FACTORS ASSOCIATED WITH SUPPORT PROVIDED TO WOMEN DURING CHILDBIRTH BY COMPANIONS IN PUBLIC MATERNITY HOSPITALS

FACTORES ASOCIADOS CON EL APOYO BRINDADO A LAS MUJERES DURANTE EL PARTO POR ACOMPAÑANTES EN MATERNIDADES PÚBLICAS

Carolina Frescura Junges Odaléa Maria Brüggemann About the authors

ABSTRACT

Objective:

to identify the factors associated with providing emotional, physical, informational and intermediation support for companions during childbirth.

Method:

this is a cross-sectional study, whose sample consisted of 861 companions from public maternity hospitals in Florianópolis, SC. Data collection was carried out from March/2015 to May/2016, using a questionnaire as a data collection instrument. The data were analyzed by Binary Logistic Regression, using the Hierarchical Model of Multivariate Analysis.

Results:

the factors associated with emotional support were: having between 8 and 11 years of study (OR: 2.70 - CI: 1.19-6.13), participation in prenatal care (OR: 3.40 - CI: 1.63 -7.10), adequate environment (OR: 3.02 - CI: 1.35-6.75) and concern about pain (OR: 2.95 - CI: 1.33-6.50); in relation to physical support: having 12 or more years of study (OR: 1.68 - CI: 1.10-2.56); in relation to informational support: companion being a woman’s mother (OR: 2.96 - CI: 1.71 to 5.12) and having knowledge about the Companion Law (OR: 1.47 - CI: 1.04 - 2.08); in relation to intermediation support: maternity hospital characteristics. Having received guidance from health professionals and participating in prenatal care were also associated with informational and intermediation support. Providing support in all four dimensions in labor was associated with all outcomes.

Conclusion:

the companion’s participation in prenatal and labor, maternity hospital characteristics and professionals’ attitude were the factors associated with support in childbirth.

DESCRIPTORS:
Humanizing delivery; Medical chaperones; Social support; Obstetric nursing; Parturition

RESUMEN

Objetivo:

identificar los factores asociados al apoyo emocional, físico, informativo e intermediación de los acompañantes durante el parto.

Método:

estudio transversal, cuya muestra estuvo conformada por 861 acompañantes de maternidades públicas de Florianópolis, SC. La recolección de datos se realizó desde marzo/2015 hasta mayo/2016, utilizando un cuestionario com un instrumento de recolección de datos. Los datos fueron analizados por Regresión Logística Binaria, utilizando el Modelo Jerárquico de Análisis Multivariante.

Resultado:

los factores asociados al apoyo emocional fueron: tener entre 8 y 11 años de estudio (OR: 2.70 - IC: 1.19-6.13), participación en la atención prenatal (OR: 3.40 - IC: 1.63-7.10), ambiente adecuado (OR: 3.02 - IC: 1.35-6.75) y preocupación por el dolor (RC: 2.95 - IC: 1.33-6.50); en relación al apoyo físico: tener 12 o más años de estudio (OR: 1.68 - IC: 1.10-2.56); en relación al apoyo informativo: acompañante ser madre de la mujer (OR: 2.96 - CI: 1.71 a 5.12) y tener conocimientos sobre la Ley de Acompañantes (OR: 1.47 - CI: 1.04 - 2.08); en relación al apoyo a la intermediación: las características de la maternidad. Haber recibido orientación de profesionales de la salud y participar en la atención prenatal también se asoció con el apoyo informativo y de intermediación. Brindar apoyo en las cuatro dimensiones en el trabajo de parto se asoció con todos los resultados.

Conclusión:

la participación de la acompañante en la atención prenatal y el parto, las características de la maternidad y la actitud de los profesionales fueron los factores asociados al apoyo durante el parto.

DESCRIPTORES:
Parto humanizado; Chaperones médicos; Apoyo social; Enfermería obstétrica; Parto

RESUMO

Objetivo:

identificar os fatores associados à realização de apoio emocional, físico, informacional e de intermediação por acompanhantes durante o parto.

Método:

estudo transversal, cuja amostra foi composta por 861 acompanhantes de maternidades públicas, da Grande Florianópolis, SC. A coleta de dados foi realizada de março/2015 a maio/2016, a partir da utilização de um questionário como instrumento de coleta de dados. Os dados foram analisados por Regressão Logística Binária, a partir do Modelo Hierarquizado de Análise Multivariada.

Resultado:

fatores associados ao apoio emocional: ter entre 8 e 11 anos de estudo (RC: 2,70 - IC: 1,19-6,13), participação no pré-natal (RC: 3,40 - IC: 1,63-7,10), ambiente adequado (RC: 3,02 - IC: 1,35-6,75) e a preocupação com a dor (RC: 2,95 - IC: 1,33-6,50); ao apoio físico: ter 12 ou mais anos de estudo (RC: 1,68 - IC: 1,10-2,56); ao apoio informacional: o acompanhante ser mãe da mulher (RC: 2,96 - IC: 1,71-5,12) e ter conhecimento sobre a Lei do Acompanhante (RC: 1,47 - IC: 1,04-2,08); ainda, ao de intermediação: as características da maternidade. Ter recebido orientações de profissionais da saúde e participado do pré-natal, também estiveram associadas ao apoio informacional e de intermediação. Ter prestado apoio nas quatro dimensões no trabalho de parto teve associação com todos os desfechos.

Conclusão:

a participação do acompanhante no pré-natal e trabalho de parto, somado às caraterísticas da maternidade e à atitude dos profissionais, foram os fatores associados ao apoio no parto.

DESCRITORES:
Parto humanizado; Acompanhantes de pacientes; Apoio social; Enfermagem obstétrica; Parto

INTRODUCTION

In Brazil, most births take place in hospitals.11. Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Brasília, DF (BR): Ministério da Saúde; 2017 [cited 2017 Oct 28]. Available from: https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/diretrizes-nacionais-de-assistencia-ao-parto-normal-versao-resumida/
https://portaldeboaspraticas.iff.fiocruz...
This setting was consolidated, mainly, in the second half of the 20th century, with the intensification of medical interventions and control over the female body.22. Nakano AR, Bonan C, Teixeira LA. Cesarean sections, perfecting the technique and standardizing the practice: an analysis of the book Obstetrícia, by Jorge de Rezende. Hist. Ciênc. Saúde Manguinhos [Internet]. 2016 [cited 2017 Oct 25];3(1):155-72. Available from: https://doi.org/10.1590/S0104-59702016000100010
https://doi.org/10.1590/S0104-5970201600...
Thus, childbirth, under the control of health professionals, migrated from a domestic and family location to a hospital environment, full of rules that excluded the family from the entire process.33. Leister N, Riesco MLG. Childbirth care: the oral history of women who gave birth from the 1940s to 1980s. Texto Contexto Enferm [Internet]. 2013 [cited 2017 Oct 25];22(1):166-74. Available from: https://doi.org/10.1590/S0104-07072013000100020
https://doi.org/10.1590/S0104-0707201300...

In 1996, WHO released a guide with guidelines for childbirth assistance emphasizing on family reintegration, with the presence of a companion during labor and delivery being ensured.44. Baldisserotto ML, Filha MMT, Gama SGN. Good practices according to WHO’s recommendation for normal labor and birth and women’s assesment of the care received: the “birth in Brazil” nacional research study, 2011/2012. Reproductive Health [Internet]. 2016 [cited 2017 Oct 25];13(3):204-65. Available from: https://doi.org/10.1186/s12978-016-0233-x
https://doi.org/10.1186/s12978-016-0233-...
In Brazil, only in 2005 Law 11,108, also called the “Companion Law”, was approved; this achievement promoted new debates in the care and scientific environment, mobilizing looks that would reveal the perceptions of women and companions with this experience.55. Frutuoso LD, Bruggemann OM. Parturient women’s companions’ knowledge of Law 11.108/2005 and their experience with the woman in the obstetric center. Texto Contexto Enferm [Internet]. 2013 [cited 2017 Oct 25];22(4):909-17. Available from: https://doi.org/10.1590/S0104-07072013000400006
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-66. Davim RMB, Araújo MGP, Galvão MCB, Mota GM, Silva RAR. Produção científica de artigos sobre o acompanhante: revisão sistemática de literatura. Rev Enferm UFPE online [Internet]. 2010 [cited 2017 Oct 25];4(Spe):1017-22. Available from: https://doi.org/10.5205/1981-8963-v4i3a6253p1017-1022-2010
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However, there are still practical obstacles that make it impossible for companions to be in all maternity hospitals and on a continuous basis.77. Bruggemann OM, Ebsen ES, Ebele RR, Batista BD. Possibilidades de inserção do acompanhante no parto nas instituições públicas. Ciênc Saúde Coletiva [Internet]. 2016 [cited 2017 Oct 25];21(8):2555-64. Available from: https://doi.org/10.1590/1413-81232015218.16612015
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-88. Gonçalves AC, Rocha CM, Gouveia HG, Armellini CJ, Moretto VL, Moretto BA. The companion in the obstetrics centre of a university hospital in southern Brazil. Rev Gaúcha Enferm [Internet]. 2015 [cited 2017 Oct 25];36(Spe):159-67. Available from: https://doi.org/10.1590/1983-1447.2015.esp.57289
https://doi.org/10.1590/1983-1447.2015.e...

The national survey Birth in Brazil (Nascer no Brasil) survey identified that 24.5% of women had no companion at any time during obstetric hospitalization, and prohibition by the institution was the most pointed reason. Only 18.8% were able to count on a continuous presence of companions and revealed that this contributed to a better and calmer experience in childbirth.99. Diniz CSG, Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey. Cad Saúde Pública [Internet]. 2014 [cited 2017 Oct 25];30(Suppl 1):S140-53. Available from: https://doi.org/10.1590/0102-311X00127013
https://doi.org/10.1590/0102-311X0012701...
The presence of a companion in labor and childbirth allows women to receive continuous support from a person from their social network.

A systematic review on the ongoing support provided to women during labor and delivery indicated that women benefit from this practice; they have a greater chance of having shorter labor, spontaneous delivery, being more satisfied with the experience of delivery, not needing intrapartum analgesia, cesarean section and instrumental delivery.1010. Bohren MA, Hofmeyr G, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth (Cochrane Review). Cochrane Database Syst Rev. [Internet]2017 Jul 7. Available from: https://doi.org/10.1002/14651858.cd003766.pub6
https://doi.org/10.1002/14651858.cd00376...

The support provided to women can be classified into four modalities: emotional support, when a companion is present continuously and performs activities that promote safety and well-being; physical support, when actions are carried out that provide comfort to women, as well as assisting practices guided by health professionals for walking and therapeutic bathing; informational support, when guidance and explanations are given about childbirth; intermediation support, characterized by the interpretation of women’s desires and trading of companions with health professionals to meet these demands, i.e., companions intercede for women.1111. Hodnett ED, Osborn RW. Effects of continuous intrapartum professional support on childbirth outcomes. Res Nurs Health. 1989;12:289-97.

Some studies describe the actions of emotional and physical support,1212. Souza SRRK, Gualda DMR. The experience of women and their coaches with childbirth in a public maternity hospital. Texto Contexto Enferm [Internet]. 2016 [cited 2017 Oct 25]; 25(1):e4080014. Available from: https://doi.org/10.1590/0104-0707201600004080014
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-1313. Francisco BS, Souza BS, Vitório ML, Zampieri MFM, Gregório VRP. Percepções dos pais sobre suas vivências como acompanhantes durante o parto e nascimento. Rev Min Enferm [Internet]. 2015 [cited 2017 Oct 25];19(3):567-75. Available from: https://doi.org/10.5935/1415-2762.20150044
https://doi.org/10.5935/1415-2762.201500...
especially during labor and delivery, but it is observed that informational and intermediation support have not been explored. Moreover, most research investigates this practice from the woman’s point of view,99. Diniz CSG, Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey. Cad Saúde Pública [Internet]. 2014 [cited 2017 Oct 25];30(Suppl 1):S140-53. Available from: https://doi.org/10.1590/0102-311X00127013
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,1414. Dodou HD, Rodrigues DP, Guerreiro EM, Guedes MVC, Lago PN, Mesquita NS. The contribution of the companion to the humanization of delivery and birth: perceptions of puerperal women. Esc Anna Nery [Internet]. 2014 [cited 2017 Oct 25];18(2):262-9. Available from: https://doi.org/10.5935/1414-8145.20140038
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15. Vaz TH, Pivatto LF. Evaluation of the presence of the companion during birth and the puerperium in a public maternity unit. Cogitare Enferm [Internet]. 2014 [cited 2017 Oct 25];19(3):545-52. Available from: https://doi.org/10.5380/ce.v19i3.3204
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-1616. Oliveira ASS, Rodrigues DP, Guedes MVC, Felipe GF, Galiza FT, Monteiro LC. The companion during labour and birth: new mothers’ perceptions. Cogitare Enferm [Internet]. 2011 [cited 2017 Oct 25];16(2):247-53. Available from: https://doi.org/10.5380/ce.v16i2.20201
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i.e., few allow companions to reveal the support they have provided.55. Frutuoso LD, Bruggemann OM. Parturient women’s companions’ knowledge of Law 11.108/2005 and their experience with the woman in the obstetric center. Texto Contexto Enferm [Internet]. 2013 [cited 2017 Oct 25];22(4):909-17. Available from: https://doi.org/10.1590/S0104-07072013000400006
https://doi.org/10.1590/S0104-0707201300...
,1717. Oliveira AS, Damasceno AKC, Moraes JL, Moreira KAP, Teles MLR, Gomes LFS. Technology used by companions in labor and childbirth: a descriptive study. Online Braz J Nurs [Internet]. 2014 [cited 2017 Oct 25];13(1):36-45. Available from: https://doi.org/10.5935/1676-4285.20144254
https://doi.org/10.5935/1676-4285.201442...

Therefore, this investigation aimed to identify the factors associated with emotional, physical, informational and intermediation support by companions during childbirth. It is considered that knowing the factors that interfere with companions’ performance as support providers is essential to develop strategies that enable their participation in an effective way.

METHOD

This is a cross-sectional study, whose data collection took place from March 2015 to May 2016 in three public maternity hospitals in Florianópolis/SC, which in this study will be called Maternity hospitals A, B and C.

The research participants were the people who remained with the women during labor (vaginal or cesarean), called companions. Companions who remained with women in labor (vaginal or cesarean) have been included. Those who accompanied women who underwent urgent or elective cesarean section and those who did not have the opportunity to carry out support actions during this period, those who had multiple pregnancies, women who died and women whose fetus or newborn have been excluded.

The sample was calculated based on the number of births in 2013 (Maternity hospital A - 1,525; Maternity hospital B - 3,759; Maternity hospital C - 3,508), considering that each maternity allows the presence of a companion. The assumed prevalence was estimated at 50%, a 95% confidence interval and a maximum error of 5%. Thus, the sample for each maternity ward was 307 interviewed at Maternity A, 349 at Maternity B and 346 at Maternity C, totaling 1,002 companions. All delivery companions who met the inclusion criteria were invited to participate; thus, data collection ended when the number of interviews reached the sample size. However, 1,147 were interviewed due to the financial availability for the execution of the project that originated this work.

A questionnaire for data collection. In the testing stage of the tool, companions from two maternity hospitals were interviewed. Adjustments were made according to the records and observations of the main researcher. Testing aimed to improve the tool, bringing it closer to the companions’ reality.

After completing the testing step, software was developed to facilitate data recording and storage. The interviewers received theoretical and practical training to use the digital questionnaire installed on netbooks; the files were stored on a flash drive and the migration system was updated via online, so that the information could be sent to the central database. The interviews took place in the rooming-in of each maternity hospital; the majority in an external environment to the hospitalization room and according to the companions’ convenience, without influence of puerperal women in the answers given.

To ensure information and data quality and minimize random or systematic errors, during data collection, some procedures were adopted, such as the use of a checklist with inclusion and exclusion criteria for the selection of research subjects; monitoring the collection throughout the fieldwork until completing the sample of each institution; daily online assessment of the quality of data recording. In addition, after the end of the data collection, some questions from the questionnaire were replicated, by telephone, in a sample of 5% of companions interviewed at each maternity hospital.

The outcome variables analyzed were emotional support, physical support, informational support and intermediation support. The predictor variables were: age (in years); skin color (white, black, mixed-raced, Caucasian); years of study (≤ 7, 8 - 11, ≥12); bond with women (baby’s partner/father, mother, others); participation in a course and/or lecture (yes, no); knowledge of the Companion Law (yes, no); participated in prenatal care (yes, no); preference for the type of delivery (none, vaginal delivery, cesarean section); maternity hospital (Maternity A, Maternity B, Maternity C); received written guidance (yes, no); adequate environment for companions (yes, no); delivery position (horizontal, reclined, vertical, others); concern about pain (yes, no); having provided support in all four dimensions in labor (yes, no); professionals encouraged participation (yes, no); professionals gave guidance on what to do as a companion (yes, no); if professionals informed about the situation and the assistance provided (yes, no).

For analysis, maternity hospitals’ databases were grouped into one, which was exported to the SPSS® 20.0 program. In the analysis process, a logistic regression was performed for factors associated with outcomes emotional, physical, informational support, intermediation support in childbirth.

High prevalence of emotional support actions led to the construction of the outcome variable “emotional support in childbirth”, which is defined by performance of four or more of the following actions by companions: stayed by their side, encouraged them, calmed them down, praised them, caressed them and held their hand. The outcome variable “physical support in childbirth” was defined by the variable: they helped women to position themselves for childbirth. The outcome variable “informational support” was structured by carrying out the three support actions: they informed about what was happening, guided them to push and guided their breathing. The outcome variable “intermediation support” was structured based on the following variable: they traded women´s wishes with health professionals.

For data analysis, only companions of women who had a vaginal delivery were included, i.e., a sample of 861 subjects. A binary logistic regression was carried out using a hierarchical model of multivariate analysis. The levels at which the variables were inserted are shown in Figure 1. An analysis was performed for each outcome; however, the structure of the hierarchical model was followed for all four outcomes.

Figure 1 -
Hierarchical model of multivariate analysis of factors associated with support provided by companions during vaginal delivery.

At each level, the variables that showed an association with type of support provided (p <0.05) were maintained in the model at lower hierarchical levels, adopting the same procedure for all levels. Adherence of variables to the model was calculated by the Hosmer and Lemeshow Contingency test, with a pre-established significance level of 5%. The results will be presented according to the adjusted odds ratio, with the confidence intervals and the significance values. All participants signed the Informed Consent Form.

RESULTS

In adjusted analysis (Table 1), having between 8 and 11 years of study, participation in prenatal care, an adequate environment for the companion, concern about pain and having provided support in all four dimensions in labor remained as independent factors associated with a greater chance of providing emotional support.

Having over 12 years of schooling, having provided support in all four dimensions in labor and having received guidance on what to do as a companion during vaginal delivery were independent factors associated with a greater chance of providing physical support (Table 1).

Table 1 -
Multivariate hierarchical analysis for the outcome emotional support and physical support, performed by companions during vaginal delivery. Florianópolis, SC, Brazil. 2015-2016. (n = 861)

Table 2 shows analysis for the outcomes informational support and intermediation support. In adjusted analysis, they remained as independent factors associated with a greater chance of providing informational support, being women’s mothers, knowing about the Companion Law, having participated in prenatal care, having received written guidance in the maternity hospital, having provided support in all four dimensions of labor and receiving guidance on what to do as a companion during vaginal delivery.

Independent factors were associated with a greater chance of providing intermediation support, having participated in prenatal care, following childbirth in maternity A, receiving written instructions at the maternity hospital, providing support in all four dimensions of labor and receiving guidance on what to do as a companion during vaginal delivery. Women with reclined position was associated with a lower chance of providing intermediation support (Table 2).

Table 2 -
Hierarchical multivariate analysis for the outcome informational support and intermediation support performed by companions during vaginal delivery. Florianópolis, SC, Brazil. 2015-2016. (n= 861)

DISCUSSION

Education can influence the way in which parturient women are advised about labor and delivery by health professionals: those with less education receive less information.1818. Nagahama EEI, Santiago SM. Práticas de atenção ao parto e os desafios para a humanização do cuidado em dois hospitais vinculados ao Sistema Único de Saúde em município da região sul do Brasil. Cad Saúde Pública [Internet]. 2008 [cited 2017 Oct 25];28(8):1859-68. Available from: https://doi.org/10.1590/S0102-311X2008000800014
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A study on the factors associated with obstetric violence showed that pregnant women who do not have completed high school are more likely to be subjected to at least one of the practices considered unnecessary, harmful or ineffective in childbirth. Higher educated women seek access to information about childbirth and safe practices, thus questioning professionals, discouraging contraindicated or potentially harmful procedures.1919. Andrade PON, Silva JQP, Diniz CMM, Caminha MFC. Fatores associados à violência obstétrica na assistência ao parto vaginal em uma maternidade de alta complexidade em Recife. Rev Bras Saúde Matern Infant [Internet]. 2016 [cited 2017 Oct 25];16(1):29-37. Available from: https://doi.org/10.1590/1806-93042016000100004
https://doi.org/10.1590/1806-93042016000...

Although studies with companions that analyzed education were not identified, in this research an association of this variable with emotional and physical support was detected. Thus, it is considered that higher levels of education may have contributed so that companions had more access to information, generating security to perform support actions and to request clarifications.

Regarding the birth environment, managers, maternity directors and, mainly, health professionals reinforce that the limited physical space and the inadequate ambience are obstacles to allow the presence of companions, considering, in some cases, that the structure of the institutions should be reformulated to meet this demand.88. Gonçalves AC, Rocha CM, Gouveia HG, Armellini CJ, Moretto VL, Moretto BA. The companion in the obstetrics centre of a university hospital in southern Brazil. Rev Gaúcha Enferm [Internet]. 2015 [cited 2017 Oct 25];36(Spe):159-67. Available from: https://doi.org/10.1590/1983-1447.2015.esp.57289
https://doi.org/10.1590/1983-1447.2015.e...
-99. Diniz CSG, Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey. Cad Saúde Pública [Internet]. 2014 [cited 2017 Oct 25];30(Suppl 1):S140-53. Available from: https://doi.org/10.1590/0102-311X00127013
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,2020. Bruggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayesk ME. The integration of the birth companion in the public health services in Santa Catarina, Brazil. Esc Anna Nery [Internet]. 2013 [cited 2017 Oct 25];17(3):432-38. Available from: https://doi.org/10.1590/S1414-81452013000300005
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Most delivery rooms in Brazil have a configuration that, in general, reports to the surgical environment, with sterile drapes and tools for interventions. Thus, it is expected that companions feel more passive in this scenario; however, the results show that, even in cases where companions considered the environment unsuitable to receive them, they were able to support to their women. The need to improve the structure of maternity hospitals to receive companions is understood; however, it is important that this organization is combined with professionals’ sensitivity to recognize the particularities of each woman and her companion.

With regard to companions’ concern about pain, it is known that fear related to labor pain is mentioned by women since pregnancy,2121. Souza MG, Vieira BDG, Alves VH, Rodrigues DP, Leão DCMR, Sá AMP. Concern of primiparous women with regard to labor and birth. Rev Pesqui Cuid Fundam [Internet]. 2015 [cited 2017 Oct 25];7(1):1987-2000. Available from: https://doi.org/10.9789/2175-5361.2015.v7i1.1987-2000
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and may also contribute to the negative perception of the experience of childbirth.2222. Pinheiro BC, Bittar CML. Percepções, expectativas e conhecimentos sobre o parto normal: relatos de experiências de parturientes e dos profissionais de saúde. Aletheia [Internet]. 2012 [cited 2017 Oct 25];37:212-27. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-03942012000100015&lng=pt&tlng=pt
http://pepsic.bvsalud.org/scielo.php?scr...
Qualitative studies consider that, in the face of pain, companions feel powerless, sometimes frightened and with difficulty to act,1313. Francisco BS, Souza BS, Vitório ML, Zampieri MFM, Gregório VRP. Percepções dos pais sobre suas vivências como acompanhantes durante o parto e nascimento. Rev Min Enferm [Internet]. 2015 [cited 2017 Oct 25];19(3):567-75. Available from: https://doi.org/10.5935/1415-2762.20150044
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,2323. Antunes JT, Pereira BC, Vieira MA, Lima CA. Presença paterna na sala de parto: expectativas, sentimentos e significados durante o nascimento. Rev Enferm UFSM [Internet]. 2014 [cited 2017 Oct 25];4(3):536-45. Available from: https://doi.org/10.5902/2179769212515
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and may be able to adopt a more passive position.

Companions concerned with pain were more likely to provide emotional support; however, there was no evidence of an association with the other support dimensions. It seems understandable that pain, at that moment, is inevitable, but it can be minimized by the presence of a person who reassures and encourages women.

The companion’s participation in prenatal consultations and obstetric follow-up can be considered dialogical spaces that promote health education. It is advisable that the person who will accompany the birth participate in prenatal care, in order to clarify doubts and be guided about their rights.2424. Carvalho IS, Costa PB Jr, Oliveira JBP, Brito RS. O pré-natal e o acompanhante no processo parturitivo: percepção de enfermeiros. Rev Bras Pesqui Saúde [Internet]. 2015 [cited 2017 Oct 25];17(2):70-7. Available from: http://periodicos.ufes.br/RBPS/article/view/13190/9240
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-2525. Oliveira SC, Ferreira JG, Silva PMP, Ferreira JM, Seabra RA, Fernando VCN. The participation of the man/father in the attendance of theprenatal presence. Cogitare Enferm [Internet]. 2009 [cited 2017 Oct 25];14(1):73-8. Available from: https://doi.org/10.5380/ce.v14i1
https://doi.org/10.5380/ce.v14i1...

It is considered essential to analyze, with a critical eye, the aspects related to prenatal care. Despite the wide coverage in Brazil, the quality of prenatal care is questionable. Several weaknesses are identified, such as difficulty in welcoming and forming bonds with women, in addition to the indiscriminate use of technologies and unnecessary interventions.2626. Cabral FB, Hirt LM, Sand ICPV. Prenatal care from puerperal women’s point of view: frommedicalization to the fragmentation of care. Rev Esc Enferm USP [Internet]. 2013 [cited 2017 Oct 25];47(2):281-7. Available from: https://doi.org/10.1590/S0080-62342013000200002
https://doi.org/10.1590/S0080-6234201300...

The early participation of companions has a positive impact on the experience of childbirth. To carry out this practice, it is necessary to have a careful look from health professionals who, despite the institutional difficulties, can carry out activities to welcome and encourage women and their companions. It is suggested that prenatal consultations consider the preparation of companions for delivery.

In contrast, in the field of educational practices, not always attending a course and/or lecture means greater participation by companions. This evidence may suggest the ineffectiveness of the content of health education actions and the focus on childbirth, which is usually directed at women.2727. Cunha ACB, Santos C, Gonçalves RM. Concepções sobre maternidade, parto e amamentação em grupo de gestantes. Arq Bras Psicol (Rio J. 1979) [Internet]. 2012 [cited 2017 Oct 25];64(1):139-55. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1809-52672012000100011&lng=pt&nrm=iso
http://pepsic.bvsalud.org/scielo.php?scr...
-2828. Souza VB, Roecker S, Marcon SS. Ações educativas durante a assistência pré-natal: percepção de gestantes atendidas na rede básica de Maringá-PR. Rev Eletr Enferm [Internet]. 2011[cited 2017 Oct 25];13(2):199-210. Available from: https://doi.org/10.5216/ree.v13i2.10162
https://doi.org/10.5216/ree.v13i2.10162...
The two aspects mentioned were not analyzed in the present study; however, it is salutary to clarify that educational actions, such as courses and groups, should be encouraged, as they are opportunities to bring the companion closer to pregnancy and childbirth.

The presence of parturient women’s mothers corresponds to a significant number of companions during childbirth.88. Gonçalves AC, Rocha CM, Gouveia HG, Armellini CJ, Moretto VL, Moretto BA. The companion in the obstetrics centre of a university hospital in southern Brazil. Rev Gaúcha Enferm [Internet]. 2015 [cited 2017 Oct 25];36(Spe):159-67. Available from: https://doi.org/10.1590/1983-1447.2015.esp.57289
https://doi.org/10.1590/1983-1447.2015.e...
-99. Diniz CSG, Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey. Cad Saúde Pública [Internet]. 2014 [cited 2017 Oct 25];30(Suppl 1):S140-53. Available from: https://doi.org/10.1590/0102-311X00127013
https://doi.org/10.1590/0102-311X0012701...
Although this aspect is relevant, it is necessary to clarify that the birth companion must be the one chosen by women, i.e., someone who contributes positively to the birth experience.

Companions can be identified as the people that women have bonds of security and trust, being mentioned their mothers and the father of the babies, especially by forming a family bond.66. Davim RMB, Araújo MGP, Galvão MCB, Mota GM, Silva RAR. Produção científica de artigos sobre o acompanhante: revisão sistemática de literatura. Rev Enferm UFPE online [Internet]. 2010 [cited 2017 Oct 25];4(Spe):1017-22. Available from: https://doi.org/10.5205/1981-8963-v4i3a6253p1017-1022-2010
https://doi.org/10.5205/1981-8963-v4i3a6...
,1414. Dodou HD, Rodrigues DP, Guerreiro EM, Guedes MVC, Lago PN, Mesquita NS. The contribution of the companion to the humanization of delivery and birth: perceptions of puerperal women. Esc Anna Nery [Internet]. 2014 [cited 2017 Oct 25];18(2):262-9. Available from: https://doi.org/10.5935/1414-8145.20140038
https://doi.org/10.5935/1414-8145.201400...
-1515. Vaz TH, Pivatto LF. Evaluation of the presence of the companion during birth and the puerperium in a public maternity unit. Cogitare Enferm [Internet]. 2014 [cited 2017 Oct 25];19(3):545-52. Available from: https://doi.org/10.5380/ce.v19i3.3204
https://doi.org/10.5380/ce.v19i3.3204...
However, this characteristic cannot be generalized, since parturient women’s mothers or life partners are not always the people who convey comfort and well-being.2929. Lacerda ACB, Silva RAR, Davim RMB. Percepção de mulheres quanto ao acompanhante durante o trabalho de parto. Rev Enf UFPE (online) [Internet]. 2014 [cited 2017 Oct 25];8(8):2710-5. Available from: https://doi.org/10.5205/1981-8963-v8i8a9975p2710-2715-2014
https://doi.org/10.5205/1981-8963-v8i8a9...

From this analysis, it is considered that women’s mothers, due to the fact that they have already experienced the experience of childbirth, can contribute positively to informational support. This finding reinforces the need for companions to be instructed on the dynamics of childbirth by professionals during pregnancy; personal experience alone should not be the only source of knowledge to provide informational support.

Health professionals’ attitudes during childbirth underscores the importance of empathic support provided by them for patient safety and positive assessment of women with childbirth.44. Baldisserotto ML, Filha MMT, Gama SGN. Good practices according to WHO’s recommendation for normal labor and birth and women’s assesment of the care received: the “birth in Brazil” nacional research study, 2011/2012. Reproductive Health [Internet]. 2016 [cited 2017 Oct 25];13(3):204-65. Available from: https://doi.org/10.1186/s12978-016-0233-x
https://doi.org/10.1186/s12978-016-0233-...
,3030. Dornfeld D, Pedro ENR. A comunicação como fator de segurança e proteção ao parto. Rev. Eletrônica Enferm [Internet]. 2011 [cited 20 Nov 2017];13(2):190-8. Available from: https://doi.org/10.5216/ree.v13i2.10925
https://doi.org/10.5216/ree.v13i2.10925...
Communication between women and the health team is a device that facilitates care. Likewise, receptivity in delivery rooms can contribute to provision of guidance to companions, enhancing the support provided.

Studies carried out with health professionals and puerperal women have indicated that guidance on proper positioning and the moment to apply force for birth are the most remembered, i.e., those that professionals reinforce most during childbirth. In many cases, however, women are discouraged from using the position of their choice, indicating the position that facilitates the work of health professionals; such an event goes against the WHO guidelines for good practice in obstetrics.44. Baldisserotto ML, Filha MMT, Gama SGN. Good practices according to WHO’s recommendation for normal labor and birth and women’s assesment of the care received: the “birth in Brazil” nacional research study, 2011/2012. Reproductive Health [Internet]. 2016 [cited 2017 Oct 25];13(3):204-65. Available from: https://doi.org/10.1186/s12978-016-0233-x
https://doi.org/10.1186/s12978-016-0233-...
,2222. Pinheiro BC, Bittar CML. Percepções, expectativas e conhecimentos sobre o parto normal: relatos de experiências de parturientes e dos profissionais de saúde. Aletheia [Internet]. 2012 [cited 2017 Oct 25];37:212-27. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-03942012000100015&lng=pt&tlng=pt
http://pepsic.bvsalud.org/scielo.php?scr...
,3030. Dornfeld D, Pedro ENR. A comunicação como fator de segurança e proteção ao parto. Rev. Eletrônica Enferm [Internet]. 2011 [cited 20 Nov 2017];13(2):190-8. Available from: https://doi.org/10.5216/ree.v13i2.10925
https://doi.org/10.5216/ree.v13i2.10925...

It is evident, therefore, that professionals’ actions and statements are replicated by companions, reaffirming the guidelines and assisting in the positioning for delivery. It is essential that it be assessed in other studies if the physical support provided is in line with women’s wishes. It is worth mentioning that intermediation support is closely related to the receptivity of professionals in the delivery room, which causes communication facilities when there is a need to adjust women’s wishes- even with regard to the positioning for delivery.

It was identified that women, when they recline in childbirth, are less likely to receive intermediation support by their companions. It is advisable that women are free to choose the birth position; however, the benefits of the vertical position should be informed.3131. Andrade MAC, Lima JBMC. O modelo obstétrico e neonatal que defendemos e com o qual trabalhamos. In: Ministério da Saúde (BR). Humanização do parto e do nascimento. Brasília, DF (BR): Ministério da Saúde; 2014. p. 19-46-3232. Miquelutti MA, Cecatti JG, Morais SS, Makuch MY. The vertical position during labor: pain and satisfaction. Rev Bras Saúde Matern Infant [Internet]. 2009 [cited 2017 Oct 25];9(4):393-8. Available from: https://doi.org/10.1590/S1519-38292009000400002
https://doi.org/10.1590/S1519-3829200900...

Women in the reclined position, which may or may not have been indicated by health professionals, become more passive in conducting their own birth. Companions may perceive this condition as suitable for the moment, making it acceptable not to interfere in the conduct of health professionals and, therefore, not to negotiate women’s wishes.

Additionally, allowing companions since 1995 as well as winning the Galba de Araújo Award and the title of Baby-Friendly Hospital seem to be strong indications that Maternity A directs its routines according to good practices in obstetrics, probably strengthens the participation of companions in childbirth.

Although the Companion Law was approved in 2005, some maternity hospitals, prior to this period, already made this benefit available to women.33 Maternities that won the Galba de Araújo award, according to the required requirements, have guidelines that encourage the presence of companions during obstetric hospitalization. Moreover, this practice is also assessed for maintaining the title of Baby-Friendly Hospital.3434. Ministério da Saúde (BR). Portaria nº 1.153, 22 de maio de 2014. Redefine os critérios de habilitação da Iniciativa Hospital Amigo da Criança (IHAC). Diário Oficial da União, Brasília, DF (BR); 2014. p. 43.

The philosophy adopted by the maternity hospital and the fact that it is a training center for health professionals directly affect how professionals incorporate good practices in obstetric care in their routines.3535. Bruggemann OM, Monticelli M, Furtado C, Fernandes CM, Lemos FN, Gayesky ME. Philosophy of care in a teaching maternity hospital: factors associated to female users satisfaction. Texto Contexto Enferm [Internet]. 2011 [cited 2017 Oct 25]; 20[4]:658-68. Available from: https://doi.org/10.1590/S0104-07072011000400003
https://doi.org/10.1590/S0104-0707201100...
It is understood, therefore, that companions, when stimulated and guided by health professionals, feel involved in childbirth and comfortable to mediate women’s wishes.

The participation of companions during labor positively influences support during childbirth. These findings reinvigorate the Brazilian legislation guidelines so that companions are present throughout the birth process and not only during labor or delivery.55. Frutuoso LD, Bruggemann OM. Parturient women’s companions’ knowledge of Law 11.108/2005 and their experience with the woman in the obstetric center. Texto Contexto Enferm [Internet]. 2013 [cited 2017 Oct 25];22(4):909-17. Available from: https://doi.org/10.1590/S0104-07072013000400006
https://doi.org/10.1590/S0104-0707201300...

Studies in women’s health assess puerperal women’s and companions’ perceptions regarding the experience of birth, contemplating labor and delivery in a same analysis.1212. Souza SRRK, Gualda DMR. The experience of women and their coaches with childbirth in a public maternity hospital. Texto Contexto Enferm [Internet]. 2016 [cited 2017 Oct 25]; 25(1):e4080014. Available from: https://doi.org/10.1590/0104-0707201600004080014
https://doi.org/10.1590/0104-07072016000...

13. Francisco BS, Souza BS, Vitório ML, Zampieri MFM, Gregório VRP. Percepções dos pais sobre suas vivências como acompanhantes durante o parto e nascimento. Rev Min Enferm [Internet]. 2015 [cited 2017 Oct 25];19(3):567-75. Available from: https://doi.org/10.5935/1415-2762.20150044
https://doi.org/10.5935/1415-2762.201500...
-1414. Dodou HD, Rodrigues DP, Guerreiro EM, Guedes MVC, Lago PN, Mesquita NS. The contribution of the companion to the humanization of delivery and birth: perceptions of puerperal women. Esc Anna Nery [Internet]. 2014 [cited 2017 Oct 25];18(2):262-9. Available from: https://doi.org/10.5935/1414-8145.20140038
https://doi.org/10.5935/1414-8145.201400...
Clinical trials and descriptive studies also follow the same model.88. Gonçalves AC, Rocha CM, Gouveia HG, Armellini CJ, Moretto VL, Moretto BA. The companion in the obstetrics centre of a university hospital in southern Brazil. Rev Gaúcha Enferm [Internet]. 2015 [cited 2017 Oct 25];36(Spe):159-67. Available from: https://doi.org/10.1590/1983-1447.2015.esp.57289
https://doi.org/10.1590/1983-1447.2015.e...
.1010. Bohren MA, Hofmeyr G, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth (Cochrane Review). Cochrane Database Syst Rev. [Internet]2017 Jul 7. Available from: https://doi.org/10.1002/14651858.cd003766.pub6
https://doi.org/10.1002/14651858.cd00376...
Thus, it is considered that individual analysis of each moment can continuously reinforce the importance of companions, especially in scenarios where there is still a restriction of their presence at certain moments of hospitalization.

The study’s limitations were that health professionals and puerperal women were not included as research subjects, which would allow data triangulation. Another limitation was the assessment of physical support, as the experience of childbirth itself presents less performance by companions in this dimension of support, when compared to labor.

CONCLUSION

The participation of companions in prenatal care and labor, maternity hospital characteristics and professionals’ attitudes were factors with greater association for carrying out support during childbirth.

Emotional support was associated with years of study (having between 8 and 11 years of study), a suitable environment to receive companions and concern about pain. In informational support, being women’s mothers increased the chances of companions providing this support. Companions who received guidance on what to do at the time of delivery were more likely to perform physical, informational and intermediation actions. Women, when reclined for childbirth, were less likely to receive intermediation support.

The findings reinforce the need for insertion of companions since prenatal care and their continued participation as support providers during labor and delivery.

ACKNOWLEDGMENT

We would like to thank the Brazilian National Council for Scientific and Technological Development.

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NOTES

  • ORIGIN OF THE ARTICLE

    This article is part of the thesis - Apoio prestado pelo acompanhante à mulher nas maternidades públicas da grande Florianópolis - SC, presented to the Nursing Graduate Program at the Universidade Federal de Santa Catarina, in 2017.
  • FUNDING INFORMATION

    This article was funded by the Brazilian National Council for Scientific and Technological Development, Universal Call 14/2013 - Range B.
  • APPROVAL OF ETHICS COMMITTEE IN RESEARCH

    This article was approved by the Research Ethics Committee of Universidade Federal de Santa Catarina, under Opinion 541.296 and CAAE 25589614.3.0000.0121.

Publication Dates

  • Publication in this collection
    14 Dec 2020
  • Date of issue
    2020

History

  • Received
    15 Nov 2018
  • Accepted
    17 May 2019
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br