EXPLORATORY STUDY ON THE IMPLEMENTATION OF GUIDELINES FOR A SAFE DELIVERY AND SATISFACTION OF WOMEN

 

Priscila Magalhães de Sousa Milfont1, Viviane Martins da Silva2, Daniel Bruno Resende Chaves3, Beatriz Amorim Beltrão4

 

1 Catholic College Rainha do Sertão

2,3,4 Federal University of Ceará

 

ABSTRACT

 

Objective: Check the implementation of the guidelines recommended by the Ministry of Health to conduct a safe natural delivery, and investigate women's satisfaction regarding the assistance provided during the process of labor and delivery. Method: Descriptive exploratory study, conducted with 21 mothers attended at a maternity hospital in the country area in Ceará. Data were collected with the aid of instruments that guided the observation of the attitudes of the professionals in relation to the woman, and interviews with the mothers. Results: Average age of 23.2 years (±6.2), single and earning less than minimum wage, without previous experience of childbirth other than the natural one. Of the 14 guidelines observed, only three were seen in all situations, these being related to the clarification of doubts of the mother, measures of mother-child affective bond and environment of labor and delivery. Conclusion: Many guidelines are not being met effectively.

Keywords: Normal Delivery, Childbirth, Quality Indicators in Health Care

 

 

 

INTRODUCTION

 

In recent decades, it has become increasingly intense the pressure for improving the quality of services provided directly to citizens, whether attended at public or private sector. During this period, governments around the world are undergoing several sectorial crises, particularly the governments of developing countries. The situation imposes considerable limits on public expenditures, which generates at the same time, dissatisfaction and a growing demand for more and better services. Delivery assistance is not far from this reality(1).

This assistance has been undergoing a series of changes, not focusing on childbirth as a medical event laden with potential risk, to focus on a conception of delivery, less medicalized, which aims at avoiding unnecessary interventionist practices, which although traditionally used, do not benefit the woman or the newborn.(2) In this perspective, the delivery has been seen from the perspective of humanization and personalization in order to allow greater participation of women in this process.(3)

Pregnancy and delivery are essential to the process of reproduction of individuals and social events of unique importance for the woman, her partner and her family. Therefore, the experiences in this process are of paramount importance to the people involved. The less medicalized model of delivery may contribute to improving the quality of care provided during the delivery process.

In this perspective the Ministry of Health is proposing policies such as the Prenatal and Birth Humanization Program (PBHP), as well as featuring publications such as the Humanized Care for Women that include guidelines to ensure improvements in the assistance provided to pregnant women and children.(2,4) These guidelines are supported by RDC Resolution No. 36, dated June 3, 2008 from ANVISA, which regulates the operation of services of obstetric and neonatal care(5).

The guidelines developed emphasize the importance of inserting the woman as an active participant in the delivery process, valuing their experiences and preferences, providing the same information about the labor and delivery; settling any possible doubts and helping reduce anxieties, accepting the pregnant woman and her companion in health services, and avoiding the use of unnecessary procedures for the birth of the child.

These policies emphasize aspects related to the humanization of care, and are intended to ensure greater security for the services provided to women during labor and delivery. Therefore, the guidelines proposed by the Ministry of Health and the recommendations of ANVISA may be used to direct assistance to women and to support the assessment of quality of care in normal birth.

It is noteworthy that the achievement of quality in assisting childbirth and the postpartum period is subject to change in attitude of all involved in these processes. One of the ways to ensure this quality consists in developing humanization in the service provided to the mothers and their families. This one, in turn, must be seen as one of the primary pillars in the construction of a policy of qualification of the Unified Health System (UHS)(6).

In order to seek the humanization of care in birth and postpartum, it is essential to take care of women, respecting their individuality. This will allow the practitioner to perceive the needs of each woman and will enable him to plan on driving his attention to the deficiencies found, increasing its effectiveness and, consequently, providing a better quality service. Humanizing means, therefore, offering quality service linking technological advances with welcoming, improvement of care settings and working conditions of professional(6).

Given this context, this study aims to verify the implementation of the guidelines recommended by the Ministry of Health to conduct a safe natural delivery, and investigate women's satisfaction regarding the assistance provided during the process of labor and delivery.

 

METHODOLOGY

 

An exploratory descriptive study with a quantitative approach, conducted in a maternity hospital in the state of Ceará. The study population consisted of women into natural labor, attended in the institution locus of the study. The participants were 21 mothers assisted by the institution during the months of April and May 2008. For the determination and selection of research participants we employed the the process of convenience sampling, bounded by time. Thus, this quantity represents the total of mothers attended the institution over these two months.

To gather the information we used two instruments. The first was a script for simple observation of the attitudes of the professionals regarding the woman. These attitudes were based on guidelines recommended by the Ministry of Health to conduct a safe and natural delivery to bring satisfaction to the mothers(4). The second instrument consisted of a questionnaire administered to postpartum women undergoing natural childbirth. Such an instrument contemplated questions about the socio-demographic and obstetrical information, as well as questions related to the care offered at the institution.

We sought the consent of the hospital, and permission of professionals, to observe the care provided. With the approval of both, women were approached in the admission of the service, in which moment it was requested their consent to participate in the study by signing an informed consent. As mentioned above, were also performed simple observations the attitudes of the professionals during the assistance provided throughout labor and delivery, after they signed the term of consent. As an example of these observations we highlight: the introduction of the health team to the woman; clarifications and information given the assistance, the research on the preferences the pregnant woman in relation to delivery and her involvement in decisions about the birth of her child. It is noteworthy that the interviews were administered to postpartum women when they were stable and without pain. The data on the observations and the statements obtained during the interviews were organized in Excel spreadsheets and analyzed using the software EpiInfo version 3.5.1. Then, the results were summarized in two tables.

To meet the ethical and legal principles, established by Resolution 196/96, which regulates the guidelines and standards of research involving humans (7), the project was submitted to the Ethics Committee in Research of Federal University of Ceará, where it was approved (protocol number 57/08, adopted on April 18, 2008).

 

RESULTS

 

The analysis of socio-demographic data showed that approximately 42.85% of participants were between 21 and 27 years with an average age of 23.2 years (±6.2). Regarding education, only 9.52% reported having completed high school and most of the respondents were single (42.8%).

Regarding income, it was found that approximately 85.7% of women earned less than minimum wage, and average income of the group at issue was evaluated in around 1.2 wages (±0.5).

Of the pregnant women who sought the institution in search of assistance, 47.61% were in their first pregnancy and most of these (95.23%) underwent prenatal with a number of consultations that was equal or greater than six. Among multiparous women, we have found an average number of normal deliveries of 2.3 (±1.6) and average number of children of 2.2 (±1.5). It is noteworthy that none of the participants reported having experienced other than natural delivery.

As for the reason that led the participants to choose natural childbirth, 55.3% of women reported that they were not given choice, and were not encouraged to have a natural childbirth. When arriving at the service, they were merely told they were able to give birth to their children through this type of delivery. Among women who opted for natural childbirth (44.7%), the main reasons reported were: faster postpartum recovery, labor pain as the consolidation of being a mother and fear of an surgical delivery with its possible sequels (postpartum hemorrhage, surgical site infection, etc..). Among the multigravidae (52.39%), the choice of natural childbirth was due to previous experiences of normal deliveries that were, to some extent, satisfactory.

Based on the evaluation of the guidelines observed in the study (Table 1), it was found that 85.72% of women did not receive any information about the routines and procedures carried out in the service. Only participants who had questions or concerns were informed about the routines and procedures.

 

Table 01 - Guidelines observed for a natural childbirth considered humane. Morada Nova, 2008.

Guidelines of the Humanized Delivery

Assisted (%)

Not Assisted (%)

Information about routines and procedures

14,28

85,72

Information on stages of labor and delivery

-

100,00

Presentation of the health team

-

100,00

Clarified doubts and anxieties

100,00

-

Presence of a companion

-

100,00

Right of taking part in decisions

-

100,00

Parturient called by name

23,80

76,19

Encouraging walking

-

100,00

Trichotomy if it is an option of the patient

-

100,00

Environment for labor and delivery

100,00

-

Resources for relaxation

33,33

66,66

Adequacy of physical infrastructure and equipment

-

100,00

Choice of the position for birth

-

100,00

Measures of affective bond between mother and child

100,00

-

 

 

By observing the provision of care for pregnant women, we have found that some guidelines were not met in the totality of study participants, such as: information about the stages of labor, presentation of the health team, a companion, right to take part in decisions, encouraging walking, trichotomy an option of the patient, adequacy of physical infrastructure and equipment, choice of position for birth.

On the other hand some guidelines were met in the totality of observations, among which are: doubts and anxieties clarified, environment for labor and delivery, measures of affective bond between mother and child. Other guidelines appeared in part in the observations such as: mother called by name (23.80%) and resources for relaxation (33.3%).

It is worth noting that the guidelines mentioned before were only observed during labor and delivery. Then we carried out an interview with the women in the study, during which they were questioned about the other guidelines. The responses are summarized in Table 02.

 

Table 02 - Guidelines investigated among the participants for a natural childbirth considered humane. Morada Nova, 2008.

Variables

Assisted

(%)

Not Assisted

(%)

Information about routines and procedures

42,85

57,14

Presentation of the health team

23,80

76,19

Presence of a companion

-

100,00

Choice of the position for birth

-

100,00

Resources for relaxation

38,90

61,90

Parturient called by name

76,19

23,80

Quality Service

100,00

-

Satisfaction with the natural childbirth

95,23

4,76

 

 

The analysis of the questionings to the women revealed that, in accordance with their opinion, most guidelines for delivery care were not met, or were only partially. Among these guidelines, stands out: information about routines and procedures (57.14%), presentation of the health team (76.19%), presence of a companion (100%), choice of position for birth (100%), resources for relaxation (61.9%). It is noteworthy that three guidelines of this group were voiced as treated by the majority of pregnant women, namely: mother called by name (76.19%), quality of service (100%) and satisfaction with natural birth (95.23%).

 

DISCUSSION

 

When assessing the socio-demographic variables of the subjects of the study, common characteristics of users of the public service investigated are observed. We found low levels of education among the patients interviewed. It is believed that this factor has influenced the answers given by women, since, due to lack of information and knowledge, many of these patients were unaware of their rights as users of a health service that assists childbirth.

The public hospitals in Brazil generally give assistance to most low-income women, who in many cases are unable to consume the services offered by private health institutions. Deliveries in most of these institutions often nullify in many ways, the possibility of the woman and her family to experience the subjective aspects of this moment(8).

The possibility of choosing of type of delivery is not actually a reality of public hospitals, especially when it comes to low-income women. These are often subjected, against their will, to a delivery of which they are unaware. The prenatal care has been identified as the first step towards humanized labor and delivery.(6) Despite the high rate of prenatal care, many of the respondents did not hold information about natural childbirth.

In addition to clarification about childbirth, women should participate actively in the decisions surrounding the birth of their babies. However, the guideline "right to participate in decisions" was not met in 100% of the observations, confirming the reality that often the woman is not seen as the protagonist of the birthing process(3).

It was found that the vast majority of births observed, no information was provided on rules and routines of the institution, as confirmed during the interview conducted with women in the postpartum period. The process of labor and delivery, isolatedly, are important stressing and anxiogenic factors. Adding it up to the fact of institutionalization, in which the woman finds herself in an unfamiliar place, usually in the company of people beyond her conviviality, also being submitted to unclear rules, we can perceive an enhancement of stress and anxiety that affects the birth process as a whole(3,9).

During data collection, it was noted that, professionals rarely identified themselves to the women (100%) or called them by name (76.19%). They would merely come up to evaluate them from time to time. These observations were confirmed by the women during the interview. The presentation of the professional is utmost importance in the process of empathy with the client. By treating the patient by the name, you can reduce or minimize considerably their anxiety, since the professional becomes more familiar by establishing links with the client.

The fact that all professionals having responded to the questions and anxiety experienced by pregnant women contributes to the hypothesis of the quality of the care provided by the institution.

Another fact observed and emphasized by the women during the interview, is that 100% of deliveries were not accompanied by relatives. The uncertainties, fears and frustrations increase when these women find themselves alone in an environment which they know little or nothing about, where the presence of a trusted person could generate more safety so that they could face this moment so important and special in their lives. Ignoring this fact may cause psychological, affective and emotional complications to these women. (3,4,9,10)

As mentioned, none of the evaluated cases met the guideline that refers to the mother's participation in decision making about the care they will receive. In the care given it still predominates the notion that the labor and delivery must be conducted exclusively by health professionals, denying the woman any right of expressing an opinion or manifesting her wishes regarding the care received. Other guidelines that refer to this discussion and have not been met in all deliveries are: "Shaving if it is the patient's option" and "choice of position to give birth." As discussed before, the uncertainty caused by the total ungovernability of the users of the public service about their assistance brings to this moment elements that greatly hinder the possibility of experiencing this enjoyable event. (3,9)

However, other guidelines were observed and treated in all cases evaluated, such as: environment for labor and delivery and measures of affective bond between mother and child. A warm, comfortable and as quiet as possible environment, leads to psychophysical relaxation of the woman, companion and staff, corroborating to provide quality to the assistance rendered(4). All the women interviewed expressed the desire to breastfeed, becoming clear the satisfaction on the routine of the institution of starting this process early. The participants also highlighted that in rooming the time for breastfeeding is definitively established, and nurses and assistants of this sector are tireless in teaching, aiding and handling the breasts and nipples, milking, proper positioning and additional care when there are difficulties in nursing. In the institution involved, the discharge of the mother and infant is conditioned, among other things, to a good routing of breastfeeding.

The association of some non-pharmacological measures such as breathing exercises, relaxation techniques and ambulation, help in pain relief during labor(4). Unfortunately, this practice is not widely used by professionals, noting that only 33.33% of investigated cases used some of these resources. These findings are consistent with the reports of 38.9% of participants who mentioned having used some of these techniques to aid relaxation.

Regarding the quality of the service itself, 100% of the interviewees reported that the service provided during labor and delivery was of good quality. In terms of satisfaction of users as to the natural birth, 95.23% reported being very satisfied. It was also found that, of the respondents who were very satisfied, the main reasons were: the hospital offers good service, professionals are fine, caring, treat them with respect and clear their doubts and the hospital is clean. Only one respondent (4.76%) showed no such satisfaction, reporting as justifications the following: not all professionals treat them well, some professionals are impolite and speak rudely; perform many touching tests; there is lack of hygiene and delay in treatment, and the absence of a companion.

Authors who aimed to assess women's satisfaction with childbirth care indicate the existence of barriers in this type of study(8). Among the obstacles identified, we point out the fact that patients generally have difficulty to criticize the health service and the professionals who attended them, especially in situations of risk. In the case of perinatal care, this difficulty may be even higher, because women tend to feel relieved, grateful and have positive feelings after the birth of a healthy child, compensating for any negative experience during servicing. In the days immediately after delivery, in particular, women may hesitate to criticize the care received and the professionals involved, particularly if they are still hospitalized(8).

 

CONCLUSION

 

Among the guidelines for natural childbirth care observed by the researchers, only three were assisted in all cases, namely: clarified doubts and anxieties, environment for labor and delivery, and measures of affective bond between mother and child. The other guidelines were not observed in any of the services rendered, or were in the assistance offered to less than 50% of women in labor. With regard to the guidelines assessed by the questionnaire, three were reported by most women in the study as attended: mother called by the name, quality service, and satisfaction with natural childbirth.
According to the presented data, it appears that most of the proposed guidelines by the Ministry of Health have not been fulfilled effectively. Thus, the results of this study reflect a poor service in relation to the humanization of the service offered to pregnant women.

Given these findings, the study suggests that guidelines related to maternity care need to be further developed in the health service investigated with a view to ensuring a safer and more humane care to women and children. Moreover, the results allowed us to recognize which the main weaknesses were highlighted in the assistance provided during labor and delivery. The findings presented may direct the planning of interventions that aim to change this reality in order to provide higher quality to the services offered.

 

 

REFERENCES

 

1.         Patah LEM, Malik AM. Modelos de assistência ao parto e taxa de cesárea em diferentes países. Rev. Saude Publica. 2011 Feb 45(1):185-94.

2.         Ministério da Saúde (Brasil), Secretaria Executiva. Programa Humanização do Parto: humanização no pré-natal e nascimento. Brasília: Ministério da Saúde; 2002.

3.         Gotardo GIB, Silva IA. Refletindo sobre a prática obstétrica à luz de um modelo de relacionamento humano. Cienc Cuid Saude. 2007 Abr/Jun 6(2):245-51.

4.         Ministério da Saúde (Brasil), Secretaria de Políticas de Saúde, Área Técnica da Mulher. Parto, aborto e puerpério: assistência humanizada à mulher. Brasília: Ministério da Saúde; 2001.

5.         Agência Nacional de Vigilância Sanitária (Brasil). Resolução RDC nº 36 de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Brasília (DF): Diário Oficial da União, 4 jun 2008; Seção 1. Available from: http://www.anvisa.gov.br/divulga/noticias/2008/040608_1_rdc36.pdf

6.         Ministério da Saúde (Brasil), Secretaria Executiva, Núcleo Técnico da Política Nacional de Humanização. Humaniza SUS política nacional de humanização: a humanização como eixo norteador das práticas de atenção e gestão em todas as instâncias do SUS. Brasília: Ministério da Saúde; 2004.

7.         Ministério da Saúde (Brasil). Conselho Nacional de Saúde. Resolução nº196/96, normas para pesquisa envolvendo seres humanos. Brasília: Ministério da Saúde; 1996.

8.         Silveira SC, Camargo BV, Crepaldi MA. Assistência ao parto na maternidade: representações sociais de mulheres assistidas e profissionais de saúde. Psicol Reflex Crit. 2010 Abr; 23(1):1-10.

9.         Sodré TM, Bonadio IC, Jesus MCP, Merighi MAB. Necessidade de cuidado e desejo de participação no parto de gestantes residentes em Londrina-Paraná. Texto Contexto Enferm. 2010 Set; 19(3):452-60.

10.      Soares RKC, Silva SF, Lessa PRA, Moura ERF, Pinheiro PNC, Damasceno AKC. Parturient´s companion and their relationship with the nursing team: a qualitative study. Online Braz J of Nurs [serial on the Internet]. 2010 June 17 [cited 2011 July 26]; 9(1). Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/2867