MOTHERS’HEALTH I N BRAZI L AND RECOVERI NG THE TRAI NI NG OF MI DW I VES
FOR CARE I N THE BI RTH PROCESS
Mir iam Apar ecida Bar bosa Mer ighi1
Dulce Mar ia Rosa Gualda2
Merighi MAB, Gualda DMR. Mothers’health in Brazil and recovering the training of m idwives for care in the birth process. Rev Lat ino- am Enferm agem 2009 m arço- abril; 17( 2) : 265- 70.
The aut hor s br iefly analy ze t he sit uat ion of m at er nal healt h car e in Br azil and, based on t heir findings, t hey
com m ent t hat t her e have been t r ansfor m at ions in t he healt h car e m odel for w om en and fam ilies and pr opose
som e m easur es, including r ecov er y of t he w or k of t he obst et r ic nur se or m idw ife ( obst et r iz, in Por t uguese) .
They com m ent t hat w om en car e t endencies in t he deliv er y pr ocess pr esuppose incor por at ion of t he par adigm
of im pr ov in g t h e ph y siology of v alu in g w om en ’s ex per ien ce, t h e appr oach t o t h e fam ily , h ealt h adv ice t h at
pr ior it izes pr ev en t ion , edu cat ion an d r elat ion sh ips, w it h ou t ign or in g saf et y . Th ey appoin t t h at bu ildin g t h is
healt h car e m odel, w hich includes t he w or k of t he m idw ife, m ay im pr ov e m at er nal healt h indicat or s.
DESCRI PTORS: obst et r ical nur sing; m idw iv es; deliv er y of healt h car e
EL CUI DADO DE LA SALUD MATERNA EN BRASI L Y EL RESCATE DE LA ENSEÑANZA
DE OBSTETRAS PARA ASI STENCI A AL PARTO
Los aut ores hacen un breve análisis de la sit uación del cuidado de la salud m at erna en Brasil, y con base en sus
hallazgos, sugieren t ransform ar el m odelo de at ención a la m uj er y a sus fam iliares; proponen algunas m edidas
que incluyen la inserción del t rabaj o de la enferm era obst ét rica y de la obst et ra en el cont ext o act ual. Com ent an
sobre la t endencia act ual del cuidado m at erno en el proceso del nacim ient o, el cual presupone la incorporación
del par adigm a que fav or ece la fisiología y la v alor ización de la ex per iencia fem enina, el abor daj e cent r ado en
la f am ilia con én f asis en la pr ev en ción , edu cación y r elación in t er per son al sin dej ar de lado la segu r idad.
Consider an que el m odelo del cuidado de la salud que incluy e el t r abaj o de la obst et r a, puede m ej or ar los
indicador es de salud m at er na.
DESCRI PTORES: enfer m er ía obst ét r ica; m at r ona; pr est ación de at ención de salud
O CUI DADO A SAÚDE MATERNA NO BRASI L E O RESGATE DO ENSI NO DE
OBSTETRI ZES PARA ASSI STÊNCI A AO PARTO
Os aut or es fazem um a br ev e análise da sit uação do cuidado a saúde m at er na no Br asil, e com base nesses
d ad os, ap on t am as t r an sf or m ações n o m od elo d e assist ên cia à m u lh er e às f am ílias e p r op õem alg u m as
m edidas, as quais inclui a inserção do t rabalho da enferm eira obst ét rica ou obst et riz no cont ext o at ual. Com ent am
qu e a t en dên cia at u al do pr ocesso de n ascim en t o pr essu põe a in cor por ação do par adigm a qu e f av or ece a
fisiologia e a valorização da experiência fem inina, a abordagem cent rada na fam ília, com ênfase na prevenção,
ed u cação e r elacion am en t o in t er p essoal, sem d eix ar d e lad o a seg u r an ça. Con sid er am q u e o m od elo d e
cuidado à saúde, que inclui o t r abalho da obst et r iz, pode m elhor ar os indicador es de saúde m at er na.
DESCRI TORES: enfer m agem obst ét r ica; obst et r iz; assist ência a saúde
Escola de Enferm agem da Universidade de São Paulo, Brazil: 1Nurse- Midwife, Faculty, e- m ail: m [email protected]; 2Midwife, Facult y, e- m ail: [email protected].
I NTRODUCTI ON
I
n Br a zi l , h e a l t h i n d i ca t o r s r e l a t e d t o obst et rical care are discouraging. A chain of event s causes t heir occurrence, for which responsibilit y can be at t r ibut ed t o t he populat ion’s sociocult ur al and econom ic characteristics, policies, inequality and social exclusion. Maternal m ortality rates are very high. The ex cessi v e u se o f cesar ean sect i o n s p i ct u r es t h e sit uat ion t hat has cont ribut ed t o t he dehum anizat ion of car e, an d t h e pr epar at ion an d act iv it ies of t h e obstetrical team in care has been the subj ect of intense debat es. I n view of t his sit uat ion, t his t ext aim s t o report dat a about m at ernal healt h, appoint t rends in wom en’s healt h care during t he reproduct ive period and contextualize the creation of a course that favors a new birt h care m odel. These aspect s are discussed in furt her det ail below.St at us of m at ernal healt h in Brazil
An analysis of t he st at us of m at ernal healt h car e in Br azil sh ow s t h e ser iou s ep id em iolog ical sit uat ion lived by wom en and t heir neonat es and t he p r e ca r i o u sn e ss o f h e a l t h ca r e p r o v i d e d t o t h e populat ion.
Th e p o l i ci e s t h a t h a v e b e e n a d o p t e d , m anagem ent problem s, reduced funds and personnel, t he lack of m at erial and m edicat ion have led t o t he b r eak d o w n o f h eal t h car e. Pr e- n at al car e, w h en available, is inadequat e. There is no assurance of a place in hospit al at t he t im e of delivery. At delivery, technology, depersonalized and interventionist m edical pract ice are given a special posit ion, and t here are high rates of cesarean sections and alarm ing rates of m at ernal m ort alit y( 1).
Mat ernal m ort alit y is t he indicat or t hat best r eflect s t he condit ions of m at er nal car e dur ing t he p r eg n a n cy - p u er p er a l p er i o d , si n ce a t i m el y a n d ad eq u at e in t er v en t ion cou ld av oid m ost of t h ese deat hs( 2).
Dat a f r om 1 9 9 7 sh ow t h at , in Br azil, 1 1 0 m ot her s die for ever y 100,000 live bir t hs, w hich is sim ilar t o som e of t h e p oor est cou n t r ies in Lat in Am er ica( 2).
The m at er nal deat h coefficient also show s social in equ alit y an d ex clu sion in Br azil. Th e dat a show s t he inequit y and r ealit y of each r egion. The m ost underprivileged regions of t he count ry display t he highest fem ale m or t alit y num ber s for m at er nal
deat hs. The w or st figur es ar e found in t he Nor t h, follow ed by t he Cent ral- West and Nor t heast , w hich ar e t he neediest r egions. The Sout h and Sout heast r egions, w hich ar e m or e dev eloped, show t he best figures( 3).
Th e m ain cau ses of m at er n al deat h s ar e: hypertension, hem orrhage, abortion com plications and p u er p er al in f ect ion s, w h ich w e con sid er ed d ir ect causes and closely relat ed t o socioeconom ic fact ors, responsible for 89% of m at ernal deat hs( 4).
A chain of events is involved. These include: social, cult ur al and econom ic char act er ist ics of t he p o p u l a t i o n ; p a t h o l o g i e s sp e ci f i c t o p r e g n a n cy ; fragm ented structure of the health system , where each person provides care in isolat ion; inefficiency of t he r efer r al an d cou n t er - r efer r al sy st em ; lack or poor distribution of hospital beds for delivery in the regions, w hich ov er loads m any inst it ut ions; abusiv e use of technology and obstetric interventions, which increase m orbidit y; qualit y of prenat al services, which is t he bot t le- neck of healt h care( 5).
For healt h care workers, low salaries lead t o a n d j u st i f y t h e i r l a ck o f co m m i t m e n t a n d t h e co m m e r ci a l i za t i o n o f h e a l t h . Ot h e r f a ct o r s a r e short com ings in t raining and work condit ions, which lead t o unnecessary bureaucracy in healt h care; t he lack of hum ane care in health, where priority is given t o m a ss t r e a t m e n t r o u t i n e s i n st e a d o f ca r e f o r individual needs; ignorance of wom en’s health- disease st or ies and gr adual subst it ut ion of clinical w or k by new t echnologies.
I n general, t here are dist ort ions in t he very concept of delivery care in Brazil, as a result of t he adopt ed paradigm , which influences t he way care is given and, consequently, its quality, interfering in both procedures and int erpersonal relat ions. The issue of the indiscrim inate use of interventions has been dealt with from different points of view, and the biom edical m odel has been m ent ioned as t he gr eat v illain. I n this context, it shows itself as a cause of the num ber of cesarean sect ions in Brazil, w hich figures am ong the highest rates in the world. I n the last four years, the state of São Paulo has had an average of 50.3% deliveries by cesarean sect ion, while t he average for the country as a whole is 40.5%( 4).
St at us of educat ion
There is a breakdown of education at all levels, which includes the training of health workers. The education of these workers is not an isolated process, but is related t o t he econom ic and social st ruct ure and est ablishes relat ions wit h various ot her processes t hat are m ore closely linked to the fields of practice(1).
Most of t he cur r icula of colleges t hat t r ain workers are bio- centered, and the educational process e m p h a si ze s d i se a se , t e ch n i ca l p r o ce d u r e s a n d t echnology. Also, t he environm ent pract ical t eaching takes place in does not allow for hum anitarian practice. Th e n eed t o r ef o r m u l at e t h e w ay h eal t h workers are t rained is known because of t he current crisis in t he healt h sphere, bot h in quant it at ive and qualit at ive t erm s.
Th e h ea l t h - d i sea se p r o cess i n v o l v es t h e com plexity and uniqueness of hum an life and requires a new out look on healt h worker t raining. Therefore, t he cur r ent t endency in educat ion should be based on t he socio- cent ered m odel.
On t he ot her hand, t raining healt h w orkers should follow a pat h in which t his space of learning can use art to bring about changes in health care, in order t o t rain people who are sensit ive and able t o underst and t he dim ension of hum ane care( 1).
Wit h regard t o delivery, t he challenge is t o understand, recover and reveal the process as unique, hum anized and m oving away from depersonalizat ion and int ervent ionist act ions( 6).
Tendency of wom en’s healt h care during delivery
The t endency of wom en’s healt h care during d e l i v e r y p r e su p p o se s t h e v a l u a t i o n o f w o m e n ’ s experience, approach of the fam ily as the basic social nucleus and healt h guidance. This can be done bot h in and out of t he hospit al cont ext , always priorit izing prevent ive, educat ional and relat ional aspect s of t he process, wit hout ignoring safet y.
Obst et ric nurses and m idwives (obst et r izes, in Portuguese) are trained in these aspects and good h eal t h car e r esu l t s can b e seen at n at i on al an d int ernat ional levels( 7).
Sheila Kit zenger under lines t he im por t ance of m id w iv es t h r ou g h ou t h ist or y in sev er al h ealt h sy st e m s. Re se a r ch i n g t h e i r p r a ct i ce , sh e ack n o w l ed g es t h at , i n m o st sy st em s, t h ey h av e pr act ically disappear ed. I n som e places, she say s, they only follow doctors’ orders. I n others, their activity is fragm ent ed and direct ed at t he procedure and not
at t he wom en t hem selves. However, in places where t hey w or k w it h aut onom y, t hey hav e at t ained v er y sat isfact ory result s and carried out an im port ant role in b r in g in g ab ou t ch an g e, ex am in in g u n iv er sally accepted obstetric practices. She states that m idwives car r ied out t he r esear ch on r out ine shav ing of t he perineum , enem a and episiot om y, not ing t hat t hese practices are not always beneficial and cause extrem e discom fort to the m others. She also says that studies in t he Unit ed Kingdom and t he Unit ed St at es hav e shown t hat deliveries by m idwives have lower rat es o f cesa r ea n sect i o n , f o r cep s, i n d u ced b i r t h a n d electronic control of focus and that m edication is used with less intensity. The babies have a high Apgar score, and are rarely int ubat ed( 8).
Given these facts, we believe the responsibility for care at norm al delivery can be t ransferred t o t he m idwives, who receive t raining t hat is bet t er suit ed t o m onit or delivery and let physiology work, calling on physicians only in cases in which there is a risk.
The World Health Organization ( WHO) agrees a n d co n si d e r s t h a t , t h r o u g h l e ss i n t e r v e n t i o n , m i d w i v e s a n d o b st e t r i c n u r se s a r e t h e m o st appropriate workers to assist norm al pregnancies and deliveries ( WHO, 1996) . This approach influences t he p r o f essi o n t h r o u g h m an y h eal t h w o r k er t r ai n i n g courses in norm al delivery. This includes t he exist ing specializat ion courses for obst et ric nurses, aft er t hey conclude t heir nur sing degr ee, as w ell as gr aduat e st udies t o t rain m idwives. These considerat ions gave rise to a discussion on a possible return to m idwifery t r a i n i n g a t u n d e r g r a d u a t e l e v e l , p a r a l l e l t o t h e specialization in obstetric nursing. This discussion has st ar t ed in r egu lar sem in ar s an d, in t er n ally, in t h e obst et ric nursing course offered at t he Mot her- Child and Psychiat ric Depart m ent of t he Universit y of São Paulo School of Nursing.
Hu m an izat ion of h ealt h car e also in v olv es learning different concepts, values and cultural practices that exist in our m idst, associated to delivery and birth ( half- cast es, indigenous, rural, urban, et c.) . Great er access to inform ation on different habits and custom s associat ed t o bir t h allow s f or a m or e f lex ible an d tolerant attitude towards differences, with m ore effective com m unicat ion bet ween healt h workers and pat ient s, seeking to m eet the needs of m others and fam ilies.
Hospitalization has been m entioned as a real o b st a cl e f o r t h e h u m a n i za t i o n o f d el i v er y ca r e. Therefore, it has been suggested that norm al delivery cent ers be set up for low risk cases. This is because they are sm all care centers, with less bureaucracy and lower risk of infection than large m aternities. The norm al delivery cent ers can be inside or out side a hospit al structure. When outside, they should be located near a h o sp i t a l , w i t h a v a i l a b l e t r a n sp o r t i n ca se o f com plicat ions. Obst et ric nurses and m idwives would be t he m ain people responsible for eut hocic delivery. An o t h e r a sp e ct t o b e co n si d e r e d i s t h e substitution of obsolete practices by scientific evidence on w hich t o base obst et ric pract ice. Alt hough som e are already well docum ented, delivery health workers st ill display a lack of int erest and knowledge on t his evidence. An exam ple of t his is t he excessive use of cesarean sect ion by physicians, which has led t o t he de- hum anizat ion of healt h care, as well as increased m ort alit y and m orbidit y for m ot hers in t he perinat al per iod, besides w ast e of t he healt h sect or ’s scar ce r esour ces.
Recover ing t he r ole of m idw ives in deliver y car e in Br azil
Governm ent agent s have acknowledged t he m odel of healt h care for wom en and fam ilies in t he reproductive process as necessary. I t has becom e the su b j ect m at t er of n at ion al h ealt h p olicies. Som e m easures t aken can be list ed, such as t he Program for Hum anizat ion in Prenat al Care and Delivery, t he setting up of norm al delivery centers and the funding of specialization courses in obstetric nursing provided by nursing schools throughout the country.
For h ealt h car e deliv er y t o w om en du r in g pregnancy and the puerperal period, the World Health Organization (WHO) and the Brazilian Ministry of Health recom m end great er part icipat ion of obst et ric nurses and m idwives because of t he im port ance of assist ing d e l i v e r y, i m p r ov e d ca r e i n n o r m a l d e l i v e r y a n d
reduct ion in t he num ber of cesarean sect ions. As a prevent ive m easure, in 1998, t he Brazilian nat ional health system (SUS) established rem uneration for care in deliveries carried out by obstetric nurses( 9).
Up t o 2005, t he only course t o t rain healt h workers in delivery care was t hrough specializat ion, with the pre-requisite of a nursing degree.
Ho w ev e r, b e ca u se o f t h e si t u a t i o n o f reproduct ive healt h care and art icles in int ernat ional and nat ional lit erat ure, t he role of m idw ives w it h a universit y degree began t o be discussed. Therefore, in 1998, t he Br azilian Associat ion of Midw iv es and Ob st et r ic Nu r ses – São Pau lo Sect ion , in t en sif ied discussions on nursing t eaching in delivery and birt h care through sem inars in the state. The m ain drawbacks shown in the current m odel for training in this field are t he high inv est m ent and ex cessiv e t im e needed t o q u alif y w or k er s. Nex t , t h e p ossib ilit y of t r ain in g m idwives ( direct ent ry) for wom en’s healt h care was considered from a new point of view. I t also takes into accou n t scien t if ic ev iden ce m idw iv es br in g t o t h e physiological and natural procedure at delivery, as well as personalized and hum ane care.
Thus, wide discussion has been ongoing on the training of m idwives, given that this is an im portant r esou r ce t o pr ov ide h ealt h car e t o w om en du r in g pregnancy, near and aft er delivery, as well as t o t he newborns and t heir fam ilies.
Midw ifer y cour ses alr eady exist ed in Br azil. They began to disappear in the early sixties. Care for w om en d u r in g t h e r ep r od u ct iv e p er iod m ov ed t o obstetric nurses trained in nursing schools.
Alt hough gr aduat e specializat ion in nur sing obstetrics has been an im portant strategy for training nurses in this field, this single track was not adequately su pply in g t h e dem an d for w or k er s in t h e cou n t r y, neither in term s of figures nor adequate training, given t he cost and social ret urns in t eaching, research and healt h car e. The need w as felt for a cour se w it h a st r uct ur e and dur at ion t hat w ould giv e m idw iv es a p r o f i l e a n d co m p e t e n ce t h a t e n a b l e d t h e m t o part icipat e act ively in t he necessary t ransform at ions in t h e h ealt h car e m odel an d t h e epidem iological situation of m aternal and perinatal health.
expected input for the quality of health of wom en and their fam ilies in the region.
Midwives were thought of as belonging to the h eal t h t eam , ca p a b l e o f w o r k i n g i n d ep en d en t l y, responsible for care delivery during norm al pregnancy and delivery. They would be an im portant resource for healt h care delivery t o pregnant w om en, w om en in deliv er y, n eon at es an d f am ilies, an d pr om ot e an d preserve t he norm alit y of t he birt h process, m eet ing wom en’s physical, em ot ional and sociocult ural needs. On t he ot her hand, t hese healt h workers would have t he profile and com pet ency t o act ively part icipat e in t r an sf or m in g t h e ep id em iolog ical h ealt h st at u s of m others and in the perinatal period.
Course creat ion proposal
I n or d er t o m eet t h e social d em an d s, an undergraduat e course in m idwifery was proposed t o the University of São Paulo – East Zone, on the occasion of an ex pansion by 1,000 places. The new cam pus w as set u p as an in t egr at ed u n it w it h cou r ses in hum anities, arts and sciences that were not available at the University of São Paulo – Capital. The intention w as t he dev elopm ent of int er disciplinar y pr oposals directed at the reality of society and the region, including new teaching m odels, research projects and com m unity ser v ices.
To r each t hese obj ect iv es, t he cour se w as planned based on t he basic cycle, in which st udent s have an opport unit y t o experience t hree int erwoven areas of t raining:
- Basic knowledge specific to health care;
- General t raining, m ade up of subj ect s t hat provide hum anistic support to later studies;
- Scientific training through problem solving, scientific initiation in which students carry out research projects linked to social issues.
St ar t ing w it h t he basic cy cle, t he ax es ar e present throughout the rem aining six sem esters of the cou r se. Each ax is con sist s of cu r r icu lar su b j ect s, ordered by crit eria of cont ent cont inuit y and growing com plexit y. The Midwifery (Obstetric) course axes are: - Biological bases of Obstetrics;
- Psy ch o- social f u n d am en t als of t h e r ep r od u ct ion pr ocess;
- Care delivery in t he reproduct ive process;
Al t h o u g h l o n g i t u d i n a l , t h e se a x e s a r e int er w oven t o conver ge t o a pr act ical and r esear ch con t ex t , t h r ou g h f i el d w or k w i t h an em p h asi s on
technical, expressive and interactive skills and problem solving groups, providing a crit ical analysis of healt h care act ivit ies. This cont ent is t herefore addressed in an int egrat ed and gradual way.
The init ial num ber of places was 60 for t he ev en in g cou r se, begin n in g in 2 0 0 5 . Th e m in im u m duration of the course was set at a m inim um of eight and a m axim um of t welve sem est ers. The profile of graduat ing st udent s was est ablished as:
- Capable of recognizing t he physical, em ot ional and sociocultural dim ensions of people’s lives which affect t he reproduct ive process and need care;
- Understand the reproduction phenom enon as unique, continuous and healthy, in which wom en are the focal point, and which occurs in a given social and historic cont ext ;
- Provide norm al developm ent of t he birt h process, p r o v i d i n g ca r e a n d su p p o r t a n d a ssu r i n g t h e participation of wom en and their fam ilies;
- Develop a health care and education process based on int eract ion wit h part nership, allowing t he people involved t o m ake t heir healt h decisions;
- Mak e clin ical obser v at ion s, scien t ific k n ow ledge, technical skills and intuitive judgm ent a part of decision m ak ing;
- Value int erdisciplinary knowledge and act ion; - Dev elop at t r ibut es based on et hical and polit ical r esponsibilit y and pr ofessional aut onom y, based on principles of equalit y, respect for self- det erm inat ion and hum ane environm ent .
Com pet encies and skills
- Provide and coordinat e healt h care for wom en and t heir fam ilies during t he reproduct ive process; - Wo r k i n p u b l i c a n d p r i v a t e h ea l t h i n st i t u t i o n s ( m at ernit ies, norm al delivery cent ers, birt h houses, outpatient departm ents, basic health clinics), teaching inst it ut ions and hom es;
- Work in m ultidisciplinary team ; - Work interactively at all levels;
- Contribute to build knowledge in the area and base pract ice on exist ing knowledge;
- Train personnel in the specific field.
GENERAL REMARKS
and per inat al m or t alit y r at es, indiscr im inat e use of int er v ent ions, w hich can easily be obser v ed in t he high cesarean section rates, reflecting the low quality of obst et rical care.
As t o a sp e ct s r e l a t e d t o p r o f e ssi o n a l educat ion in healt h, dat a ar e not v er y encour aging ei t h er. Cu r r i cu l a ar e b i o cen t er ed an d r ep et i t i v e. Cl i n i ca l t ea ch i n g o ccu r s i n a n en v i r o n m en t t h a t d i sco u r a g e s ch a n g e a n d d o e s n o t f a v o r ca r e hum anizat ion.
I n policies as w ell as in car e hum anizat ion proposals, the training of obstetrical nurses or m idwives has been valued. To fill this gap, the Obstetrics Course
has been cr eat ed, based on innov at iv e educat ional m odels. The goal is to allow these students to becom e sensitive professionals who are apt to understand the dim ension of hum ane care and to participate actively in m at er n al an d per in at al h ealt h t r an sf or m at ion s, t urning t hem int o im port ant resources in healt h care delivery to pregnant, parturient and puerperal wom en, as well as infants and relatives.
Th er ef or e, t h e au t h or s b eliev e t h at t h ese pr ofessionals can posit iv ely affect t he unfav or able m at ernal and perinat al healt h indicat ors, w hich has b e e n t h e ca se i n d i f f e r e n t Eu r o p e a n a n d No r t h Am er ican count r ies.
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