EFFICACY OF AN EDUCATIONAL MANUAL ON THE SUPPORT PROVIDED BY COMPANIONS IN AN OBSTETRIC CENTER: A RANDOMIZED CLINICAL TRIAL

OEFICACIA DE UN MANUAL EDUCATIVO EN EL APOYO PROPORCIONADO POR ACOMPAÑANTES EN UN CENTRO DE OBSTETRICIA: ENSAYO CLÍNICO ALEATORIZADO

ABSTRACT

Objective:

to evaluate the effectiveness of an educational manual on the support provided by companions during the labor process in an obstetric center.

Method:

a Randomized Clinical Trial conducted with 248 participants, comprising 124 companions and 124 puerperal women. The study took place between November 2018 and October 2019 at an obstetric center in Fortaleza, Ceará, Brazil. The Companion Characterization Form, the Support Evaluation Form, and the Postpartum Woman's Labor Experience and Satisfaction Evaluation Form were used. The data were analyzed using the Statistical Package for the Social Sciences statistical program. Chi-square and Fisher tests were employed, as well as the Mann-Whitney test. The Relative Risk (RR) and the 95% Confidence Interval (CI) were calculated for the main dependent variables.

Results:

it was evident that the companions from the Intervention Group were more likely to engage in physical, emotional, informational and advocacy/intermediation support actions, with a statistically significant difference observed in all support dimensions when comparing both groups. The companions from the Intervention Group performed more support actions (20 vs 6; p:0.001) and rated the experience of accompanying the birth more favorably (100.0 vs 74.2; p:0.001). It was identified that the puerperal women accompanied by participants from the Intervention Group were more likely to express satisfaction with how the labor process took place.

Conclusion:

the intervention applied in the maternity unit using an educational manual aimed at parturients’ companions is effective and contributes to providing support during childbirth.

DESCRIPTORS:
Social support; Humanized delivery; Intervention studies; Nursing; Health promotion; Patient satisfaction

RESUMEN

Objetivo:

evaluar la efectividad de un manual educativo en el apoyo proporcionado por acompañantes durante el proceso de parto en un centro obstétrico.

Método:

Ensayo Clínico Aleatorizado realizado con 248 participantes: 124 acompañantes y 124 puérperas. El estudio se llevó a cabo entre noviembre de 2018 y octubre de 2019 en un centro obstétrico de Fortaleza, Ceará, Brasil. Se utilizó un Formulario de caracterización del acompañante; un Formulario para evaluar el apoyo proporcionado y un Formulario para evaluar la experiencia y satisfacción de las puérperas con el trabajo de parto. Los datos se analizaron en el programa estadístico Statistical Package for the Social Sciences. Se emplearon las pruebas de chi-cuadrado y Fisher y la de Mann-Whitney. Se calculó el Riesgo Relativo (RR) y el Intervalo de Confianza (IC) del 95% para las principales variables dependientes

Resultados:

se evidenció que los acompañantes del Grupo Intervención fueron más propensos a desarrollar acciones de apoyo físico, emocional, informativo y de soporte/intermediación, verificándose una diferencia estadística significativa en todas las dimensiones de apoyo al comparar ambos grupos. Los acompañantes del Grupo Intervención realizaron más acciones de apoyo (20 vs 6; p:0,001) y evaluaron de mejor manera la experiencia de estar presentes en el parto (100,0 vs 74,2; p:0,001). Se determinó que las puérperas acompañadas por participantes del Grupo Intervención fueron más propensas a mostrarse satisfechas con la forma en la que se desarrolló el trabajo de parto.

Conclusión:

la intervención que se aplicó en la maternidad empleando el manual educativo y direccionada a acompañantes de parturientas es efectiva y ayuda a proporcionar apoyo durante el parto.

DESCRITORES:
Apoyo social; Parto humanizado; Estudios de intervención; Enfermería; Promoción de la salud; Satisfacción del paciente

RESUMO

Objetivo:

Avaliar a efetividade de um manual educativo no apoio prestado por acompanhantes durante o processo parturitivo em um centro obstétrico.

Método:

Ensaio Clínico Randomizado realizado com 248 participantes, sendo 124 acompanhantes e 124 puérperas. O estudo foi realizado em centro obstétrico em Fortaleza, Ceará, Brasil, entre os meses de novembro de 2018 a outubro de 2019. Utilizou-se o Formulário de caracterização do acompanhante; Formulário de avaliação do apoio prestado; e Formulário de avaliação da experiência e satisfação da puérpera com o trabalho de parto. Os dados foram analisados no programa estatístico Statistical Package for the Social Sciences. Foram utilizados os testes qui-quadrado e Fisher e o teste de Mann-Whitney. O Risco Relativo (RR) e o Intervalo de Confiança (IC) de 95% foram calculados para as principais variáveis dependentes

Resultados:

Evidenciou-se que acompanhantes do grupo intervenção tiveram mais probabilidade de desenvolver ações de apoio físico, emocional, informacional e advocacia/intermediação, verificando-se diferença estatística significativa em todas as dimensões de apoio quando comparados os dois grupos. Acompanhantes do grupo intervenção realizaram um maior número de ações de apoio (20 vs 6; p:0,001) e melhor avaliaram a experiência de acompanhar o parto (100,0 vs 74,2; p:0,001). Identificou-se que puérperas acompanhadas por participantes do grupo intervenção foram mais propícias a demonstrar satisfação com a forma como ocorreu o trabalho de parto.

Conclusão:

A intervenção aplicada na maternidade com uso de manual educativo direcionada a acompanhantes de parturientes é efetiva e contribui para a prestação de apoio durante o parto.

DESCRITORES:
Apoio social; Parto humanizado; Estudos de intervenção; Enfermagem; Promoção da saúde; Satisfação do paciente

INTRODUCTION

The childbirth process involves a phase that produces profound physical and emotional changes in a woman's body to adapt it to the maternal-fetal needs for birth. In the face of such changes, it becomes necessary to use of physical, educational, psychological and behavioral resources to ensure the required support for women during all stages of labor1. For this reason, continuous support during the childbirth process is relevant, defined by the constant presence of a companion, doula, health professional, or a person from the woman's social network2^-3.

The beneficial and satisfactory nature of this support provided by the companions during labor and childbirth is evidenced by various scientific findings, favoring women's physiological4, psychological2^,5 and emotional dimensions throughout labor and childbirth6^-7. However, Brazilian maternity wards still do not fully accept the presence of companions or accept it only partially (during labor). Among the factors that hinder the inclusion of companions non-acceptance by professionals and inadequate organizational structure of the services8.

In cases where the companion undergoes some training process aimed at equipping them to provide support to the parturient, women’s satisfaction levels regarding the actions carried out by their companions are even more effective9.

Based on this assumption, an educational manual was developed for individuals intending to participate in childbirth as companions10. The study results indicated that the educational manual was effective in equipping the companions to perform support actions for the women in labor, with companions in the Intervention Group carrying out a significantly higher number of support actions when compared to the Control Group10. However, it was recommended to evaluate the effectiveness of implementing the intervention using the aforementioned manual in the context of the maternity ward.

Studies aimed at proving the effectiveness of educational materials for companions will support usage of the educational technology and contribute to the companions' active participation during childbirth, encouraging the development of their own skills. Given the problematization previously conducted, the following question arose: In the context of the maternity ward, which is the effect of an intervention using an educational manual for parturients' companions on the provision of support during the childbirth process and women's satisfaction? Therefore, this study aimed at evaluating the effectiveness of an educational manual in the support provided by companions during the labor process in an obstetric center.

METHOD

This is a Randomized Clinical Trial (RCT). In this research, the intervention took place using an educational manual entitled "Preparing to accompany childbirth: What is important to know?", implemented in an obstetric center, and its effects were observed on the following outcomes: support actions provided by the companions to the parturients and the puerperal women’s satisfaction regarding labor and childbirth. The assumptions set forth in the Consolidated Standards of Reporting Trials (CONSORT) statement were considered, specifically for non-pharmacological interventions.

The study was conducted at the Obstetric Center of the Assis Chateaubriand Maternity School (Maternidade Escola Assis Chateaubriand, MEAC) in Fortaleza-CE, Brazil, with parturients admitted to the institution and their companions. MEAC allows the presence of the companion in the pre-, intra-, and post-partum periods, with wards equipped with the appropriate infrastructure to receive the woman's chosen companion. The study population consisted of two target groups: companions of parturients admitted to the MEAC Obstetric Center between November 2018 and October 2019; and puerperal women whose companions were involved in the research.

Selection of the sample respected the following inclusion criteria: being the chosen companion of the woman in labor; having completed at least fourth year of Elementary School (schooling level compatible with the Flash readability index calculated for the manual herein evaluated); and being the companion of a woman with an indication for normal delivery, as well as puerperal women with companions of this profile. The subjects included were companions of parturient women admitted to the MEAC obstetric center in labor, regardless of the obstetric outcome related to the mode of delivery (C-section or vaginal delivery).

The exclusion criteria were as follows: presenting a compromised physical or mental health status that would hinder data collection; participating in another research study in the institution, to avoid bias; and being in the expulsion stage at the beginning of data collection. The discontinuation criteria were the following: withdrawing from the study after the beginning of data collection; deciding not to or being unable to accompany the labor/childbirth process; occurrence of childbirth at the time of the intervention or before it was initiated; and change of address and/or telephone number that would preclude contact after childbirth, if the only way to communicate with the participant is by phone.

Sample size calculation was performed using the formula for comparative groups of two experimental means with a bilateral test, considering the quantitative variable outcome in an unpaired sample. Thus, a total sample size of 108 participants was obtained, with 54 for each group. Adding a 10% safety margin for potential losses, 62 companions were required for each group, totaling a sample size of 124 companions. Additionally, 124 puerperal women whose companions were part of this research were also included. Thus, a total of 248 participants were included in this research, comprising 124 companions and 124 puerperal women.

Furthermore, in the Obstetric Center, the companions were randomized using a sequence of numbers generated on the http://www.randomizer.org website. The study was double-blind, as the team responsible for data collection and the individual conducting the statistical analysis were not informed about which group each puerperal woman and her companion belonged to. However, neither the companions nor the researcher responsible for applying the intervention were blinded, as this is an educational intervention.

The population was divided into two groups: Control Group (CG), comprised by eligible companions to participate in the research who received routine guidance, that is, instructions given in the delivery room by health professionals and students, among others, as well as puerperal women whose companions were involved in this group; and Intervention Group (IG), made up of companions who participated in an intervention using the educational manual tested in the research and the respective puerperal women they accompanied.

The manual in question consists of 38 illustrations and 11 topics that sequentially address preparation for going to the Maternity ward until the postpartum period, including techniques to support the parturient and the use of non-pharmacological pain relief methods. The manual has previously been evaluated by representatives of the target audience and validated for its face (writing, illustrations, structure and presentation) and content (objectives, motivation and relevance) by specialists in the fields of Women's Health and/or Obstetrics10. The joint reading of the manual lasted a mean of twenty minutes, with interruptions for clarifying doubts and questions raised by the companion.

During the intervention, which took place in the obstetric center itself, the manual was initially presented along with its purpose, and the possibility of interruptions for questions or comments was agreed upon. Subsequently, a joint reading of the manual was carried out with the companion. The companion was asked to keep the received manual confidential, not lending or replicating the material, as it was still in the testing phase. The intervention was conducted by a team of nurses, part of the data collection team, with expertise in Obstetrics and competence in health education, in the morning and afternoon shifts and from Monday to Friday.

The independent variables were as follows: the companion’s sociodemographic characteristics (gender, age, marital status, schooling and family income); their obstetric history (pregnancies, births, abortions); their kinship to the woman in labor; and whether the companion took part in educational strategies promoted by the prenatal care service. The dependent variables were the following: support actions performed by the companion; experience and satisfaction in accompanying childbirth; degree and usefulness of the support provided; level of cooperation with health professionals; and satisfaction with the way, duration and quality of care provided by the health professionals during labor and childbirth. Additionally, the “puerperal woman's experience and satisfaction with labor and childbirth” variable was used.

Three instruments were used for data collection, two directed at the companion and one targeted at the puerperal woman. Each instrument applied to the companions had a unique numbering system, which served as the basis for identifying the other instruments.

The first instrument assessed the characterization of the companions and items that verified their knowledge about support techniques during childbirth. This instrument was applied to all eligible companions, regardless of whether they were in the IG or CG.

The second instrument10 was used to evaluate the support provided by the companion in the delivery room, as well as their satisfaction. It was applied through telephone interviews with the companions during the final assessment, that is, after they had already participated in childbirth as companions. In addition to the support techniques performed, this instrument investigated the companions' satisfaction and self-confidence in providing support to the women in labor.

The third instrument used in this research is divided into three parts: I. Characterization of the puerperal woman; II. Abbreviated Childbirth Experience and Satisfaction Questionnaire (Questionário de Experiência e Satisfação com Parto, QESP)11; and III. Pain Intensity Assessment (measuring from 0 to 10, using a Likert-type scale to measure the mean and maximum pain intensities during labor and childbirth). This instrument was applied to the puerperal women during their stay in the joint accommodation. QESP shows good internal consistency (Cronbach's Alpha = 0.9087) and test-retest reliability of 0.58611. The original QESP tool consists of 104 questions referring to expectations, experience, satisfaction and pain related to labor, childbirth and the immediate postpartum period. The instrument has groups of variables related to each other, resulting in 8 subscales. QESP has been used and validated in a Brazilian study10.

To operationalize data collection, the following stages were developed: Baseline; Final Assessment - Companions; Final Assessment- Puerperal women.

In the initial approach (Baseline) companions of women admitted to the MEAC Obstetric Center were recruited. The companions that met the inclusion criteria were invited to participate in the study. At that moment, the Free and Informed Consent Form (FICF) was signed and the companion's knowledge assessment instrument was applied. This stage was conducted by nurses, properly trained to carry out this data collection.

In the final assessment, after the intervention and childbirth, within a period of up to 15 days after delivery, a group of trained professionals from the data collection team made a telephone contact with the companion. During this contact, the instrument for Evaluation of the Support Provided by the Companion was applied.

In the puerperal women's final assessment, after the intervention, the data collection team comprised by trained health care professionals contacted each postpartum woman in the Rooming-In area. The puerperal women were asked to sign the FICF, and the instrument for evaluating satisfaction with the childbirth experience was applied. Guiding the field team responsible for conducting this research stage, a previous training session was developed through the Standard Operating Procedure, aiming to standardize and guide the approach to the participants.

The data were compiled and analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 24.0, and subsequently presented in tables. The Kolmogorov-Smirnov test was used to check normality of the continuous data distribution. In all the continuous variables tested, it was evidenced that the sample followed a non-normality pattern. Such being the case, the continuous variables were expressed using median and interquartile range, and the categorical ones in absolute and relative frequencies. The groups were compared at baseline and after the intervention in separate analyses. For these comparisons, the chi-square test, Fisher's exact test, and the Mann-Whitney test were used. The Relative Risk (RR) and 95% Confidence Interval (CI) were calculated for the main dependent variables. A critical alpha of 0.05 was established to determine the significance level.

The project was submitted for evaluation to the MEAC Ethics Committee. This study was registered in the Brazilian Clinical Trials Registry (ReBEC) database, with registration number RBR-29q75w.

RESULTS

The study included 62 companions from the IG and 62 from the CG, as well as the 124 parturients/puerperal women supported by these companions. Figure 1 shows the inclusion and follow-up of the participants in each research stage.

Figure 1 -
Diagram representing the flow of participants in each phase of the study according to the CONSORT statement for non-pharmacological interventions. Fortaleza-CE, from November 2018 to October 2019.

Table 1 presents the sociodemographic and obstetric information, along with the analysis of the prior knowledge about different types of support provided to the parturient by the companions involved in the research.

Table 1 -
Distribution of the companions according to sociodemographic and obstetric characteristics and evaluation of prior knowledge about types of support for the women in labor Fortaleza, CE, Brazil, 2019 (n=124).

Variables	Total (n=124) Md (p25/p75)	IG (n=62) Md (p25/p75)	CG (n=62) Md (p25/p75)	p
Age (years old)	32 (25/44)	32 (25/45)	33 (27/42)	0.869*
Schooling (years)	10 (6/12)	10 (8/12)	9 (6/12)	0.104*
Income (reais)	998 (988/2,000)	998 (988/2,000)	998 (850/2,000)	0.640*
Obstetric Data (n=80)
Pregnancy	2 (1/4)	2 (1/3)	3 (1/5)	0.721*
Delivery	2 (1/3)	2 (1/3)	3 (1/4)	0.551*
Miscarriage	0 (0/1)	0 (0/1)	0 (0/1)	0.647*
	N (%)	N (%)	N (%)	p
Gender
Female	80 (64.5)	44 (71.0)	36 (58.1)	0.133†
Male	44 (35.5)	18 (19.0)	26 (41.9)
Marital status
With a partner	77 (62.1)	35 (56.5)	42 (67.7)	0.195†
No partner	47 (37.9)	27 (43.5)	20 (32.3)
Kinship with pregnant woman
Partner/Companion	44 (35.5)	18 (29.0)	26 (41.9)	0.133†
Other (mother, aunt, sister)	80 (64.5)	44 (71.0)	36 (58.1)
Participation in educational activities for childbirth guidance
Yes	31 (25.0)	11 (17.7)	20 (32.3)	0.062†
No	93 (75.0)	51 (82.3)	42 (67.7)
Knowledge about support actions for the women in labor
Yes	76 (61.3)	34 (54.8)	42 (67.7)	0.140†
No	48 (38.7)	28 (45.2)	20 (32.3)
	Total (n=124) Md (p25/p75)	IG (n=62) Md (p25/p75)	CG (n=62) Md (p25/p75)	p
Physical Support Actions	3 (0/8)	2 (0/8)	4 (0/7)	0.452*
Emotional Support Actions	2 (0/3)	0 (0/3)	2 (0/2)	0.383*
Informational Support Actions	0 (0/1)	0 (0/1)	0 (0/1)	0.847*
Advocacy/Intermediation Actions	0 (0/1)	0 (0/0)	0 (0/1)	0.301*
Total Support Actions	6 (0/11)	4 (0/11)	6 (0/11)	0.474*

• ^*
  Mann-Whitney U test; ^†Pearson's chi-square test.

Through the analysis of Table 1, homogeneity between the groups of companions included in this research was verified, as there was no statistically significant difference in any of the sociodemographic and obstetric variables investigated.

Table 2 displays diverse information regarding the support for the women in labor, highlighting the main actions adopted by the companions during this process.

Table 2 -
Distribution of the companions' data according to types of support provided during labor and childbirth. Fortaleza, CE, Brazil, 2019 (n=124).

Variables	Total (n=124)	IG (n=62)	CG (n=62)	p	RR (95% CI)
	N (%)	N (%)	N (%)
Physical Support Actions
Acupressure	37 (29.8)	33 (53.2)	4 (6.5)	0.001*	2.67 (1.94-3.67)
Counterpressure	58 (46.8)	54 (87.1)	4 (6.5)	0.001*	7.68 (3.99-14.76)
Shower bath	79 (63.7)	56 (90.3)	23 (37.1)	0.001*	5.31 (2.49-11.34)
Compresses	57 (46.0)	47 (75.8)	10 (16.1)	0.000*	3.68 (2.32-5.84)
Massages	87 (70.2)	59 (95.2)	38 (45.2)	0.001*	8.36 (2.80-24.9)
Visualization techniques	51 (41.1)	41 (66.1)	10 (16.1)	0.001*	2.79 (1.90-4.10)
Breathing technique	74 (59.7)	52 (83.9)	22 (35.5)	0.000*	3.51 (1.97-6.23)
Walking	70 (56.5)	52 (83.9)	18 (29.0)	0.001*	4.01 (2.25-7.13)
Birthing chair	87 (70.2)	58 (93.5)	29 (46.8)	0.001*	6.16 (2.41-15.74)
Rocking in the chair	59 (67.6)	45 (72.6)	14 (22.6)	0.000*	2.91 (1.89-4.49)
Swiss ball	82 (66.1)	56 (90.3)	26 (41.9)	0.000*	4.78 (2.24-10.17)
Swaying	61 (49.2)	48 (77.4)	13 (21.0)	0.001*	3.54 (2.19-5.72)
Position changes (sitting, squatting, on all fours, on the side, ...)	70 (56.5)	53 (85.5)	17 (27.4)	0.001*	4.54 (2.46-8.36)
Promotion of a quiet and private environment	69 (55.6)	49 (79.0)	20 (32.3)	0.001*	3.00 (1.82-4.94)
Promotion of adequate lighting	53 (41.9)	44 (71.0)	8 (12.9)	0.000*	3.38 (2.23-5.13)
Emotional Support Actions
Constant presence	75 (60.5)	59 (95.2)	16 (25.8)	0.000*	12.84 (4.26-38.70)
Praying	74 (58.7)	57 (91.9)	17 (27.4)	0.001*	7.70 (3.32-17.85)
Supporting words	63 (50.8)	56 (90.3)	7 (11.4)	0.001*	9.03 (4.20-19.41)
Holding hands	75 (60.5)	60 (96.8)	15 (24.2)	0.000*	19.60 (5.02-76.52)
Sharing past experiences	57 (46.0)	44 (71.0)	13 (21.0)	0.001*	2.87 (1.88-4.37)
Informational Support Actions
Guidelines (what to do, what is expected or not)	71 (57.3)	47 (75.8)	24 (38.7)	0.000*	2.33 (1.47-3.70)
Advocacy/Intermediation Actions
Called a health professional for help/clarifying doubts	77 (62.1)	54 (87.1)	23 (37.1)	0.001*	4.12 (2.15-7.87)
Called a health professional to convey the woman's wishes	74 (58.7)	56 (90.3)	18 (29.0)	0.000*	6.30 (2.94-13.50)

• ^*
  Pearson’s chi-square test

Regardless of the group to which the individual was allocated, it was found that all participants used some form of support technique during the childbirth process. In addition to that, a statistically significant difference was observed between the groups in all support actions provided to the parturients that were investigated, indicating that the companions included in the Intervention Group and that were properly equipped to support the parturients, through the use of the educational booklet tested in this research, developed all these actions throughout the childbirth process.

It is worth noting the emphasis on the following variables: holding hands, where it was found that the participants from the Intervention Group were 19.60 (95% CI: 5.02-76.52) times more likely to perform this action; and constant presence, which was performed 12.84 (95% CI: 4.26-38.70) times more by the same group.

Table 3 shows the companions' satisfaction about the assistance received, including the evaluation of how it was offered, the duration and the actions performed by the professionals during labor and delivery, based on the number of companions that indicated the “Quite/Very” options.

Table 3 -
Distribution of the companions' data according to variables related to satisfaction with labor and delivery. Fortaleza, CE, Brazil, 2019 (n=124).

Variables	Total (n=124)	IG (n=62)	GC (n=62)	p	RR (95% CI)
	N (%)	N (%)	N (%)
Labor
Satisfaction in accompanying	109 (87.9)	62 (100.0)	47 (75.8)	0.001*	-
Satisfaction with the support provided	87 (70.2)	60 (96.8)	27 (43.5)	0.001*	12.75 (3.29-49.47)
Satisfaction with how it took place	64 (51.6)	58 (93.5)	6 (9.7)	0.001*	13.59 (5.25-35.15)
Satisfaction with the time	68 (54.8)	58 (93.5)	10 (16.1)	0.001*	11.94 (4.62-30.86)
Satisfaction with the care provided by the health professionals	74 (59.7)	58 (93.5)	16 (25.8)	0.001*	9.79 (3.79-25.27)
Delivery
Satisfaction in accompanying	108 (87.1)	62 (100.0)	46 (74.2)	0.001*	-
Satisfaction with the support provided	59 (47.6)	51 (82.3)	8 (12.9)	0.001*	5.10 (2.95-8.83)
Satisfaction with how it took place	75 (60.5)	58 (93.5)	17 (27.4)	0.001*	9.47 (3.67-24.42)
Satisfaction with the time	81 (65.3)	62 (100.0)	19 (30.6)	0.001*	-
Satisfaction with the care provided by the health professionals	84 (67.7)	62 (100.0)	22 (35.5)	0.001*	-

• ^*
  Pearson's chi-square test

Regarding the satisfaction in accompanying the parturients during the childbirth process, statistically significant differences were found when comparing the intervention and control groups, in all the satisfaction requirements evaluated. It was observed that the individuals who were previously trained through a preparatory intervention on supporting actions for the parturients using an educational manual were more likely to demonstrate satisfaction with the support provided, the way the childbirth process took place, the time and the actions performed by the professionals during labor and delivery.

Examples of these findings include: the participants from the Intervention Group are 13.59 (95% CI: 5.25-35.15) times more likely to demonstrate satisfaction with how labor proceeded; 12.75 (95% CI: 3.29-49.47) times more likely to report satisfaction with the support provided during labor; and 11.94 (95% CI: times more likely to indicate satisfaction with the duration of labor.

After calculating the items of each subscale separately, a calculation of the assessment medians by the parturients regarding their experience and satisfaction with childbirth was also performed, as shown in Table 4.

Table 4 -
Distribution of the puerperal women's assessment means regarding their experience and satisfaction with childbirth. Fortaleza, CE, Brazil, 2019 (n=124).

Variables	Total (n=124) Md (p25/p75)	IG (n=62) Md (p25/p75)	CG (n=62) Md (p25/p75)	p
Subscale 2: Positive Experience	53 (42/58)	57 (54/61)	43 (39/52)	0.000*
Subscale 3: Negative Experience†	24 (20/26)	26 (24/27)	21 (16/23)	0.000*
Subscale 4: Relaxation	17 (13/20)	20 (16/22)	14 (12/18)	0.000*
Subscale 6: Support from the companion	19 (15/24)	23 (19/24)	17 (12/24)	0.000*
QESP Final Score	110 (96/127)	125 (118/132)	97 (80/105)	0.000*

• ^*
  Mann-Whitney U test; ^†Scales with reversed scores: 1. Very; 2. Quite, 3. A little; 4. Not at all

A statistical association was evidenced in all the QESP subscales that were analyzed, confirming that the puerperal women whose companions were included in the group that received an educational intervention using the manual were more likely to report better experiences and satisfaction with childbirth.

DISCUSSION

The continuous presence of a companion and the development of support actions provided by them contribute to improving the maternal and perinatal indicators. However, despite the countless benefits provided by the companions, there is still a restriction on their presence and participation in supporting women in labor in maternity wards. It is recommended to implement protocols that record the presence of companions throughout the entire hospitalization time for childbirth, to duly train health professionals, and to improve the structures and organization of health services12.

To ensure that women have the freedom to choose their companions, it is essential for the responsible agencies to oversee health institutions linked to the public health system (SUS) or to private health institutions. In addition to that, changes in the training of health professionals working in childbirth assistance are necessary. In the current debate on public policies related to childbirth care, it is imperative to ensure this right, which has historically been a central demand of the feminist movement13.

In this research, regardless of the group to which each individual was assigned, it was found that all participants used some form of support technique during the childbirth process. The following support actions provided by the companions during labor and delivery are highlighted: holding hands, continuous presence, supporting words, massages and using the birthing chair, among others. In addition to these, a network meta-analysis on the effects of non-pharmacological strategies to reduce labor pain showed that the Bonapace Method is the preferred strategy for reducing labor pain. This method involves the father or a significant partner to help reduce childbirth pain by practicing pain modulation techniques based on endogenous neurophysiological models14.

In this study, the statistical analysis confirmed that the companions from the Intervention Group showed better performance in developing all the support techniques provided to the women in labor during the childbirth process. Therefore, for not having participated in a specific educational strategy to equip and train them, the Control Group participants reached lower performance levels in carrying out support actions during labor. In this context, it is observed that a factor pointing to the deficiency in the humanization of childbirth assistance is the companions' unpreparedness, who are oftentimes unaware of their role15.

Corroborating with the findings identified in this research, the presence of a companion, which constitutes an emotional support action, promotes confidence and safety during childbirth, in addition to being a source of support and strength capable of alleviating pain and the feeling of loneliness and generating emotional and physical well-being16. In addition to that, it is known that physical support produces a sense of relaxation and pain relief in women in labor, which can awaken in the companions the satisfaction of seeing the support provided acting to increase maternal well-being17.

In this study, it was verified that all types of support actions, among which physical, emotional, informational and advocacy/intermediation support stand out, were more developed by the companions from the Intervention Group, showing that prior training influences their instrumentalization and contributes to previously trained companions developing support actions with the parturients.

Continuous physical presence was an important role played by the companions, particularly in environments where continuous obstetric care was not available or not practiced. The continuous presence of a companion signaled to the woman the availability of support when needed and helped pass the time throughout the entire labor process2.

The presence of a companion during the childbirth process contributes benefits. It provides feelings of safety and confidence, not only in the physiological aspect of childbirth but also strengthening family ties by allowing the companion to get close and establish contact with the woman and the newborn immediately after birth. These benefits are crucial for emotional well-being and the emotional bond among all involved7. Moreover, the supportive care provided by a companion is effective in shortening the duration of labor and increasing the parturients’ satisfaction level18.

Regarding the presence of the partner in the delivery room, it is considered essential that health professionals approach childbirth as an event filled with sensations. In this way, both the partner and the parturient have the opportunity to express their sensitivity and give space to their emotions since, as human beings, they have subjectivity and feelings that, once expressed, require respect and care19.

It is known that it is essential for the companion to have adequate prior knowledge and for the health professional to be open and receptive to their presence, as this is fundamental for greater participation and involvement of both the companion and the woman during the childbirth process9. Thus, it is important to invest in initiatives aimed at health professionals, aiming to adopt a receptive stance and develop skills to engage and value companions during childbirth practices, which would exert a significant impact on the interaction between professionals, companions and parturients8.

In this context, the need for training processes aimed at the parturients' companions is clear, in which information is shared about the childbirth mechanisms and effective ways for the companions to participate during labor and delivery, as they are increasingly present in the childbirth process, in order to optimize their presence at this moment. It is crucial for Obstetric Nursing to recognize how important it is to prepare these companions during childbirth, enabling all the benefits of their presence during labor and birth.

The presence of a companion during childbirth has been recognized as a significant factor in increasing women's satisfaction with their delivery experience, potentially reducing feelings of isolation and anxiety that many mothers may experience during this period. The active presence of a companion has been associated not only with an improvement in psychological aspects but also with women's greater degree of participation and empowerment regarding childbirth-related decisions. Consequently, this collaboration between the parturient and her companion results in an overall increase in satisfaction with the delivery experience20.

In light of the above, some limitations were identified in the study, such as the inclusion and participation of companions of parturients in training processes developed in the maternity ward for their role in labor and delivery, highlighting the following: lack of availability and/or interest in participating in the research; occurrence of childbirth before or during the intervention; and change of companion at the delivery time. Other aspects that hindered follow-up and analysis of the impact of the intervention tested in this research, using an educational manual, on the satisfaction and social support felt by the puerperal women were the following: discharge of the puerperal woman from the maternity ward before applying the QESP instrument and the follow-up interview; and changes in phone contacts, precluding further contact with the companion and hindering non-verbal communication, an important tool for understanding the participant's understanding of the questions asked.

For future research studies, it is recommended to develop and evaluate the effect of other technologies that present the same informative content but can be disseminated more widely, such as phone apps. Thus, it is suggested to conduct studies that assess the efficacy of other educational interventions, involving the companions, on variables of the childbirth process and on maternal and neonatal outcomes.

CONCLUSION

The intervention applied in the maternity ward using an educational manual aimed at parturients' companions is effective and contributes to providing support during the childbirth process. The companions included in the Intervention Group with the educational manual performed a significantly higher number of support actions when compared to those from the Control Group.

It was evidenced that those who had access to the educational manual were more likely to provide physical, emotional, informational and advocacy/intermediation support to the parturients. The support actions that were most significant included holding hands and constant presence. In addition, the puerperal women whose companions were included in the group that received an educational intervention with the manual had better experiences and satisfaction with labor and childbirth.

This study plays a crucial role in promoting maternal health and improving the childbirth experience, as it can be used as a guide for companions, providing practical and relevant knowledge. Therefore, it not only provides valuable insights into the efficacy of the educational manual but also actively contributes to improving the support provided by companions in obstetric centers, positively impacting health and society as a whole.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Effectiveness of an educational manual in the support provided by companions in an obstetric center: A randomized clinical trial, presented to the Graduate Program in Nursing of Universidade Federal do Ceará, in 2019.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Assis Chateaubriand Maternity School - UFC, opinion No. 3,046,203/2018 and Certificate of Presentation for Ethical Appraisal 03011518.7.0000.5050.

• TRANSLATED BY

  Leonardo Parachú

Edited by

EDITORS

Associated Editors: Bruno Miguel Borges de Sousa Magalhães, Maria Lígia dos Reis Bellaguarda. Editor-in-chief: Elisiane Lorenzini

Publication Dates

• Publication in this collection
  22 July 2024
• Date of issue
  2024

History

• Received
  09 Sept 2023
• Accepted
  26 Dec 2023