Introduction
In 1985, with the goal of improving the quality of obstetric care in several countries, the Pan American Health Organization (PAHO) and the World Health Organization (WHO) met to discuss the cautious use of technologies in the attention of labor and birth.[1] In 1996, the WHO[2] published a practical guide describing a series of practices and recommendations for childbirth care, from the results of international discussions and scientific evidence-based data, providing a framework to combat high maternal and neonatal mortality rates. Since then, several governments have issued and tried to implement these practices, contributing significantly to reducing avoidable deaths.[1]
In Brazil, with the movement of favoring the improvement of the assistance to delivery, the Brazilian Ministry of Health created the Program for the Humanization of Prenatal and Childbirth Care[3] (PHPN, in the Portuguese acronym) on January 6, 2000. This program aims to improve the assistance during the gestation, childbirth and puerperal periods, guaranteeing the women's civil rights throughout this process.
There is scientific evidence that several practices followed during the assistance to gestation and childbirth or pregnancy outcomes promote better obstetric results and are important for the reduction of negative perinatal outcomes. Appropriate obstetrical care with the use of convenient technology may significantly decrease the number of complications that occur during childbirth. However, the inappropriate use of technology and unnecessary interventions can cause maternal and fetal harm.[4]
However, even with all the governmental initiatives to implement these practices, unnecessary interventions and high maternal mortality rates persist in the national and international scenario.[1] The WHO, in 2013, reported that ∼ 289,000 women worldwide died during pregnancy, childbirth and the puerperium, with a worldwide death rate of 210 mothers per 100,000 live births.[1]
Given this reality, the present study aims to evaluate the perception of the health professionals involved in the labor process regarding normal deliveries, and to compare two maternities hospitals in the city of Goiânia, Brazil, regarding the perception of these professionals on the routines and practices recommended by the WHO on delivery care.
Methods
This is an analytical, comparative study with a quantitative approach, performed in two public maternity hospitals in the city of Goiânia, in the state of Goiás, Brazil, and maternity 1, a maternity of low complexity, is one of the oldest in the city, and has a structure oriented to the “hospital-centered” model of care, but is beginning to follow the process of humanization. Maternity 2, also of low complexity, which was opened more recently, was designed to be a model for humanized care.
The study was conducted with 86 health professionals who assisted in immediate labor and delivery in the two maternity hospitals. Of these, 43 professionals belonged to maternity 1, and 43 professionals were from maternity 2. The participants fulfilled the selection criteria and consented to their participation in the research after the responsible researcher provided them with explanations about the nature of the study, and after they signed the free and informed consent form (FICF). We used convenience sampling to compose the study group, that is, the total number of professionals was achieved by the spontaneous presentation of volunteers during the period of data collection.
The study included professionals involved in the labor process in maternity wards 1 and 2 who had worked for more than one year in their respective institutions. Health professionals who worked in other sectors of the maternity ward and who had no direct contact with women in parturition were excluded from the study.
The health professionals were approached during their shifts at the maternity. Those who agreed to participate in the study answered a questionnaire about the delivery assistance adapted from the questionnaire used in the study by Boaretto.[5] This questionnaire was scientifically validated, and evaluated the perception of the hospitals' board of directors regarding the PHPN in twenty public maternity hospitals in the city of Rio de Janeiro, Brazil. The adaptation made for this study was the inclusion of data such as time of graduation and amount of time working at the institution for each participant. Later, we performed a pilot test with 10 participants to observe the difficulties of the application of the questionnaire, as well as their doubts.
The questionnaire used in this study contains 40 questions divided into four blocks, namely: data from the registry, humanization policy, presence of a companion and procedures performed.
A descriptive analysis of these data was performed. For the quantitative variables, the mean and standard deviation (SD) were calculated. Data analysis was performed using the Chi-square test and Fisher's exact test. In addition, a comparison was made between the two maternity hospitals regarding the perception of the professionals about the humanization policy, and the performance of practices considered useful and those considered ineffective by the WHO. The following variables were compared: knowledge about the PHPN, appreciation of prenatal care, presence of a companion, an obstetric nurse as a team member, analgesia, stimulus to walk, delivery in vertical position.
The study was performed in accordance with the Directives and Norms Regulating Research Involving Human Beings (Resolution 466/12 of the Brazilian National Health Council), after having been approved by the Research Ethics Committee of our institution (protocol no. 861,536).
Results
Regarding the characterization of the sample, 43 professionals were interviewed in each maternity ward. [Table 1] presents information about the health professionals. In maternity ward 1, other professionals were involved in childbirth besides doctors and nurses, but there was not any obstetric nurse present.
Table 1
Data about the professionals in each maternity. Goiânia-GO, 2015
|
Information
|
Maternity 1
(n = 43)
|
Maternity 2
(n = 43)
|
p
|
|
N
|
%
|
N
|
%
|
|
|
Time of graduation (years)
|
|
< 5
|
11
|
25.6
|
12
|
27.9
|
0.128*
|
|
5-10
|
5
|
11.6
|
13
|
30.2
|
|
10-20
|
19
|
44.2
|
14
|
32.6
|
|
≥ 20
|
8
|
18.6
|
4
|
9.3
|
|
Time working in the institution (years)
|
|
0-1
|
21
|
48.8
|
15
|
34.9
|
< 0.001*
|
|
2-3
|
3
|
7.0
|
14
|
32.6
|
|
3-6
|
5
|
11.6
|
12
|
27.9
|
|
≥ 6
|
14
|
32.6
|
2
|
4.7
|
|
Profession
|
|
Doctor
|
11
|
25.6
|
19
|
44.2
|
0.001#
|
|
Obstetric Nurse
|
—
|
0.0
|
10
|
23.3
|
|
Nurse
|
9
|
20.9
|
6
|
14.0
|
|
Physiotherapist
|
2
|
4.7
|
—
|
0.0
|
|
Psychologist
|
3
|
7.0
|
—
|
0.0
|
|
Nurse Technician
|
18
|
41.9
|
8
|
18.6
|
Note: *Chi-square test; #Fisher's exact test; p < 0.05.
[Table 2] shows that most of the professionals interviewed said they knew about the program. Regarding the prenatal care appreciation, most professionals know it, agree with it, and perform it in both maternities (p = 0.241).
Table 2
Knowledge about the policies of humanization in each maternity. Goiânia-GO, 2015
|
Humanization policies
|
Maternity 1
(n = 43)
|
Maternity 2
(n = 43)
|
p
|
|
N
|
%
|
N
|
%
|
|
Knowledge of the PHPN
|
|
Yes
|
40
|
93.0
|
43
|
100.0
|
0.241*
|
|
No
|
3
|
7.0
|
—
|
0.0
|
|
Appreciation of prenatal care
|
|
Know and disagree
|
1
|
2.3
|
1
|
2.3
|
0.005#
|
|
Know, agree, but do not perform
|
15
|
34.9
|
3
|
7.0
|
|
Know, agree, and perform
|
25
|
58.1
|
39
|
90.7
|
|
Do not know
|
2
|
4.7
|
—
|
0.0
|
|
Presence of a professional obstetric nurse
|
|
Know and disagree
|
2
|
4.7
|
10
|
23.3
|
< 0.001#
|
|
Know, agree, but do not perform
|
31
|
72.1
|
—
|
0.0
|
|
Know, agree, and perform
|
7
|
16.3
|
33
|
76.7
|
|
Do not know
|
3
|
7.0
|
—
|
0.0
|
Abbreviation: PHPN, Brazilian Program for the Humanization of Prenatal and Childbirth Care.
Note: *Chi-square test; #Fisher's exact test; p < 0.05.
Regarding the knowledge about the importance of the presence of an obstetric nurse, in maternity 1, most professionals know about it, agree with it but do not follow it, while in maternity 2, most professionals said they know about it, agree with it and follow it.
[Table 3] provides information on the procedures considered useful by the WHO. There was a significant difference between the two maternities regarding non-pharmacological methods (p = 0.010) and vertical birth (p < 0.001).
Table 3
Routine implementation of procedures considered useful by the WHO in each maternity. Goiânia-GO, 2015
|
Useful procedures
|
Maternity 1
(n = 43)
|
Maternity 2
(n = 43)
|
p
|
|
N
|
%
|
N
|
%
|
|
Use of the partogram
|
|
Yes
|
38
|
88.4
|
38
|
88.4
|
0.435#
|
|
No
|
3
|
7.0
|
1
|
2.3
|
|
Not able to report
|
2
|
4.7
|
4
|
9.3
|
|
Stimulus to Movement/non-supine positions
|
|
Yes
|
40
|
97.6
|
42
|
100.0
|
0.309#
|
|
No
|
1
|
2.4
|
—
|
0.0
|
|
Non-pharmacological methods of combating pain
|
|
Yes
|
30
|
75.0
|
40
|
95.2
|
0.010#
|
|
No
|
10
|
25.0
|
2
|
4.8
|
|
Childbirth in the vertical position
|
|
Yes
|
3
|
8.6
|
25
|
64.1
|
< 0.001#
|
|
No
|
32
|
91.4
|
14
|
35.9
|
|
Presence of a companion
|
|
Know and disagree
|
5
|
11.6
|
—
|
0.0
|
< 0.001*
|
|
Know, agree, but do not allow
|
32
|
74.4
|
4
|
9.3
|
|
Know, agree, and allow
|
3
|
7.0
|
39
|
90.7
|
Note: *Chi-square test; # Fisher's exact test; p < 0.05.
[Table 4] presents the procedures considered ineffective or that should be used with caution according to the WHO. There was a significant difference between the two maternities regarding trichotomy (p < 0.001), analgesia (p < 0.001), routine use of oxytocin (p = 0.006) and episiotomy (p < 0.001).
Table 4
Routine implementation of procedures considered ineffective or that should be used with caution according to the WHO in each maternity. Goiânia-GO, 2015
|
Ineffective procedure
|
Maternity 1
(n = 43)
|
Maternity 2
(n = 43)
|
p
|
|
N
|
%
|
N
|
%
|
|
Routine trichotomy
|
|
Yes
|
28
|
65.1
|
6
|
14.0
|
< 0.001*
|
|
No
|
12
|
27.9
|
33
|
76.7
|
|
Not able to inform
|
3
|
7.0
|
4
|
9.3
|
|
Enema
|
|
Yes
|
—
|
0.0
|
2
|
4.7
|
0.340#
|
|
No
|
39
|
90.7
|
38
|
88.4
|
|
Not able to inform
|
4
|
9.3
|
3
|
7.0
|
|
Routine use of oxytocin
|
|
Yes
|
28
|
65.1
|
14
|
32.6
|
0.006*
|
|
No
|
15
|
34.9
|
27
|
62.8
|
|
Not able to inform
|
—
|
0.0
|
2
|
4.7
|
|
Routine episiotomy
|
|
Yes
|
23
|
53.5
|
6
|
14.0
|
< 0.001*
|
|
No
|
18
|
41.9
|
35
|
81.4
|
|
Not able to inform
|
2
|
4.7
|
2
|
4.7
|
|
Early amniotomy routine
|
|
Yes
|
12
|
27.9
|
7
|
16.3
|
0.283#
|
|
No
|
23
|
53.5
|
30
|
69.8
|
|
Not able to inform
|
8
|
18.6
|
6
|
14.0
|
|
Epidural analgesia
|
|
Yes
|
5
|
11.6
|
42
|
97.7
|
< 0.001*
|
|
No
|
25
|
58.1
|
—
|
0.0
|
|
Not able to inform
|
13
|
30.2
|
1
|
2.3
|
Note: *Chi-square test; #Fisher's exact test; p < 0.05.
Discussion
In the present study, the health professionals in maternity 1 mentioned the practices recommended by the WHO that form part of their routine: the use of the partograph and encouraging women to move and deliver in non-supine positions. On the other hand, the practices considered ineffective or performed inappropriately were the routine use of oxytocin, episiotomy and trichotomy. In maternity 2, regarding the practices recommended by the WHO, most of the professionals reported using the partogram, encouraging women to move and deliver in non-supine positions, the presence of a companion, as well as having the obstetric nurse as part of the team. Regarding the practices considered ineffective or inappropriate in this maternity hospital, only epidural analgesia was mentioned.
The Brazilian Ministry of Health recommends the presence of an obstetric nurse as part of the team, since this contributes to the reduction of unnecessary interventions, besides reducing the rate of cesarean sections.[3]
[6] The presence of a physiotherapist, for example, in the attention to labor is not an established practice in maternities. However, this professional plays an important role in this process, since it is her job to assist the pregnant woman in childbirth, guiding the control of the pelvic floor musculature, and suggesting positions that relieve pain and facilitate labor.[7] In the two maternities investigated, only the one that followed humanized assistance models has an obstetric nurse as part of their team and, consequently, less ineffective procedures were observed there. However, in maternity 1, other professionals compose the team that manages childbirth.
Many professionals believe that the presence of a companion would make things difficult for them because of the risk of interference in their jobs; they even think that their service is being inspected by the companion.[8] In the study conducted by Bruggemann et al[9], the health professionals' expectation about the presence of a companion in labor was initially negative, but was overcome after the experience.[9] In maternity 1, it was observed that most of the professionals did not follow the recommendations due to the lack of physical structure, since the pre labor room is very small and designed to accommodate more than one patient at a time, which makes the presence of a companion uncomfortable, because it makes the progress of the service difficult. In this room there is no accommodation for the companions, no screen dividing the beds; therefore, it is uncomfortable for the parturient and for her companion, because they are forced to share this very intimate moment with strangers.
The partograph is a communication instrument that allows the observation of the evolution of labor through a graphic representation. It contains information about dilation, uterine dynamics and heart rate.[10] The WHO recommends the use of the partograph in labor, with the aim of improving care, avoiding unnecessary interventions and reducing maternal and fetal morbidity-mortality.[2] In a study performed in a maternity school in the state of Alagoas, Brazil, it was observed that the use of the partograph is scarce. In addition, when it is used, the necessary items are not completely filled.[11] In a meta-analysis performed by Lavender, Hart and Smyth, five clinical trials were evaluated, and two studies evaluated the use or not of the partograph involving 1,590 women. It was concluded that there was insufficient evidence to recommend the routine use of it, with no difference between the use of the partograph and the reduction of the cesarean rates.[12] However, according to the Brazilian Ministry of Health, the use of this device improves the quality of delivery care, since it allows the identification of possible complications, so the health professionals can intervene effectively.[3] In the present study, it was observed that the partogram is widely used in both maternities (88.4%).
As to the stimulus to movement and delivering in non-supine positions, most of the professionals of the two maternities said that they carry out this type of practice. In a meta-analysis involving 21 studies with a total of 3,706 women, it was observed that the vertical position decreased labor time in about one hour. In addition, women in the non-supine position who walked required less analgesia and perceived more comfort throughout the process.[13]
Many doctors still use the lying position (lithotomy) because, according to them, it facilitates the examination to verify the dilation of the uterine cervix and the evolution of the birth through observation and palpation, allowing the active conduction of the delivery by the doctor, even though they are aware of the fact that this position does not favor the evolution of labor.[14] In the Brazilian study called “Nascer no Brasil”(“Being Born in Brazil”), which was conducted in the five regions of the country in 266 hospitals, it was observed that the lithotomy position was present in 90% of deliveries, and in the Midwestern Region, it was more frequent. However, it was observed that freedom of movement in the first phase of labor reduces labor time, but it does not appear to be associated with increased interventions or negative effects related to the well-being of mothers and newborns.[4]
One of the practices considered ineffective or inappropriately used is analgesia.[2] In the present study, most of the professionals in maternity 1 said they did not perform this type of procedure, whereas in maternity 2 the majority reported performing it. In the “Being Born in Brazil” study, which involved 23,840 women, it was observed that women with higher education and who had delivered in private hospitals and clinics had a higher proportion of use of analgesia. For socioeconomically disadvantaged women, a greater use of painful procedures and lower use of analgesia was observed.[4] In a study conducted with 40 patients divided into 2 groups to compare the effect of epidural analgesia and combined analgesia, it was observed that the combined technique provides rapid pain relief, and both of them are safe and effective for labor. Moreover, the increase in the use of the forceps in the expulsion stage is not related.[15]
Many professionals believe that trichotomy is necessary due to hygiene issues and to avoid possible infections; besides, it facilitates the suture in cases of laceration or epsiotomy.[14] However, a meta-analysis performed by Porto et al[16] involving three clinical trials with 1,039 women concluded that there is no evidence to recommend its routine use.[14] In the present study, it was observed that most professionals reported it being a routine in maternity 1 (65.1%); however, in maternity 2, the majority (76.7%) reported not performing this type of procedure.
The routine use of oxytocin was reported by most professionals in maternity 1, whereas in maternity 2, most of the professionals said they did not perform it. This type of procedure is used to induce or accelerate labor, but it may cause adverse effects, such as uterine hyperstimulation and, consequently, it presents a risk to the fetus.[17] Nevertheless, the indiscriminate use of oxytocin, mainly in the beginning of the labor, leads to the fact that the pain does not follow the dilation, and, with this, the women get exhausted mainly when they perceive that the pain has increased and there is no evolution of this process, often resulting in them choosing a cesarean section.[11] In the “Being Born in Brazil” survey, it was observed that the infusion of oxytocin and amniotomy were techniques widely used to accelerate labor, and were performed in 40% of women at normal risk.[4] In the present study, 65.1% of the professionals reported that this type of procedure is routine in maternity 1, while in maternity 2, 62.8% said they did not perform it.
Amniotomy prior to full dilatation (early amniotomy) is often used to accelerate labor. In the present study, this practice did not prevail in the maternities studied. In a study performed at a delivery center in the district of Sapopemba, in the city of São Paulo, Brazil, involving 1,079 deliveries, it was observed that amniotomy was performed in 53.4% of the deliveries.[18] A systematic review involving 14 randomized clinical trials evaluating 4,893 women to verify whether amniotomy decreases labor time concluded that there was no evidence of its impact in the duration of the delivery, but amniotomy was associated with an increased risk of progression to cesarean section.[19] In the present study, the majority of professionals in both maternities reported it not being part of the routine (53.5% in maternity 1, and 69.8% in maternity 2).
The WHO[2] recommends that the rate of episiotomy stays between 10% and 30% of all deliveries. In a study by Monte and Rodrigues,[17] it was observed that the interviewed professionals have often perform episiotomy because they feel insecure and fear lacerations, even if the scientific evidence proves otherwise.[2] However, scientific evidence demonstrates that grade 1 and 2 lacerations present better results regarding pain, blood loss and dyspareunia than episiotomy.[14]
Finally, in the present study, when comparing the two maternities, the routines of maternity 2, which was created as a model of humanization, follow more the recommendations of the WHO, such as the presence of a companion, of an obstetric nurse, the stimulation of movements and non-supine positions, and the use of the partograph. In maternity 1, a series of interventions considered by the WHO to be ineffective or inappropriately used, such as the routine use of oxytocin, episiotomy, trichotomy and the lack of permission of the presence of a companion were observed.
Therefore, in this study, many professionals admit they do not follow some recommendations made by the WHO due to lack of structure and adequate health professionals in the maternity wards.
