Para reinventar o parto e o nascimento no Brasil: de volta ao futuro

"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.

[Postpartum care for women in primary care: building an assessment model]

Postpartum care for women in primary healthcare (PHC) is important for reducing their morbimortality, but there is no clearly described theory on such care, and the assessment studies are rare. This study aimed to develop and systematize an assessment model for women's postpartum care in PHC, verifying it evaluability. An evaluability study was performed using a Brazilian and international literature review, review of national documents, and interviews with stakeholders. Such evidence backed the elaboration of an assessment model that was validated in a consensus workshop. The data were analyzed with thematic analysis. The study elaborated the program's theory, in which postpartum care in PHC ideally takes place with a comprehensive approach to the woman's physical, psychological, emotional, and social needs, considering the individuality of women with liveborn children or in situations of fetal/neonatal death, initiating prenatal care and continuity in the postpartum period, and with the involvement of spouses and other family members. The program's theory established the program's contextualization and logical design, with objectives, targets, activities, outputs, results, and impact, previously not explained systematically in the literature and documents. Postpartum care was found to be evaluable through an implementation analysis, and the program's theory was defined, with the potential for use by various stakeholders at both the national and international levels to implement and/or improve comprehensive postpartum care for women.

Psychometric properties of the Mackey Childbirth Satisfaction Rating Scale cross-culturally adapted to Brazilian Portuguese

OBJECTIVE

To analyze the psychometric properties of the Brazilian version of Mackey Childbirth Satisfaction Rating Scale (MCSRS).

METHODS

The MCSRS questionnaire was applied to postpartum mothers before discharge at low-risk maternity hospital in Brazil. The inclusion criteria were maternal age between 18 and 34 years, delivery of a live infant, and gestational age at birth over 36 weeks. In analyzing psychometric properties, dimensionality was evaluated by exploratory factor analysis and reliability by Cronbach's alpha and McDonald's omega.

RESULTS

Fifty-three questionnaires were filled out by the postpartum mothers for an analysis of psychometric properties. Of the participants, 84.9% had vaginal deliveries; and 58.5% had deliveries by obstetricians and 41.5% by midwives. Two latent dimensions model was significantly better than those obtained with the single-factor model (Dc233 = 145.9, p < .001). The first dimension explains 35% of the variance related to the items covering care giving, and the second explains 17% of the variance related to self-satisfaction and satisfaction with the partner. High communality was found for factor 1 (0.36-0.71) and factor 2 (0.28-0.50). For factors 1 and 2, Cronbach's alpha was 0.96 and 0.92, and McDonalds' omega was 0.96 and 0.89, respectively. The reliability coefficient omega for the overall reliability of the questionnaire was 0.97.

CONCLUSION

The psychometric properties of the Brazilian version of the MCSRS yielded two dimensions related to professional care giving and family. This version demonstrated good reliability and is thus a potential instrument to promote improvement of childbirth care in the country. Nonetheless, confirmation of the structural model of the tool should be sought.

Os movimentos feministas e o processo da Reforma Sanitária no Brasil: 1975 a 1988

RESUMO O presente ensaio visou apresentar reflexões iniciais de uma pesquisa mais ampla ainda em curso sobre as relações entre os movimentos feministas e a Reforma Sanitária Brasileira no período de 1975 a 1988. Tema pouco estudado em uma conjuntura adversa, a ditadura militar, mas também marcada por efervescências políticas e sociais, a partir de uma pesquisa documental preliminar, foram identificados eventos e documentos que indicam diálogos entre esses dois movimentos sociais. Engajados na luta pela redemocratização social e democratização da saúde, os movimentos feministas e sanitário apresentaram propostas convergentes exemplificadas pela formulação e tentativa de implementação do Programa de Assistência Integral à Saúde da Mulher (Paism). Primeira política pública de saúde que traz a integralidade, um dos princípios do Sistema Único de Saúde, no Paism, encontram-se proposições defendidas pelo Movimento Sanitário e vinculadas às pautas feministas na saúde. Entretanto, esses trânsitos parecem ter sido marcados por algumas dificuldades relacionadas com a conjugação das denominadas questões mais ‘amplas’ com as ‘específicas’ e os desafios para elaboração de pautas comuns entre os dois movimentos. Reconhece-se, portanto, a complexidade da temática. Ousa-se apresentar essas reflexões para explicitar os diálogos, as conquistas alcançadas e, talvez, contribuir para a construção de estratégias renovadas de luta pelo direito à saúde.

Good practices in normal childbirth: reliability analysis of an instrument by Cronbach's Alpha

OBJECTIVES

to analyze the internal consistency of the evaluation instrument of the adherence to the good practices of childbirth and birth care in the professionals, through Cronbach's Alpha Coefficient for each of the dimensions and for the total instrument.

METHOD

this is a descriptive and cross-sectional study performed in obstetric centers of eleven public hospitals in the Federal District, with a questionnaire applied to 261 professionals who worked in the delivery care.

RESULTS

The study was attended by 261 professionals, 42.5% (111) nurses and 57.5% (150) physicians. The reliability evaluation of the instrument by the Cronbach Alfa resulted in 0.53, 0.78 and 0.76 for dimensions 1, 2 and 3, after debugging that resulted in the exclusion of 11 items.

CONCLUSIONS

the instrument obtained Cronbach's alpha of 0.80. There is a need for improvement in the items of dimension 1 that refer to attitudes, knowledge, and practices of the organization of the network of care to gestation, childbirth, and birth. However, it can be applied in the way it is used to evaluate practices based on scientific evidence of childbirth care.

Every birth is a story: process of choosing the route of delivery

ABSTRACT Objective: To analyze the discourses on the choice of the route of delivery from the perspective of women and health professionals in a public network. Method: The methodological approach is the discourse analysis. The data collection was through interviews and the treatment of the data was based on discourse analysis. Results: The categories were: 1- Between the preference and the decision there is no choice; 2- The complexity of the choice of the route of delivery; 3- It is necessary to legitimize the choice of the woman. Final considerations: From the perspective of women in labor the route of delivery is determined by the physician and women are not proactive. The nurses' performance is timid, although their presence is fundamental for stimulating the physiological delivery and promoting the autonomy of women. It identifies the need for the physician to adopt a welcoming attitude, informing the women about the pros and cons involved in choosing the route of delivery.

Factors related to health services determine breastfeeding within one hour of birth in the Federal District of Brazil, 2011

Objective:

To identify factors associated with breastfeeding in the first hour of life.

Methods:

A cross-sectional study conducted among mothers and children under one year of age, who attended the second stage of the polio vaccination campaign in the Federal District, Brazil, in 2011. The sample was composed of 1,027 pairs of mothers and children. Breastfeeding in the first hour of life was considered as the dependent variable; and the independent variables were: socio-demographic characteristics of the mother, prenatal, delivery and postpartum care, reference to physical or verbal violence/neglect during delivery, and children health. Unadjusted and adjusted prevalence ratios (PR) were used as measures of association, calculated by Poisson regression.

Results:

The prevalence of breastfeeding in the first hour of life was 77.3%. Inadequate prenatal care (PR = 0.72), cesarean section (PR = 0.88) and no access to rooming-in after birth (PR = 0.28) were factors that interfered negatively in breastfeeding in the first hour of life. No factor was associated with breastfeeding in the first hour of life for mother and children.

Conclusions:

Factors related to health services such as prenatal care, type of delivery and postpartum rooming-in interfered with breastfeeding in the first hour of life, indicating that health services, as well health professional practices were major determinants the breastfeeding in the first hour of life.

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 e prevenção quaternária: o que é e o que fazer

O objetivo deste artigo é justificar a necessidade de prevenção quaternária frente à 'violência obstétrica' (VO), terminologia que agrupa todas as formas de violência e danos originados no cuidado obstétrico profissional, bem como discutir estratégias e ações de prevenção quaternária a serem realizadas pelos médicos de família e comunidade (MFC), pelas equipes de atenção primária à saúde (APS) e suas entidades associativas. A prevalência de violência obstétrica no Brasil é alta: ¼ das mulheres relata terem sofrido maus-tratos durante o atendimento ao parto, além de excesso de intervenções desnecessárias (como venóclise, ocitocina de rotina e episiotomia) e privação de uma assistência baseada em boas práticas, tais como parto em posição vertical, possibilidade de se alimentar e de se movimentar durante o trabalho de parto e presença de um acompanhante. Destaca-se o excesso crônico de cesarianas (55,6% do total de nascimentos) no Brasil, mais prevalente no setor privado (85%) do que no público (40%). Ações de prevenção quaternária dirigidas à VO são propostas e discutidas, como: (1) a elaboração (individual e coletiva) de planos de parto orientados pelas equipes de APS no pré-natal (para os quais se oferece um roteiro); (2) a introdução de outros profissionais qualificados no cuidado ao parto de risco habitual (incluindo MFC capacitados); e (3) a participação dos MFC e profissionais da APS e suas associações no movimento social e político pela “humanização” do parto, com apoio às mudanças nas maternidades já em funcionamento e às novas iniciativas de serviços de cuidado ao parto.