ORIGINAL ARTICLES
Women’s perception of the process of labor coaching: a descriptive study
Jane da Rosa Palinski1; Silvana Regina Rossi Kissula Souza2; Juliana Taques Pessoa da Silveira3; Natália Rejane Salim4; Dulce Maria Rosa Gualda5
1,2,3Universidade Federal do Paraná
4,5 Universidade de São Paulo
ABSTRACT
Objective: This qualitative study searched for an understanding of women’s perceptions of the participation of a companion, chosen by them, during the labor process. Method: The research study was carried out between August and November 2009 at a teaching maternity hospital in the municipality of Curitiba, Parana State, Brazil. Ten (10) women who took part in a coached delivery were the subjects of this study. Data was obtained by means of a semi-structured interview undertaken during the puerperium and submitted to a thematic analysis. Results: Results evidenced that a companion’s presence brings about security, peacefulness, support, and comfort during the labor process. Conclusion: The importance of the nursing team with regard to assisting and enabling the coach’s presence is pointed out, thus fostering a good evolution in the labor process and strengthening family bonds.
Keywords: Humanized Childbirth, Delivery, Labor
The need for the assistance to the parturient and her family encouraged the WHO in 1996 to launch a document entitled “Safe Maternity – Assistance to Normal Labor: a practical guide”. From this manual, based on scientific evidence, some recommendations were developed about the practices related to normal labor.(1)
This document aims to offer direction and suggest improvements in terms of the assistance to normal labor, allowing women the right to safer labor practices that would reduce maternal and perinatal mortality, and which would lead to a reduction in hospitalization. It questions procedures which are performed out of habit or routine rather than being based on any scientific criteria. (1)
In these recommendations there are many practices which should be encouraged in that they aim to ensure the humanization of the labor process. Among these is the creation of conditions such that the concerns related to the period before and during the labor process are dealt with so that they are perceived by the woman to be feasible and safe, thereby increasing the confidence of the women concerned; the respect of privacy for women in the place of labor or, in other words, the right to choose a location that generates empathy among the health professionals and the pregnant woman; the pregnant woman’s decision in relation to her companions, husband/partner or family member; the choice on the part of the parturient about the professional who will assist in the labor process; the maximum availability of information and explanation; the availability of non-invasive and non-pharmacological methods such as massages and relaxing techniques to relieve pain during the labor process; liberty when it comes to the positioning and movement of the parturient during the labor process; allowing, at an early stage, skin-to-skin contact between the mother and the newborn and the offer of some support to initiate the breast-feeding process within one hour of birth.(2)
The Brazilian Ministry of Health recognizes the necessity for changes in health care, and in 2001 published the manual, “Labor, Abortion and Puerperium – Humanized Assistance to Women”, where some proceedings, reactions, reflections and directives were represented according to a proposal for humanized assistance. This manual aimed to spread knowledge of the concepts and practices of the labor process, integrating the technical capacities with the necessary humanization for women’s healthcare.(3)
Among the inclusion of humanization formats in the process of giving birth, we highlight the permission for the presence of a companion, freely chosen by the parturient, during this period. The presence of a companion contributes to the physical and emotional welfare of the woman, and also works in a positive way in terms of handling pain and tension, contributing to a good labor, and reducing the quantity of possible complications during and after labor. (4)
In order to guarantee this right for women, Bill #11,108 was approved in 2005 by the Brazilian National Congress and regulated by the Brazilian Ministry of Health Ordinance #2,418 of 2005, which endorses the parturient’s right to the presence of a companion during the labor process and the immediate post-labor moments, within the scope of the Brazilian Unified Health System (SUS, in Portuguese). However, a process of reorganization of the health services and of the associated professionals is yet needed, so then these practices can be fully implemented. (5, 6)
During the pre-natal period, the participation of the father/companion is increasingly frequent nowadays, and it must also be encouraged during the in-group activities to prepare the couple, or the chosen companion, for the labor. The labor process and the puerpium are moments filled with deep feelings, moments of constructive crisis, with a great positive potential to stimulate the formation of bonds and to provoke personal transformations. (7)
Thus, the presence of a companion is one of the practices that is now incorporated into the movement towards the humanization of the birthing process, providing positive aspects both for the health professionals and for the parents, the binomial mother and the child. (5)
The maternity hospital in which this study was performed has placed emphasis on the adoption of a model of humanized assistance, offering to the parturient, the opportunity to count on the presence of a companion of her own choice during the whole process of labor. In light of these considerations, this study aims to understand the perceptions of the women with regard to the participation of a companion during the process of giving birth.
METHODOLOGY
This study which adopts a qualitative-descriptive approach, was performed in the Collective Accommodation unit of a public maternity hospital and medical school, which serves low-risk parturients, located in the municipality of Curitiba, from August to November 2009.
Ten women participated in this research. Each of these went through their labor processes accompanied by a chosen companion. As inclusion criteria, puerperals were included who went through the normal labor processes in the presence of the companion, who participated voluntarily in the interview process, independently of race, parity or any other non-mentioned indicators. Puerperals who submitted to surgical labor or who suffered any sort of post-partum complication were excluded.
The number of participants in the sample followed the criterion of saturation, by which the constitution of the collaborators in a qualitative study has to be determined by the need for information, and the saturation of data is pursued until no other new information is added, and the data then becomes repetitive. (8)
The subjects involved in this study were invited to take part on a voluntarily basis. After the presentation and explanation of the objectives, each received a Free and Clear Consent Agreement (FCCA) sheet. After reading and signing the Agreement, the proposed interviews were scheduled. It is important to highlight that the under-aged puerperal, accompanied by her legal representatives, agreed to take part in this study, after signing an adapted FCCA.
The data collection was executed through a semi-structured interview that dealt with information referring to identification, such as age and marital status, the chosen companion, and the acknowledgement of Bill #11,108/2005. The first contact in order to schedule the interviews, happened with the parturient in the Obstetric Center, pre-labor, when they were invited to participate in the research.
After the labor process, and when they had been placed in the Collective Accommodation (the place where the puerperal stays hospitalized for at least 48 hours), the best moment to perform the interview was determined with the participant. This was performed in a private room in the Collective Accommodation, providing the necessary privacy and tranquility for the participants. With the consent of the women, the interviews were recorded, and lasted around thirty minutes.
Following this, the interviews were transcribed. The analysis of the material was carried out using the following steps: comprehensive reading of the selected material, searching for a general view through the elaboration of assumptions that worked as a basis for the analysis and interpretation of the material; the exploration of the material; the moment of analysis itself when, through the identification of parts or sections of the text already selected during the first stage, we began to develop the topics based on the theoretical concepts. (9)
The subjects were identified by the names of flowers, chosen by themselves, guaranteeing the anonymity of the participants in this study. The data collected and analyzed were filed in an electronic format and will be saved for five years from the time of writing.
To perform this research, all the ethical precepts involving human beings were respected, according to the Brazilian National Health Council Resolution 196/96. This project was also presented to the Ethics in Research Committee of the Sector of Health Sciences of Parana Federal University, and approved in the meeting of the Committee on July 10th 2009, under registration CEP/SD 738.073.09.06 and CAAE 2216.0.000.091-09.
RESULTS
From the research data presented, a characterization of the women that participated in this study was obtained. The participants were between the ages of 13 and 36 years.
In relation to their marital status, five were self-declared single and five lived with their partners. In terms of age, the single women were between 13 and 21 years of age, and those who lived with a partner were between 21 and 36 years of age. In other words, women who were older were in a stable relationship with their partners.
When the participants were questioned about their labor companion, six affirmed that the companion was their mother, and four mentioned their partner.
In relation to the acknowledgement of Bill 11,108/2005, five of the mothers said that they did not know anything about the legal article, and five of them had already heard or read about it.
The participants were asked about whether or not they had participated in any seminar or labor-preparation workshops during the pre-natal care. All answered in the negative.
The analysis of the discourse allowed the intercrossing of topics related to the perception of the women in relation to their companion during the process of labor. These were divided into positive feelings such as security, tranquility, physical support, gratitude and emotion, and negative feelings which were reported as solitude and fear during some parts of the process of labor due to lack of companionship, and also feelings related to pressure during the moment of labor.
In terms of the positive feelings, the participants had a favorable view in relation to the participation of their companion during the labor process. One of the most frequently mentioned feelings was one of security, as stated by them:
Oh! It was good because I felt safer, I was there with a support. We even feel better when giving birth, everything is more exciting, just because you can count on someone. (Daisy)
Very good! Excellent, well… I don’t know… Wonderful… You feel good, safe, it’s a relief to know there is someone there (...). (Orchid)
I felt safer, really, with him there, because in the moment when I was alone, I was feeling like, you know, a little afraid (...) (Fleur de Lis)
I felt enormously safe to have someone from my family close to me, I felt a certain security (...). (Sunflower)
Another positive feeling on the part of the mothers in relation to the presence of a companion was one of tranquility. As can be seen from the following speeches, they mentioned that they were somewhat nervous:
She gave me tranquility. I was too nervous and she let me be calm and confident (...) (Tulip)
Then we felt that there was someone right there, someone to help you… It’s much more comfortable and easy. (Violet)
[...] It was a new experience […] I was too nervous… (Tulip)
The women also reported the physical support given by their companions, such as the simple gesture of holding the hands of the mothers during labor, as can be seen from the following statements:
[The companion] held my hand all the time, and it was really good. (Jasmine)
Oh! It was so good because she held my hand all the time! (Violet)
Wow, it was wonderful [...], you know there is someone giving you support, holding your hand, it’s really good [...]. (Orchid)
The participants also mentioned many emotions such as gratitude and happiness associated with having a companion present during the process of giving birth:
[...] It was really good, I’d say it was gratifying the reward I got [...] to see my best friend by my side… It was… Well… Very good [...](Daisy)
It was a great pleasure to have a companion by my side, [...] It was a good sensation, it was cool. (Pansy)
The women who had the opportunity to count on the presence of a companion during the whole process of labor referred to this practice as follows:
She was there all the time, from the beginning of my hospitalization until my baby was born… She was with me all the time. (Violet)
She was my companion before, during and after the birth, helping me a lot. (Jasmine)
On terms of negative feelings, it was recorded that in the case of some companions, their participation only occurred during some parts of the process, even though the parturients wanted them to be present during the whole process of labor. Their dissatisfaction can be perceived from the following statements:
Unfortunately, he was there only during the labor and in the post-partum. (Orchid)
[The companion] only participated during labor and during the post-partum, and I wished [the companion] had been there all the time. (Fleur de Lis)
[The companion] got in a little before, when I was in pain, [...] and stayed there until the time of delivery, around two hours, for quite a while, until the baby was clean and when the baby was given to me, then he left. (Lily)
The women who did not have the presence of their companions continuously during the complete birth process, mentioned feelings of solitude and need, even in the presence of health professionals and, when these companions were present, they declared it to be a favorable situation, as indicated by the following quotes:
[...] We felt a little bit lonely there, even though there were members of the team taking care of everything, but you know, we felt a little bit needy during those moments [...] (Rose)
[...] Because you are alone there, you feel lonely, it is so awful; with a companion it is so much better [...]. (Sunflower)
The woman who spent some lonely moments during the delivery declared a sense of fear, as shown by the following:
[...] Because during the moment I was alone there, I was feeling, like… I was scared, you know… [...] (Fleur de Lis)
However, the presence of a companion for some women gave them the feeling of being under pressure, because while trying to help the partner during labor, they asked the mother to push harder. However, some women felt embarrassed and did not like the situation, such as is mentioned in the following:
Well I liked it, but I felt a little under pressure, as he pressed me to push, [...] I didn’t like him pushing me.(Lily)
DISCUSSION
The women involved in this study were in favor of the participation of their companions during the whole process of giving birth.
In this study, six of the companions were the mothers of the parturients, reaffirming the necessity for the presence of their own mothers or women who were experienced during the process of labor, as it was also observed that the participants were young and single mothers.
These moments indicate the B support and the transmission of information, of moral and behavior values when the parturients are accompanied by their mothers. This is because such women make use of the experiences they have gone through to help their daughters, evoking attributes that are sociably accepted in terms of motherly posture. (10)
Thus the relationship between the mother and the baby can be strengthened when the parturient takes some attributes into consideration, which have been experienced by their biological mother. (11)
In relation to Bill 11,108, as explained above, it was observed that, even though they were unaware of this legal device, the women were accompanied by their companions. This demonstrates that institutions are adhering and complying with the Companion’s Bill.
It is important to mention that in the maternity hospital in which this study was performed, the mothers and their companions have the opportunity to participate in labor preparation workshops, previously scheduled, which aim to give pregnant women and their companions time to learn about the characteristics of the labor process, as well as becoming familiar with the environment in which the birth process will occur, leading to a reduction in maternal and family stress. On the other hand, the participants who took part in this study did not enroll in any of these workshops.
On the topic of positive feelings in relation to the presence of a companion, it was evident that the feeling of safety that the chosen companion gave to the woman was highlighted. The presence of the companion gave physical and emotional benefits to the parturient, providing safety. This contributed to the reduction in labor complications during the whole process, decreasing the excessive use of drugs, c-sections, risks to health, and a reduction in hospitalization time. (5)
In a study performed in a public maternal hospital in the state of Sao Paulo in 2005, it was observed that the parturients who had a companion of their choice present during the process of labor referred to a higher global satisfaction with the experience, than did those women that did not have a companion during the process. (12)
The presence of someone one knows during the process of birth can provide the parturient with a feeling of safety and, added to that, the establishment of an affective communication and a bond to others, in the sense that lets the mother to be feel less vulnerable to feelings of solitude and giving her the opportunity to express herself freely. (11)
In this sense, the health professionals, especially the nursing team, have an important role to play as facilitators of this process. Therefore, these professionals can assist the provision of humanized labor by going beyond the legal prerogatives, by making easier the actions of caretaking aimed at the inclusion of a companion in the birth process. (13) Despite this fact, the design in which this process is lived by the parturient is the result of her history, the relationship with her partner, with her family, with her physical and emotional state, the way in which she is assisted during the labor process, and also the cultural aspects of the society in which it is played out, and which constitute the representations of the labor process. (1)
The tranquility caused by the presence of a companion was also demonstrated through the interviews, because the birthing process is a period in which the woman feels stressed in that she is confronting a new situation. However, this stress was reduced by the presence of someone familiar to her.
The women also reported physical support, the fact that their companion held their hands, bringing comfort. The literature points to this sort of support as being a benefit for a good development before birth. The physical support that the companion provides is through actions such as touching, massaging and providing motivation, to ambulation, position changes, looking to offer physical comfort to the woman and aiming to provide a better situation with regard to the birth process. (1)
Some other feelings were also reported, such as gratitude, and support provided by the presence of the companion during this process. Throughout the period prior to the birth, the parturient can refer to many different feelings and sensations with regard to what is going on around her, which can provide support, or not, during this time. In this sense, it is the responsibility of the maternity hospital or other hospital institution to house the mother and provide specific care according to her needs and individual choices. (13)
When dealing with negative feelings, it was observed that there was a gap in the understanding of, and compliance to, the law when some women reported that they were denied the presence of a companion during the process of birth, especially during the period before labor.
The lack of participation in the form of the companion has been justified by many health services by a lack of physical space, and also the ability of the health teams to give aid to the companion. (13)
Even with the current legislation and all the movement that there is for the observance of the law, some women reported that they felt lonely during some part of the process, and even when surrounded by health professionals, the feeling was the same.
In this sense, health professionals must be prepared to provide the woman and the chosen companion with a calm and positive situation, helping to make this moment to be lived through and remembered as a positive experience. (14)
When dealing with the importance of the presence of a companion during the whole pregnancy process, and to the fact she is supposed to be stimulated during all stages of this process, either during the pre-natal visits or in health education groups, the mother is still limited by many factors. One of these factors is related to the questions of the organization and the environment of the institution concerned. In the maternity hospital in which this study was performed, there aren’t any private rooms available for women to experience this process privately. This maternity hospital has a collective pre-labor room, with six beds separated by partitions. However, this did not interfere completely with the participation of the companions during the process of labor. As seen in the literature, this is a common reason mentioned by the health professionals supporting their decision to prohibit the presence of a companion, as they consider the space to be inadequate. In addition, it does not provide any sort of privacy to the women and their companions.
In a similar study performed in Fortaleza with regard to the participation of companions and their association with the nursing team, these professionals also commented that the medical team feels uncomfortable with regard to the presence of a companion, as it is reported that sometimes they end up performing invasive proceedings such as episiotomies and the use of forceps, and they have certain suggestions as to how the companions might react to such proceedings. (15)
Some women had the opportunity to have their companions during the whole process of birth, labor and puerperium, and demonstrated through their reports how this was important and healthy in terms of the straightening of family bonds.
Despite this fact, the support of the companion cannot be perceived only as an alternative way to minimize the discomfort typical of this period. Mainly it should be thought of as a right of the parturient and it should be acknowledged that a companion can be an extremely positive factor during the process of the humanization of labor. (3)
According to the Brazilian Ministry of Health, labor, “…when is lived with pain, anguish, fear and isolation, can develop psychological, affective and emotional disturbances, which can influence the mother/pupil relationship, besides her affective and conjugal life.” (3)
Besides considering the importance of the presence of a companion, a woman reported that she felt pressured by the companion during the moment of labor, because he asked many times that she push harder to help the baby. Surely, this companion was imitating the attitudes presented by the health professionals assisting the labor process.
Within this context, it is important to recognize the individuality of each parturient as a means to humanize healthcare. When performing in this way, the health professional develops a link with every woman in terms of their own needs and capacities, constructing interpersonal relationships that are less unequal and authoritarian, resulting in physical and emotional welfare for the parturient and her companion. (3)
During the moment of birth, it is necessary that the woman gets all the attention she needs, because this is an undeniable step to guaranteeing that she can undergo labor safely and well. (3)
It is a fundamental right of any women that the obstetric health team is ready to support her, her companion and her family, respecting all the meanings of this moment, promoting the creation of a deeper bond, and transmitting to the mother to be a sense of reliability and tranquility. (3)
CONCLUSION
Throughout the years, many efforts have been made with regard to the humanization of labor healthcare assistance. Among these attempts, the presence of companion has been highlighted as being favorable to the birth process, an aspect which is congruent with the results found in this research.
This study has limited itself to describing the perceptions of the women that had their labor process supported by a companion. However, it is important to mention that there could be situations in which some women might freely decide not to have a companion present, or in the case that they have some sort of difficulty in having a companion present, due to the fact they may have other children, which was not mentioned in this study.
Besides the fact that the desire of these women to have a companion present was demonstrated in the reports, it was also observed that there was sometimes a hiatus in the participation of the companion during the whole process. This indicates that Bill #11,108/2005 is not being completely adhered to by this institution.
In this sense, to achieve significant results, it is necessary to encourage a change in the attitudes and behavior of all the health professionals team, respecting the liberty of the woman in her choices during the process. This is especially true with regard to the nursing team, which has an important role to play in providing this level of humanized healthcare.
Corroborating the findings of other studies about the presence of a companion, this research shows that such participation provides feelings of safety, tranquility, support, caretaking and emotion to the women concerned. In addition, other varied feelings worked to engender positive results during the labor process, and increased the familial bond.
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CONTRIBUTIONS OF THE AUTHORS
Jane da Rosa Palinski: concept, planning, data collection and interpretation of data.
Silvana Regina Rossi Kissula Souza: concept and planning, analysis and interpretation of data, writing and review of the manuscript.
Juliana Taques Pessoa da Silveira: analysis and interpretation of data, writing of the manuscript.
Natália Rejane Salim: writing and review of the manuscript.
Dulce Maria Rosa Gualda: writing and review of the manuscript.
Received: 12/09/2011
Approved:14/05/2012