ORIGINAL ARTICLES

Technology used by companions in labor and childbirth: a descriptive study

Amanda Souza de Oliveira¹, Ana Kelve de Castro Damasceno¹, Jamile Lopes de Moraes¹, Karla de Abreu Peixoto Moreira², Liana Mara Rocha Teles¹, Linicarla Fabíole de Souza Gomes¹

¹Federal University of Ceará (UFC)
²Fortaleza Metropolitan Area College (FAMETRO)

ABSTRACT
Aim: To evaluate the knowledge of companions about the use of support techniques during childbirth.
Method: A descriptive, cross-sectional quantitative study undertaken at the Assis Chateaubriand Maternity Hospital with a sample of 62 companions. Data collection was undertaken from May to November 2011, through individual interviews and a survey. The Pearson's chi-square tests and Fisher's exact test for statistical associations were used.
Results: 59 (95.2%) of the companions who witnessed the birth did not undergo any training; 32 (51.6%) were selected at the time of entry of the pregnant women in the emergency room; emotional support activities were predominant. The experience of witnessing the birth was considered to be positive on the part of 58 (96%) of the companions.
Discussion: the most common relationship between companion and the pregnant woman were mother and daughter respectively. Feelings of insecurity and fear were experienced by some of the companions.
Conclusion: the companion’s presence during labor constitutes a major form of care.
Descriptors: Humanizing delivery, Technology, Obstetric Nursing.

INTRODUCTION

Throughout history, the technologies used during childbirth have changed. Since the institutionalization of childbirth, women no longer give birth in their homes, in familiar surroundings and in the company of people they trust.  Instead, they usually give birth in the medical and technical environment of a hospital. On the positive side, the safety to the health of women and newborns has clearly increased, but on the other hand, we see the imposition of institutional practices and interventional technologies over the humanization of labor and the birth process.

Reflecting on the use of technologies from the perspective of care, it is clear how we seek innovative ways to modify the everyday routine in terms of a better quality of life and greater job satisfaction⁽¹⁾.

The technology used in healthcare can be defined as a complex phenomenon that leads to everyday reflections concerning the experiences of care with regard to the client who depends on it⁽²⁾.

The use of technologies can also contribute to an improvement in the daily lives of nurses, providing information and enhancing the acquisition of knowledge as part of continuing professional education⁽³⁾.

In this sense, the idea of technology is not only linked to technological equipment.  It also involves the “know-how” and a “just do it” approach. Hard technologies must not be seen to be more important than the soft technologies; on the contrary, human beings need to experience communication, hospitality, interpersonal bonds, and the relationships that can be referred to as ‘soft technologies’⁽⁴⁾.

Nursing is related to the use of such soft technologies. Therefore, the need for care occurs when the existence of people becomes significant, regardless of the role they play (nurse, teacher, team member, user). In this conception of relational and reciprocal care, in which nurse and patient mutually affect and are affected, the feelings, emotions, beliefs, values and knowledge of both participants are present⁽⁴⁾.

The care involved in labor and delivery are crucial for the women involved in order for them to acquire a positive view about labor and birth. It is necessary to provide the woman with an adequate intrapartum support, including emotional, physical, women informational, and clinical support, in order to offer greater safety and comfort to women in labor.  This emotional support consists of being there during labor and transmitting support, praise and encouragement⁽⁵⁾. In this context, we highlight the presence of a companion, a reliable person chosen by the woman giving birth, who will the support her during the labor process.

In Brazil, advice with regard to the presence of a companion during the birthing process has emerged through various events. In 1985, the Conference on Appropriate Technology for Birth & Childbirth took place in Fortaleza-CE, in which the World Health Organization (WHO) recommended free access, during labor and postpartum, to a companion chosen by the woman.  This will benefit the mother and positively influence the labor process⁽⁶⁾. In 2005, twenty years after this conference, n.11.108 Act was approved, which guarantees the woman in labor the right to have a companion, chosen by her, during labor, delivery and the immediate postpartum period in the maternity clinics that are part of the Brazilian Public Unified Health System (SUS)⁽⁷⁾.

The presence of a companion during labor is an effective practice that enhances the humanization of care⁽⁸⁾. The encouragement of the presence of a companion, and the recognition of women as protagonists in the process, creates a new paradigm of delivery care – the humanization of childbirth.

It is known that the quality of support provided by the companion is almost always proportional to his/her ability to be more demanding and active in the delivery process. However, the opportunity for such a companion is still restricted. A lot of hospital obstetric services facilities are not designed with the idea of offering adequate infrastructure to involve a companion. In addition, the process of receiving the woman and her companion is not always done in a complete and humanized form⁽⁹⁾.

In the current context of obstetric care in Brazil, whose public policy in the area of women's health is guided by the humanistic paradigm, the implementation of alternative technologies to those used in the current model of obstetric care is encouraged. With political support, and based on scientific evidence, obstetric nurses should use techniques they consider favorable to the physiological progress of the labor process and non-pharmacological practices for pain relief, including the training of a companion who will be present at the birth.

In nursing practice, the care offered to the woman in labour by a companion constitutes an important aspect of care, and should be encouraged and implemented in hospitals. Therefore, it is important to develop educational technologies that provide ways for the companion to offer better support to the parturient woman. Taking into account that educational technology should be used in order to encourage the participation of subjects in the educational process, contribute to the construction of citizenship, and increase the autonomy of those involved⁽¹⁰⁾, this study asks the following question: how much knowledge do the companions of pregnant women have, and how do they act in providing support during labor and birth?

The overall goal was to evaluate the knowledge of companions about the support they can offer during childbirth. The specific objectives were: to determine the role of the companion with regard to relaxation techniques and pain relief during childbirth; to identify the knowledge of the companion on the stages of labor, the interventions during this period, and the role of the professionals who care for the women during childbirth; and to investigate the doubts and difficulties faced by the companion during childbirth.

METHOD

This is a descriptive, cross-sectional study which adopts a quantitative approach. The sample was composed of companions of women in labor in the maternity ward (AC) of the Assis Chateaubriand Maternity-School (MEAC), Fortaleza, CE, and who also acted as companions during childbirth.

The companions of women who had some complications during delivery were excluded, since in this case the involvement of the companion during the birthing process could be restricted. The sample was one of convenience. Based on the above criteria, (Figure 1), a total of 62 companions were involved during the period of data collection.

Data collection took place from May to November 2011. The schedule for data collection was based on the availability of the volunteer researchers involved in the study, and the following schedules were defined: daily from Monday to Saturday. In order to maximize the sample size, use was made of a questionnaire, together with individual interviews with companions. The use of the questionnaire focused the content to be explored, and the use of individual interviews allowed the (re)elaboration of the questions based on the doubts presented by the subjects.

The questionnaire consisted of 36 objective questions divided into five topics: characterization of the companion; knowledge of the companion on technical support during childbirth; knowledge of the companion about childbirth itself; knowledge of the companion about the professionals who assist childbirth; and an evaluation of the experience of being a companion during labor.

Data were analyzed using the Statistical Package for Social Sciences for Personal Computer (SPSS-PC), version 17.0. The statistical associations between variables were determined using Pearson’s statistical chi-square test (x²) and Fisher's exact test. The establishment of correlations was assessed by the Spearman test. Associations were considered significant when p<0.05. The results were presented in spreadsheets and discussed in terms of the relevant literature.

The project was submitted for assessment to of Assis Chateaubriand Maternity Hospital Ethics Committee (MEAC), of the Federal University of Ceará (UFC), Register 067/11. The participants signed the Informed Consent/IC Form. Under the rules of Resolution 466/2012 from the National Board of Health for research on human subjects, the confidentiality in terms of all the information collected, as well as the participants' anonymity, was assured and guaranteed.

RESULTS

The age of the companions who were present at the birth ranged from 19 to 67 years, with an average age of 44.3 (SD = 12.8). Regarding education, the companions had between 0 and 16 years of study, with an average of 7.9 years (SD = 3.8). Companion’s personal salaries varied between R$ 68.00 and R$ 3,500.00, with an average income of R$ 1,016.69 (SD = 745.05). Table 1 shows the sociodemographic characteristics of such companions.

We observed a positive direct correlation between education and income (rs = 0.557, p = 0.00) and negative direct correlation between educational level and the number of pregnancies (rs = -0.665, p = 0.00), educational level and number of births (rs = -0.636, p = 0.00) and education and the number of abortions (rs = -0.253, p = 0.04).

By observing Table 2 below, it appears that in terms of pre-natal Care (PN), 58 (93.5%) women underwent follow up consultations, and the number of these varied between 3 to 11, averaging 6 PN consultations (SD = 1.8).

There was no significant correlation between the education level of the companion and the number of accompanied antenatal visits (rs = 0.31, p = 0.810).

Of the companions who were present at the birth, 59 (95.2%) did not undergo any training for this purpose. Only two companions were considered qualified: one was a nurse technician and the other was a community health government agent.

Slightly more than half of the companions (32, 51.6%) were chosen by the woman to witness the birth at the time she entered emergency room. The others (28; 54.2%) were selected during gestation, and two (3.2%) were selected at the time of inter-hospital transfer. The time with regard to chosing the companion had no significant association with the evaluation of the birth experience (Fisher: 1,0).

In terms of having witnessed any childbirth previously, 12 (19.4%) had such an experience. Despite not having witnessed a birth previously, 57 of the remainder (91.9%) knew the signs/symptoms of the proximity of childbirth, with most citing painful and frequent uterine contractions (52, 83.9%), amniorrhexis (40, 64, 5%), loss of mucus plug (8, 12.9%), pelvic pain (5, 8.1%), tugs (4, 6.5%), pain in back (2, 3.2%), agitation (1, 1.6%) and reduced fetal movements (1, 1.6%).

Table 3 presents the characterization of the support and/or pain relief activities undertaken by the companion during childbirth, as well as the support techniques they had heard about.

As far as the activities were concerned, the most common were forms of emotional support, such as a constant presence and words of encouragement. Other support activities performed included positioning aid (8, 12.9%), breathing technique (2, 3.2%), holding hands (2, 3.2%) and helping with the exercises (1, 1.6%). Despite the fact that they had heard about different support activities, many of these were not carried out by   the companions. The activity “aid in positioning” had a statistically significant association with companions with an education equal to, or more than, eight years of study (x²: 4.168, p: 0.041); other supportive roles had no statistically significant association with this variable.

During the birth, 6 (9.7%) companions had doubts about the stages of labor, such as removal of the placenta, great delay and no understanding of the birth process, and a feeling that the woman had no opening for passage of the fetus.

Some procedures performed during delivery also raised questions in 9 (14.5%) companions: amniotomy, drug delivery and the initial care for the newborn.

Also relevant was the notable difficulty of the companions in distinguishing the role and responsibility of professionals assisting in childbirth. From the interviewed companions, 36 (58.1%) said they know the doctors’ role in childbirth, 27 (43.5%) were aware of the nurses’ role, 15 (24.2%) said they knew the function of the nursing technician and 21 (33.9%) were aware of the role of the doulas.

According to the companions, the doctor is responsible for performing the delivery (15, 24.1%), intervening in the event of complications (4, 6.4%), and performing episiotomy episiorrhaphy (3, 4.8%), cutting the umbilical cord (2, 3.2%) and vaginal ring (2, 3.2%).

Regarding the role of the nurse, they cited the following professional responsibilities: assisting the physician (8, 12.9%), supporting the women (5, 8.0%), administering medicine (3, 4.8%), performing the cleaning and organization of the environment (2, 3.2%), performing the delivery (2, 3.2%), providing care for the newborn (1, 1.6%) and removing the placenta.

As for the nursing technician, companions cited as their roles: administering medication (3, 4.8%), helping with bathing and cleaning (2, 3.2%), learning how to deal with the labor process (2, 3.2%), performing venipuncture (1, 1.6%), checking blood pressure (1, 1.6%), assessing and recording the procedures (1, 1.6%).

About the role of doulas, the companions mentioned: performing massage (5, 8%), assisting in the exercises and ambulation (4, 6.4%), soothing and advising on labor (5, 8%), and aiding bathing (1. 1.6%).

Of the interviewed companions, only 25 (40.3%) said they knew the rights and duties of a companion. Companions reported the right to accompany the woman, to have proper meals and be informed about the woman’s clinical condition. As to the duties, they mentioned observing professionals, meeting the guidelines of the institution, not smoking, not wearing inappropriate clothes and not leaving the ward.

No significant relationship between education and their knowledge of rights and duties existed (x²: 1.987, p: 0.159).

Only 10 (16.1%) had heard of humanized birth, and this relationship was statistically significant with regard to higher education (x²: 5,843a, p: 0.016). The statements related to the aspect of greater emotional support and care provided by the health professional in this type of delivery, the comfort granted to the women and closeness between mother and baby after birth.

The evaluation of the experience of witnessing the delivery was considered positive by 58 (96%) of the companions, who gave the following main reasons: the opportunity to support the woman (39, 62.9%), the chance of witnessing the birth (28 , 45.2%), the learning process (6, 9.7%) and to have received a good response from the health professionals (2, 3.2%). Only one person (1.6%) considered it a negative experience, although she did not explain her opinion, and two (3.2%) considered it an impartial experience.

Some companions mentioned that they faced difficulties during the period when they were present at the birth, such as: insecurity, (29, 46.8%); fear (27, 43.5%) a lack of knowledge about the techniques of physical support (23, 37.1%), a lack of knowledge about institution facilities (1, 1.6%), a lack of understanding of the procedures performed (1, 1.6%) and being embarrassed in front of health professionals (1, 1.6%).

DISCUSSION

In the present study, the predominant population were made up of female companions. This is a bias in this study, since the data collection took place in the Maternity Ward, where the presence of male companions is not allowed. Therefore, the only interviewed male companion was approached during the visiting hours established by the institution. In a study conducted at the same institution, it was found that 84 (80.0%) of companions were female ⁽¹¹⁾. The presence of a companion during labor is still evaluated as essentially feminine, although this attitude is being modified.

The relationships among the companions and the women in labor were frequently mother and daughter. This reveals that the relationship of complicity, mutual aid and support between mother and daughter.

It also showed a feature of modern society, where the daughter witnesses the mother’s labor and the mother is involved in the labor of her daughter. The other companions also had some kinship with the woman, indicating closeness and trust as determinant factors when it comes to the choice of a companion.

Many of the companions were from the capital, which is due to the characteristics of the institution being studied. Since emergency care is one of its main facilities, several women in the capital, feeling the first signs of labor, directly seek this institution. Another feature is the fact that it is one of the model units in obstetric care in the state of Ceará. Thus, only high risk pregnancies/deliveries are sent from other municipalities to this maternity hospital, and these usually progress to surgical delivery, in which the presence of the companion is not allowed.

The correlation between the average education high rates and family income  demonstrates the socioeconomic diversity present in the public hospitals, and differs from several pre-established concepts.

Moreover, a higher level of education expands the variety of educational technologies that can be used with this target audience. Although the maternity ward in which this research was conducted allows the presence of a companion during childbirth, the results indicate that such companions are not qualified for this role.

The participation of the companion in pre-natal consultations is important, among other reasons, for gathering information regarding the childbirth process in order to understand the stages involved. During the prenatal period, the companion acquires a greater bond with the pregnant woman, increasing the degree of complicity and confidence between them. It is therefore of utmost importance that during the prenatal period, the nurse encourages the presence of a companion as part of the consultation process and provides orientation courses for them.

Slightly more than half of the companions who were present at the birth were chosen during pregnancy. This is a positive aspect because it allows the pregnant woman to previously select people with whom she is intimate and confident enough, to share the unique moment that is childbirth. Also, the early choice lets the companion attend prenatal visits and receive appropriate training.

Few companions were in any doubt about the procedures performed by the professionals. Doubts concerning the stages of labor were also almost not presented, in part because many of the companions had already witnessed deliveries previously, or already had experience of childbirth themselves; many of them already had knowledge about the signs of proximity and the delivery phases.

Among the techniques used by companions, the emotional support - the constant presence and words of encouragement - were the most evident. A survey with 35 postpartum women showed that most participants consider that moving and walking are beneficial during labor, in that it provides pain relief, allows them to go to have a shower or a bath, and accelerates labor⁽¹²⁾.

Although some companions had heard about other technical support to women in labor, many of them were not performed. This raises a negative inference with regard to the lack of training in limiting the care technologies used. Several studies have explored the lack of training of companions when it comes to providing emotional support and physical comfort to women in labor, being restricted only by the hierarchical relationships between health professionals and users, involving a technical and instrumental model of care to take an active role in supporting the mother⁽¹³⁾.

The companion finds it difficult to define the roles of the different professionals working in a childbirth situation, particularly nurses, confusing their role with that of the nurse technician/assistant. The health professional must report to the woman and her companion, and explain the purpose of the procedures, in order to provide the soft technologies of care to the patient. The delivery must be assisted by a multidisciplinary team, and the duties of each professional should be respected. The companion and the woman in labor have the right to know the professionals who provide them with assistance, in order to know where to look in case of any doubts and eventualities that may arise.

Each maternity ward should inform the companions about their rights and duties during their period in the institution, in accordance with its rules and routines. In this study, we noted that many companions were not aware of their rights and duties, becoming more submissive and less demanding in terms of claiming their rights, and subject to failure while performing their duties.

We observed that the companions are not familiar to the term “humanized birth”, restricting the concept to the idea of being welcomed by the health professionals. The term “humanization of childbirth” can be analyzed in different levels, involving humanization as evidence-based care; humanization as the legitimacy of a claim and defense policy regarding the rights of the women; humanization as the result of appropriate technology in health; humanization as professional and corporate legitimacy on the dimensioning of roles and responsibilities of the actors involved in the birth situation; humanization referred to as a rational use of resources; humanization as the legitimacy of the woman in labor’s participation in decisions about her health; and humanization as the right to pain relief. Also in this aspect, a qualitative study of health professionals showed disagreement about the concept of humanized childbirth, and what is done in practice, which indicates that this humanization policy is still far from being considered efficient⁽¹⁴⁾.

The experience of being present at the labor was viewed almost unanimously by the companions as being positive. However, feelings of insecurity and fear arose in some companions. Although it is known how important it is to provide guidance and advice to the pregnant woman and her companion from prenatal period as a way to minimize these concerns, we perceive that this really does not happen as it should. A qualitative study in a ward in a public maternity hospital in Curitiba pointed out that all research participants stated that they had not participated in any lectures or workshops about preparation for delivery during the entire prenatal care course. This same study allowed us to analyze the perceptions of women regarding the presence of a companion during childbirth, sending them positive feelings such as: safety, tranquility, physical support, gratitude and emotional support⁽¹⁵⁾.

CONCLUSION

We conclude that the companion’s presence during labor constitutes an important aspect of care, which enables the extension of care to women in labor. However, the effectiveness of this approach is directly related to the higher degree of safety and knowledge of the companion to effectively use a range of different ways to support the woman in labor.

The prevalence of emotional support and care provided by the companion’s support was clear; activities in the form of physical support were discrete. Also, the limited extent of knowledge on the part of the companions about their rights and duties, the philosophy of humanized childbirth and, in particular, on the roles and responsibilities of health professionals working in the birthing process was clarified.

This study contributes to establishing directions regarding educational strategies to be applied with companions who wish to be present at the birth, identifying the topics that the companions are less familiar with or which pose particular difficulties.

One limitation of this study has been the small number of subjects. This is due to the difficulty in data collection, because many of the companions who were present at the birth do not remain with the patient in the postpartum period, either due to lack of time or to institutional barriers. Moreover, the limited amount of information about male companions is relevant, so the results may not translate to the reality of the male population. We can also see as a limitation, the fact that no data was collected on Sundays and at nights.

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Authors’ part in research:
Amanda Souza de Oliveira, Linicarla Fabíole de Souza Gomes e Jamile Lopes de Moraes: research data collecting;
Ana Kelve de Castro Damasceno e Karla de Abreu Peixoto Moreira: guidance and data analysis;
Liana Mara Rocha Teles: data analysis, crossing and statistical tests.

Recebido: 03/26/2013
Revisado:03/23/2014
Aprovado:03/23/2014