Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 9, e2, p. 1-10, 2019
DOI: 10.5902/2179769228225
ISSN 2179-7692
Submission: 26/07/2017 Acceptance: 17/10/2018 Publication: 15/07/2019
Original Article
Assistance with labor and birth from the perspective of mothers cared for at a public maternity
Assistência ao parto e nascimento sob a ótica de puérperas atendidas em uma maternidade pública
Asistencia al parto y nacimiento a partir del punto de vista de puerperas atendidas en una maternidad pública
Jocasta Maria de Oliveira MoraisI
Sibele Lima da Costa DantasII
Bruna Silva do Nascimento PazIII
Sabrina de Matos BezerraIV
I Enfermeira. Mestre em Saúde e Sociedade pelo Programa de Pós-graduação em Saúde e Sociedade - PPGSS da Universidade do Estado do Rio Grande do Norte – UERN. Universidade Potiguar – UnP. Mossoró, Rio Grande do Norte, Brasil. jocasta-enfermagem@hotmail.com. ORCID: http://orcid.org/0000-0001-8787-4066
II Enfermeira. Mestre em Cuidados Clínicos em Enfermagem e Saúde (PPCCLIS/UECE). Universidade Estadual do Ceará – UECE. Fortaleza, Ceará, Brasil. sibelelcosta@gmail.com. ORCID: http://orcid.org/0000-0001-7196-3769
III Enfermeira. Universidade Potiguar-UnP. Mossoró, Rio Grande do Norte, Brasil. edilmarpaz@yahoo.com.br. ORCID: http://orcid.org/0000-0002-4677-5683
IV Enfermeira. Universidade Potiguar–UnP. Mossoró, Rio Grande do Norte, Brasil. sabrinapazmatos@outlook.com. ORCID: http://orcid.org/0000-0001-9905-2406.
Abstract: Aim: to analyze labor and birth care, from the point of view of puerperal women cared for at a public maternity hospital. Method: a qualitative, descriptive study performed with ten puerperae at the obstetric center of a public institution in the city of Russas, Ceará, Brazil. Data were collected from recorded interviews, transcribed and analyzed using the collective subject discourse technique. Results: three central ideas emerged from the analysis: lack of humanized care and its limitations; dissatisfaction with the service offered; and information on the benefits of normal birth. Conclusion: this research indicates the need to reflect on health policies and practices directed to labor and birth care and how the different actors are inserted in this dynamic, understanding the limits and potentialities of health care for the highlighted group.
Descriptors: Humanization of Care; Parturition; Postpartum Period
Resumo: Objetivo: analisar a assistência ao parto e nascimento, sob a ótica de puérperas atendidas em uma maternidade pública. Método: estudo de natureza qualitativa, descritivo, realizado com dez puérperas no centro obstétrico de uma instituição pública da cidade de Russas, Ceará, Brasil. Os dados foram coletados a partir de entrevistas gravadas, transcritas e analisadas mediante a técnica do discurso do sujeito coletivo. Resultados: da análise emergiram três ideias centrais: falta de assistência humanizada e suas limitações; insatisfação com o atendimento prestado; e informação dos benefícios do parto normal. Considerações finais: essa investigação aponta a necessidade de refletir acerca das políticas e práticas em saúde direcionadas para a assistência ao parto e nascimento e a forma como os diferentes atores se inserem nesta dinâmica, entendendo os limites e as potencialidades da atenção em saúde a esse grupo em destaque.
Descritores: Humanização da Assistência; Parto; Período pós-parto
Resumen: Objetivo: analizar la asistencia al parto y al nacimiento, a partir del punto de vista de las puérperas atendidas en una maternidad pública. Método: estudio de naturaleza cualitativa, descriptiva, realizado con diez puérperas, en el centro obstétrico de una institución pública, de la ciudad de Russas, Ceará, Brasil. Los datos fueron recolectados a partir de entrevistas grabadas y transcritas y analizadas por la técnica del discurso del sujeto colectivo. Resultados: del análisis surgieron tres ideas centrales: falta de asistencia humanizada y sus limitaciones; insatisfacción con la atención prestada; e información sobre los beneficios del parto normal. Conclusión: esta investigación resalta la necesidad de reflexionar sobre las políticas y prácticas en salud direccionadas a la asistencia al parto y al nacimiento y a la forma como los diferentes actores se insertan en esa dinámica, entendiendo los límites y las potencialidades de la atención en salud a ese grupo destacado.
Descriptores: Humanización de la Atención; Parto; Periodo Posparto
Introduction
Historically, delivery care was the exclusive responsibility of women, since only midwives attended this practice. They were recognized in society for their experience, although they had no scientific knowledge.1
In the global context, institutionalization of childbirth is related to the end of World War II, when governments at the time perceived the need to reduce the high rates of maternal and infant mortality. From then on, in Brazil and the world as a whole, the parturient was separated from her relatives in the parturition process, remaining isolated in a preterm room, with little or no privacy.2
Childbirth has become a hospital-centered event, eliminating midwifes from the art of delivery and taking away the mother's dominion during this process; and with associated risk, marked by unnecessary and harmful interventions resulting in high caesarean section rates. However in Brazil, there is currently a movement to change from this model of delivery and birth care to return the autonomy of women, such that they can exercise their power of choice and be protagonists in the process.2-3
It cannot be denied that advances achieved in the areas of analgesia, anesthesia and antepartum and intrapartum fetal monitoring, use of antibiotics and hemorrhage control, together with all accumulated experience and knowledge, have reduced maternal and fetal morbidity and mortality. Nevertheless, these innumerable technological and therapeutic innovations in medical services, in addition to a lack of risk minimization, have not resolved certain issues, such as women's dissatisfaction with the quality of childbirth care that fails to meet their most subjective of needs.4
Childbirth is a unique experience with great psychological significance that can leave either positive or negative memories, depending on the woman`s experience. It is more than a physiological process, it is an event replete with meaning, during which women should be the protagonist.5
This perspective highlights questions that guided the present investigative proposal: How was the experience with the multiprofessional care team in the obstetrical center according to puerperal women? What assistance strategies were provided for these women at the time of delivery? Are humanization practices seen in the care of these women?
The health team therefore needs to provide pregnant women with important information regarding care during labor and birth, enabling her participation and decision making during prepartum, delivery and postpartum (PDP). It should be stressed that decision-making also depends on prior knowledge and experience, as well as the values, beliefs, fears and wishes of the woman and her family.6 Thus, the objective of this study was to analyze labor and birth care, from the point of view of puerperal women attending a public maternity hospital.
Method
A qualitative, descriptive study developed at the obstetric center of a public institution in the city of Russas, Ceará, Brazil. Participants in this study were puerperal women who were hospitalized in the joint accommodation and met the following inclusion criteria: mothers who were 18 years of age or older and had their children through vaginal delivery. Exclusion criteria were those with cognitive limitation or psychological disorder, and who demonstrated difficulty in understanding and answering the questions. Determining the number of participants obeyed the saturation criterion for the information. At the termination of data collection, ten puerperal women had participated.
Data collection took place from March to April 2016, in two stages. The first determined the operation of the institution and obtained information necessary for the recruitment and beginning of data collection. In the second stage, a semi-structured interview questionnaire was applied to each participant, divided into two parts: identification data of the puerperal women (age, schooling, race / color, marital status and number of children); and the second part, with the guiding questions based on the objective of this research.
The mean duration of the interviews was 50 minutes and the participants were more than 24 hours postpartum. The guiding questions were: What is your opinion about the humanization of care given to the puerperal women in this unit? Did the care strategies implemented during the PDP meet your expectations? What aspects enhanced or limited humanization in prepartum, delivery, and postpartum care?
To ensure privacy for the women, the interviews took place individually, in a private room within the institution during which their opinions were saved with an audio recorder. The schedule was agreed in advance with the puerperal women and those responsible for the institution. All research participants signed the Term of Free and Informed Consent.
The individual speeches were transcribed and analyzed using Collective Subject Discourse (CSD) technique. As such, the relevant content of each response was selected, searching for and naming the central ideas, and later the statements were edited.7
All ethical aspects were respected, as required by Resolution no. 466/12 of the National Health Council, which deals with research on human beings. The project was submitted to the Research Ethics Committee of Potiguar University and approved under Resolution No. 1,658,854, on August 2, 2016.
Results and Discussion
Ten puerperal women were interviewed in the joint housing, aged between 18 and 39 years. Of these, five were primiparous and five multiparous; two were married, five were single and three were in a stable relationship. Seven were mixed race, while three were white. Two of the interviewees had given birth to their second child, two a third child and one a seventh child. Two had completed elementary education, three had incomplete elementary education. Two had completed high school, two with incomplete high school and one with incomplete higher education.
From analysis of the data, three collective subject discourses (CSD I, CSD II and CSD III) emerged. CSD I was related to the opinion of the puerperal women about the care received, showing a central idea: lack of humanized care and its limitations as presented in Table 1. When asked about the care received during the labor and birth, it was observed that, although they affirmed they were well attended, they lacked clarification about what would happen. They also referred to the unit as traditional, thereby demonstrating they were knowledgeable about humanized childbirth care as shown on television media and that this differed from the care they were offered.
Table 1 – CSD related to the question: What is your opinion about the assistance received during the labor and delivery in this unit? Russas - CE, 2016
|
Central idea |
Collective Subject Discourse (CSD) I |
|
Lack of humanized care and its limitations |
As far as possible, I was well attended [...] as I had no question of clarifying what it would be like, I also found here a very traditional thing, because as you see, on TV reports, things about humanized childbirth, we see that there are many things and possibilities to help, at this moment they do not offer here [...]. |
The humanization of childbirth care is defined as a process in which the professional must respect the aspects of the physiology of the woman, not interfering in an unnecessary way and that their action is directed to the promotion of health, collaborating in the formation of affective ties with the family and the emotional bond between mother and newborn.8
With this in mind, the Ministry of Health launched the Rede Cegonha [Stork Network] in 2011, to provide women with better health care, quality of life and well-being during pregnancy, childbirth, postpartum and child development during the first two years of life. According to the Ministry of Health, a woman giving natural birth to a child has an important life-experience. In this manner, positive experiences may lead to corresponding significant effects on the life of the mother and newborn. Furthermore, humanized care at delivery and birth must be based on the respect, dignity and autonomy of women and their families, thereby rendering this to be a pleasurable and non-traumatic moment.9
Implementation of educational actions during all stages of the pregnancy-puerperal cycle is very important, but it is especially during the prenatal period that the pregnant woman can be counseled regarding a quality labor and birth, in order that she can experience childbirth in a positive way, while aware of practices to prevent risks and complications in the puerperium and greater success in breastfeeding.10 Considering prenatal and birth as important experiences for each woman, health professionals need to adopt a position of educators who share knowledge, seeking to develop in women their autonomy to live the gestation, the birth and the puerperium.10
The sensitivity, involvement and greater approximation of the nurse with the parturient, as well as providing an environment that provides care and comfort, enhances care during delivery and birth in the perspective of humanization.11 At present, the experience of a full and natural gestation is demanded by women themselves, facing the cultural significance of the birth process.11
However, nurses have encountered some difficulties in their performance, sometimes due to limitations imposed by the physical structure and hospital routine, or by the medicalocentric [doctor-centric] characteristics of the hegemonic care model. It is up to the nurse, as an educator, to help women understand normal birth and its benefits and their right to quality labor and birth care.12
One of the problems found has been the lack of information. In a general sense, women are unaware of their own rights guaranteed by law, such as the presence of someone to accompany them at the time of childbirth. In addition, they undergo unnecessary procedures and often do not receive humanized care, generating not only physiological but also psychological problems, such as postpartum depression.13
CSD II discusses the opinions of puerperal women about the care strategies performed during PDP, revealing a central idea: dissatisfaction with the care provided, as presented in Table 2. When questioned about their experiences and / or perceptions, the discourse showed that some interviewees were dissatisfied with the care received, because they envisaged this moment in a certain form, but faced a reality different from that which they had expected. Meanwhile, others, even though they were also dissatisfied, showed no surprise about the service, saying that it was exactly as they had expected, perhaps after hearing from third parties how the unit works.
Table 2 – CSD related to the question: Did the care strategies during prepartum, delivery and postpartum meet your expectations? Russas – CE, 2016
|
Central idea |
Collective Subject Discourse (CSD) II
|
|
Dissatisfaction with the care provided |
[...]I came here expecting one thing but it was another [...] I thought of it one way, but when I arrived it was totally different, a poor service. It was the same way they spoke to me, professionals who are not attentive and human [...] |
When questioned about how they would act if they could change places with the care team, some women interviewed said they would "pay more attention", "become more aware", "treat well", indicating that dialogue is an essential tool in building a humanized service.
From the findings in this research, it can be affirmed that the lack of dialogue and information exchange between professionals and puerperal women influenced, to a certain extent, their choice regarding the type of delivery. Research has highlighted the importance of the decision by pregnant woman regarding the type of delivery to which she will be submitted, after receiving prior information on the costs and benefits of each procedure. However, little has been offered to the pregnant woman in prenatal care services regarding such clarifications.14
We expect to see changes in care practices seen in different hospitals in relation to the time of parturition. Thus, it is necessary for the health team to develop actions to welcome the pregnant woman, her relatives and the newborn, thereby prioritizing the formation of healthy bonds.2
The importance of women-centered comprehensive care is emphasized in order to replace medical interventions and the abusive use of technology by a humanistic paradigm. The focus is care through actions that contemplate the multiplicity of social and cultural differences within the female population. Professionals need to provide care that aims at completeness in childbirth care, as well as clarifying questions and strengthening the bond with puerperal women.2
CSD III was related to the opinion of the puerperal women on aspects that strengthen and limit humanization in the PDP and the influence of these factors in the choice for type of delivery. This demonstrated the following central idea: information on the benefits of normal birth, as presented in Table 3.
Table 3 – CSD related to the question: what are the strengthening and limiting aspects for humanization in the prepartum, delivery and postpartum? Russas - CE, 2016
|
Central idea |
Collective Subject Discourse (CSD) III
|
|
Information regarding the benefits from a normal delivery |
I do not want to have more children, but if it happens I want normal. It's better, you suffer, but then it is over. Yes, the pain is better and just at the time. I would choose normal childbirth despite so much pain [...] |
The third central idea relates to access of information and awareness regarding the benefits of normal childbirth as a potential factor for humanization in PDP care. In the discourses, it was observed that the PDP moment can influence the type of delivery chosen, in the case of a second pregnancy.
Thus, in order to achieve the proposal of humanization of labor and birth, it is necessary to raise the awareness of health professionals to exercise attention, dialogue, welcoming and communication with the parturient.2
Delivery care is the time when a woman needs to be respected, with her privacy maintained, feeling confident, welcomed, and not subjected to unnecessary procedures.15 However, the Brazilian care model performs a series of interventions, often invasive, such as excessive vaginal touching, restrictions in the position to give birth, serum therapy, inducing labor with oxytocin, episiotomy and Kristeller maneuver. This sequence of factors causes a natural birth to become dangerous, painful, and traumatic, leading women to choose cesarean section.15
The comfort and safety of the mother and her newborn are related to the trust placed in the health team that welcomes them. Thus, it is extremely important to humanize the professional-user relationship, with practices that not only address issues related to maternal-fetal health, but which also pay attention to the mental health of puerperal women, providing them support in times of pain, while maintaining the women's privacy during childbirth and respecting their choice regarding type of delivery.15
It is evident that numerous factors are involved in the women`s decision-making process regarding type of delivery. In this study, the puerperal women demonstrated knowledge about the benefits of vaginal delivery by stating: I would choose normal birth despite so much pain. It's better, you suffer, but then it is over.
Final Considerations
Through the interviewees' discourse, it was concluded women understand that labor and birth care should be based on attention and clarification. Access to information about the benefits of normal birth was demonstrated to be a strengthener for the humanization of care.
The feeling that prevailed was one of dissatisfaction, since some women had different expectations than the reality they encountered in the maternity. However, it is highlighted that there were discourses that demonstrated conformity with the service provided, mentioning that they already expected that the professionals would not be attentive.
The study presents limitations, since it portrays a single reality, however, it is hoped to sensitize professionals and managers responsible for women's health care, with a view to constructing care models that are more favorable to humanization.
Considerations from this study contribute to discussions in the academic and professional milieu on the need to consider the service for women in their entirety and strengthen their role of protagonist in the childbirth, thereby consolidating humanized care programs.
References
1. Velho MB, Santos EKA, Brüggemann OM, Camargo VC. Vivência do parto normal ou cesáreo: revisão integrativa sobre a percepção de mulheres. Texto & Contexto Enferm [Internet]. 2012 abr-jun [acesso em 2017 jul 16];21(2):458-66. Disponível em: http://www.scielo.br/pdf/tce/v21n2/a26v21n2.pdf. doi: http://dx.doi.org/10.1590/S0104-07072012000200026.
2. Matos GC, Escobal AP, Soares MC, Härter J, Gozales RIC. A trajetória histórica das políticas de atenção ao parto no Brasil: uma revisão integrativa. Rev Enferm UFPE On Line. [Internet]. 2013 mar [acesso em 2017 jul 16];7(Esp):870-8. Disponível em: http://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/11552/13485. doi: 10.5205/reuol.3934-31164-1-SM.0703esp201307.
3. Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Práticas na assistência ao parto em maternidades com inserção de enfermeiras obstétricas, em Belo Horizonte, Minas Gerais. Esc Anna Nery Rev Enferm [Internet]. 2016 abr-jun [acesso em 2017 jul 16];20(2):324-31. Disponível em: http://www.scielo.br/pdf/ean/v20n2/1414-8145-ean-20-02-0324.pdf. doi: 10.5935/1414-8145.20160044.
4. Stancato K, Vergílio MSTG, Bosco CS. Avaliação da estrutura e assistência em sala de pré-parto, parto e pós-parto imediato-PPP de um hospital universitário. Cienc Cuid Saúde [Internet]. 2011 jul-set [acesso em 2017 jul 21];10(3):541-8. Disponível em: http://eduem.uem.br/ojs/index.php/CiencCuidSaude/article/download/12656/pdf. doi: 10.4025/cienccuidsaude.v10i3.12656.
5. Santos RB, Ramos KS. Sistematização da Assistência de enfermagem em centro obstétrico. Rev Bras Enferm [Internet]. 2012 jan-fev [acesso em 2017 jul 21];65(1):13-8. Disponível em: http://www.scielo.br/pdf/reben/v65n1/02.pdf.
6. Ribeiro JF, Lima MR, Cunha SV, Luz VLES, Coêlho DM, Feitosa VC, et al. Percepção das puérperas sobre a assistência à saúde em um centro de parto normal. Rev Enferm UFSM [Internet]. 2015 jul-set [acesso em 2017 jul 16];5(3):521-30. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/14471/pdf. doi: 10.5902/2179769214471.
7. Figueiredo MZA, Chiari BM, Goulart BNG. Discurso do Sujeito Coletivo: uma breve introdução à ferramenta de pesquisa qualiquantitativa. Distúrb Comun [Internet]. 2013 abr [acesso em 2017 ago 02];25(1):129-36. Disponível em: https://revistas.pucsp.br/index.php/dic/article/download/14931/11139.
8. Lima PVSF, Soares ML, Fróes GDR, Machado JR, Santos SM, Alves, et al. Liga de humanização do parto e nascimento da Universidade de Brasília: relato de experiência. Rev Eletrônica Gest Saúde [Internet]. 2015 [acesso em 2017 ago 02];6(3):2783-98. Disponível em: http://periodicos.unb.br/index.php/rgs/article/view/3260.
9. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Gravidez, parto e nascimento com saúde, qualidade de vida e bem-estar. Brasília (DF): Ministério da Saúde; 2013. 19p.
10. Silva SPC, Prates RCG, Campelo BQA. Parto normal ou cesariana? Fatores que influenciam na escolha da gestante. Rev Enferm UFSM [Internet]. 2014 jan-mar [acesso em 2017 jul 21];4(1):1-9. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/8861. doi: http://dx.doi.org/10.5902/217976928861.
11. Santos GS, Souza JLO, Almeida LS, Gusmão MH. A importância do enfermeiro no atendimento humanizado no pré-parto. Diálogos Ciênc [Internet]. 2012 set [acesso em 2017 jul 21];10(31):224-8. Disponível em: http://dialogos.ftc.br/index.php?option=com_docman&task=doc_download&gid=323&Itemid=15. doi: 10.7447/dc.2012.025.
12. Almeida OSC, Gama ER, Bahiana PM. Humanização do parto: a atuação dos enfermeiros. Rev Enferm Contemp [Internet]. 2015 jan-jun [acesso em 2017 jul 21];4(1):79-90. Disponível em: https://www5.bahiana.edu.br/index.php/enfermagem/article/view/456. doi: 10.17267/2317-3378rec.v4i1.456.
13. Valente A. As outras dores do parto. Centro Universitário de Volta Redonda [Internet]. 2015 [acesso em 2016 dez 17]. Disponível em: http://www.unifoa.edu.br/divulgacao-cientifica/noticias/as-outras-dores-do-parto.
14. Malheiros PA, Alves VH, Rangel TSA, Vargens OMC. Parto e nascimento: saberes e práticas humanizadas. Texto & Contexto Enferm [Internet]. 2012 abr-jun [acesso em 2016 dez 02];21(2):329-37. Disponível em: http://www.scielo.br/pdf/tce/v21n2/a10v21n2.doi: http://dx.doi.org/10.1590/S0104-07072012000200010.
15. Sousa JV, Oliveira MS, Encarnação SC. Influência da escolha do parto pelas gestantes. Rev Eletrôn Atualiza Saúde [Internet]. 2015 jul-dez [acesso em 2016 dez 02];2(2):31-43. Disponível em: http://atualizarevista.com.br/wp-content/uploads/2015/07/revista-atualiza-saude-v.2-n.2.pdf.
Authors Contributions
1 - Jocasta Maria de Oliveira Morais
Conception and planning of the research project; gathering or analysis and interpretation of the data; composition and critical revision.
2 - Sibele Lima da Costa Dantas
Analysis and interpretation of the data; composition and critical revision.
3 - Bruna Silva do Nascimento Paz
- Concept and planning of the research project; data gathering.
4 - Sabrina de Matos Bezerra
- Concept and planning of the research project; data gathering.
How to cite this article
Morais JMO, Dantas SLC, Paz BSN, Bezerra SM. Assistance to labor and birth from the perspective of mothers cared for at a public maternity. Rev. Enferm. UFSM. 2019 [Access at: Year Month Day];vol e2:1-10. DOI:https://doi.org/10.5902/2179769228225