1. Companionship at hospital birth – a profile from the Born in Brazil Survey Simone G. Diniz, Odalea Maria Bruggemann, Eleonora D’Orsi, Sonia Lansky, Camilla Schneck, Jane Sandall, Susanna Rance, Jacqueline Torres, Daphne Rattner, Silvana Granado, Marcos Dias, Arthur Schlithz, Maria do Carmo Leal

2. Background: evidence Since late 80s, studies show robust evidence on the maternal and neonatal health benefits, and high maternal satisfaction, with continuous presence and support during childbirth. That lead to the international recommendation by WHO in the 90s, that “continuous support during labour has clinically meaningful benefits for women and infants and no known harm, and that all women should have support throughout labor and birth” World Health Organization. "Care in normal birth: a practical guide." Geneva: World Health Organization (1996).

3. Companionship policies in Brazil In Brazil, evidence was used to support the first laws about the right to companions at birth in the 90,s, adopted in several states. In 2005, a national law which applies to all women in public or private services (No.11.108) affirmed the right to have a companion of women’s choice during antenatal care, labour, delivery and post- partum periods. The pace and extent of implementation in hard to track, since no national data on companionship is available in the Brazilian Health Information System (DATASUS).

4. Services resist companions of women’s choice

5. Aims of this research Analyze the implementation of the companions in labor, delivery and immediate postpartum in Brazilian public, mixed and private sector Identify who is the companion present, and if it is the woman's choice Identify maternal, institutional, type of care and ambience factors associated with the presence of companions in the public and private sector

6. Objective Robust evidence of the benefits of a continuous support during birth led to the recommendation by WHO that it should be offered for every women. In Brazil, it is guaranteed by law since 2005, but scarce data on implementation is available. We aimed to estimate the frequency and associated socio-demographic, obstetric and institutional predictors of having companionship in childbirth. Descriptive statistical analysis was done for the characterization of companions (on different moments of hospital stay), maternal and institutional characteristics; associations were investigated in bivariate analyses, stratified and multivariate models. The sample included 23,839 women, 24,5% of them had no companion at all, 20,2% had a continuous companionship, 55,2% had partial companionship. Women´s partner was present in 23,7% of deliveries. Women with lower income, less educated, non-white, younger and using public sector had fewer companions at any moment of birth, in all regions. Implementation was associated with change in institutional culture and rules, ambience and facilities, which is dependent on political will from policy makers.

7. Methods Nationwide survey: - from February 2011 to August 2012 - 23,839 women - 268 Maternity centres - 191 cities Interviews of 90 women from each selected centre. Data from hospital charts and prenatal care cards. Information about the operational structure of each centre. Telephone interview 45-60 days after birth Analyses comparing data from women who had the birth paid for by health insurance and those attended in public health centres.

8. Main study sample in Brazilian map 191 cities 266 hospitals North 23 municipalities 32 hospitals Northeast 55 municipalities 68 hospitals Southeast 62 municipalities 88 hospitals South 30 municipalities 44 hospitals Midwest 17 municipalities 30 hospitals

9. Methodology Descriptive statistical analysis was done for the characterization of companions (on different moments of hospital stay), maternal and institutional characteristics; Associations were investigated in bivariate analyses, stratified and multivariate models. The sample included 23,839 women, was expanded to general population represented

10. Results

12. Frequency distribution of factors related to having a companion at birth

16. In conclusion Women with lower incomes are more vulnerable to having no companion at all, and has the lowest rates of "some companionship" Women who have vaginal birth, are younger, have less education, non-white skin color, and SUS users, are more frequently deprived from companions in childbirth

17. In services that are teaching hospitals, with beds are all public or mixed, and with less prepared to receive companions (do not have any accomodation) women have lower rates of companions in labor / childbirth The most important predictors for the presence of companions are institutional: a policy of "permission" (law enforcement) for all, but there is an important difference between permission and effective presence; the higher difference is during delivery (49.9%)

20. Companionship, frequencies (total, any parto of hospital stay, during admission)

21. Companionship during labor (including women who went into labor and who did not)

22. Companionship during delivery, and in immediate post-partum period

23. Who was the companion? Partner/father of the child; others who; your choice?)

24. The experience: does it help, is birth better with a companion?)

25. Companionship during delivery, by region The highest rates of companions in delivery are in the Southeast (45.1%) and South (41.4) regions, and lowest in the North and Northeast 14.5% (18.5%)

26. Companions in delivery according to maternal characteristics Women who have vaginal birth, are younger, have less education, non-white skin color, unmarried, SUS users and attended by a doctor, are more frequently (vulnerable to) deprived from companions in childbirth

27. Companionship during delivery and services characteristics In services that are general hospitals, teaching hospitals, with beds are all public or mixed, and with less preparation to receive companions (do not have any accomodation) women have lower chances / rates of companions in delivery / childbirth

28. Income and companionship Women with lower incomes are more vulnerable to having no companion at all, and has the lowest rates of "some companionship" Note: The denominator of "companion all time" includes women who did not go into labor, which underestimates the data

29. Policy of the institution and the presence of companions: "allowed for all" and effective companionship according to women The most important predictor for the presence of companions is a policy of "permission" (law enforcement) for all, but there is an important difference between permission and effective presence; the higher difference is during delivery (49.9%)

30. The care that a woman receives during labor and delivery, like the quality of the experience of birth itself, are markers of the woman´s and baby’s place in social hierarchies, including dimensions such as social class, race/ethnicity, health status, marital status, physical ability, sexual respectability, and others.