ABSTRACT

OBJECTIVE

To analyze if the presence of a companion favors the use of best practices in the delivery care in the South region of Brazil.

METHODS

This is a cross-sectional analysis of the longitudinal study Nascer no Brasil. We analyzed data from 2,070 women from the South region of Brazil who went into labor. The data were collected between February and August 2011, by interviews and medical records. We performed a bivariate and multivariate analysis, calculating the crude and adjusted prevalence ratios using Poisson regression with robust variance estimation. The level of significance adopted was 5%.

RESULTS

Most women had a companion during labor (51.7%), but few remained during delivery (39.4%) or cesarean section (34.8%). Less than half of the women had access to several recommended practices, while non-recommended practices continue to be performed. In the model adjusted for age, education level, source of payment for the delivery, parity, and score of the Brazilian Association of Market Research Institutes, the presence of a companion was statistically associated with a greater supply of liquids and food (aPR = 1.34), dietary prescription (aPR = 1.34), use of non-pharmacological methods for pain relief (aPR = 1.37), amniotomy (aPR = 1.10), epidural or spinal analgesia (aPR = 1.84), adoption of non-lithotomy position in the delivery (aPR = 1.77), stay in the same room during labor, delivery, and postpartum (aPR = 1.62), skin-to-skin contact in the delivery (aPR = 1.81) and cesarean section (PR = 2.43), as well as reduced use of the Kristeller maneuver (aPR = 0.67), trichotomy (aPR = 0.59), and enema (aPR = 0.49).

CONCLUSIONS

In the South region of Brazil, most women do not have access to the best practices in addition to undergoing several unnecessary interventions. The presence of a companion is associated with several beneficial practices and the reduction in some interventions, although other interventions are not impacted.

DESCRIPTORS
Humanizing Delivery; Humanization of Assistance; Patient Rights; Evidence-Based Practice; Maternal-Child Health Services

INTRODUCTION

The fragmented, curative, and hospital health care model characterized the construction of the Brazilian health system, privileging and consolidating individual medical practices, financed by the social security system, to the detriment of collective actions of health promotion and prevention. In this scenario, modern obstetrics and the technocratic model of labor care were easily legitimized and the complex event of delivery and birth was separated from the family and community life to become a medical and hospital matter²³23. Maia MB. Humanização do parto: políticas públicas, comportamento organizacional e ethos profissional. Rio de Janeiro: Editora Fiocruz; 2010.. The adoption of obstetric practices that arose with the institutionalization of labor, in order to control the physiological process of birth and rationalize work patterns, gradually characterized the parturition process as pathological and denied the intrinsic ability to give birth to the women⁹9. Davim RMB, Torres GV, Dantas JC, Melo ES, Paiva CP, Vieira D, et al. Banho de chuveiro como estratégia não farmacológica no alívio da dor de parturientes. Rev Eletr Enf. 2008 [cited 2017 Jun 16];10(3):600-9. Available from: http://www.fen.ufg.br/revista/v10/n3/v10n3a06.htm
http://www.fen.ufg.br/revista/v10/n3/v10... .

From a physiological, family, and social event, delivery and birth become a medical act, in which the risk of pathologies and complications becomes the rule and not the exception²³23. Maia MB. Humanização do parto: políticas públicas, comportamento organizacional e ethos profissional. Rio de Janeiro: Editora Fiocruz; 2010.. In this Brazilian model, practices that are considered to be harmful by the World Health Organization³⁰30. Organização Mundial da Saúde, Saúde Reprodutiva e da Família, Unidade de Maternidade Segura, Saúde Materna e Neonatal. Assistência ao parto normal: um guia prático. Brasília (DF): Ministério da Saúde; 1996. (WHO) and that do not have scientific evidence for their use are used, such as the routine use of a peripheral venous catheter (74.9%), zero diet (74.8%), lithotomy position (91.7%), routine use of oocytes (36.4%) and amniotomy (39.1%), Kristeller maneuver (36.1%), and excessive number of episiotomies (53.5%). However, the best practices that should be encouraged are not fully implemented, such as the use of non-pharmacological methods (NPM) for pain relief (26.7%) and the respect for the continuous presence of a companion of the woman's choice (18.8%)¹⁰10. Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa nacional Nascer no Brasil. Cad Saude Publica. 2014;30 Supl 1:S140-53. https://doi.org/10.1590/0102-311X00127013
https://doi.org/10.1590/0102-311X0012701... ^,2121. Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura- Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica. 2014;30 Supl 1:S17-32. https://doi.org/10.1590/0102-311X00151513
https://doi.org/10.1590/0102-311X0015151... . Considering that the concept of best practices in labor care is not yet described in the literature, they are understood here as the adoption of the recommendations of the WHO³⁰30. Organização Mundial da Saúde, Saúde Reprodutiva e da Família, Unidade de Maternidade Segura, Saúde Materna e Neonatal. Assistência ao parto normal: um guia prático. Brasília (DF): Ministério da Saúde; 1996., the implementation of scientific evidence, and the elimination of unnecessary interventions.

The Brazilian Ministry of Health has sought to qualify labor and birth care and support the implementation of scientific evidence with public health policies. One of these policies is the Rede Cegonha²⁵25. Ministério da Saúde (BR). Portaria N° 1459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde – SUS-, a Rede Cegonha. Brasília (DF); 2011 [cited 2017 Jun 16]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011.html
http://bvsms.saude.gov.br/bvs/saudelegis... , which is a network that aims to ensure safe delivery and birth to women and newborns, including support of companions of the women's free choice.

In a systematic review of support during birth, women who receive continuous support during delivery are more likely to have spontaneous vaginal birth and less prolonged labor, they are less likely to undergo intrapartum analgesia/anesthesia, instrumental vaginal, or cesarean delivery, and they are less likely to have a baby with low fifth-minute Apgar score¹⁷17. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;(7):CD003766. https://doi.org/10.1002/14651858.CD003766.pub5
https://doi.org/10.1002/14651858.CD00376... .

In a randomized clinical trial conducted in Brazil, mothers with a companion of their choice had greater overall satisfaction with the labor and delivery experience than those in the control group. However, we need to evaluate the influence of a companion in the adoption of best practices in delivery care ³3. Brüggemann OM, Parpinelli MA, Osis MJD, Cecatti JG, Carvalhinho Neto AS. Support to woman by a companion of her choice during childbirth: a randomized controlled trial. Reprod Health. 2007;4:5. https://doi.org/10.1186/1742-4755-4-5
https://doi.org/10.1186/1742-4755-4-5... . In a qualitative research, women have reported that the companion provides security and the necessary emotional support, using words and gestures of care and comfort²⁹29. Motta CCL, Crepaldi MA. O pai no parto e apoio emocional: a perspectiva da parturiente. Paidéia (Ribeirão Preto). 2005;15(30):105-18. https://doi.org/10.1590/S0103-863X2005000100012
https://doi.org/10.1590/S0103-863X200500... ^,3131. Perdomini FRI, Bonilha ALL. A participação do pai como acompanhante da mulher no parto. Texto Contexto Enferm. 2011;20(3):445-52. https://doi.org/10.1590/S0104-07072011000300004
https://doi.org/10.1590/S0104-0707201100... . It has been reported that the support of a companion, associated with best practices such as showering and movement, becomes a factor capable of reducing pain and duration of labor⁵5. Brüggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayescki ME. A inserção do acompanhante de parto nos serviços públicos de saúde de Santa Catarina, Brasil. Esc Anna Nery. 2013;17(3):432-8. https://doi.org/10.1590/S1414-81452013000300005
https://doi.org/10.1590/S1414-8145201300... ^,3535. Silva LM, Barbieri M, Fustinoni SM. Vivenciando a experiência da parturição em um modelo assistencial humanizado. Rev Bras Enferm. 2011;64(1):60-5. https://doi.org/10.1590/S0034-71672011000100009
https://doi.org/10.1590/S0034-7167201100... .

The Brazilian Ministry of Health recognizes the benefits of this practice and the publication of Law 11,108, in 2005^aaPresidência da República (BR), Casa Civil, Subchefia para Assuntos Jurídicos. Lei N° 11.108, de 7 de abril de 2005. Altera a Lei n° 8.080, de 19 de setembro de 1990, para garantir às parturientes o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde - SUS. Brasília (DF); 2005 [citado 16 jun 2017]. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2005/lei/l11108.htm , ensures the right to a companion to the mothers during labor, delivery, and immediate postpartum within the Unified Health System (SUS), including its own network or a contracted network. Despite this, many women are still deprived of this right. General data from the research Nascer no Brasil suggest that Brazilian women are being exposed to the risks of iatrogenesis and the continuous presence of a companion is still not ensured for most of them (81.2%), despite being considered a marker of safety and quality of care¹⁰10. Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa nacional Nascer no Brasil. Cad Saude Publica. 2014;30 Supl 1:S140-53. https://doi.org/10.1590/0102-311X00127013
https://doi.org/10.1590/0102-311X0012701... .

Thus, the objective of this study was to analyze if the presence of a companion favors the use of best practices in delivery care in the South region of Brazil.

METHODS

This is a cross-sectional analysis of a longitudinal study, carried out from the research: “Nascer no Brasil: inquérito nacional sobre parto e nascimento”. That study has considered eligible all health institutions in Brazil that registered at least 500 births per year according to the Live Birth Information System (SINASC), 2007^bbMinistério da Saúde (BR). Sistema de Informação da Atenção Básica -SIAB. Brasília (DF); 2008 [citado 16 jun 2017]. Disponível em: http://www2.datasus.gov.br/SIAB/index.php?area=04A01&item=1 . The sample were mothers hospitalized because of delivery and who had newborns at 22 gestational weeks or more, or who weighted more than 500 g at birth, with the exception of mothers whose delivery had occurred at home, in the transportation to the maternity, or in another health unit other than the one selected²⁰20. Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, et al. Birth in Brazil: national survey into labour and birth. Reprod Health. 2012;9:15. https://doi.org/10.1186/1742-4755-9-15
https://doi.org/10.1186/1742-4755-9-15... .

Data collection was conducted in 2011 and 2012 with interviews using electronic forms. The first questionnaire was completed during interviews with the mothers within the first 24 hours after birth. The second questionnaire was filled with data available in the maternal medical records after discharge from the hospital or on the 42nd day for the woman and on the 28th day for the newborn that remained hospitalized. A total of 50 supervisors and 200 interviewers participated in the study, which makes up 27 state teams. Detailed information on data collection is described in another publication²⁰20. Leal MC, Silva AAM, Dias MAB, Gama SGN, Rattner D, Moreira ME, et al. Birth in Brazil: national survey into labour and birth. Reprod Health. 2012;9:15. https://doi.org/10.1186/1742-4755-9-15
https://doi.org/10.1186/1742-4755-9-15... .

The sample size was 90 mothers and their newborns for each health institution randomly chosen, being representative of the Brazilian regions. The sample was stratified by geographic macroregion, type of municipality (capital/interior), and hospital administration (public, mixed, or private). The sample amounted to 23,940 women, distributed in 191 municipalities in all the states of the country. The sample size in each stratum was calculated based on the cesarean rate in Brazil in 2007 of 46.6%, with a significance of 5% to detect differences of 14% (difference between mixed hospitals and private hospitals) with a power of 80%. The sample design of the Nascer no Brasil has been described in detail by Vasconcellos et al.⁴⁰40. Vasconcellos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saude Publica. 2014;30 Supl 1:49-58. https://doi.org/10.1590/0102-311X00176013
https://doi.org/10.1590/0102-311X0017601...

For this study, we selected data from the South region of Brazil, collected between February and August 2011, in 46 health institutions randomly chosen (17 from the State of Paraná, 13 from the state of Santa Catarina, and 16 from the state of Rio Grande do Sul) amounting to 4,139 women. We included those that went into labor (spontaneous or induced), amounting to a sample of 2,070 women. We considered in labor women who had cervical dilatation of four centimeters or more.

The data used in this study emerged from two instruments: a questionnaire from the hospital interview with the mother and an instrument for collecting data from the maternal medical record.

Each obstetric practice was considered as an outcome variable. The outcome variables selected from the interview with the mother were: offering of liquid or food (yes, no), free movement (yes, no), use of NPM for pain relief (yes, no, considering bath, shower, labor ball, massage, squatting stool, rocking chair), amniotomy (yes, no), tricotomy (yes, no), enema (yes, no), non-lithotomy position (yes - lying on the side, sitting/reclining, in the bath, four supports, squatting, standing; no – lithotomy) Kristeller maneuver (yes, no), PPP room – prepartum/delivery/postpartum (yes, no), and skin-to-skin contact (yes, no). The outcome variables selected from the maternal medical report were: dietary prescription (yes, no), oxytocin prescription (yes, no), epidural or spinal analgesia (yes, no), and episiotomy (yes, no).

The two main variables of exposure were: companion in the labor and companion in the delivery, being constructed compositely, with data from the interview and the maternal medical record.

To test the association between the presence of the companion and best practices (outcomes) in labor and delivery care, multivariate models were constructed (one for each outcome), adjusted by five variables identified in the literature²¹21. Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura- Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica. 2014;30 Supl 1:S17-32. https://doi.org/10.1590/0102-311X00151513
https://doi.org/10.1590/0102-311X0015151... . The adjustment variables, selected from the interview with the mother, were: age (12 to 19, 20 to 34 years, 35 or more), education level (incomplete elementary school, complete elementary school, high school, complete higher education or more), and socioeconomic score of the ABIPEME – Brazilian Association of Market Research Institutes (class A+B, class C, class D+E). The adjustment variables selected from the maternal medical records were: parity (primiparous, multiparous) and source of payment for delivery (public, private). The hypothesis studied was that the presence of a companion favors the best practices.

The economic classification criterion adopted to generate the ABIPEME variable was the one recommended by the Brazilian Association of Research Companies (ABEP), which estimates the buying power of urban individuals and families based on the ownership of goods and the education level of the head of the family¹⁵15. Gama SGN, Viellas EF, Schilithz AOC, Theme Filha MM, Carvalho ML, Gomes KRO, et al. Fatores associados à cesariana entre primíparas adolescentes no Brasil, 2011-2012. Cad Saude Publica. 2014;30 Supl 1:S117-27. https://doi.org/10.1590/0102-311X00145513
https://doi.org/10.1590/0102-311X0014551... .

We used the statistical program Stata/SE, version 11. We applied descriptive statistics and the chi-square test used in the comparison of proportions. To estimate the crude and adjusted prevalence ratios and their respective 95% confidence intervals (95%CI), we used Poisson regression with robust variance. We considered that the variables that were part of the adjusted model belonged to the same hierarchical level. Values of p < 0.05 were considered significant.

This research is guided by Ordinance 196/96 of the National Health Council, which provides guidelines and standards for human research (CEP/ENSP - Protocol 92/10). All mothers signed the informed consent.

RESULTS

The sociodemographic and obstetric characteristics of the participants who went into labor and, therefore, were included in this study (n = 2,070) are presented in Table 1. Most women were in the age group of 20 to 34 years (67.8%), socioeconomic class C (60.3%), multiparous (57.0%), had vaginal delivery (85.0%), with delivery in the public sector (89.7%), and remained with a companion during labor (51.7%). However, less than half had a companion during delivery (39.4%) or cesarean section (34.8%). Regarding education level, few women had complete higher education (5.7%).

Regarding obstetric practices performed during labor, less than half of the women were allowed to drink or eat during this period (32.7%). Most of them were able to move (59.2%), but few used a NPM for pain relief (32.7%) – bathtub, shower, labor ball, massage, squatting stool, rocking chair. Most received oxytocin (52.2%) and had their membranes ruptured artificially (51.2%). Most of them had trichotomy (43.6%) and enema (37.0%), and few received epidural or spinal anesthesia (9.1%). During delivery, very few of them could choose a different lithotomy position to give birth (5.1%), and many received an episiotomy (44.1%) or uterine fundal pressure to push the baby (Kristeller maneuver) (27.6%). Few women remained in the same room during prepartum, delivery, and postpartum (PPP room) (16.4%) and less than half had skin-to-skin contact with the baby soon after birth (43.3%).

Table 2 presents the crude and adjusted prevalence and prevalence ratios of the obstetric practices performed during labor, according to the presence of a companion. The presence of a companion during labor, after adjusting for the variables of age, education level, source of payment of delivery, parity, and ABIPEME score, was significantly associated with a greater supply of liquid or food (aPR = 1.34, 95%CI 1.10–1.63), prescription of some type of diet (aPR = 1.34, 95%CI 1.15–1.57), use of NPM for pain relief (aPR = 1.37, 95%CI 1.21–1.56), and use of amniotomy (aPR = 1.10, 95%CI 1.01–1.21) and epidural or spinal analgesia (aPR = 1.84, 95%CI 1.33–2.54). In addition, the presence of a companion during labor was associated with reduced use of trichotomy (aPR = 0.59, 95%CI 0.53–0.65) and enema (aPR = 0.49, 95%CI 0.43–0.56).

Table 3 presents the crude and adjusted prevalence and prevalence ratios of the obstetric practices performed during labor, according to the presence of a companion during delivery/birth. During delivery, the presence of a companion remained significantly associated with the adoption of different lithotomy positions by the woman (PR = 1.77, 95%CI 1.16–2.72), stay in the PPP room (PR = 1.62, 95%CI 1.31–2.00), and skin-to-skin contact between the mother and the baby soon after birth, both in the delivery (PR = 0.81, 95%CI 1.64–1.99) and cesarean section (PR = 2.43, 95%CI 1.22–4.85). In addition, the Kristeller maneuver was significantly less performed in women who were with a companion (PR = 0.67, 95%CI 0.58–0.78).

The frequency of some interventions that are considered unnecessary or inappropriate, such as episiotomy and oxytocin, were not significantly affected by the presence of a companion.

DISCUSSION

The results show that most women in the South region do not have access to the best practices in the birth and delivery care. The presence of a companion was more frequent in labor than in delivery or cesarean section. We identified high rates of enema, trichotomy, Kristeller maneuver, amniotomy, oxytocin, episiotomy, and water and food restriction. Moreover, little more than half of the mothers had freedom of position and movement and very few managed to give birth in a non-lithonomy position. Most did not have access to the NPM for pain relief, PPP rooms, and skin-to-skin contact with the newborn soon after delivery. However, the presence of a companion in the labor implied a greater supply of liquids or food, dietary prescription, NPM for pain relief, and reduced trichotomy and enema. In the delivery, the presence of a companion was associated with the adoption of a non-lithonomy position, PPP room, skin-to-skin contact, and reduced use of the Kristeller maneuver.

The fact that companions are more present during labor than in the delivery is similar to the findings of a study carried out in the State of Santa Catarina, Brazil, in which the stay of a companion in the delivery room was not allowed in the same proportion as in the other obstetrical service sites⁵5. Brüggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayescki ME. A inserção do acompanhante de parto nos serviços públicos de saúde de Santa Catarina, Brasil. Esc Anna Nery. 2013;17(3):432-8. https://doi.org/10.1590/S1414-81452013000300005
https://doi.org/10.1590/S1414-8145201300... . This restriction may be because many professionals do not consider delivery/birth as a family event, but rather a medical act, which should be cared for in a “sterile” environment, without the presence of laypersons, because of their potential for risk and the possibility of interventions in the event of complications.

Trichotomy and enema, performed in almost half of the women, are harmful and ineffective practices that should be discouraged and eliminated because they do not have a significant beneficial effect on the rates of infection or dehiscence of the perineal wound or other neonatal infections²2. Basevi V, Lavender T. Routine perineal shaving on admission in labor. Cochrane Database Syst Rev. 2014;(11):CD001236. https://doi.org/10.1002/14651858.CD001236.pub2
https://doi.org/10.1002/14651858.CD00123... .

The Kristeller maneuver was widely used, despite the lack of sufficient evidence to support its recommendation, being similar to other Brazilian studies¹¹11. D'Orsi E, Chor D, Giffin K, Angulo-Tuesta A, Barbosa GP, Gama AS, et al. Qualidade da atenção ao parto em maternidades do Rio de Janeiro. Rev Saude Publica. 2005;39(4):645-54. https://doi.org/10.1590/S0034-89102005000400020
https://doi.org/10.1590/S0034-8910200500... ^,2121. Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura- Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica. 2014;30 Supl 1:S17-32. https://doi.org/10.1590/0102-311X00151513
https://doi.org/10.1590/0102-311X0015151... . In addition to providing greater maternal discomfort, this maneuver brings deleterious effects to the uterus, perineum, and fetus and it is ineffective in reducing the second stage of labor¹1. Api O, Balcin ME, Ugurel V, Api M, Turan C, Unal O. The effect of the uterine fundal pressure on the duration of the second stage of labor: a randomized controlled trial. Acta Obstet Gynecol Scand. 2009;88(3):320-4. https://doi.org/10.1080/00016340902730326
https://doi.org/10.1080/0001634090273032... ^,2424. Matsuo K, Shiki Y, Yamasaki M, Shimoya K. Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration. Arch Gynecol Obstet. 2009;280(5):781-86. https://doi.org/10.1007/s00404-009-1015-2
https://doi.org/10.1007/s00404-009-1015-... .

Although delivery is a physiological event, other interventions, such as routine oxytocin infusion and amniotomy, have been performed to prevent prolonged labor. In this study, half of the women received at least one of the two interventions, even though there was insufficient evidence to justify these practices³³33. Schmitz T, Meunier E. Mesures à prendre pendant le travail pour réduire le nombre d'extractions instrumentales. J Gynecol Obstet Biol Reprod (Paris). 2008;37 Suppl 8:S179-87. https://doi.org/10.1016/S0368-2315(08)74756-2
https://doi.org/10.1016/S0368-2315(08)74... .

In addition to the risks associated with the liberal use of oxytocin for the correction of the dynamics during labor, including maternal exhaustion, uterine hyperstimulation, rupture of the uterus or placenta, and fetal distress²²22. Lovold A, Stanton C. Use of oxytocin and misoprostol for induction or augmentation of labor in low – resource settings: a working paper review. Washington (DC): Department of Population, Family and Reproductive Health; 2008 [cited 2017 Jun 16]. Available from: http://www.pphprevention.org/files/Induction_Augmentationworkingpaper
http://www.pphprevention.org/files/Induc... , continuous intravenous infusion also limits the freedom of movement of the women, which may prolong the duration of labor. In relation to early amniotomy, a review study has concluded that this procedure should not be routinely recommended and it should be a decision discussed with the women before using it³⁶36. Smith RMD, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev. 2013;(6):CD006167. https://doi.org/10.1002/14651858.CD006167.pub4
https://doi.org/10.1002/14651858.CD00616... .

The high prevalence of episiotomy in Latin America⁶6. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009;(1):CD000081. https://doi.org/10.1002/14651858.CD000081.pub2
https://doi.org/10.1002/14651858.CD00008... was also found here. Episiotomy is essentially characterized as a second-degree laceration, capable of breaking down several muscle groups and increasing the occurrence of third and fourth degree lacerations³⁸38. Steiner N, Weintraub AY, Wiznitzer A, Sergienko R, Sheiner E. Episiotomy: the final cut? Arch Ginecol Obstet. 2012;286(6):1369-73. https://doi.org/10.1007/s00404-012-2460-x
https://doi.org/10.1007/s00404-012-2460-... . Ideally, the rate of episiotomy should not exceed 10%, a goal considered reasonable by the WHO³⁰30. Organização Mundial da Saúde, Saúde Reprodutiva e da Família, Unidade de Maternidade Segura, Saúde Materna e Neonatal. Assistência ao parto normal: um guia prático. Brasília (DF): Ministério da Saúde; 1996.. Several countries have pursued a restrictive policy for episiotomy. In the USA, the percentage dropped significantly from 17.3% in 2006 to 11.6% in 2012¹³13. Friedman AM, Ananth CV, Prendergast E, D'Alton ME, Wright JD. Variation in and factors associated with use of episiotomy. JAMA. 2015;313(2):197-9. https://doi.org/10.1001/jama.2014.14774
https://doi.org/10.1001/jama.2014.14774... . However, high rates are still prevalent; in a study carried out in Spain, the rate was 33.5% in 2011³⁹39. Valero SP. Episiotomía en partos vaginales eutócicos en el Hospital Universitario “La Ribera”. Nure Investig. 2013 [cited 2017 Jun 20];(63):1-6. Available from: http://www.nureinvestigacion.es/OJS/index.php/nure/article/view/620/609
http://www.nureinvestigacion.es/OJS/inde... , and in a research conducted in England, the rate was 25%³²32. Redshaw M, Heikkila K. Delivered with care: a national survey of women's experience of maternity care 2010. Oxford (UK): University of Oxford, National Perinatology Epidemiology Unity; 2010.

Few of the women studied received some type of diet. This may be related to the resistance of health professionals in relation to water and food intake by the mother, although scientific evidence shows deleterious effects of fasting on labor^ccAmorim M. Assistência ao parto baseada em evidências. Rio de Janeiro; 2012 [citado 16 jun 2017]. Disponível em: http://estudamelania.blogspot.com.br/2012/09/assistencia-ao-parto-baseada-em.html and the WHO considers the provision of oral fluids a useful practice that should be stimulated³⁰30. Organização Mundial da Saúde, Saúde Reprodutiva e da Família, Unidade de Maternidade Segura, Saúde Materna e Neonatal. Assistência ao parto normal: um guia prático. Brasília (DF): Ministério da Saúde; 1996..

Almost half of the women studied did not move during labor, despite movement and vertical positions reducing the pain and duration of that period¹⁹19. Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2009;(2):CD003934. https://doi.org/10.1002/14651858.CD003934.pub2
https://doi.org/10.1002/14651858.CD00393... .

In addition to these various interventions, we highlight that most women did not have access to NPM for pain relief, despite the efficacy of these methods⁷7. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009;2:CD000111. https://doi.org/10.1002/14651858.CD000111.pub3
https://doi.org/10.1002/14651858.CD00011... . These results differ from other studies with smaller samples, performed in public hospitals in the South region of Brazil, in which women had more access to NPM, indicating that these experiences are still specific and depend on the care philosophy⁵5. Brüggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayescki ME. A inserção do acompanhante de parto nos serviços públicos de saúde de Santa Catarina, Brasil. Esc Anna Nery. 2013;17(3):432-8. https://doi.org/10.1590/S1414-81452013000300005
https://doi.org/10.1590/S1414-8145201300... ^,1616. Gayeski ME, Brüggemann OM, Monticelli M, Santos EKA. Application of nonpharmacologic methods to relieve pain during labor: the point of view of primiparous women. Pain Manag Nurs. 2015;16(3):273-84. https://doi.org/10.1016/j.pmn.2014.08.006
https://doi.org/10.1016/j.pmn.2014.08.00... .

The PPP system and skin-to-skin contact in the delivery room occurred in less than half of the mothers. The PPP room allows the presence of persons of the mother's choice and a humanized and safe care for the mother-baby binomial³⁷37. Stancato K, Vergílio MSTG, Bosco CS. Avaliação da estrutura e assistência em sala de pré-parto, parto e pós-parto imediato-PPP de um hospital universitário. Cienc Cuid Saude. 2011;10(3):541-8. https://doi.org/10.4025/cienccuidsaude.v10i3.12656
https://doi.org/10.4025/cienccuidsaude.v... . Early skin-to-skin contact provides immediate and long-term benefits as it improves the effectiveness of the first feeding, regulates the body temperature of the baby, and contributes to maternal attachment²⁷27. Moore ER, Anderson GC, Bergman N, Dowswell. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012;(5):CD003519. https://doi.org/10.1002/14651858.CD003519.pub3
https://doi.org/10.1002/14651858.CD00351... .

In this highly interventionist reality, the presence of a companion was associated with a reduction in the use of unnecessary or inadequately used interventions, either in labor, such as the use of amniotomy, trichotomy, and enema, or in the delivery, such as reducing the use of Kristeller maneuver. These practices were not evaluated in the systematic review updated in 2013¹⁷17. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;(7):CD003766. https://doi.org/10.1002/14651858.CD003766.pub5
https://doi.org/10.1002/14651858.CD00376... .

In addition, the presence of a companion during labor favored the supply of liquids and food and the use of NPM for pain relief. In the delivery, the companion favored the adoption of a non-lithonomy position, the care of the woman in the PPP system, and skin-to-skin contact soon after birth. In women who underwent cesarean section, early skin-to-skin contact was 2.4 times more likely when a companion was present. The implementation of these best practices, supported by scientific evidence, was also not evaluated in the systematic review on the support at birth¹⁷17. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;(7):CD003766. https://doi.org/10.1002/14651858.CD003766.pub5
https://doi.org/10.1002/14651858.CD00376... .

These findings may be related to the care philosophy implemented in health institutions, since, by allowing a companion, other practices are also recognized as beneficial and become part of the routine, as already mentioned in other research studies that portray local experiences in Brazil⁵5. Brüggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayescki ME. A inserção do acompanhante de parto nos serviços públicos de saúde de Santa Catarina, Brasil. Esc Anna Nery. 2013;17(3):432-8. https://doi.org/10.1590/S1414-81452013000300005
https://doi.org/10.1590/S1414-8145201300... ^,1818. Lansky S. Gestão da qualidade e da integralidade do cuidado em saúde para a mulher e a criança no SUS – BH: a experiência da comissão perinatal. Rev Tempus Actas Saude Coletiva. 2010;4(4):191-9.. In addition, when a companion is welcomed and encouraged to perform actions of physical comfort, he participates in the application of NPM¹⁶16. Gayeski ME, Brüggemann OM, Monticelli M, Santos EKA. Application of nonpharmacologic methods to relieve pain during labor: the point of view of primiparous women. Pain Manag Nurs. 2015;16(3):273-84. https://doi.org/10.1016/j.pmn.2014.08.006
https://doi.org/10.1016/j.pmn.2014.08.00... and acts as intermediation, negotiating the woman's wishes with the health team¹⁷17. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;(7):CD003766. https://doi.org/10.1002/14651858.CD003766.pub5
https://doi.org/10.1002/14651858.CD00376... .

In Brazil, health institutions that allow the presence of a companion are those that seek to reduce unnecessary interventions, which have no evidence and are not recommended by the WHO for delivery care, and those that have implemented minimal changes in the environment and in the furniture, such as having chairs for all the companions⁵5. Brüggemann OM, Oliveira ME, Martins HEL, Alves MC, Gayescki ME. A inserção do acompanhante de parto nos serviços públicos de saúde de Santa Catarina, Brasil. Esc Anna Nery. 2013;17(3):432-8. https://doi.org/10.1590/S1414-81452013000300005
https://doi.org/10.1590/S1414-8145201300... ^,99. Davim RMB, Torres GV, Dantas JC, Melo ES, Paiva CP, Vieira D, et al. Banho de chuveiro como estratégia não farmacológica no alívio da dor de parturientes. Rev Eletr Enf. 2008 [cited 2017 Jun 16];10(3):600-9. Available from: http://www.fen.ufg.br/revista/v10/n3/v10n3a06.htm
http://www.fen.ufg.br/revista/v10/n3/v10... ^,1010. Diniz CSG, D'Orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, et al. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa nacional Nascer no Brasil. Cad Saude Publica. 2014;30 Supl 1:S140-53. https://doi.org/10.1590/0102-311X00127013
https://doi.org/10.1590/0102-311X0012701... . Thus, the correlation between the presence of a companion and the adoption of best practices in institutions may have contributed to these results. We should also consider that the health professional tends to change his or her attitude when a companion is present, which can be observed in studies that show that women are more satisfied with the experience of delivery and with the guidelines and care received from health professionals when they have a companion of their choice³3. Brüggemann OM, Parpinelli MA, Osis MJD, Cecatti JG, Carvalhinho Neto AS. Support to woman by a companion of her choice during childbirth: a randomized controlled trial. Reprod Health. 2007;4:5. https://doi.org/10.1186/1742-4755-4-5
https://doi.org/10.1186/1742-4755-4-5... ^,44. Brüggemann OM, Osis MJD, Parpinelli MA. Apoio no nascimento: percepções de profissionais e acompanhantes escolhidos pela mulher. Rev Saude Publica. 2007;41(1):44-52. https://doi.org/10.1590/S0034-89102006005000015
https://doi.org/10.1590/S0034-8910200600... ^,2828. Morhason-Bello IO, Adedokun BO, Ojengbede OA, Olayemi O, Oladokun A, Fabamwo AO. Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial. Aust N Z J Obstet Gynaecol. 2009;49(2):145-50. https://doi.org/10.1111/j.1479-828X.2009.00983.x
https://doi.org/10.1111/j.1479-828X.2009... .

Despite the benefits presented, after adjusting for the control variables, the presence of a companion in the South region did not have any impact on free movement, type of delivery, and rates of episiotomy and oxytocin.

The presence of a companion may not have reduced the prescription of oxytocin and episiotomy because they are routinely used in many institutions, often without the knowledge or authorization of the mothers, further reinforcing a technocratic and mechanistic model of delivery care. These findings are similar to those found in a systematic review¹⁷17. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;(7):CD003766. https://doi.org/10.1002/14651858.CD003766.pub5
https://doi.org/10.1002/14651858.CD00376... , in which the support had no impact on the occurrence of oxytocin and episiotomy. In a qualitative study, women who had an episiotomy were unaware of the purpose of the procedure and reported that they were not asked to authorize the procedure¹⁴14. Frigo J, Cagol G, Zocche DA, Zanotelli SS, Rodrigues RM, Ascari RA. Episiotomia: (des) conhecimento sobre o procedimento sob a ótica da mulher. BJSCR. 2014 [cited 2017 Jun 16];6(2):5-10. Available from: http://www.mastereditora.com.br/periodico/20140403_200543.pdf
http://www.mastereditora.com.br/periodic... .

International studies seek to identify the reasons that hinder the appropriation of evidence-based interventions and the shift in care practice around the world, including practices that could be used in places with few resources. Among the reasons, the lack of access of professionals to scientific knowledge in developing countries stands out, as well as the lack of interest of professionals and managers of health services in the production of better obstetric and neonatal care⁸8. Conde-Agudelo A, Rosas-Bermudez A, Gülmezoglu AM. Evidence-based intrapartum care in Cali, Colombia: a quantitative and qualitative study. BJOG. 2008;115(12):1547-56. https://doi.org/10.1111/j.1471-0528.2008.01930.x
https://doi.org/10.1111/j.1471-0528.2008... ^,1212. Fauveau V, Bernis L. “Good obstetrics” revisited: too many evidence-based practices and devices are not used. Int J Gynaecol Obstet. 2006;94(2):179-84. https://doi.org/10.1016/j.ijgo.2006.05.020
https://doi.org/10.1016/j.ijgo.2006.05.0... ^,3434. SEA-ORCHID Study Group, Laopaiboon M, Lumbiganon P, Mcdonald SJ, Henderson-Smart DJ, Green S, Crowther CA, et al. Use of evidence-based practices in pregnancy and childbirth: South East Asia Optimising Reproductive and Child Health in Developing Countries Project. PLoS One. 2008;3(7):e2646. https://doi.org/10.1371/journal.pone.0002646
https://doi.org/10.1371/journal.pone.000... .

In this study, epidural or spinal analgesia was more frequent in women with a companion. This result differs from that found in a systematic review, in which the support reduced the need for analgesia¹⁷17. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;(7):CD003766. https://doi.org/10.1002/14651858.CD003766.pub5
https://doi.org/10.1002/14651858.CD00376... . Although this procedure interferes with the evolution of labor, the result of this study may be related to the reversal of the concept present in the Brazilian obstetric reality, in which the excess of interventions is often considered a synonym of good care.

It is important to note that most of the variables analyzed here were selected from the interview questionnaire used with the mother, being self-reported and therefore susceptible to understanding bias.

Another limitation is related to the study design, that is, because this is a cross-sectional study, we only estimated the association of the presence of a companion with best practices in delivery care, but we cannot indicate causality. Thus, we need to consider that the existing association may be due to the care model adopted in some institutions, in which the presence of a companion is included in a list of best practices already performed. The Diretriz Nacional de Assistência ao Parto Normal, published in 2016, highlights that the continued support from the companion of the women's choice does not waive the support provided by the hospital staff from the adoption of the best practices available²⁶26. Ministério da Saúde (BR), Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Diretriz Nacional de Assistência ao Parto Normal: relatório de recomendação. Brasília (DF): CONITEC; 2016 [cited 2017 Jun 16]. Available from: http://conitec.gov.br/images/Consultas/2016/Relatorio_Diretriz-PartoNormal_CP.pdf
http://conitec.gov.br/images/Consultas/2... .

The continuous support provided by a companion during labor/delivery is characterized as a protective factor as it favors the reduction of interventions and harmful and aggressive practices at a time when the mother and the newborn are extremely vulnerable to the hospital routines and the decisions of professionals. In this way, the adaptation of maternity hospitals to include and accommodate a companion is imperative. Regarding the use of resources needed to ensure continued support, we highlight that the support from the companion of the woman's choice and her own social network, based on the benefits already described, could favor resource saving in relation to the number of professionals needed to ensure this permanent support²⁶26. Ministério da Saúde (BR), Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Diretriz Nacional de Assistência ao Parto Normal: relatório de recomendação. Brasília (DF): CONITEC; 2016 [cited 2017 Jun 16]. Available from: http://conitec.gov.br/images/Consultas/2016/Relatorio_Diretriz-PartoNormal_CP.pdf
http://conitec.gov.br/images/Consultas/2... , which could be destined to the structural adequacy of institutions to the presence of a companion.

In order to ensure the presence of a companion of the woman's free choice, responsible agencies need to supervise health institutions linked to the SUS or supplementary health, and changes need to happen in the training of professionals to assist the delivery. In the current debate on public policies on delivery care, this right needs to ensure, which has historically been the agenda of the womens movement.

Women should also be encouraged, in social networks and organized groups, to strive for a dignified and humanized care, which rescues the feminine protagonism and see the delivery as a physiological and family event.

Considering the Brazilian context, in which the companions of the woman's choice have been considered as the support provider, further studies are needed to explore other results from their presence, increasing the knowledge about their role in delivery and birth.

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