Presence of a full-time companion in Brazilian maternities linked to the Rede Cegonha

Goiabeira, Yara Nayá Lopes de Andrade; Thomaz, Erika Barbara Abreu Fonseca; Lamy, Zeni Carvalho; Santos, Alcione Miranda dos; Leal, Maria do Carmo; Bittencourt, Sonia Duarte de Azevedo; Gama, Silvana Granado Nogueira da; Queiroz, Rejane Christine de Sousa

doi:10.1590/1413-81232022274.07462021

Abstract

The objective was to estimate the proportion of women with a full-time companion in Brazilian maternities linked to the Rede Cegonha (RC) and to compare them between the macro-regions in Brazil. A nationwide study, carried out from December/2016 to October/2017. 10,665 puerperal women from all regions of Brazil participated in the study, who gave birth at one of 606 maternity hospitals with a regional action plan approved by RC. Proportions and respective 95% confidence intervals were estimated, adjusted for the cluster effect, by comparing the macro-regions using Wald’s chi-square test. The presence of a full-time companion occurred in 71.2% of maternities, being higher among women aged 20-35 years, brown-skinned, with higher education, married, and assisted in vaginal delivery. Almost 30% of puerperal women did not have a full-time companion. In the Southeast and Midwest regions, self-declared black women, with less schooling and unmarried women were less accompanied. The moment of delivery had less presence of the companion (29.2%). Despite the advances, this right is still not fully fulfilled, pointing to the occurrence of social inequities among Brazilian macro-regions.

Key words:
Maternal health; Maternal-child health services; Hospitals Maternity; Health policy; Social inequity

Introduction

In 2011, Brazil created the Rede Cegonha (RC) Strategy to implement actions that ensure a network of maternal and child care based on a new model of care during delivery and birth based on available scientific evidence. From there, it was sought to institute good practices according to the recommendations of the World Health Organization (WHO). Thus, RC was organized into four components: prenatal care; delivery and birth; puerperium and comprehensive child health care; and logistic system¹1 Organização Mundial de Saúde (OMS). Assistência ao parto normal: um guia prático. Relatório de Grupo Técnico. Genebra: OMS; 1996.

2 Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011.

3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.

4 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.^-⁵5 Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

In the category of delivery and birth, we highlight the importance of guaranteeing the presence of a free-choice and full-time companion (pre-delivery, delivery, and immediate post-delivery) in the maternity hospital. This is a right established by the Companion Law 11,108, of April 7, 2005, that considered it beneficial to maternal health, providing emotional support, optimizing the physiology of the delivery, reducing the length of hospital stay, and the number of cesarean sections. This action can prevent abuse and unnecessary interventions during delivery, offering quality control of professional care²2 Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011.^-³3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.^,⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.

7 Brasil. Ministério da Saúde (MS). 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 [recurso eletrônico]. Brasília: MS; 2017. [acessado 2018 abr 10]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf.

8 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, Pernambuco. Rev Bra Saude Matern Infant 2016; 16(1):29-37.

9 Leal AC, Gama SGN, Pereira APE, Pacheco VE, Carm CN, Santos RV. A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil. Cad Saude Publica 2017; 33 (Supl. 1):e00078816.^-¹⁰10 Barros TCX, Castro TM, Rodrigues DP, Moreira PGS, Soares ES, Viana APS. Assistência à Mulher para a Humanização do Parto e Nascimento. Rev Enferm UFPE 2018; 12(2):554-558..

WHO classified the presence of a full-time companion as very useful and to encourage to have one. Although there is plenty of this information, the absence of a companion persists in some hospital establishments during delivery¹1 Organização Mundial de Saúde (OMS). Assistência ao parto normal: um guia prático. Relatório de Grupo Técnico. Genebra: OMS; 1996.

2 Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011.^-³3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.^,⁷7 Brasil. Ministério da Saúde (MS). 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 [recurso eletrônico]. Brasília: MS; 2017. [acessado 2018 abr 10]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf.^-⁸8 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, Pernambuco. Rev Bra Saude Matern Infant 2016; 16(1):29-37.^,¹¹11 Carvalho EMP, Gottems LBD, Pires MRGM. Adesão às boas práticas de atenção ao parto normal: construção e validação de instrumento. Rev Esc Enferm USP 2015; 49(6):890-898..

A national hospital-based study called “Nascer no Brasil” (Born in Brazil), conducted between February 2011 and October 2012, examined 266 public, private and mixed hospitals, in which less than 20% of women benefited from the presence of a full-time companion ³3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.^,⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.. This result violates the Best Practices instituted by WHO and the right established by the Companion Law, which should be fulfilled in its entirety. However, this study did not include data from establishments in health regions with a Regional Action Plan approved by Rede Cegonha (PAR-RC) since RC was still in the process of being implemented in the country⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.^,⁹9 Leal AC, Gama SGN, Pereira APE, Pacheco VE, Carm CN, Santos RV. A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil. Cad Saude Publica 2017; 33 (Supl. 1):e00078816.^,¹²12 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; (Supl. 30):S17-S47..

Considering that this right was not yet fully implemented, we highlight this study by the need to identify possible changes in the national scenario after the implementation of RC from the perspective of the presence of a full-time companion, aiming to estimate the proportion of women with a full-time companion in maternity hospitals linked to Rede Cegonha and comparing them between macro-regions in Brazil.

Method

This is a cross-sectional study with a quantitative approach carried out nationwide. The second evaluation cycle of hospital services located in a health region with the RC action plan was from December 2016 to October 2017. This is an excerpt from the research entitled “Evaluation Practices in Delivery and Birth Care in Maternity Hospitals in Rede Cegonha”, financed by the Ministry of Health (Ministério da Saúde - MS) and carried out in partnership with the Federal University of Maranhão (Universidade Federal do Maranhão - UFMA), with the National School of Health Public (Escola Nacional de Saúde Pública - ENSP) and Oswaldo Cruz Foundation (FIOCRUZ)³3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018..

All 606 public health establishments or those affiliated with the SUS that in 2015 were located in health regions with PAR-RC were eligible. Also, they should have the following inclusion criteria: 500 or more deliveries and in health regions with PAR-RC independently having resources or not (N=581); or less than 500 deliveries, in a health region with PAR-RC and having resources (N=25). This set of hospital establishments was responsible for 61.2% of deliveries in the SUS in 2017 (SINASC) and about 50% of deliveries performed in the country¹³13 Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2015.

14 Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2017

15 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2015.^-¹⁶16 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2017.. Of these, 86 establishments were located in the North, 174 in the Northeast, 224 in the Southeast, 81 in the South, and 41 in the Midwest.

We obtained this information through the linkage between the Live Birth Information System (Sistema de Informações de Nascidos Vivos - SINASC) and the National Registration of Health Establishments (Cadastro Nacional de Estabelecimentos de Saúde - CNES)¹³13 Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2015.

14 Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2017

15 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2015.^-¹⁶16 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2017..

We interviewed 10,665 puerperal women from all regions of Brazil whose delivery had taken place in the selected establishment from 00:00 am on the first day of the team’s stay in the place until 11:59 pm on the last day of assessment stipulated for that maternity hospital.

In all regions, the number of postpartum women selected per hospital was proportional to their size (deliveries/year). Thus, we defined a fixed number of days of data collection according to the volume of deliveries in eligible health units. Thus, four days in the North region, two days in the Northeast and Southeast regions, five days in the South region, and seven days in the Midwest region. The sampling included all eligible postpartum women over several days of collection in all establishments that met the inclusion criteria, reducing the likelihood of selection bias.

We evaluated 1,996 women in the North region, 2,172 in the Northeast region, 2,526 in the Southeast, 2,109 in the South region, and 1,862 in the Midwest region. The sampling plan generated an over-representation of the North, South, and Midwest regions, corrected through a calibration procedure⁴4 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.^-⁵5 Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

The sample of postpartum women was stratified by geographic macro-region. We calculated the minimum sample size of postpartum women in each region based on a 50% vaginal birth rate to detect differences of 5%, with a significance level of 5% and 80% power, totaling a minimum of 1,800 postpartum women for each macro-region, plus 10% for any losses. Vilela et al. detailed more information about the sample design⁵5 Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

We did not include women in clinical instability such as the use of oxygen therapy, sedation, intermediate units or in ICU, mental disorder, hearing loss, hospitalized due to abortion, or who did not understand Portuguese. Refusals represented 0.8% of the total eligible postpartum women (n=89).

Data collection was carried out in loco immediately after delivery, by a field team of trained health professionals with experience in maternity hospitals, reducing possible memory biases. An electronic form was used, on the web platform - REDCap (Research Electronic Data Capture). The questionnaire for postpartum women was based on documents and guidelines of the Ministry of Health¹1 Organização Mundial de Saúde (OMS). Assistência ao parto normal: um guia prático. Relatório de Grupo Técnico. Genebra: OMS; 1996.^-²2 Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011.^,¹⁷17 Brasil. Lei nº 11.108, de 07 de abril de 2005. Dispõe sobre o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2005; 08 abr.

18 Brasil. Ministério da Saúde (MS). Diretrizes de Atenção à Gestante: a operação cesariana. Brasília: MS; 2015.[acessado 2019 jul 8]. Disponível em: http://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf.

19 Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Universidade Estadual do Ceará. Brasília: MS; 2014 [acessado 2019 mar 29]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/parto.pdf.^-²⁰20 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018 [acessado 2019 mar 29]. Disponível em: http://www.saude.pr.gov.br/arquivos/File/Politica_ Nacional_de_Atencao_Integral_a_Saude_da_Crianca_PNAISC.pdf.

For this study, the term hospitalization refers to the different moments in which the woman had or did not have a companion, considered as pre-delivery, delivery, and/or post-delivery. The variables included in this study were: maternal age (≤19 years old, 20 to 35 years old, >35 years old), self-reported skin color (white, black, brown-skinned, Asian, indigenous), education (≤ 4 years, 5- 9 years, 10-12 years, ≥ 13 years), current marital status (single, married/in a common-law marriage, separated/divorced/widowed), father´s age (≤19 years old, 20 to 50 years old, >50 years old), planned pregnancy (no, yes), type of pregnancy (single, twin), type of delivery (vaginal, forceps, cesarean), maternity allowed the presence of a companion (no, yes), the pregnant woman had a companion during hospitalization (no, yes), full-time companion (pre-delivery, delivery and post-delivery) (no, yes), at which time the companion was not allowed to be present (only in the pre-delivery, only in the delivery, only in the post-delivery period, pre-delivery and delivery, pre-delivery and post-delivery, delivery and post-delivery, pre-delivery, delivery and post-delivery), nighttime companion (no, yes), who was the companion (child’s father/partner, friend, mother and, sister, doula, another person), reason reported by the puerperal woman for not having a companion (maternity prohibited, prohibition of male companions, companions only for adolescents, only companions over 18 years old, lack of knowledge of the law, did not want to have a companion, there was no companion, it was necessary to pay to have a companion, another reason).

The outcome of interest was obtained by the post-delivery woman’s positive answer to the question: Did you have a full-time companion (pre-delivery, delivery, and post-delivery) in this maternity hospital? (yes, no).

We used Stata® software, version 14.0 for data analysis, using bivariate analyzes and calculating absolute and relative frequencies. All analyzes were calibrated to ensure that the distribution of the sampled post-delivery women matched the distribution of deliveries that took place in the 606 hospitals in 2017⁴4 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.^-⁵5 Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

For data analysis, we compared the proportions and respective 95% confidence intervals (95% CI) of all variables between macro-regions using Wald’s Chi-square test, considering an alpha of 5%, adjusted for the effect of the cluster as a methodological strategy to reduce possible errors in the variance estimates.

The research was approved by the Research Ethics Committee of the Federal University of Maranhão - UFMA and by the National School of Public Health Sérgio Arouca, CAAE 56389713.5.3001.5240, on December 14, 2016. All people interviewed signed the Informed Consent Form.

Results

Most deliveries were in the Southeast region with 2,512 (23.7%). Mothers in the age group of 20 to 35 years old (n=7,292, 68.5%), brown skin color (n=6,000, 57.9%) were the most accompanied. However, in the South region, women had between 10 to 12 years of education (n=5,956, 56.2%), married/in common-law marriage/living with a partner (n=8,491, 78.2%) and with a vaginal delivery (=5,851, 55.3%) (Table 1).

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Table 1
Sociodemographic and obstetric characteristics of puerperal women having their delivery in health units linked to the Rede Cegonha, according to macro-regions. Brazil, 2016-2017.

Mothers were younger in the North (24.1%) and Northeast (23.6%); the Southeast had the highest proportion of single mothers (25.2%) and the proportion of cesarean sections in the country remained high (42.9%), mainly in the North and Midwest regions.

Almost all women (n=10,017; 94.1%) reported that maternity allowed the presence of a companion at some point during hospitalization (pre-delivery, delivery, or post-delivery), while 71.2% (n= 7,503) of them had a full-time companion, with the highest proportion in the South region (81.3%) and the lowest proportion in the Midwest (62.0%) and North regions (69.1%) (Table 2).

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Table 2
Distribution of the presence of the full-time companion in health establishments linked to the Rede Cegonha. Brazil, 2016-2017.

When considering only puerperal women who did not have a full-time companion (n=3,131, 28.6%), the time of delivery was the most reported because the companion was not allowed (29.2%), predominantly in the North and Northeast regions. At night, 169 puerperal women (9.6%) reported that the maternity ward did not allow the presence of a companion. During hospitalization, the partner (43.7) was most frequently present, followed by the mother (33.2%).

When considering only women who did not have a companion, the most reported reason was not having someone to be with them, higher in the South region (33.3%), followed by the Southeast region (30.6%). In the North and Northeast regions, the absence of a companion was due to the prohibition of the presence of a companion by the maternity hospital, with 28.8% and 27.7%, respectively (Table 2).

Table 3 shows the sociodemographic and obstetric characteristics of puerperal women with and without a companion, compared by macro-region and by country. Most women who had a companion throughout the country belonged to the age group of 20 to 35 years old and brown skin color, between 10 to 12 years of study, with a partner, and who underwent vaginal delivery (p<0.05).

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Table 3
Sociodemographic and obstetric characteristics of mothers with and without a companion, who had a delivery in health establishments linked to the Rede Cegonha, compared by macro-region. Brazil, 2016-2017.

However, women over 35 years old, self-declared black, with ≤ 4 years of education, and separated/divorced/widowed were less accompanied in the Midwest and Southeast regions.

Discussion

Our analyzes carried out by geographic region show an increase in the presence of full-time companions in maternity hospitals across the country after the implementation of the RC when compared to the study “Born in Brazil” of 2011, in which only 18.8% of women had a constant companion ⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.. Women of mixed color, with higher education, married, and with a vaginal delivery were more frequently accompanied. However, in the Southeast and Midwest regions, self-declared black women, with low education, single or without a partner were less accompanied. The time of delivery was reported as the main period in which the presence of a companion was not allowed, with a predominance in the North and Northeast regions.

As a limitation of the study, there was the non-inclusion of the private sector and the restriction of the sample to puerperal women from establishments with PAR-RC, which may mean that extrapolations to Brazil must be analyzed with some care because in the maternity hospitals not included here, maybe the proportion of companions is lower due to limited financial resources - since establishments linked to RC had greater investments to adapt the structure and changes in the work process. However, health establishments linked to RC accounted for 61.2% of SUS deliveries in 2017, in Brazil⁵5 Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

We believe that the inclusion of private maternity hospitals in this study would achieve more satisfactory results regarding the presence of a full-time companion in the maternity ward, due to greater monitoring and effective compliance with the norms and rights for patients in these health services.

We highlight nationwide results as positive aspects, with representation by macro-regions, obtained after the implementation of RC and best practices in delivery and birth care, which allowed us to observe the implementation of this policy of the right to a full-time companion in maternity hospitals.

When compared to the study “Born in Brazil”^3.6, where most unaccompanied women were black, with less education and single registered in the Northeast and Midwest regions, this study showed a reduction in these characteristics in the Northeast region, increasing in the Southeast and remaining high in the Midwest.

Results of international studies conducted in Ecuador²¹21 Gutiérrez JP, Flores RL, Genao BA. Social inequality in sexual and reproductive health in Ecuador: an analysis of gaps by levels of provincial poverty 2009-2015. Int J Equity Health 2019; 18(1):49., Kenya²²22 Afulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC Pregnancy and Childbirth 2018; 18(1):150., Israel, and Syria²³23 Abdulrahim S, Bousmah M. Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria from 2000 to 2011. Int J Health Serv 2019; 49(3): 623-641. highlight that white, literate, wealthy, and employed women were more accompanied. This shows social discrimination in childbirth care, suggesting two types of inequities: racial and educational, in a greater or lesser proportion, depending on the level of regional development. In Brazil, these data violate the principles of equity in health care, often linked to social hierarchies, including dimensions such as race/skin color, ethnicity, education, marital status, social class, and others²⁴24 D'Orsi E, Bruggemann OM, Diniz CS, Aguiar JM, Gusman CR, Torres JA, Ângulo-Tuesta A, Rattner D, Domingues RMSM. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saude Publica 2014; (Supl. 30):S154-S168..

The study “Born in Brazil” carried out nine years ago showed that women who underwent cesarean delivery were more accompanied at some point during hospitalization⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.^-⁷7 Brasil. Ministério da Saúde (MS). 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 [recurso eletrônico]. Brasília: MS; 2017. [acessado 2018 abr 10]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf.. However, this study points to an inversion of these results after the implementation of the RC since women having a vaginal delivery were more accompanied, suggesting an improvement in the model of care for vaginal delivery in a humanized way, promoting autonomy, decision-making, and empowerment of the woman for childbirth^{3-4, 8-10,12,21,24-25}.

Although there has been a great advance in the presence of a full-time companion in all regions of the country, a national study conducted by Bittencourt et al. ⁴4 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821. assessed the level of implementation of best practices after the implementation of RC, and showed that the presence of a companion was not adequate for 8.4% of Brazilian maternities, with structural and work process restrictions observed in 30% of the institutions. We found similar results in a study conducted in three Arab countries²⁶26 Bittencourt SDA, Domingues RM, Reis LG, Ramos MM, Leal MC. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 120(120):257. and in Kenya²²22 Afulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC Pregnancy and Childbirth 2018; 18(1):150., pointing out structural and organizational barriers as the greatest challenges for the fulfillment of best practices of companions.

In this study, 5.7% of women who did not have a companion mentioned personal reasons, which does not make hospital establishments responsible for non-compliance with the aforementioned policy. Therefore, the best practices in delivery and birth care are at different stages of implementation, with variation between macro-regions.

The research also observed that the presence of a companion reduces even more specifically at the time of delivery, especially in the North and Northeast regions. The results of other studies³3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.^,⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.^,²⁸28 Soares RS, Lima ACLS, Sampaio J, Melo Neto AJM, Gomes LB, Freitas WMF. Fatores relacionados à presença do acompanhante e uma maternidade da Paraíba 2015/2016. Rev Uningá 2017; 53(2):67-72. justify this conduct due to the institution’s structural barriers and the resistance of the care team^4.29. Professionals should be aware of the benefits of this WHO recommendation and the management team should encourage the implementation of this evidence-based practice.

The presence of a companion during pre-delivery, delivery, and post-delivery provides greater emotional support to the woman, optimizing the physiology of childbirth, reducing the number of cesarean sections and the postpartum recovery period. This conduct ensures the safety and quality of professional care, reducing violence and inappropriate childbirth practices³3 Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.^-⁴4 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.^,⁶6 Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.^,⁸8 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, Pernambuco. Rev Bra Saude Matern Infant 2016; 16(1):29-37.^,²²22 Afulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC Pregnancy and Childbirth 2018; 18(1):150.^,²⁶26 Bittencourt SDA, Domingues RM, Reis LG, Ramos MM, Leal MC. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 120(120):257..

The main reason why puerperal women did not have a companion in the South and Southeast regions was that they did not have someone to be with them. In the North and Northeast regions was because of the prohibition of a companion in the maternity ward. Similar results⁴4 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.^,⁸8 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, Pernambuco. Rev Bra Saude Matern Infant 2016; 16(1):29-37.^-⁹9 Leal AC, Gama SGN, Pereira APE, Pacheco VE, Carm CN, Santos RV. A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil. Cad Saude Publica 2017; 33 (Supl. 1):e00078816.^,²⁸28 Soares RS, Lima ACLS, Sampaio J, Melo Neto AJM, Gomes LB, Freitas WMF. Fatores relacionados à presença do acompanhante e uma maternidade da Paraíba 2015/2016. Rev Uningá 2017; 53(2):67-72. approach that the care produced in maternity hospitals tends to be crossed by a socioeconomic and cultural hierarchy, added to the structural inadequacies of the institution or factors related to women, such as not having or not wanting the presence of a companion.

Conclusion

Brazil has advanced in the best practices in childbirth care aimed at the presence of a full-time companion after the implementation of the RC in 2011, increasing the presence of a full-time companion from 18.8% (2011) to 71.2% (2017) throughout the country, in approximately six years.

In general, the South and Southeast regions, regions with greater socioeconomic development, present more satisfactory results than other regions. However, socio-economic and cultural conditions and inequality, marked in the North and Northeast, point to the occurrence of social inequalities among Brazilian macro-regions in the right of a full-time companion.

Despite these advances, challenges remain to ensure that institutions fulfill this right guaranteed by law in its entirety, and it is necessary to reinforce the principles of equity, integrality, universality, and humanization. We suggest creating companion registration protocols at all times from hospitalization to delivery, professional training, and structural and organizational adequacy of the health services.

Well-conducted and implemented public policies are interventions with a pro-equity approach, with greater efforts in areas of greater social vulnerability, and can contribute to the scenario of care during childbirth in Brazil, with an emphasis on its usefulness for the decision-making management bodies.

Acknowledgment

To the Ministério da Saúde, à Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ) - Research Productivity Grant to Erika B. A. F. Thomaz (Process: 306592/2018-5; Call CNPq Nº 09/2018) and Fundação de Amparo à Pesquisa and Desenvolvimento Científico e Tecnológico do Maranhão (FAPEMA), Edital UNIVERSAL nº 01172/18, funding and trust for the Universidade Federal do Maranhão e Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz for the realization of this great and invaluable national survey for maternal health in the country.

References

¹
Organização Mundial de Saúde (OMS). Assistência ao parto normal: um guia prático. Relatório de Grupo Técnico. Genebra: OMS; 1996.
²
Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011.
³
Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.
⁴
Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.
⁵
Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800.
⁶
Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.
⁷
Brasil. Ministério da Saúde (MS). 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 [recurso eletrônico]. Brasília: MS; 2017. [acessado 2018 abr 10]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf.
⁸
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, Pernambuco. Rev Bra Saude Matern Infant 2016; 16(1):29-37.
⁹
Leal AC, Gama SGN, Pereira APE, Pacheco VE, Carm CN, Santos RV. A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil. Cad Saude Publica 2017; 33 (Supl. 1):e00078816.
¹⁰
Barros TCX, Castro TM, Rodrigues DP, Moreira PGS, Soares ES, Viana APS. Assistência à Mulher para a Humanização do Parto e Nascimento. Rev Enferm UFPE 2018; 12(2):554-558.
¹¹
Carvalho EMP, Gottems LBD, Pires MRGM. Adesão às boas práticas de atenção ao parto normal: construção e validação de instrumento. Rev Esc Enferm USP 2015; 49(6):890-898.
¹²
Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; (Supl. 30):S17-S47.
¹³
Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2015.
¹⁴
Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2017
¹⁵
Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2015.
¹⁶
Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2017.
¹⁷
Brasil. Lei nº 11.108, de 07 de abril de 2005. Dispõe sobre o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2005; 08 abr.
¹⁸
Brasil. Ministério da Saúde (MS). Diretrizes de Atenção à Gestante: a operação cesariana. Brasília: MS; 2015.[acessado 2019 jul 8]. Disponível em: http://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf.
¹⁹
Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Universidade Estadual do Ceará. Brasília: MS; 2014 [acessado 2019 mar 29]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/parto.pdf.
²⁰
Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018 [acessado 2019 mar 29]. Disponível em: http://www.saude.pr.gov.br/arquivos/File/Politica_ Nacional_de_Atencao_Integral_a_Saude_da_Crianca_PNAISC.pdf
²¹
Gutiérrez JP, Flores RL, Genao BA. Social inequality in sexual and reproductive health in Ecuador: an analysis of gaps by levels of provincial poverty 2009-2015. Int J Equity Health 2019; 18(1):49.
²²
Afulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC Pregnancy and Childbirth 2018; 18(1):150.
²³
Abdulrahim S, Bousmah M. Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria from 2000 to 2011. Int J Health Serv 2019; 49(3): 623-641.
²⁴
D'Orsi E, Bruggemann OM, Diniz CS, Aguiar JM, Gusman CR, Torres JA, Ângulo-Tuesta A, Rattner D, Domingues RMSM. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saude Publica 2014; (Supl. 30):S154-S168.
²⁵
Gama SGN, Viellas EF, Schilithz AOC, Filha MMT, Carvalho ML, Gomes KRO, Costa MCO, Leal MC. Fatores associados à cesariana entre primíparas adolescentes no Brasil, 2011-2012. Cad Saude Publica 2014; 30(Supl. 1):S117-S127.
²⁶
Bittencourt SDA, Domingues RM, Reis LG, Ramos MM, Leal MC. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 120(120):257.
²⁷
Kabakian-Khasholian T, El-Nemer A, Bashour H. Perceptions about labor companionship at public teaching hospitals in three Arab countries. Int J Gyn Obstetrics 2015; 129(3):223-226.
²⁸
Soares RS, Lima ACLS, Sampaio J, Melo Neto AJM, Gomes LB, Freitas WMF. Fatores relacionados à presença do acompanhante e uma maternidade da Paraíba 2015/2016. Rev Uningá 2017; 53(2):67-72.
²⁹
Anjos AM, Gouveia HG. Presença do acompanhante durante o processo de parturição e nascimento: análise prática. Rev Enferm UERJ 2019; 27:e38686.

Publication Dates

Publication in this collection
22 Apr 2022
Date of issue
Apr 2022

History

Received
31 May 2020
Accepted
14 May 2021
Published
16 May 2021

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹
Organização Mundial de Saúde (OMS). Assistência ao parto normal: um guia prático. Relatório de Grupo Técnico. Genebra: OMS; 1996.

[2] ²
Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011.

[3] ³
Leal MC, Bittencourt SDA, Esteves-Pereira AP, Ayres BVS, Silva L. BRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JÁ, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.

[4] ⁴
Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-821.

[5] ⁵
Vilela MEA, Leal MC, Thomaz EB, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBA, Lamy Z. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: Os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800.

[6] ⁶
Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad Saude Publica 2014; 30 (Supl. 30):S140-S141.

[7] ⁷
Brasil. Ministério da Saúde (MS). 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 [recurso eletrônico]. Brasília: MS; 2017. [acessado 2018 abr 10]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf.

[8] ⁸
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, Pernambuco. Rev Bra Saude Matern Infant 2016; 16(1):29-37.

[9] ⁹
Leal AC, Gama SGN, Pereira APE, Pacheco VE, Carm CN, Santos RV. A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil. Cad Saude Publica 2017; 33 (Supl. 1):e00078816.

[10] ¹⁰
Barros TCX, Castro TM, Rodrigues DP, Moreira PGS, Soares ES, Viana APS. Assistência à Mulher para a Humanização do Parto e Nascimento. Rev Enferm UFPE 2018; 12(2):554-558.

[11] ¹¹
Carvalho EMP, Gottems LBD, Pires MRGM. Adesão às boas práticas de atenção ao parto normal: construção e validação de instrumento. Rev Esc Enferm USP 2015; 49(6):890-898.

[12] ¹²
Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; (Supl. 30):S17-S47.

[13] ¹³
Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2015.

[14] ¹⁴
Brasil. Ministério da Saúde (MS). Sistema de Informação sobre Nascidos Vivos - SINASC. Brasília: MS; 2017

[15] ¹⁵
Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2015.

[16] ¹⁶
Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). Brasília: MS; 2017.

[17] ¹⁷
Brasil. Lei nº 11.108, de 07 de abril de 2005. Dispõe sobre o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2005; 08 abr.

[18] ¹⁸
Brasil. Ministério da Saúde (MS). Diretrizes de Atenção à Gestante: a operação cesariana. Brasília: MS; 2015.[acessado 2019 jul 8]. Disponível em: http://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf.

[19] ¹⁹
Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Universidade Estadual do Ceará. Brasília: MS; 2014 [acessado 2019 mar 29]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/parto.pdf.

[20] ²⁰
Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018 [acessado 2019 mar 29]. Disponível em: http://www.saude.pr.gov.br/arquivos/File/Politica_ Nacional_de_Atencao_Integral_a_Saude_da_Crianca_PNAISC.pdf

[21] ²¹
Gutiérrez JP, Flores RL, Genao BA. Social inequality in sexual and reproductive health in Ecuador: an analysis of gaps by levels of provincial poverty 2009-2015. Int J Equity Health 2019; 18(1):49.

[22] ²²
Afulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC Pregnancy and Childbirth 2018; 18(1):150.

[23] ²³
Abdulrahim S, Bousmah M. Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria from 2000 to 2011. Int J Health Serv 2019; 49(3): 623-641.

[24] ²⁴
D'Orsi E, Bruggemann OM, Diniz CS, Aguiar JM, Gusman CR, Torres JA, Ângulo-Tuesta A, Rattner D, Domingues RMSM. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saude Publica 2014; (Supl. 30):S154-S168.

[25] ²⁵
Gama SGN, Viellas EF, Schilithz AOC, Filha MMT, Carvalho ML, Gomes KRO, Costa MCO, Leal MC. Fatores associados à cesariana entre primíparas adolescentes no Brasil, 2011-2012. Cad Saude Publica 2014; 30(Supl. 1):S117-S127.

[26] ²⁶
Bittencourt SDA, Domingues RM, Reis LG, Ramos MM, Leal MC. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 120(120):257.

[27] ²⁷
Kabakian-Khasholian T, El-Nemer A, Bashour H. Perceptions about labor companionship at public teaching hospitals in three Arab countries. Int J Gyn Obstetrics 2015; 129(3):223-226.

[28] ²⁸
Soares RS, Lima ACLS, Sampaio J, Melo Neto AJM, Gomes LB, Freitas WMF. Fatores relacionados à presença do acompanhante e uma maternidade da Paraíba 2015/2016. Rev Uningá 2017; 53(2):67-72.

[29] ²⁹
Anjos AM, Gouveia HG. Presença do acompanhante durante o processo de parturição e nascimento: análise prática. Rev Enferm UERJ 2019; 27:e38686.

	N¹ (n=1,996)			NE¹ (n=2,172)			SE¹ (n=2,526)			S¹ (n=2,109)			CO¹ (n=1,862)			TOTAL (n=10,665)			p- value
	f	%	IC95%	F	%	CI95%	f	%	CI95%	f	%	CI95%	f	%	CI95%	f	%	CI95%
Total deliveries	1,985	18.7	.	2,137	20,1	.	2,512	23.7	.	2,105	19.9	.	1.862	17.6	.	10,601	100.0	.	<0.01
Mother´s age																			<0.01
≤19 years old	481	24.1	22.2-26.1	521	23.6	21.9-25.6	453	17.5	16.0-19.1	396	18.5	16.9-20.3	354	19.0	17.0-21.2	2,205	20.6	19.7-21.5
20 to 35 years old	1,352	67.7	65.5-69.8	1,439	66.8	64.6-68,8	1,749	69.8	67.8-71.6	1,439	68.7	66.6-70.7	1.313	70.5	67.9-72.9	7,292	68.5	67.4-69.5
>35 years old	163	8.2	7.1-9.5	212	9.6	8.4-11.0	324	12.7	11.4-14.2	274	12.8	11.4-14.3	195	10.5	8.9- 12.4	1,168	10.9	10.3-11.7
Mother´s skin color																			<0.01
White	237	11.9	10.5-13.5	345	15.9	14.4-17.6	743	29.4	27.6-31.4	1,351	63.3	61.1-65.5	328	18.3	16.3-20.5	3,004	25.8	24.8-26.7
Black	165	8.4	7.2-9.8	317	14.7	13.2-16.3	378	14.9	13.5-16.5	213	10.3	9.0-11.8	232	12.1	10.6-13.7	1,305	13.2	12.5-14.0
Brown-skinned	1,521	76.1	74.1-77.9	1,417	65.4	63.2-67.4	1,353	53.6	51.5-55.6	518	24.9	23.0-26.9	1.191	63.6	61.0-66.2	6,000	57.9	56.8-59.0
Asian	31	1.6	1.1-2.3	45	1.9	1.4-2.6	28	1.1	0.7-1.8	13	0.7	0.4-1.2	70	3.5	2.7-4.4	187	1.6	1.3-1.9
Indigenous	31	1.4	1.0-2.1	21	1.0	0.7-1.6	7	0.3	0.1-0.5	6	0.3	0.1-0.6	19	0.9	0.6-1.4	84	0.7	0,5-0,9
No information	11	0.6	0.3-1.0	25	1.1	0.7-1.7	17	0.7	0.4-1.1	8	0.5	0.2-1.1	22	1.6	0.7-3.5	83	0.8	0.6-1.1
Years of Education																			<0.01
≤ 4 years	127	6.3	5.3-7.5	189	9.0	7.7-10.3	85	3.4	2.7-4.3	99	4.9	4.0-6.0	71	3.7	2.9-4.7	571	5.7	5.2-6.3
5-9 years	672	34.1	31.9-36.3	745	33.8	31.7-35.9	716	28.2	26.4-30.1	726	34.5	32.4-36.7	565	30.6	28.2-33.2	3,424	31.6	30.6-32.7
10-12 years	1,024	50.9	48.7-53.2	1,133	52.4	50.2-54,6	1,555	61.1	59.1-63.1	1,156	54.8	52.5-57.0	1.088	58.8	56.1-61.3	5,956	56.2	55.0-57.3
≥ 13 years	159	8.0	3.8-5.7	99	4.6	3.8-5.7	162	6.9	5.9-8.1	127	5.7	4.8-6.8	137	6.8	5.8-8.1	684	6.2	5.7-6.8
No information	13	0.7	0.4-1.2	6	0.2	0.1-0.5	8	0.3	0.1-0.6	1	<0.01	<0.01-0.4	1	<0.01	<0.01-0.3	29	0.3	0.2- 0.4
Single																			<0.01
Married/Common-law marriage	356	18.0	16.3-19.8	361	16.7	15.1-18.4	625	25.2	23.4-27.1	310	14.8	13.3-16.5	337	18.0	16.0-20.1	1,989	19.9	19.0-20.8
Separated/Divorced/idow	1,613	80.7	78.8-82.4	1,748	80.4	78.6-82.1	1,857	73.2	71.3-75.0	1,774	84.0	82.2-85.6	1.499	80.6	78.4-82.6	8,491	78.2	77.3-79.1
	22	1.1	0.7-1.7	50	2.2	1.6-3.0	37	1.4	1.0-1.9	24	1.1	0.7-1.8	26	1.4	0.9-2.1	159	1.5	1.3-1.9
Other	1	<0.01	<0.01-0.3	0	0.0	0.0	0	0.0	0.0	0	0.0	0.0	0	0.0	0.0	1	<0.01	<0.01-0.01
No information	3	0.1	<0.01-0.5	13	0.7	0.4-1.2	6	0.2	0.1-0.5	1	<0.01	<0.01-0.3	0	0.0	0.0	23	0.3	0.2- 0.5
Father´s age																			<0.01
≤19 years old	151	7.9	6.8- 9.3	177	8.3	7.2-9.7	153	6.1	5.2-7.2	137	6.5	5.5-7.7	108	5.7	4.7-7.0	726	7.1	6.5- 7.7
20 to 50 years old	1,710	88.8	87.2-90.1	1,898	89.2	87.7-90.5	2,285	92.2	91.0-93.3	1,915	91.8	90.4-92.9	1.687	92.5	91.1-93.6	9,495	90.8	90.1-91.4
>50 years old	65	3.3	2.6-4.2	53	2.5	1.9-3.2	38	1.7	1.2-2.3	36	1.7	1.2-2.4	34	1.8	1.3-2.5	226	2.1	1.9- 2.5
Planned pregnancy																			<0.01
No	1,361	68.1	66.0-70.2	1,343	61.8	59.6-63.9	1,654	65.1	63.2-67.1	1,248	59.4	57.2-61.5	1.203	65.7	63.2-68.0	6,809	63.9	62.8-65.0
Yes	630	31.7	29.6-33.8	825	38.1	36.0-40.3	871	34.8	32.8-36.8	856	40.4	38.2-42.6	651	33.9	31.6-36.3	3,833	36.0	35.0-37.0
No information	5	0.2	<0.01-0.6	2	0.1	<0.01-0.5	1	<0.01	<0.01-0.3	5	0.2	<0.01-0.6	7	0.4	0.2-0.9	20	0.1	<0.01-0.2
Type of pregnancy																			0.41
Single	1,976	99.0	98.4-99.4	2,150	99.1	98.6-99.4	2,493	98.6	98.0-99.0	2,081	98.7	98.0-99.1	1.840	98.9	98.3-99.3	10,540	98.8	98.6-99.1
Twin (two or more)	20	1.0	0.6- 1.5	22	0.9	0.6-1.4	32	1.3	0.9-2.0	28	1.3	0.9-2.0	22	1.1	0.7-1.7	124	1.1	0.9-1.4
No information	0	0.0	0.0	0	0.0	0.0	1	<0.01	<0.01-0.3	0	0.0	0.0	0	0.0	0.0	1	<0.01	<0.01-0.1
Type of delivery																			<0.01
Vaginal delivery	1,036	52.6	50.4-54.9	1,170	54.6	52.4-56.7	1,460	57.1	55.0-59.1	1,187	56.6	54.3-58.7	998	52.4	49.7-55.1	5,851	55.3	54.1-56.4
Forceps delivery	1	<0.01	<0.01-0.4	6	0.3	0.1-0.7	29	1.1	0.7-1.7	17	0.8	0.5-1.3	2	0.1	<0.01-0.4	55	0.6	0.4- 0.8
Caesarean	938	46.3	44.1-48.6	974	44.2	42.0-46.4	1,002	40.4	38.4-42.5	877	41.3	39.1-43.5	839	46.4	43.7-49.0	4,630	42.9	41.9-44.1
No information	20	1.0	0.6-1.5	22	0.9	0.6-1.4	33	1.4	1.0-2.0	28	1.3	0.9-2.0	23	1.1	0.8-1.7	126	1.2	0.9-1.4

	N¹ (n=1,996)			NE¹ (n=2,172)			SE¹ (n=2,526)			S¹ (n=2,109)			CO¹ (n=1,862)			TOTAL (n=10,665)			p- value
	f	%	CI95%	f	%	CI95%	f	%	CI95%	f	%	CI95%	f	%	CI95%	f	%	CI95%
Maternity allowed the presence of a companion														<0.01					<0,01
No	120	5.8	4.9- 7.0	173	7.5	6.4-8.7	112	4.4	3.6-5.3	39	1.9	1.4-2.6	183	9.9	8.1-12.1	627	5.7	5.2-6.2
Yes	1,874	94.1	93.0-95.1	1,994	92.2	91.0-93.3	2,412	95.5	94.6-96.3	2,069	98.0	97.3-98.6	1,668	89.6	87.4-91.4	10,017	94.1	93.6-94.6
No information	1	<0.01	<0.01-0.4	5	0.3	0.1-0.8	2	<0.01	<0.01-0.3	1	<0.01	<0.01-0.9	11	0.5	0.3-0.9	20	0.2	<0.01-0.3
Total	1,995	13.7	13.5-13.8	2,172	31.1	30.7-31.4	2,526	36.5	36.1-36.9	2,109	11.1	10.9-11.2	1,862	7.6	7.4-7.9	10,664	100.0	100.0
The pregnant woman had a companion during hospitalization																<0.01			<0,01
Não/Não se aplica	200	9.7	8.5- 11.1	278	12.2	10.9-13.7	298	11.6	10.4-13.0	142	6.7	5.7- 7.9	338	17.4	15.3-19.7	1,256	11.4	10.8-12.2
Sim	1,793	90.2	88.8-91.5	1,892	87.7	86.2-89.0	2,225	88.4	86.2-89.0	1,967	93.3	92.1-94.3	1,524	82.6	80.3-84.7	9,401	88.5	87.8-89.2
No information	1	<0.01	<0.01-0.4	2	0.1	<0.01-0.5	0	0.0	0.0	0	0.0	0.0	0	0.0	0.0	3	<0.01	<0.01-0.2
Total	1,994	13.7	13.5-13.8	2,172	31.1	30.7-31.5	2,523	35.6	36.1-36.9	2,109	11.1	10.9-11.2	1,862	7.6	7.5-7.9	10,660	100.0	100.0
Presence of full-time companion																<0.01			<0,01
Não/Não se aplica	642	30.7	28.7-32.8	665	29.1	27.2-31.2	700	28.3	26.5-30.2	396	18.6	16.9-20.3	738	37.8	35.2-40.5	3,131	28.6	27.5-29.6
Sim	1,347	69.1	67.0-71.0	1,511	70.6	68.5-72.5	1,815	71.5	69.6-73.3	1,710	81.3	79.6-83.0	1,120	62.0	59.3-64.6	7,503	71.2	70.2-72.2
No information	4	0.2	<0.01-0.6	6	0.3	0.1-0.6	5	0.2	<0.01-0.5	2	<0.01	<0.01-0.3	4	0.2	<0.01-0.6	21	0.2	0.1-0.3
Total	1,993	13.7	13.5-13.8	2,172	31.1	30.7-31.5	2,520	36.5	36.1-36.8	2,108	11.1	10.9-11.2	1,862	7.7	7.5-7.9	10,665	100.0	100.0
Time when the companion was not allowed to be present														0.09					0,09
Only in pre-delivery	22	5.0	3.3-7.6	43	11.3	8.4-15.1	56	14.8	11.4-19.0	41	16.9	12.6-22.3	41	11.9	8.6- 16.0	203	11.9	10.3-13.8
Only in delivery	172	40.9	35.9-45.8	142	39.8	34.6-45.3	53	15.2	11.4-19.8	44	20.4	15.5-26.3	127	31.8	26.0-38.2	538	29.2	26.8-31.7
Only in post-delivery	53	12.3	9.5-15.9	22	5.8	3.8-8.7	174	44.9	39.6-50.4	48	20.3	15.5-26.0	39	10.2	7.4- 13.8	336	22.1	20.0-24.3
Pre-delivery and delivery	31	6.5	4.5-9.1	18	4.6	2.8-7.3	10	3.4	1.7- 6.3	8	3.7	1.8-7.4	12	3.8	2.0-7.1	79	4.3	3.3-5.6
Pre-delivery and post-delivery	40	9.7	7.1-13.1	6	1.9	0.8-4.2	57	14.7	11.2-19.0	39	17.1	12.7-22.7	19	4.6	2.9-7.2	161	9.1	7.6- 10.8
Delivery and post-delivery	55	11.8	9.1- 15.1	74	22.4	18.0-27.6	18	5.2	3.1-8.3	34	12.7	9.1- 17.3	100	23.6	19.4-28.5	281	14.0	12.2-16.0
Pre-delivery, delivery and post-delivery	61	13.8	10.8-17.6	59	14.2	11.0-18.1	8	1.8	0.9-3.7	20	8.9	5.8- 13.5	52	14.1	10.7-18.4	200	9.4	8.1-10.9
Total	434	17.3	16.8-17.9	364	30.9	30.0-31.8	376	34.8	33.8-35.9	234	7.6	7.3- 7.8	390	9.4	8.8- 10.0	1,789	100.0	100.0
Companion at night																	<0.01		<0,01
No	48	11.0	8.3-14.4	5	1.5	0.6-3.8	72	17.5	14.0-21.7	17	6.1	3.8-9.7	27	5.9	4.0-8.5	169	9.6	8.1-11.2
Yes	390	89.0	85.6-91.7	366	98.5	96.2-99.4	322	82.5	78.3-86.0	235	93.9	90.3-96.2	369	94.1	91.5-96.0	1,682	90.4	88.8-91.9
Total	438	16.9	16.4-17.5	371	30.7	29.8-31.6	394	35.4	34.4-36.4	252	7.8	7.5-8.0	396	9.2	8.7-9.8	1,851	100.0	100.0
Companion
Child's father/Partner	483	27.7	25.6-29.9	394	21.1	19.2-23.0	1,306	58.2	56.0-60.4	1,514	76.2	74.1-78.2	684	45.8	42.9-48.7	4,381	43.7	42.6-44.8	<0.01
Friend	164	8.9	7.7-10.3	233	12.2	10.7-13.9	111	5.2	4.2-6.2	75	3.8	3.0-4.7	111	7.6	6.2- 9.2	694	7.9	7.2-8.5	<0.01
Mother	639	35.5	33.2-37.8	755	39.5	37.2-41.8	625	28.3	26.3-30.3	571	28.3	26.3-30,5	528	34.4	31.8-37.0	3,118	33.2	33.1-34.3	<0.01
Sister	291	16.1	14.4-17.9	326	18.0	16.2-19.9	261	11.8	10.5-13.3	167	8.3	7.1-9.6	197	12.3	10.7-14.1	1,242	13.9	13.1-14.8	<0.01
Doula	1	<0.01	<0.01-0.3	7	0.3	0.1-0.7	8	0.4	0.2-0.8	3	0.1	<0.01-0.4	2	0.1	<0.01-0.4	21	0.3	0.2- 0.4	0.16
Other person	540	30.3	28.1-32.5	667	35.2	33.0-37.5	464	20.6	18.9-22.5	364	18.4	16.7-20.3	373	23.9	21.7-26.3	2,408	26.5	25.4-27.5	<0.01
No information	3	0.2	<0.01-0.6	4	0.2	<0.01-0.5	5	0.2	<0.01-0.5	1	<0.01	<0.01-0.3	5	0.4	0.1-0.9	18	0.2	0.1- 0.3	0.42
Total	1,793	13.9	13.8-14.1	1,892	30.8	30.4-31.2	2,224	36.4	36.0-36.8	1,967	11.7	11.5-11.8	1,524	7.2	7.0-7.3	9,400	100.0	100.0
Reason for companion's absence
Maternity did not allow	66	35.4	28.7-42.6	88	30.3	25.0-36.3	46	15.6	11.7-20.4	14	10.1	6.0- 16.6	77	25.0	18.5-32.7	291	23.4	20.8-26.3	<0.01
No male companion allowed	52	25.2	19.6-31.9	55	19,9	15.4-25.3	22	7.4	4,9- 11,1	7	5.0	2.3-10.3	38	11.4	8.1-15.7	174	13.9	11.9-16.2	<0.01
Companion only for adolescents	14	7.4	4.3- 12.3	5	1.4	0.6- 3.4	7	2.3	1.1-4.8	0	0.0	0.00	3	0.8	0.2- 2.4	29	2.3	1.5-3.4	<0.01
Only companion over 18 years old	5	3.0	1.2- 7.1	7	2.4	1.1- 5.1	0	0.0	0.0	0	0.0	0.0	11	3.0	1.7- 5.5	23	1.5	0.9-2.4	<0.01
The pregnant woman did not know she could have a companion	5	3.2	1.3- 7.5	16	5.9	3.5- 9.8	26	8.7	5.8- 2.9	4	3.5	1.3-8.9	18	5.0	3.2- 8.0	69	6.4	4.9-8.3	0.18
She did not want to have a companion	10	5.0	2.6- 9.2	18	5.9	3.7-9.4	30	9.4	6.6- 13.4	23	17.5	11.7-25.4	41	11.6	8.4-15.6	122	8.5	7.0-10.4	<0.01
There was no one to be with her	41	20.5	15.4-26.8	47	17.6	13.3-22.8	100	34.8	29.2-40.7	53	36.0	28.4-44.4	96	27.2	22.1-33.0	337	26.7	23.9-29.7	<0.01
She had to pay to have a companion	0	0.0	0.0	0	0.0	0,0	1	0.1	<0.01-2.8	0	0.0	0,0	2	<0.01	0.1-1.7	3	0.2	<0.01-0.9	<0.01
Other reasons	32	15.1	10.8-20.8	74	27.9	22.5-33.9	87	28.8	23.7-34.5	55	38.4	30.6-46.9	84	26.8	20.3-46.9	332	27.3	24.4-30.4	<0.01
No information	4	2.0	0.7-5.2	8	4.0	1.9-8.3	8	2.4	1.2- 4.9	3	2.1	0.7- 6.4	9	2.5	1.3-4.8	32	2.9	1.9-4.4	0.92
Total	200	11.7	11.3-12.1	273	32.7	31.6-33.8	299	37.6	36.5-38.7	141	6.5	6.2-6.8	327	11.5	10.5-12.5	1,240	100.0	100.0

	N¹ (n=1,872)				NE¹ (n= 1,992)				SE¹ (n=2,409)				S¹ (n=2,069)				CO¹ (n=1,668)				TOTAL (n=10,010)
	f	Yes (%)	CI 95%	P value	f	Yes (%)	CI 95%	P value	f	Yes (%)	CI 95%	P value	f	Yes (%)	CI 95%	P value	f	Yes (%)	CI 95%	P value	f	Yes (%)	CI 95%	P value
Maher´s age (years old)				<0.01				<0.01				<0.01				<0.01				0.01				<0.01
≤19	452	98.0	96.2-99.0		478	97.9	96.1-98.8		438	95.7	93.4-97.2		392	98.4	96.5-99.2		325	94.8	91.9-96.6		2,085	97.0	96.1-97.7
20 to 35	1,267	95.4	94.1-96.4		1,318	94.7	93.3-95.8		1,666	92.5	91.1-93.8		1,409	94.5	93.2-95.6		1,180	92.2	90.5-93.6		6,84	93.8	93.1-94.4
>35	153	94.1	88.5-97.5		196	92.0	87.3-95.0		305	87.8	83.5-91.1		268	93.8	89.9-96.3		163	87.0	81.0-91.3		1,085	90.3	88.1-92.2
Mother´s skin color				0.85				<0.01				<0.01				0.32				0.45				0.02
White	217	95.8	92.0-97.9		317	95.7	92.7-97.4		709	92.7	90.4-94.5		1,328	95.9	94.7-96.9		294	93.4	89.5-95.9		2,865	94.4	93.3-95.3
Black	155	96.8	92.9-98.6		300	93.2	89.5-95.7		359	92.1	88.9-94.3		206	93.0	88.3-95.8		205	89.0	84.1-92.5		1,225	92.7	91.0-94.2
Brown-skinned	1,431	96.1	94.9-97.0		1,291	95.4	94.1-96.4		1,291	92.3	90.6-93.7		509	94.9	92.7-96.4		1,070	92.6	90.9-94.0		5,592	94.2	93.4-94.9
Asian	31	94.1	79.1-98.5		42	94.9	81.3-98.7		27	96.8	80.1-99.6		12	82.3	37.4-97.3		61	92.1	82.2-96.7		173	94.2	88.9-97.1
Indigenous	28	89.1	73.6-96.0		19	100.0	100.0		6	86.9	43.2-98.3		6	66.9	26.9-91.7		18	84.0	60.2-94.8		77	92.2	85.1-96.1
No information	10	90.3	53.9-98.7		21	100.0	100.0		17	100.0	100.0		8	92.5	58.8-99.1		20	94.1	75.4-98.8		76	97.7	93.5-99.2
Education level of the mother (years)				0.33				<0.01				<0.01				<0.01				<0.01				<0.01
≤ 4	113	92.3	86.1-95.9		170	92.5	87.3-95.6		80	85.7	75.6-92.0		95	89.9	82.4-94.4		63	80.4	68.4-88.6		521	90.1	86.8-92.6
5-9	624	96.0	94.2-97.3		687	93.3	91.1-95.0		677	88.6	85.8-91.0		714	92.8	90.6-94.5		498	91.0	88.2-93.2		3,200	91.9	90.7-93.0
10-12	972	96.5	95.1-97.5		1,038	96.5	95.1-97.5		1,486	94.4	93.0-95.4		1,136	96.7	95.4-97.6		982	93.2	91.5-94.6		5,614	95.4	94.7-96.0
≥ 13	151	96.3	91.9-98.4		92	100.0	100.0		159	95.6	90.5-98.0		123	99.1	93.8-99.9		124	94.9	89.6-97.6		649	97.0	95.0-98.3
No information	11	72.5	40.2-91.2		5	81.8	32.8-97.6		7	76.6	38.6-94.4		1	100.0	100.0		1	100.0	100.0		25	77.6	57.0-90.0
Current maternal marital status				<0.01				0.39				0.09				<0.01				0.02				<0.01
Single	334	96,2	93.5-97.8		330	94.8	91.8-96.8		593	89.8	87.0-92.1		304	94.0	90.3-96.4		292	88.6	84.5-91.7		1,853	92.2	90.7-93.5
Married/Common-law marriage	1,513	95,9	94.8-96.8		1,602	95.5	94.4-96.4		1,776	93.5	92.1-94.6		1,740	95.4	94.3-96.3		1,352	93.0	91.5-94.2		7,983	94.7	94.0-95.2
Separated/ Divorced/Widow	20	91,2	72.3-98.0		47	86.4	72.5-93.9		34	90.6	73.5-97.1		24	92.9	74.9-98.3		24	92.4	73.5-98.1		149	89.2	81.9-93.8
Other	1	100,0	100.0		,	.	.		,	.	.		,	.	.		,	.	.		1	100.0	100.0
No information	3	100,0	100.0		13	92.5	61.4-99.0		5	82.3	34.0-97.7		1	100.0	100.0		,	.	.		22	91.0	69.6-97.8
Father´s age (years old)				0.13				<0.01				0.04				<0.01				0.42				<0.01
≤19	146	96,7	92.1-98.6		160	97.6	93.3-99.1		151	95.9	91.1-98.2		137	98.8	95.4-99.7		97	91.8	84.8-95.7		691	96.7	94.8-97.9
20 to 50	1,604	96,3	95.2-97.1		1,746	95.2	94.0-96.1		2,175	92.8	91.5-93.8		1,875	95.1	94.0-96.0		1,513	92.7	91.3-93.9		8,913	94.2	93.6-94.8
>50	57	86,2	75.1-92.8		48	100.0	100.0		37	78.4	60.1-89.7		36	92.3	78.4-97.5		31	82.6	65.7-92.2		209	89.0	82.6-93.2
Planned pregnancy				0.51				0.02				0.01				0.12				0.99				<0.01
No	1,279	95,7	94.4-96.7		1,243	94.4	92.9-95.6		1,574	91.6	90.1-93.0		1,220	94.6	93.2-95.8		1,083	92.3	90.5-93.7		6,399	93.4	92.7-94.1
Yes	590	96,5	94.7-97.7		745	96.4	94.8-97.5		834	94.1	92.2-95.6		844	95.9	94.3-97.0		577	92.0	89.4-94.0		3,590	95.2	94.3-96.0
No information	3	73,4	19.9-96.8		2	100.0	100.0		1	100.0	100.0		5	100.0	100.0		7	100.0	100.0		18	96.6	78.5-99.5
Type of pregnancy				0.91				0.17				<0.01				<0.01				0.88				<0.01
Single	1,856	95,9	94.9-96.7		1,972	95.3	94.2-96.1		2,379	92.5	91.3-93.5		2,042	95.1	94.0-96.0		1,647	92.2	90.8-93.4		9,896	94.1	93.5-94.6
Twin	16	96,4	77.8-99.5		20	85.6	62.9-95.4		29	93.5	77.2-98.4		27	100.0	100.0		21	91.4	71.2-97.9		113	92.7	84.9-96.6
She does not know/does not want to inform	,	.	.		,	.	.		1	100.0	100.0		,	.	.		,	.	.		1	100.0	100.0
Type of delivery				0.39				0.49				0.18				0.63				0.24				0.04
Vaginal	968	95,5	94.0-96.6		1,072	94.8	93.2-6.0		1,393	91.7	90.1-93.1		1,171	94.9	93.5-96.1		897	91.4	89.4-93.0		5,501	93.5	92.7-94.2
Forceps	1	100,0	100.0		5	100.0	100.0		28	97.6	84.3-99.7		17	100.0	100.0		2	100.0	100.0		53	98.4	89.1-99.8
Cesarean	886	96,4	94.9		895	95.8	94.3-97.0		956	93.4	91.5-94.9		854	95.2	93.5-96.5		747	93.2	91.1-94.8		4,338	94.8	94.0-95.5
She does not know/does not want to inform	16	96,4	97.5		20	85.6	62.9-95.4		30	93.7	77.8-98.4		27	100.0	0.0		22	91.7	72.0-97.9		115	92.8	85.1-96.7