about the assistance provided. Of the companions who participated in births via cesarean section (N = 265) 36.2% were dissatisfied with the explanations about the care provided, 35.5% with the guidance on their role in the birth and 33.6% with the encouragement received to participate in care (Table 4).

Table 4 -
Degree of satisfaction of companions according to hospitalization phase, Metropolitan Region of Florianópolis. Florianópolis, Santa Catarina, Brazil, 2015-2016

	Degree of satisfaction
Stage of care flow	Satisfied	Dissatisfied
	n (%)	n (%)
Antenatal Screening
With the experience in general	898 (88.2)	120 (11.8)
Welcoming	791 (77.7)	227 (22.3)
Guidance on their role	599 (58.8)	419 (41.2)
Explanations about the care provided	703 (69.1)	315 (30.9)
Stimulus to participate in care	652 (64)	366 (36)
Labor
With the experience in general	1067 (93.2)	78 (6.8)
Welcoming	988 (86.3)	157 (13.7)
Guidance on their role	757 (66.1)	388 (33.9)
Explanations about the care provided	849 (74.1)	296 (25.9)
Stimulus to participate in care	801 (70)	344 (30)
Vaginal Delivery*
With the experience in general	821 (95.5)	39 (4.5)
Welcoming	767 (89.2)	93 (10.8)
Guidance on their role	585 (68.1)	275 (31.9)
Explanations about the care provided	632 (73.5)	228 (26.5)
Stimulus to participate in care	619 (72)	241 (28)
Cesarean Section†
With the experience in general	261 (91.6)	24 (8.4)
Welcoming	226 (79.2)	59 (20.8)
Guidance on their role	184 (64.5)	101 (35.5)

• Source: Research Data, 2015-2016
• Number of vaginal deliveries in the sample = 860; ^† Number of cesarean sections in the sample = 285.

DISCUSSION

The results of this study showed that the public maternity hospitals in the Metropolitan Region of Florianópolis (MRF) need adjustments in infrastructure and care processes to guarantee the rights of women's companions. Failure to comply with legal provisions regarding the rights companions was associated with cesarean section. The prevalence of violations of the right to “written guidance on the companion’s role” and to the “identification of the health professional who assisted the woman” are surprising because the regulations that are not complied with concern low-cost and low-complexity actions, but which have a great impact on the resourcefulness and satisfaction of the companions with the care provided16^-19.

Despite the political and legal provisions aimed at guaranteeing the presence of companions during childbirth, the high percentage of violations of at least one of their rights during the maternity stay suggests the systematic institutional failure to comply with regulations, compromising satisfaction with care and women's safety. Although there are no specific data regarding the violation of the rights of companions, their social similarity with the parturient, allow us to suppose that disrespect for their rights is more frequent in public than in private health services2^,8^,11.

The main barriers to the guarantee of the rights of companions during the hospitalization of women are the lack of appropriate facilities, ignorance about their rights, institutional devaluation, socio-racial discrimination and the exclusion of men from health services6^-7^,9^,11^,18^-19.

The preference of women for having companions who are their partners/fathers of the babies during childbirth has been reported in the literature2^,8^,12^,14. The inclusion of the partner in prenatal care and the social claims for the father's rights contribute to the inclusion of men in pregnancy and childbirth19^-20. The fact that fathers are often present at the birth of their children raises a debate about the organization of the obstetric care service and sexist professional attitudes. Facilities with collective wards restrict the presence of male companions to preserve the privacy of puerperal women. However, this means that couples cannot share this special moment6^,7^,17.

More than a third of the study participants considered the environment unsuitable for their stay, and they were not informed about their right to meals, suggesting institutional non-compliance with the rules3^,7^,17. The lack of clarity regarding the provision of meals and the inadequate accommodations are more frequently observed in public health services, and are some of the causes of the reduced presence of companions6^,17. The violation of these rights can be partially attributed to the restricted budget of public institutions, which imposes a daily challenge on managers. However, the lack of ambience, the poor infrastructure and the lack of understanding and consideration of the health service towards the companions of women in labor and childbirth also suggest that their presence is undervalued by health managers and professionals6^,9.

In addition to budgetary limitations, the representation of childbirth and the abuse of power by health professionals also contribute to the violation of the rights of companions. The representation of childbirth as a moment of danger, pain and suffering, as well as men's unwillingness to experience painful experiences, are justifications for excluding fathers from the birth scene11. The maintenance of care routines that value the intervention is another risk factor for the violation of the companions’ rights, regarding the presence of these individuals during complex procedures, representing the abuse of power of health professionals, especially doctors9^,17.

Ignorance of the legislation and of their rights as companions is also a risk factor for the violation of rights. Companions’ participation in prenatal care can empower them to participate in childbirth to the extent that it clarifies their rights and participation6^,19^-21.

Companions’ inexperience is also a risk factor for the violation of rights, as shown in this study. Preparation for childbirth, during prenatal care and at the beginning of hospitalization, can help companions feel comfortable in the hospital context and facilitate interaction with the team16. However, a study on the support actions promoted by companions to parturients in maternity hospitals in Florianópolis, Santa Catarina, found that a small percentage (19.3%) of the participants were experienced and/or were prepared for childbirth (8.6%), and more than half of them provided support to women in all dimensions, demonstrating that their potential to support women does not depend on prior knowledge14.

The offer of written guidance on the rules, duties and on their role during hospitalization facilitates the inclusion of companions in care16. A study with companions in an obstetric center in Santa Catarina showed that information is usually provided verbally and does not include guidance on their role at any time during hospitalization18. Guidance to companions at admission and during hospitalization allows them to understand the birth process and care dynamics, and this depends on the attitude of the professionals who assist the women10^,16.

Communication ensures patient safety by reducing the risk of unnecessary and non-consensual interventions21. Knowing the name of the health professional who provided care to the woman, being informed and having their questions/doubts about such care properly clarified are companion’s rights. However, the high percentage of reports in which the health professionals who assisted the women did not identify themselves, did not clarify doubts and did not inform about the progress of care in this study is surprising. As providers of support for the women, companions need an open communication channel with the health team to mediate their needs and wants, and professional empathy is the only requirement for their establishment and maintenance13.

The participation of companions in childbirth is a care technology, which successfully reduces interventions in the parturition process1^-2^,14. However, this study revealed that encouragement to their participation is timid and dependent on coordinated changes in professional and institutional attitudes2^,8^,10^,14. To be able to contribute to the well-being and care of the women, companions must be welcomed with dignity and respect16^,18.

Welcoming was the aspect of the care process with the highest prevalence of violation of the rights of companions in this study, with emphasis on the moment of birth, which obtained the worst indicator. The implementation of welcoming actions requires changes in professional perspectives so that the prominent role of those involved is understood, and in obstetric care companions play a relevant role19^,21. Reorganization of the service is necessary to create care flows that respect regulations and contribute to the satisfaction of those involved8^,12^,16^-17.

There was a disagreement between the degree of dissatisfaction of the companions with the experience (11.8%) and the high percentage of violation of rights, which can be attributed to the lack of knowledge of their rights and the low expectation regarding their welcoming in the hospital environment. When companions are close to the women during labor and delivery they tend to make more positive assessments2^,10^,18^,20.

Nevertheless, there is considerable dissatisfaction among companions with guidance on their role during hospitalization, with possible impacts on later experiences. Despite the scarcity of studies on companions’ satisfaction, this finding can be explained by the devaluation of the presence of these individuals associated with lack of knowledge of their potential as providers of support for women during labor by health professionals10^,14^,16.

CONCLUSION

The description of the violation of the companions’ rights during the hospitalization of women for childbirth reveals the challenges to be faced in order to consolidate this practice and comply with regulations. The high prevalence of violation of the rights of companions regarding the availability of written information about their role, identification of the health professional assisting the woman and the encouragement of their participation in care, as well as their dissatisfaction with welcoming, demonstrate the enormous gap between what was foreseen by the policy and legislation and the reality in maternity hospitals in Grande Florianópolis, Santa Catarina.

Investment in actions aimed at qualifying the care provided by health professionals, including adopting a welcoming attitude and developing skills to involve and value companions during childbirth care practices, can impact the interaction between professional-companion-parturient.

Despite the provisions of normative acts that protect the rights of companions, inadequacies persist in infrastructure, professional qualification and care flows that compromise satisfaction with the childbirth experience. The inspection of health services regarding compliance with regulations and the involvement of governments in prioritizing the adequacy of public maternity hospitals to current regulations are necessary to guarantee the rights of companions.

Overcoming obstacles to the exercise of the rights of companions during the hospitalization of women for childbirth needs a new impetus to modify professional attitudes in the management of care processes, removing old patterns that still influence obstetric care. The demand for structural reforms in maternity hospitals to comply with the legislation must be strengthened, in addition to the review of legal and political provisions that guide the inclusion of companions in childbirth.

A limitation of this study is the indirect measurement of the violation of companions' rights, which possibly underestimates the magnitude of the problem in the population.

An innovation of this study is that it shows an institutional violence, still unexplored, which is the violation of the rights of the companion of the woman's choice during hospitalization for childbirth. The findings support the need for broader investigations using different methodologies. Then, it will be possible to reveal its potential as an agent of social control of institutional violence, contributing to safe motherhood.

Acknowledgments

This study is a subproject of the larger project “The participation of women’s chosen companions in prenatal care, labor and delivery in the public and supplementary health system” supported by the National Council for Scientific and Technological Development (Universal Public Notice 14/2013).

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Edited by

Associate editor

Helga Geremias Gouveia

Editor-in- chief

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  05 Dec 2022
• Date of issue
  2022

History

• Received
  13 Sept 2021
• Accepted
  11 Apr 2022