RESEARCH ARTICLES
Implementation of a humanized childbirth care model in the city of Juiz de Fora
Jane Márcia ProgiantiI; Flávia Terra HauckII
IAssociated Professor from Maternal-Infant Department from the Faculty of Nursing at the State University of Rio de Janeiro. Brazil. E-mail: jmprogi@uol.com.br.
IIObstetrician Nurse. Master in Nursing at the State University of Rio de Janeiro. Brazil. Email: flaviahauck@hotmail.com
ABSTRACT: It is a historical and social study which aimed at analyzing the strategies for the implementation of a humanized childbirth care model in the city of Juiz de Fora – between 1998 and 2001. Oral and written documents comprised the study’s analytical corpus, which has followed three steps: sorting, classification and articulation of data among themselves and with Pierre Bourdieu’s concepts. The results indicated that the strategies were actions in short, medium and long term, which aimed at informing and raising awareness of doctors and the population at large, as well as training human resources to implement humanized obstetric practices and the reconfiguration of the obstetric field in the city of Juiz de Fora. We have concluded that actions involving awareness-raising and information were not enough for doctors to adhere to the guidelines of the humanized model, and that the Commission has achieved its goal after establishing the Specialization Course in Obstetric Nursing and the Birth Center.
Keywords: Humanization; Obstetric Nursing; History of Nursing; Women’s Health.
INTRODUCTION
In 1994, the city Juiz de Fora deployed the Maternal Death System and the Information System on Live Births, which have provided a greater visibility of the situation of maternal and perinatal deaths in the town. This fact justified the creation, in 1996, of the Municipal Committee for the Prevention of Maternal Mortality in Juiz de Fora1.
This committee worked in conjunction with the Regional Committee on Maternal Mortality and pointed out the need for changes in childbirth care, since, in the year 1996, the rate of maternal deaths in Juiz de Fora was 123 for every hundred thousand live births2.
It should be highlighted that maternal deaths occurring the city, in their majority, were linked to the quality of care and the preventable causes, since 66% of maternal deaths happened between 1996 and 2000 were due to direct obstetric causes, i.e., related to improper interventions (45% of pregnancy-related deaths took place in women who underwent cesarean section), omissions, incorrect treatment or a chain of events arising from any of these causes2.
These high rates of maternal mortality and cesarean sections contradicted discussions and recommendations in relation to childbirth that were happening in Brazil and worldwide, because, in 1998, the Brazilian Ministry of Health (MS) launched a series of ordinances by changing devices related to childbirth care in Brazil, with the objective of reducing maternal and neonatal morbidity and mortality. Among them, the completion of a normal childbirth without dystocia on the part of the obstetrician nurse was instituted and regulated by the Ordinance nº 2.815, of September 22nd, 1998, and the limit of payment of the maximum percentage of cesarean sections in relation to the total amount of births per hospital was approached by the Ordinance nº 2.816, of May 29th, 19983,4.
In the same year, amid the recommendations of the Maternal Mortality Committee of Juiz de Fora and after exposure of a report from the Department of Programming and Monitoring of the Municipal Secretariat of Health from the city of Juiz de Fora (SMS/JF) on the situation of the maternal health in the city, which showed an excessive number of caesarean sections and the consequent generation of unnecessary expense to the coffers of the Municipal Health Fund, the SMS/JF created the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth2.
On April 16th, 1998, the municipal health secretary sent the names of the members of the Commission for appointment through the Letter nº 135/98. Soon after the first meeting, it was decided that the group would develop strategies with the purpose of reducing the rate of cesarean sections by means of the implementation of the Model of Humanized Care to Childbirth.
Accordingly, the aim of this study was to describe the strategies developed by the Interinstitucional Commission for the Reduction of Cesarean Sections and Protection to the Natural Childbirth to deploy the Humanized Model of Childbirth Care in the city of Juiz de Fora.
This study is relevant as it contributes to the history of the movement for the humanization of labor and childbirth, to the history of Nursing and to the history of the obstetric field.
THEORETICAL AND METHODOLOGICAL BENCHMARK
It is a qualitative study with historical and social nature, which made use of hybrid oral history as its research method, which is characterized by comparing the oral data with other documents5. This work is linked to the master’s dissertation entitled: “Implementation of Humanized Care to Childbirth - Juiz de Fora (1998 - 2001)”.
The written documents that formed the corpus of analysis of this study were: Action Plan designed by the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth; Report of the Department of Programming and Monitoring from the SMS/JF on the individual number of caesareans held by doctors associated with the Brazilian Unified Health System (SUS); three letters from the SMS/JF (Letter nº 0001/98, Letter nº 206/98, Letter nº 135/98); a document on the procedures recommended by the Guide for Childbirth Care of the World Health Organization (WHO) sent to doctors and hospitals by the heads of the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth; three papers published in the newspaper Tribuna de Minas, one on the high rate of cesarean sections in Juiz de Fora and other two on the creation of the Birth Center from the School of Nursing at the Federal University of Juiz de Fora (UFJF); the book written by the obstetrician nurse Betània Maria Fernandes entitled “The Birth Center: experiences and livings guide a new thinking on health” and ministerial ordinances nºs 2.815/98, 2.816/98 and 985/99.
The oral documents were produced by means of semi-structured interviews conducted together with the study subjects. Accordingly, we have interviewed two members of the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth - the social worker Terezinha de Jesus Nascimento Martins da Costa and the obstetrician nurse Betània Maria Fernandes; in addition to two obstetrician nurses who, at the time of the study, did the Specialization Course in Obstetric Nursing at the UFJF and who currently work in maternities in Juiz de Fora - Heloísa Clartine de Oliveira e Andréa Dias Silva Kingma Lanziotti.
During the analytical process, we firstly performed the organization of written data in chronological order; this step included the full transcription of recorded interviews in media player (MP4). The second step was the data classification, which included the thorough and critical reading of findings. The central ideas of the selected documents were gathered into categories. The third step, characterized by abstraction and analysis, covered the movement of triangulation between the findings and theoretical benchmark of this research, pointing to the study objectives6. In order to support the analysis, we have used the concepts of symbolic power, symbolic domination, habitus, capital and field, which were produced by the French sociologist Pierre Bourdieu7.
The research was guided by ethical and legal principles contained in the Resolution nº 196/96 of the National Health Council (CNS) from the Brazilian Ministry of Health, which regulates the researches involving human beings, being approved by the Research Ethics Committee from the State University of Rio de Janeiro, according to the Opinion nº 082/2011. It should be emphasized that all the respondents have consented the disclosure of their names in this research and in other publications.
RESULTS AND DISCUSSION
This study has shown us that the strategies of the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth were actions in short, medium and long term. These actions have targeted: information and awareness of doctors and population at large, training of human resources to implement the humanized obstetric practices and reconfiguration of obstetric field of the city of Juiz de Fora.
The implementation of the action plan
Actions to inform and raise awareness of doctors and the population at large
In order to achieve the purpose of transforming the childbirth care model in the obstetric field, the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth should inform health professionals and the population about its purposes and sensitize them towards achieving support.
With the aim of informing doctors, in 1997, the Interinstitucional Commission made use of the report produced by the Department of Programming and Monitoring from the SMS/JF, which had a individual survey of the amount of caesarean sections and vaginal deliveries performed by doctors associated with the SUS, and sent the Letter nº 0001/98 to every obstetrician practitioner, requesting collaboration to the urgent reversal of the high cesarean section rates in the city, besides suggesting an individual reach 20% of caesareans.
On June 22nd of the same year, the above mentioned commission routed to the Services of Obstetrics and Gynecology, associated with the SUS, the letter nº 206/98, containing copies of the ordinances nºs 2.815 and 2.816, of May 29th, 1998, which deal with devices related to childbirth, such as the inclusion of the procedure of vaginal delivery without dystocia, performed by obstetrician nurse, inclusion of analgesia in procedures of natural childbirth, alteration of values of such procedures and about payment of the maximum percentage of caesarean sections in relation to total births for every hospital.
Thus, the Interinstitucional Commission has shown that its power was legitimized by higher instances, which, in this case, is the MS. The act of associating its actions with a higher power is to assert with authority a truth that has legal effect, i.e., it is an act of knowledge that might be executed like any symbolic power7.
In an attempt to sensitize directors and doctors working in the obstetric field, on September 24th, 1998, it was held at the Society of Medicine and Surgery, the event entitled “Pathways to Change the Care to Labor and Childbirth: experiences in two maternities”, whose speakers were the obstetricians Marcos Bastos Augusto Dias, director of the Maternity Leila Diniz (RJ), and João Batista de Castro Marinho, clinical director of the perinatal line of the Hospital Sofia Feldman, in the city of Belo Horizonte. In that occasion, we invited all members of the obstetric services of the city for attending the event.
Sensitizing directors of maternities to change the model and to reduce the rate of cesarean surgeries was the main objective [...], I wish they could hear for the 1st time what humanization of labor is. Moreover, we made contact with the directors of the Sofia Feldman and Leila Diniz, and we reported that it was very important that the directors of maternities could hear other medical directors of maternities in major centers to talk about humanization. (Professor, Obstetrician Nurse Betânia Maria Fernandes)
Accordingly, the symbolic power of an agent ensures its symbolic productions that serve as an instrument of symbolic domination7. Thus, it was expected that the scientific authority of doctors, who, at that time, occupied prominent positions in institutions with the new model already deployed, could stimulate adherence of obstetricians to the movement for transforming the obstetric model.
It should be noted that this strategy of sensitization of professionals was also a strategy used by managers of the city of Rio de Janeiro in past struggles for the care humanization in two institutions, Maternity Leila Diniz and Maternity Alexander Fleming8,9.
Nevertheless, in the case of Juiz de Fora, as can be seen in the following speech, the target audience did not appear as expected.
We made this seminar and it was wonderful, [...] there was a very large participation, but there were more students, unfortunately, our assessment is that it could have been more professionals. (Professor, Obstetrician Nurse Betânia Maria Fernandes)
The political support of local directors to the project, as an instrument of struggle, would be crucial to build consensus towards the ideals produced by the Commission. Therefore, the Commission insisted and, in June 1999, sent them a document that made comparisons among cesarean rates advocated by the WHO - which is 15% - with rates of the city at stake in 1998, which was 55,3 %. It has also informed on the WHO guidelines contained in the “Safe Care in Normal Birth: a practical guide” and the classification of care practices during natural births. Furthermore, it has sent folders to encourage vaginal deliveries, which were designed by the Commission itself, in order to be fixed on the walls and murals of institutions to achieve the female population.
In May 1998, the newspaper Diario Regional published a story with the title of “Cesarean deliveries are most”, which contained information about the cesarean rate in Juiz de Fora and about the establishment of the Commission10.
The media plays a symbolic power through the formation of opinion of common sense that serves as a disseminator of values and ideas11. The Commission, when making use of this media field, sought to take advantage of this power relationship to inform the general population and reach its support.
Action to form human resources
In order to implement such strategy, the Commission contacted the Secretariat of Health Policies/MS, through the Technical Coordination for Women's Health, requesting that it could discuss about the implementation of the Specialization Course in Obstetric Nursing (Lato Sensu) in the city of Juiz de Fora. Thus, this course was deployed in 2000, through a partnership between the Faculty of Nursing from the UFJF and the MS.
At that time, the MS aimed at expanding the participation of obstetrician nurses in the SUS network for implementing the humanized model. That is why it was financing specialization courses in Obstetric Nursing, in faculties and schools of Nursing throughout the country, with a view to addressing the lack of such specialists12.
The project of the UFJF Course was developed by the Professor from the Department of Maternal-Infant from the Faculty of Nursing at the UFJF, Betânia Maria Fernandes, who was also a member of the Commission. The course took place in the years 2000, 2001 and 2002, under her coordination.
As noted in the following statement, the purpose of the creation of the above mentioned course was to train nurses to work in direct care to deliveries in maternity wards of the city and, subsequently, in the future Birth Center:
Our major proposal was to qualify nurses [...] we needed, at least, two years to prepare such professionals to work in maternities, then when we had a larger number of nurses (midwives) could act within the Birth Center. (Professor, Obstetrician Nurse Betânia Maria Fernandes)
The courses faced the barriers aroused from the practical point of view, and one of them was the non-availability of a field for conducting the practical teaching, within the city's maternities, thereby demonstrating the power of medical professionals in the institutional scope in the face of the Commission’s power.
Thus, in order to develop practical skills, the students had to perform their practical classes at the Hospital Sofia Feldmam, in Belo Horizonte:
[...] Our practice field was at the Sofia Feldmam, and, there, we could experience a little of the humanized model focused on women and with shares of a nurse midwife. (Obstetrician Nurse Andréa Dias Silva Kingma Lanziotti)
The specialization courses in Obstetric Nursing were essential to increase the number of nurses legally authorized for conducting direct care in cases of natural childbirth. In the symbolic level, they would add, to the habitus of the nurses, skills that would increase their volume of capital and would give them legal and technical conditions to fight in the city’s obstetric field. This would be necessary to produce and reproduce relationships able to provide material and symbolic profits. Accordingly, the acquisition of institutionalized capital, provided by the Faculty of Nursing from the UFJF, under the form of title, is related to the institutional legitimation of symbolic power. Such power, in the form of academic titles, gives legitimacy to a particular agent for being, explaining, defining or acting in a certain field13,14.
Actions to reconfigure the obstetric field
In order to prepare the project of the Birth Center, the Commission’s agents were personally know the experience of the Birth Center called Nove Luas, Lua Nova LTDA, in Niterói, State of Rio de Janeiro. Thereafter, the agents Betânia Maria Fernandes e Terezinha de Jesus Nascimento Martins da Costa elaborated the project of creation of the Birth Center of Juiz de Fora, supported by the Ministerial Ordinance nº 985/1999, which created, in the SUS scope, the Center for Natural Childbirth and had just been launched by the MS:
The Commission managed to find ways for us to know the Birth Center of Niterói and we went [...] from there we started to do some investigations, I brought the epidemiological data and Betânia Maria Fernandes had this whole discussion in tip of the tongue [...] with her willingness to do so, she said: “you can leave it to me, I'll hold it”. (Social Worker Terezinha de Jesus Nascimento Martins da Costa)
The initial proposal of the foundation of the Birth Center was to build it by means of the SMS/JF, however, even before the proposal for its creation being forwarded to the above mentioned public body, the professor Betânia Maria Fernandes was invited by the Dean of the Federal University of Juiz de Fora (UFJF), Margarida Salomão, to expose her idea:
It was by chance that the Birth Center was established within the University, the Dean was in a meeting with the pro-deans, and the newspaper Folha de São Paulo solved to publish the matter, in the cover page, with a report of the Birth Center of Sapopemba, and, then, the Dean showed the story and said that she thought it would be a breakthrough. [...] Margarida Salomão drew me attention, there, to talk to me, so I called Teresinha de Jesus Nascimento Martins da Costa. (Professor, Obstetrician Nurse Betânia Maria Fernandes)
By exposing the proposal to build the Birth Center to the Dean Margarida Salomão, it was established that the UFJF would make the project feasible.
At that meeting [...] she wanted to know if the city of Juiz de Fora would add a Birth Center and then we made that speech, spoke of maternal mortality [...] Terezinha de Jesus Nascimento Martins da Costa, as an epidemiologist, showed that the data relating to rates of caesarean surgeries and maternal mortality were very high. Next, I said what I experienced, as a college teacher, this hostile model. [...] Then, she asked us to forward the project for creating the Birth Center (belonging to the Commission), because the UFJF would take on the project. (Professor, Obstetrician Nurse Betânia Maria Fernandes)
The first step was to refer the Project of the Birth Center of Juiz de Fora, held by the Commission and incorporated by the UFJF, to the MS Coordinator of creation of projects related to birth centers, the doctor Capistrano Costa Filho.
On March 21st, 2000, the then Minister of Health, José Serra, was personally in Juiz de Fora to sign the agreement between the MS and the UFJF. This document has established that the MS would be responsible for the purchase of stuffs, while the UFJF would assume the building and the staffing15.
On this occasion, it was published that the goal of the Birth Center from the FACENF/UFJF was to hold 600 deliveries per year and that it would practically spend around 450 thousand reais (Brazilian currency) during its construction and deployment. It should be highlighted that, at that time, the Minister of Health told the press that the Brazilian birth centers would be low-cost alternatives for childbirth care16. This fact makes it clear that such agreement met the MS interests to reduce expenses, as well as the Dean’s plans, which probably had intentions on making alliances and promoting actions that subsequently could bring election-related profits in relation to the population of the city. Thus, it is worth mentioning that she was a candidate for Federal Deputy, in 2010, and became mayor of Juiz de Fora, in 2012, for the second time.
It is observed that, during the creation process of the Birth Center of Juiz de Fora, there was no participation of the SMS/JF. The political articulations for its implementation were among the spheres of the MS and of the Dean’s Building at the UFJF. Differently, during the creation process of the Birth Center of the city of Rio de Janeiro, in 2004, the political articulations took place between the MS and the SMS/RJ. Here, the faculties of nursing, specifically the Faculty of Nursing from the State University of Rio de Janeiro, were supportive of the process, providing scientific and institutionalized capital for that the nurses would improve their conditions to fight in the field17.
During the creation process of the Birth Center of Rio de Janeiro, another fact draws attention: city managers faced much opposition, including judicial resistances raised by the medical corporation. These oppositions have enhanced the demonstration in support to the women's social movement towards the project, which gave more power to the implementation of it18, which was a fact that did not occur in the case of Juiz de Fora.
In closing the activities of the Commission, on December 14th, 2001, it was inaugurated the Birth Center from the Faculty of Nursing at the UFJF, with a skeleton staff of seven obstetrician nurses, four nursing assistants, two social workers, four general services assistants and one ambulance driver2. The center worked for seven years and up to its closure, in 2008, performed 703 deliveries.
The Humanized Model of Childbirth Care has guided the actions of obstetrician nurses, whose non-interventionist practices have encouraged the procedure of normal birth as a successful experience to women, which might be shared with their family members8,9,12,17-20.
CONCLUSION
The strategies of the Interinstitucional Commission for the Reduction and Protection to the Natural Childbirth were actions in short, medium and long term. These actions which aimed at informing and raising awareness of doctors and the population at large, as well as training human resources to implement humanized obstetric practices and the reconfiguration of the obstetric field in the city of Juiz de Fora.
The actions of awareness-raising and information were not enough to the point of achieving adherence of doctors and general population to the proposed objectives, since there was no support from the medical directors of maternities and neither movement of the female population of Juiz de Fora in the sense of pressuring the authorities in pursuit of humanization of labor and childbirth.
It is considered that the Brazilian context, at that time, was favorable for that the actions of training human resources were successful. Thus, the UFJF has consecutively obtained in 2000, 2001 and 2002, funds financed by the MS for holding three specialization courses in Obstetrician Nursing in the Faculty of Nursing, which was crucial for that the actions of field reconfiguration were implemented.
Thus, after completion of the first course funded by the MS, it was established, in the year 2001, the Birth Center of the Faculty of Nursing at the UFJF. Thereafter, the Interinstitucional Commission closed its operations and its main protagonists, the nurse Betânia Maria Fernandes and the social worker Terezinha de Jesus Nascimento Martins da Costa returned to their activities, in order to train nurses from the newly created Birth Center so that they could go ahead producing non-interventionist obstetric practices with the encouragement to performances of natural childbirths, since it is a pleasurable event of women's life and their relatives.
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