THE INTEGRATION OF THE BIRTH COMPANION IN THE PUBLIC HEALTH SERVICES IN SANTA CATARINA , BRAZIL a

This is a descriptive, quantitative study which aims to describe the integration of the parturient woman's companion of choice during labor, delivery and immediate postpartum in health services linked to the Unified Health System (SUS) providing childbirth assistance in Santa Catarina, Brazil and to identify the aspects which facilitate or hinder this process. The population consisted of 138 state services. Data was collected from May 2010 to June 2011 through a questionnaire sent to the directors and by telephone contact, subsequently analyzed by descriptive statistics. Of the 135 departments surveyed, 54.8% reported that they always allow the companion to be present, 32.6% allowed them sometimes, 11.9% never allowed the companion and 0.7% did not respond. Most of the services allow the companion to be present. However, in some services this practice is still implemented with restrictions, as the parturient woman's choice is not respected and the presence of the companion is prevented during the birth. 1 Obstetric nurse. Doctorate in Tocogynecology. Professor of the Department of Nursing and Post-Graduate Nursing Program, at the Federal University of Santa Catarina (PEN/UFSC). CNPq researcher. Florianópolis, Santa Catarina, Brazil E-mail: odalea@ccs.ufsc.br 2 Nurse. Doctorate in Nursing. Professor (retired) of the Department of Nursing at the UFSC. Florianópolis, Santa Catarina, Brazil. E-mail: mila@ccs.ufsc.br 3 Nurse. Master's Degree in Public Health. Doctorate student on Post-Graduate Nursin Program at UFSC. Nurse of the Santa Catarina State Health Department (SES). Florianópolis, Santa Catarina, Brazil. E-mail: haimeelentz@hotmail.com 4 Nurse, graduate of Federal University of Santa Catarina. Fellow of PIBIC/CNPq/UFSC 2010-2011. Florianópolis, Santa Catarina,Brazil E-mail: marcicaetano@hotmail.com 5 Obstetric nurse. Master's in Nursing. Nurse at the University Hospital at UFSC. Florianópolis, Santa Catarina, Brazil. E-mail: michelegayeski@hotmail.com RESEARCH PESQUISA INVESTIGACIÓN A inserção do acompanhante de parto nos serviços públicos de saúde de Santa Catarina, Brasil Esc Anna Nery (print)2013 Jul-Sep; 17 (3):432 438 Odaléa Maria Brüggemann1, Maria Emilia de Oliveira2, Haimée Emerich Lentz Martins3, Marcela Caetano Alves4, Michele Edianez Gayeski5 La integración del acompañate del parto en los servicios de salud pública en Santa Catarina, Brasil Health Services; Humanized Delivery; Patient's companion; Obstetric Nursing.


INTRODUCTION
Great efforts have been made in Brazil, by governmental institutions and non-governmental institutions alike, for changes to occur in obstetric care, particularly regarding the adoption of practices based in scientific evidence.The discussion on these practices gained representativity following the Conference on Appropriate Technology for Childbirth Processes, held in Fortaleza-Ceará in 1985, in which it was made clear that the woman's well-being must be ensured through the free access of a member of the family, chosen by her, during the birth and post-natal period 1 .
Eleven years on from this Conference, the World Health Organization (WHO), by means of the publication Safe Motherhood -Care in Normal Birth: A Practical Guide, took the position of recommending that the parturient woman should be accompanied by persons in whom she trusts and with whom she feels comfortable, emphasizing that this practice contributes to the humanization of care and reduction in obstetric interventions 2 .
The benefits of support during labor have been assessed in systematic reviews published in the Cochrane Library since 1995, and are periodically updated.The most recent review analyzed 21 randomized clinical trials, finding that in five of them, the support for the parturient woman was provided by a companion from the woman's social network.The principal results indicate that this practice contributes to the increase in spontaneous vaginal births; also to a reduction in the need for intrapartum analgesia, in dissatisfaction/negative perception in relation to the birth experience, in the duration of labor, in the number of Cesareans, in instrumental vaginal births, and in the number of new-borns with low Apgar scores in the 5 th minute of life 3 .
Based on the WHO's recommendations 2 and scientific evidence, some Brazilian health institutions have revised their procedures and have adopted a position of allowing a companion of the parturient woman's choice to be present from the moment of entering hospital through to discharge 4,5 .
This practice was backed with the publication of Law n. 11.108/2005, known as the "Companion's Law", based on which the health services of the Unified Health System (SUS), either its own or those used by arrangement with the private sector, are obliged to allow the presence of a companion chosen by the parturient woman, throughout the entire period of labor, birth and the immediate post-partum period 6 .
The implementation of assistential policies and practices in the health services, however, depends on the motivation and commitment of the health professionals to abandoning inappropriate and potentially prejudicial practices for which there is no evidence of benefit.It is known that in various Brazilian maternity centers, the parturient women remain deprived of the presence of a companion of their choice to support them during the entire process of giving birth 5,7 .
In this context, it becomes necessary to investigate the extent to which the Companion's Law, in effect since 2005, has been implemented in the maternity centers, as -in addition to being the women's right -it is also a beneficial practice.The scientific evidence indicates that support during labor contributes not only to improvement in maternal and neonatal health indicators, but also to greater satisfaction with the experience of childbirth on the part of the women and their families 3 .
Thus, this investigation's objective was to describe the integration of the parturient woman's companion of choice during labor, birth and the immediate post-partum period in the health services linked to the SUS which provide childbirth care in the State of Santa Catarina, Brazil, and to identify the aspects which facilitate and hinder this process.

METHOD
This is descriptive research with a quantitative approach.The population was made up of all the health services linked to the SUS which provide childbirth care in Santa Catarina, Brazil.
Data collection was undertaken in the period May 2010 -June 2011.A questionnaire was used, with open and closed questions, covering variables related to the health services' characteristics, the obstetric indicators, the training of the professionals who worked in obstetric care and data on the integration of the companion in the process of childbirth (whether the institution permits or not the presence; who can be a companion; in which parts of the maternity area -triage, pre-partum area, the rooms for vaginal births/Cesareans, the post-partum recovery rooms; and the degree of relatedness to the woman).This instrument was pre-tested in three health services which provide childbirth care in the municipalities of SC.After the evaluation and reformulations necessary, it was sent to the 138 technical directors by the correspondence service of the SC State Health Department, along with a letter of explanation on the research and the Terms of Free and Informed Consent (TFIC) for signing.The week after the material was sent, telephone contact was made to ascertain that it had been received.If the institution had not received it for some reason it was re-sent by email.
Once the deadline stipulated for handing back the questionnaire had passed, telephone contact was made with services which had not done so, and the questionnaire was re-sent once more by email.Even so, many questionnaires were not returned.After exhaustive contacts, responses were not received from all the services.As a result, contact by telephone was re-established in March and April 2011 with each institution that had not responded, so that they would take a position in relation to participating or not in the research.Taking advantage of the opportunity, with a view to obtaining information which could reduce the possible sample bias, that is, to investigate the number of services which permit or do not permit the companion to be present, the following question was posed: generally speaking, can one consider that the institution permits or does not permit the companion to be present during labor, birth and the immediate post-partum period?The responses were recorded in the general list of the health services included in the study and were later categorized.
All the data collection instruments were revised, codified and typed in the EPI INFO program, version 2002, in which descriptive analysis of the data was undertaken (absolute and relative frequency).
All the aspects which involve the research are in line with Resolution n° 196/96 of the National Health Council.The project was approved by the Research Ethics Committee of the SES/SC, protocol n. 0026.1602/09.All the participants signed the TFIC.

RESULTS
Of the 138 health services linked to the SUS which provide childbirth assistance in the State of Santa Catarina, 59 sent back the filled-out printed questionnaire.Of these 41 (69.5%) stated that they always allow the companion to be alongside the parturient woman, 16 (27.1%)stated that they sometimes do, one (1.7%)never allows it, and one (1.7%)did not respond.It should be emphasized that only two of them did not plan to permit this, and 12 (20.3%)intended always to permit the presence of the companion.Law n. 11.108/2005 is known of by 96.6% of the management boards of the health services, with 73.7% having undertaken discussions in relation to the same with the health professionals 6 .
All the health services which did not send back the filled-out questionnaire (79) were contacted by email or telephone.Through this search, the information was obtained from 76 services on the integration of the companion, with 33 responding that they always permit him or her to be present during labor, birth and the immediate post-partum period, 28 stating that they sometimes permit this, and 15 that they do not permit it.
Thus, of the 135 health services, that is, those who participated in the study through responding to the questionnaire (59) and those who only provided the information over the telephone (76), 74 (54.8%) stated that they always permit the companion, 44 (32.6%) sometimes permit this, 16 (11.9%)never permit it, and one (0.7%) did not answer.
The health services studied (59) were distributed across the six regions of the State of Santa Catarina, Brazil with 25.4% in the West Region; 23.7% in the Vale do Itajaí, 18.6% in the North Region; 13.6% in the Planalto Serrano; 10.2% in the South Region and 8.5% in the East Region.The majority of them initiated obstetric care between 1920 and 1979 (59.3%), had between 1 and 5 beds in the obstetric center (61.0%) and 1 to 15 beds for rooming-in (64.4%).
The obstetric doctor was highlighted as the person responsible for attendance in obstetric triage and in the birth.In the pre-partum period, it was the nursing technicians who most acted directly in the attendance, followed by the obstetric nurses and general nurses.One's attention is called to the significant number of nurses (generalists and specialists in obstetrics) who assisted with the birth, as it is equivalent to that of the obstetricians.In all the services, the nurse technicians and auxiliary nurses assisted the women most in the post-partum period, followed by the generalist nurses (Table 1).
In the majority of the services, the companion remained with the women from triage through to the post-partum recovery room, apart from the Cesarean room, as less than half permitted the companion in this area.It calls attention, however, that 15.3% of the services still do not allow the companion in the room where vaginal birth takes place and 23.7% do so only sometimes (Table 2).
In Table 3 one can observe that the majority of the services responded that they respect the woman's choice of companion, but some still determine which person may enter and remain with her.This practice's implementation in the services was facilitated by its support and acceptance by the nurses, nursing technicians and nursing management.It calls attention that nearly half of them stated that the solicitation by the pregnant/parturient women is a facilitating aspect.Among the difficulties found for the companion's integration, the inadequacy of the physical area stood out, followed by non-acceptance on the part of the doctors (Table 4).

DISCUSSION
The results show that practically all the health services in Santa Catarina, Brazil allow the companion to be present; the majority always, and some, sometimes.This reality may result from the fact that the project which originated the Companion's Law was developed in the State.In addition to this, the publication of Normative Ruling N° 001/2009/SES 8 , which establishes guidelines for the health services to put into effect the integration of the companion of the woman's choice during labor, birth and the immediate post-partum period, is the result of a work articulated between the State Health Department, the Department of Nursing of the Federal University of Santa Catarina, the Brazilian Association of Obstetric Nurses -Santa Catarina 3) * Two health services did not provide the information (ABENFO/SC) and representatives of the health services, which also may have contributed to these results.Some services still do not allow the companion to be present.Although this number is not significant, it is data to be considered, as having a companion is a woman's right under Law 6 , authorized by public policies and federal resolutions, and consequently must be instituted in all the public services.
One of the study's limitations was that not all the health services responded to the questionnaire sent.This fact may have created a bias in the data, given that nearly all those who responded made it possible for the woman to have a companion present.The data collected later by telephone, in an attempt to minimize this bias, did not describe the reality in the State faithfully, as they merely express whether the service permitted or not the companion's presence, but not the extent to which this occurred.As a result, it is considered that the data arising from the questionnaires can be better interpreted and discussed.
The fact that the generalist and specialist nurses assist at the birth in percentages equal to that of the obstetricians may have contributed to the presence of the companion of the woman's choice in the majority of the services studied.Studies show that attention in low risk births by obstetric nurses is associated with changes in the institutional routines through the implementation of beneficial practices 9 .In addition to this, the public policies have considered the integration of these professionals, with a view to a change in the childbirth model, which fact may have widened the scope for specialist nurses to work in.It should be stressed that although the generalist nurses do not have legal support to help with births in non-emergency situations 10 , the fact that they work in the majority of the services may be due to the shortage of specialists in various regions, especially in those which are more distant from the State's capital.
In a general way, the functioning of the nursing team, with emphasis on the nurse technicians and auxiliary nurses, is significant in the pre-partum and post-partum periods as well, which may have contributed to the acceptance of the companion in these spaces.In the delivery room (vaginal births or Cesareans), the presence of the companion is still not permitted in the same proportion as in the other locales mentioned above.This space, historically, is the domain of the doctors, whose training is centered on the biological model, which regulates and controls birth, and which consequently may have been decisive in the exclusion of the companion 9 .In addition to this, one has to bear in mind that some health professionals still hold beliefs, values and fears which lead them to reject the idea of having a companion present while they provide assistance 5 .

Birth companion in Santa Catarina, Brazil
For new obstetric practices to be incorporated into childbirth care, changes are necessary in the attitudes of the set of health professionals and managers, as well as a restructuring of the organization and the philosophy of care 5 .
The presence of a companion during labor and birth depends on the social context, on the country's health policy, and on its legislation; but principally it depends on the maternity philosophy, which may contribute through encouraging and permitting, not permitting, or imposing restrictions 11 .The services analyzed in this study represent this reality, as the presence of the companion is still not permitted in line with the current legislation, with some parturient women still remaining alone, that is, with their right not being respected.As a result of this, they cannot enjoy the benefits which this practice offers.
Studies show that the presence and the participation of the companion has positive effects in various spheres of the assistance to childbirth in general and birth in particular 5,12 .The companion may be seen as non-invasive technology during the labor, as his or her effect favors the woman's innate ability for decision-making 13 .The principal results of the randomized clinical trial carried out in Brazil indicate that the support given by the companion of the woman's choice positively influenced her satisfaction with the labor and birth 14 .This investigation's findings allow one to consider that the presence of the companion of the woman's choice is a reality in the majority of the health services in Santa Catarina, Brazil.Not all health services, however, give the woman the right to choose the person who will take on this role; instead she has to abide by the institution's decision regarding who shall be her companion.This imposing attitude does not take into consideration that many women plan the participation of one person in particular to give them the support they wish for and need to receive throughout their pregnancies.
The presence of a companion of the woman's choice, a trusted person from her social network, makes it possible for the same to feel supported emotionally and physically through conversations, massage and help in walking, as well as encouraged in the various places that the birth takes place 15 .This practice's implementation in the health services, although still affected by the restrictions noted above, can only be effected through the mobilization of the health professionals and the managers.In this study, the support of the nurses, the team and the nursing management stood out as facilitating the process, showing that the position taken by these professionals can be decisive in the acceptance of the companion and can contribute to effectuation, as previously emphasized in other studies 5,16 .It is relevant, however, to emphasize that the demands of the service user were also recognized as a facilitating aspect by the services.This denotes that women's knowledge of the Companion's Law 6 can contribute to their empowerment, becoming a fundamental instrument for the demanding and exercising of this right of theirs.
The position taken by the doctors is indicated both as a facilitating and hindering aspect, demonstrating that in some situations they may have contributed to the integration of the companion, but that in others they may have hindered it or made it difficult.Other studies on the issue note that the final decision on the presence of the companion depends on the decision of the medical team, which is responsible for his or her inclusion or exclusion 5,16 .
Considering that the majority of the health services initiated obstetric attendance between the decades of the 20's and the 70's, it is understandable that inappropriate physical structure has been indicated as one of the aspects which most made it difficult to integrate the companion.This did not, however, prevent the implementation of this practice, even if it was only implemented in a partial way.This result is similar to that of a study undertaken in two hospitals linked to the SUS in a city in the Southern Region of Brazil 17 .It should be stressed that National Health Surveillance Agency (ANVISA) Resolution no 36 stipulates that health institutions must have appropriate physical structure for the companion to remain present 18 .Nevertheless, inappropriate physical structure is still used as an argument and justification for not permitting the companion to remain with the woman by some institutions and health professionals 5 .

CONCLUSION
The majority of health services in Santa Catarina, Brazil allow the presence of the companion during labor, birth and the immediate post-partum period, that is, they are seeking to comply with what is stipulated by Law.In some, however, this practice is implemented with restrictions, not respecting the parturient woman's choice and preventing the companion's presence at the moment of birth (vaginal or Cesarean).The companion remains with the woman with the greatest frequency in obstetric triage, the pre-partum area and the room for post-partum recovery following vaginal births.
The nurses' support is a facilitating aspect for implementing this practice.The doctors' non-acceptance, and the inappropriateness of the physical area, have made it difficult to put it into practice, but have not prevented it.This investigation's findings demonstrate that it is still necessary to invest in strategies and guidelines which viabilize the full implementation of the Companion's Law in Santa Catarina, Brazil, ensuring the right conquered by the women and supported by the health professionals engaged in the humanization of childbirth.

Birth companion in Santa Catarina, BrazilTable 1 .
Brüggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayeski ME Professionals who provide attention in obstetric triage, the pre-partum and birth in the health services.Santa Catarina, Brazil, 2010.(n = 59)

Table 2 .
Areas in the institution where the companion is permitted.Santa Catarina, Brazil, 2010.(n = 59)

Table 3 .
Companion who may be present in the various areas in the health services.Santa Catarina, Brazil, 2010.(n = 59)

Table 4 .
Aspects which facilitate or hinder the integration of the companion.Santa Catarina, Brazil, 2010.(n = 59)