A vagina-escola: seminário interdisciplinar sobre violência contra a mulher no ensino das profissões de saúde

"Beautiful Registrations": Metrics and Prenatal Care in Rural Bahia, Brazil

In Brazil, lack of quality in the delivery of prenatal care is a persistent concern. In this study, I analyze the dynamics taking place in the prenatal clinical encounter, and illuminate how the requirement to produce metrics through registration and monitoring endorses a form of bureaucratic care. This form of care develops in a context characterized by scarcity and a lack of medical resources, where healthcare professionals attempt to contain uncertainty. Ruled by notions of risk, centered in measuring practices, and saturated by an overvaluation of technology, bureaucratic care reinforces the disenfranchizement and stigmatization of Black rural women.

Factors intervening in the childbirth experience: a mixed-methods study

OBJECTIVE

To analyze the childbirth experience focusing on the intervening factors and on the delivery method.

METHOD

A sequential and explanatory mixed-methods study guided by the World Health Organization document for positive childbirth experiences. The participants were puerperal women in a maternity teaching hospital from inland São Paulo (Brazil). The first quantitative stage involved descriptive analysis with Poisson regression of 265 answers to the "Termômetro da Iniciativa Hospital Amigo da Mulher e da Criança" ("Women- and Baby-Friendly Hospital Initiative Thermometer") questionnaire. The second stage, qualitative, thematically analyzed the interviews conducted with 44 puerperal women who took part in the first stage. Data integration was by connection.

THE RESULTS AND DISCUSSION

The analysis by connection showed that among the factors that restricted the positive experience, C-section was predominant (61.9%), understood as an option due to fear of pain, the treatment modality and previous traumas. Restrictions referring to the presence of a companion (99.6%), not having privacy (83%), disrespectful situations (69.5%), too many touches (56.9%) and the absence of skin-to-skin contact (55%), among others, potentiated fear, loneliness, concern, shame, the perception of disrespect and insecurity with the assistance provided. The promoting factors were as follows: choosing the companion (95.4%) for collaborating in the safety perception, not having infections (83.9%), having continuous team monitoring (82.2%) and pain relief methods (78.9%), which were valued by the women.

CONCLUSION

The intervening factors that promoted positive experiences were related to clinical and protocol-related issues and to service availability. The restrictive factors were associated with excess interventions, deprivation of rights and of choice, absence of privacy and restriction referring to the presence of a companion. Women with a normal postpartum period felt more insecure and disrespected when compared to those subjected to C-sections, whose choices were considered, although they had lower prevalence of skin-to-skin contact. There is an urgent need to apprehend women's experiences and turn them into actions that guarantee their lives in a safe and respectful way.

Avaliação da organização e práticas de assistência ao parto e nascimento em três hospitais de Santa Catarina, Brasil

O objetivo foi avaliar a assistência hospitalar ao parto e ao nascimento, analisando aspectos de gestão e assistência desde a admissão das mulheres para o parto até o pós-parto. Foi realizada uma pesquisa avaliativa dos aspectos de gestão e práticas de assistência ao parto e nascimento, desenvolvida no período de novembro de 2019 a fevereiro de 2020, em três hospitais de Santa Catarina, Brasil, com melhor desempenho em uma avaliação nacional de boas práticas de assistência ao parto e ao nascimento. A coleta de dados envolveu análise documental, observação e entrevistas com profissionais da gestão, assistência e puérperas. Foram analisados 30 indicadores, que compuseram uma matriz de análise e julgamento, agrupados nas dimensões Político-Organizacional e Tático-Operacional. O julgamento orientou-se pela comparação entre a pontuação observada e a pontuação máxima esperada em cada um dos componentes da matriz avaliativa. A assistência ao parto e ao nascimento foi parcialmente satisfatória nos hospitais 2 e 3 e insatisfatória no hospital 1. A dimensão Político-Organizacional foi classificada como insatisfatória e a Tático-Operacional parcialmente satisfatória nos três hospitais. Nenhum hospital obteve avaliação satisfatória em mais de 40% dos indicadores. Os hospitais analisados ainda não conseguiram consolidar as mudanças no modelo assistencial na perspectiva do cuidado humanizado, orientado por evidências científicas e direitos.

[Racial disparities: an analysis of obstetrical violence among Afro-Brazilian women]

The objective was to understand and analyze the experiences of Afro-Brazilian women regarding pregnancy, delivery and postpartum care. It involves empirical research, with a qualitative approach. Women were interviewed who declared themselves black or colored and were attended in the public health services in the municipalities of the State of Pernambuco. The narratives were collected through semi-structured interviews. The Content Analysis technique was used. The narratives addressed the issues of obstetric violence and institutional racism. The intersection of levels of oppression such as race, class and gender are determinant in interventions and abusive practices in the helathcare that involves childbirth. The conclusion drawn is that structural racism hinders and denies access to black women to their reproductive rights.

A change laboratory for maternity care in Brazil: Pilot implementation of Mother Baby Friendly Birthing Initiative

Disrespectful and abusive treatment of women during childbirth is a worldwide problem. This research aimed to develop and implement a Mother Baby-Friendly Hospital Initiative (MBFHI) in an academic maternity hospital in Brazil and evaluate how change could be sustained. Change Laboratory principles guided a process of action research, which was conducted between 2017 and 2019. Clinicians and managers joined the researchers in discussion sessions to redesign routines and care pathways. Observation, interviews, focus groups, and historical and documentary analysis provided information about the existing activity system, which we analysed qualitatively using MBFHI criteria to identify themes. Evidence of inappropriate obstetric interventions and impersonal interactions between clinicians and patients stimulated us to devise innovative solutions. The challenges identified by this exercise included: poor infrastructure and ambience; difficulty adhering to evidence-based protocols; social and professional hierarchies; and clinicians being poorly educated about women's rights. Although challenges remained, positive changes included a friendlier environment, improved patient privacy, and fewer unnecessary procedures. Resources released by these changes allowed us, collaboratively, to track the further implementation and sustainability of change. We conclude that the Change Laboratory can help motivated clinicians and managers humanise patients' experiences, make care more evidence-based, and expand learning of mother-friendly maternity care. Tensions and contradictions between education and patient care reported here may resonate in settings other than maternity care.

Cesarean section rates in São Paulo State: regional inequalities in SUS obstetric care

Abstract Objectives: to analyze the relation between cesarean section rates in SUS childbirth care establishments in São Paulo State and urbanization conditions, according to Robson group classification system. Methods: Sistema de Informação sobre Nascidos Vivos (Live Births Information System) and Cadastro Nacional de Estabelecimentos de Saúde (National Registry of Health Establishments) 2016 databases were analyzed. The studied outcome was cesarean section rates in the establishments, grouped by administration type (public or nonprofit entities) and urbanization condition. Results: the cesarean section rate in SUS childbirth care establishments was 50.5%, ranging from 41.1% in metropolitan regions up to 75.2% in the low urbanized regions. Cesarean section rates in public administration establishments (38.2%) were significantly lower than the nonprofit administration maternity hospitals (62.3%). Robson groups 5 and 2 contributed mostly to the cesarean section global rate (36.6% and 21.5%, respectively). Conclusions: The less urbanized regions showed significantly higher cesarean section rates than the metropolitan and highly urbanized regions. Cesarean section rates of public administration establishments were significantly lower than the nonprofit administration establishments. However, when separated by urbanization condition its difference was only observed in the metropolitan regions.

Labor and childbirth care in maternity facilities in Brazil's North and Northeast regions: perceptions of the evaluators of the Stork Network Program

This article eevaluates delivery and birth care practices in maternity facilities in Brazil's North and Northeast regions. We conducted a qualitative evaluation of 91 facilities in the North and 181 facilities in the Northeast. The data was collected using systematic observation by a team of 44 previously trained evaluators and recorded in a field diary. A thematic analysis of the collected data was performed, resulting in three core themes: challenges of collegial management; challenges for coping with obstetric violence; and the potential of the evaluation process for driving change. Advances were made in the implementation of good labor and childbirth care practices; however, some maternity facilities still reproduce hierarchical models without spaces for collegial management and accounts of obstetric violence were common. Health professionals used the presence of risk to justify the low level of adoption of good practices. However, the findings reveal progress towards the humanization of care. The results also show the potential of the evaluation process for driving change. Although progress has been made towards the adoption of the good practices recommended by the Stork Network Program both in the area of management and care delivery, many challenges remain in view of the dominance of a hierarchical management model associated with an interventionist approach to health care.

Individual birth planning as a teaching-learning strategy for good practices in obstetric care

OBJECTIVE

To verify students' knowledge about individual birth planning and learn their opinion about the use of this teaching-learning strategy for good obstetric practices.

METHOD

This is a descriptive study conducted with midwifery students who made primary health care internships. Data collection was performed digitally from 01/2017 to 05/2017 through the Google Forms®Platform. The analysis was performed by descriptive categorization statistics of statements. The study followed the required ethical standards.

RESULTS

The form was sent to 97 students and answered by 40% of them. All respondents reported knowing the birth planning, and 87% applied it during prenatal care. The most frequent (45%) points about the birth plan were those that promoted women's empowerment and autonomy. The most cited methodological suggestions for its application were to focus on content (76%) and increase the number of meetings (50%). Individual birth planning was recognized by 79% of the participants as an important teaching strategy.

CONCLUSION

In addition to knowing birth planning and applying it, the students consider it very relevant for teaching and learning good obstetrical practices.

Um corte na alma: como parturientes e doulas significam a violência obstétrica que experienciam

Resumo: Neste artigo busca-se entender como mulheres (parturientes e doulas) significam as violências obstétricas que vivenciam. O estudo foi realizado a partir da análise das narrativas de três parturientes e duas doulas a respeito da assistência experienciada na maior maternidade da Paraíba em 2017. As cinco mulheres frequentavam as reuniões de um grupo de gestantes, nas quais eram trocadas informações sobre a assistência ideal a partir dos preceitos da humanização do parto e nascimento. Informação e empoderamento, elementos cruciais na pauta da humanização, não foram suficientes para garantir que essas mulheres não fossem violentadas. Pelo contrário, elas vivenciam sua invisibilização como sujeitos, ao passo que seus corpos são objetificados. A informação, que deveria ter sido ferramenta para garantia de direitos, funcionou e instrumentalizou a violência.

The satisfaction of the normal delivery: finding oneself

OBJECTIVE

To understand the satisfaction women experience during the normal delivery.

METHODOLOGY

Qualitative, exploratory and descriptive study, developed during January and February of 2017, from interviewing twenty women that were satisfied with their natural delivery, residing on the countryside of Sao Paulo. The Symbolic Interactionism and the Thematic Content Analysis support this study.

RESULTS

The main theme "Normal delivery as a means to find oneself" developed through three thematic units that report the satisfaction in the normal delivery: "Decision for normal delivery", "Childbirth with welcoming support", "Violence: it is not all roses". The satisfaction has been correlated to the accomplishment of the dream of giving birth, welcoming support of Doulas/health professionals and the presence of a companion/family members during the process, but it also reveals labors marked by invasive, imposing and unwelcoming experiences.

CONCLUSIONS

The empowerment granted and felt by the woman during the normal delivery experience reinforces the urgency of investments to promote sociocultural transformations that concern childbirth in Brazil.

Institutional violence during the parturition process in Brazil: integrative review

ABSTRACT Objective: To identify the types of institutional violence of childbirth reported by the woman, the birth companion and health professionals. Method: Integrative review that analyzed 33 articles in the LILACS, BDENF, INDEXPSI, regional SciELO, Scopus, Web Of Science and PubMed databases. Results: Women were the main violence rapporteur, with predominance of the psychological type. Precarious infrastructure and the imposition of professional decisions were identified by the companion as violence. For health professionals, performing procedures without consent does not characterize violence, but guarantees childbirth security. Final considerations: The most common types of violence in Brazilian maternity hospitals are psychological, physical and structural. Most of the time, violence is reported by women, although professionals also perceive and admit its perpetuation.

Report on the midwives' experiences in the Brazilian National Health System: A qualitative research

OBJECTIVE

to describe the experiences of midwives who graduated from the University of São Paulo's midwifery program and the characteristics of their work within the Brazilian National Health System (SUS).

DESIGN

a descriptive, qualitative field study.

SETTING

interviews were scheduled by telephone or e-mail and were held with the midwives outside their work environment. Interviews lasted for up to one hour and were recorded.

PARTICIPANTS

ten midwives who had graduated from the University of São Paulo's midwifery program and were working or had worked in the SUS at the time of the study.

ETHICAL ISSUES

the study protocol was approved by the internal review board of the School of Arts, Sciences and Humanities, University of São Paulo. All pertinent ethical principles were followed. MEASURES AND FINDINGS: data were collected at interviews focussing on the participants' work and their experiences while working in the SUS. The dialogues during the interview sessions allowed the participants to build on and extend the proposed topics. After the data had been transcribed and read, the discourses were grouped in accordance with the similarity of their content, resulting in four thematic categories: the inclusion of midwives into the obstetric team; dealing with contradictions: challenges of the profession; working in the SUS: between precariousness and guaranteeing access to health services; and making a difference. The findings provoke reflection on the challenges faced by midwives in their work within the SUS: challenges associated with the difficulties in working in the public healthcare sector, difficulties in their relationships with other healthcare professionals, difficulties related to a general lack of knowledge on this specific occupation in Brazil, the absence of a midwifery model of care, difficulty in dealing with obstetric abuse, and the dilemmas facing the midwives during their daily practice of midwifery.

KEY CONCLUSION

despite the difficulties encountered, the midwives consider the care they provide to be differentiated. They perceive gradual changes in the care offered to women by the healthcare facilities and by other professionals, and believe that they make a difference in their workplaces. In addition, they want to work in the SUS and are committed to transforming the quality of care provided to women in Brazil.

PRACTICAL IMPLICATIONS

the experiences related by midwives reflect the midwifery scenario nationwide, highlighting the perspectives for change. The emphasis placed by midwives on their social role and their commitment to changing current midwifery care models and to consolidating the SUS is noteworthy.

Violência obstétrica: revisão integrativa de pesquisas qualitativas

Objetivo: Describir cómo los factores que afectan las prácticas de atención del parto interfieren en la experiencia del parto y en el nacimiento.Síntesis de contenido: Se trata de una revisión integradora de investigaciones cualitativas. A partir de las búsquedas en las bases de datos seleccionadas, se encontraron 17 051 artículos,de los cuales, según los criterios preestablecidos, se eligieron 54. De acuerdo con el análisis de los estudios elegidos, emergieron cuatro categorías, a saber: Preconcepciones contemporáneas sobre el parto normal y la cesárea, Elementos desfavorables para la vivencia satisfactoria del parto, Banalización de la violencia obstétrica y Presupuestos sobre la asistencia humanizada del parto. Los resultados revelaron que las prácticas de asistencia al parto estaban desactualizadas, eran inapropiadas, se consideraban“normales” y estaban marcadas por el autoritarismo y por la falta de respeto hacia las mujeres, lo cual caracteriza la violencia obstétrica. Por su parte, el modelo humanizado, al valorar elprotagonismo femenino, hace que la experiencia del parto sea más gratificante. Conclusión: Las prácticas de asistencia al parto en Brasil no respetan los derechos sexuales y reproductivos, lo que se refleja en los altos índices de cesáreas innecesarias y en los maltratos que las mujeres sufren en los hospitales materno-infantilesbrasileños.