Abstract

Objective

To assess adherence to best practices in labor and childbirth care by doctors, nurses, obstetric nursing residents, and obstetric medical residents working in public hospitals in the Federal District of Brazil.

Method

A cross-sectional study was conducted with care providers working in 11 public hospitals in the Federal District of Brazil between January and March 2015. A questionnaire containing 20 sociodemographic questions and 50 five-point Likert items was administered. The average scores of each group and each hospital were analyzed.

Results

Nurses obtained the highest scores for the use of evidence-based practices (57.8 ± 12.9), while doctors achieved the highest scores for the work process dimension (72 ± 8.5). Medical residents obtained the highest scores for organization of labor and childbirth care (56.5 ± 8.5). No statistically significant differences were found between groups. Hospital scores ranged from 55 to 64. No statistically significant differences were found between hospitals. Most professionals encourage natural childbirth.

Conclusion

It is necessary to strengthen actions to promote greater adherence to best care practices, both in relation to organization of labor and childbirth care and to the attitudes and values of health professionals.

Keywords
Women’s health; Health knowledge, attitudes, and practices; Humanized childbirth; Health services research

Introduction

Women’s health, particularly antenatal and labor and childbirth care, has been a prominent issue on Brazil’s health agenda since the 1990s. In this respect, there has been a shift away from the biomedical model towards an integrated and regionalized approach that addresses perinatal risks and ensures timely access to quality primary and specialist care¹1. Leal MC, Pereira APE, Domingues RMSM, Filha Mariza MT, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S17-S32.,²2. Patah LEM, Malik AM. Models of childbirth care and cesarean rates in different countries. Rev Saude Publica [Internet]. 2011 [cited 2017 Dec 10];45(1):185-194. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102011000100021&lng=en
http://www.scielo.br/scielo.php?script=s... .

The organizational model for labor and childbirth care proposed by the Ministry of Health in the 1990s and reinforced in 2011 follows international recommendations. It consists of practice guidelines for the delivery of quality evidence-based and comprehensive care for women and their newborn babies, recognizing that women and their families are the main actors in maternal healthcare³3. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comande D, Diaz V, Geller S, Hanson C, Langer A, Manuelli V, Millar K, Morhason-Bello I, Castro CP, Pileggi VN, Robinson N, Skaer M, Souza JP, Vogel JP, Althabe F. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet [Internet]. 2016 [cited 2017 Dec 10]; 388(10056):2176-2192. Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)31472-6.pdf
http://www.thelancet.com/pdfs/journals/l... .

The guidelines envisage the organization of thematic antenatal, childbirth, and infant care where work processes are the driving force behind change in practice. The approach reinforces the use of soft and soft-hard technologies (technical and scientific knowledge) for childbirth care in cases of low-risk pregnancies and deliveries. Efforts have been made to strengthen maternity services and develop innovative strategies to overcome conflicts generated by power relations that permeate the everyday actions of health workers in hospital settings⁴4. Cavalcanti PCS, Gurgel Junior GD, Vasconcelos ALR, Guerrero AVP. A logical model of the Rede Cegonha network. Physis [Internet]. 2013 [cited 2018 Jan 08]; 23(4):1297-1316. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312013000400014&lng=en
http://www.scielo.br/scielo.php?script=s... .

Brazil’s guidelines are aligned with recommendations put forward by the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine⁵5. American College of Obstetricians and Gynecologists. Obstet Gynecol. Levels of maternal care. Obstetric Care Consensus No. 2. [Internet]. 2015 [cited 2017 Jul 17]; 125:502-515. Available from: https://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Levels-of-Maternal-Care
https://www.acog.org/Resources-And-Publi... . In 2015, these organizations published guidelines for organizing an integrated system for regionalized obstetric care with services that provide care at different levels of complexity. These services should have health professionals with special training and facilities with adequate technical support. The implementation of these guidelines requires a global approach that supports respectful and humanized antenatal, intrapartum, and postnatal care³3. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comande D, Diaz V, Geller S, Hanson C, Langer A, Manuelli V, Millar K, Morhason-Bello I, Castro CP, Pileggi VN, Robinson N, Skaer M, Souza JP, Vogel JP, Althabe F. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet [Internet]. 2016 [cited 2017 Dec 10]; 388(10056):2176-2192. Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)31472-6.pdf
http://www.thelancet.com/pdfs/journals/l... .

The Federal District of Brazil has an estimated population of three million, 65% of which uses public health services. Births in the district dropped from 46,967 live births in 2001 to 44,538 in 2014⁶6. Secretaria do Estado de Saúde do Distrito Federal. Plano Distrital de Saúde 2016-2019. Brasília. [Internet] 2016 [cited 2019 Mar 10]. Available from: http://www.seplag.df.gov.br/wp-conteudo/uploads/2017/12/Avalia%C3%A7%C3%A3o-do-Plano-Plurianual-2016-2019-Ano-base-2016.pdf
http://www.seplag.df.gov.br/wp-conteudo/... . Caesarean section rates have steadily climbed, from 39.9% in 2000 (19,416 caesarean sections compared to 29,180 normal births) to 52.9% in 2014 (28,393 caesarean sections compared to 25,122 normal births), far exceeding the ideal rate recommended by the World Health Organization (WHO). These statistics have fuelled debate about medically indicated caesarean sections, where mother and baby can be exposed to unnecessary risks, including maternal death⁷7. Leite ICR, Margoto RM, Borges TC, Xavier EA, Corassa GP, Freitas MA. A Análise da Taxa de Cesáreas no Distrito Federal e em um Hospital Público Regional nos últimos 15 anos. Revista de Medicina e Saúde de Brasília [Internet]. 2018 [cited 2019 Mar 01]; 7(1):24-37. Available from: https://portalrevistas.ucb.br/index.php/rmsbr/article/view/9055
https://portalrevistas.ucb.br/index.php/... .

The federal district’s Department of Health (SES-DF) adhered to the Rede Cegonha (the Stork Network) in 2011 and has since developed a range of actions, including improvements in coordination and communication between primary care and birth locations, changes in the obstetric care model, greater adherence to best obstetric care practices, and changes in work processes envisaging the adoption of evidence-based care strategies.

The delivery of quality comprehensive care for women poses a huge challenge for the federal district’s and country’s health systems alike. However, a number of potential synergies have been identified to advance effective change in labor and childbirth care through the implementation of best perinatal practices. These practices include the review of routine care and process and outcome monitoring, improvements in the ambience of healthcare facilities, and provision of obstetric nursing care for low-risk deliveries⁸8. Gomes MASM. Commitment to change. Cad Saude Publica [Internet]. 2014 [cited 2018 Jan 08]; 30(Supl. 1):S41-S42. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2014001300011&lng=en
http://www.scielo.br/scielo.php?script=s... .

Studies have highlighted knowledge gaps in the assessment of professional practices and the evaluation of health services⁹9. Malacarne MP, Luiz SG, Amaral TR, Siqueira MM. Avaliação de serviços de saúde no campo da Saúde Coletiva: uma sistematização em curso. Rev. Bras. Pesqui. Saúde [Internet]. 2017 [cited 2018 Jan 08]; 18(1):62-67. Available from: file:///C:/Users/Leila/Downloads/15136-41937-1-SM.pdf,¹⁰10. Kendall T, Langer A. Critical maternal health knowledge gaps in low- and middle-income countries for the post-2015 era. Reproductive health [Internet] 2015 [cited 2018 Jan 08]; 12(1):55. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475304/pdf/12978_2015_Article_44.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... remains a challenge for the majority of health providers given the complexities involved⁹9. Malacarne MP, Luiz SG, Amaral TR, Siqueira MM. Avaliação de serviços de saúde no campo da Saúde Coletiva: uma sistematização em curso. Rev. Bras. Pesqui. Saúde [Internet]. 2017 [cited 2018 Jan 08]; 18(1):62-67. Available from: file:///C:/Users/Leila/Downloads/15136-41937-1-SM.pdf. In view of the above, the aim of this study was to assess adherence to best practices in labor and childbirth care among doctors, nurses, and obstetrics residency program residents working in public hospitals in the Federal District.

Method

A cross-sectional survey was conducted in the 11 public hospitals that make up the federal district’s Rede Cegonha between January and March 2015. The SES-DF is responsible for administering 16 hospitals, 11 of which provide labor and childbirth care, and one childbirth center. According to the National Registry of Healthcare Establishments, these facilities have a total of 806 maternity beds (607 SUS beds and 199 nonSUS beds) and 512 obstetric professionals (416 doctors and 105 nurses). Seven of the hospitals have obstetrics and gynecology doctor residency programs and obstetrics nurse residency programs.

Stratified sampling was used whereby participants were divided into subgroups (obstetricians, obstetric nurses, medical residents, and nursing residents) based on the proportion of professionals allocated to each participating hospital, resulting in a final sample of 261 health professionals, comprising 111 nurses (42.6%) and 150 doctors (57.5%).

The respondents were interviewed by a team of three nurses, two of whom were obstetric nurses. The team administered a questionnaire containing 20 sociodemographic questions and 50 five-point Likert items (totally disagree, partially disagree, don’t know, partially agree, and totally agree) designed to assess the adoption of best practices in labor and childbirth care across three dimensions: organization of labor and childbirth care (items 1 to 12), evidenced-based practices (items 13 to 35), and work process (items 36 to 50). Negatively worded questions were reverse scored, in accordance with the questionnaire instructions¹¹11. Carvalho EMP, Göttems LBD, Pires MRGM. Adherence to best care practices in normal birth: construction and validation of an instrument. Revista da Escola de Enfermagem da USP. [Internet]. 2015 [cited 2018 Jan 08]; 49(6):889-897. Available from: http://www.scielo.br/scielo.php?pid=S0080-62342015000600889&script=sci_arttext
http://www.scielo.br/scielo.php?pid=S008... .

A previous study¹²12. Göttems LBD, Carvalho EMP, Guilhem D, Pires MRGM. Good practices in normal childbirth: reliability analysis of an instrument by Cronbach’s Alpha. [Internet]. Rev. Latino-Am. Enfermagem 2018; [cited 2019 Mar 04]; 26:e3000. Available from: http://www.scielo.br/pdf/rlae/v26/pt_0104-1169-rlae-26-e3000.pdf
http://www.scielo.br/pdf/rlae/v26/pt_010... conducted to assess the reliability of the instrument found Cronbach’s alpha values of 0.53, 0.78, and 0.76 for dimensions 1, 2, and 3, respectively, after excluding 11 items. To ensure the reliability of the data of the present study, the questionnaire was therefore administered excluding the suggested items, resulting in 39 items that obtained an overall Cronbach’s alpha value of 0.80.

The categorical variables were analyzed using the frequency distribution and proportions. To analyze the Likert questions, the score was transformed to a scale ranging from zero (terrible) to 100 (excellent)¹³13. Curado MAS, Teles J, Marôco J. Analysis of variables that are not directly observable: influence on decision-making during the research process. Rev. Esc. Enferm. USP [Internet]. 2014 [cited 2018 Jan 08]; 48(1):146-152. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342014000100146&lng=en
http://www.scielo.br/scielo.php?script=s... . After calculating the average scores, the following parameters adapted from Costa et al.¹⁴14. Costa MAR, Versa GLGS, Bellucci Júnior JA, Inoue KC, Sales CA, Matsuda LM. Admittance of Risk-Classified Cases: Assessment of Hospital Emergency Services. Esc. Anna Nery Rev. Enferm. [Internet]. 2015 [cited 2018 Jan 08]; 19(3):491-497. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452015000300491&lng=pt
http://www.scielo.br/scielo.php?script=s... were applied to the professionals and hospitals: good = 90 to 100; satisfactory = 70 to 89; poor = 50 to 69; and inadequate = 0 to 49.

The Kolmogorov-Smirnov test was used to check normality. Analysis of variance (ANOVA) was performed with the continuous variables. Where ANOVA showed a statistically significant difference, post-hoc testing was performed using Tukey’s TSD with Bonferroni correction. The categorical variables were analyzed using contingency tables assessed using Pearson’s chi-squared test or Fisher’s exact test. Post-hoc testing was performed with Bonferroni correction when appropriate. A 5% significance level was adopted (p < 0.05). Statistical analysis was conducted using the software Statistical Package for Social Sciences 20.0 Mac (SPSS 20.0 Mac, SPSS Inc., Chicago, Illinois, USA).

The project was approved by SES-DF’s Health Ethics Committee (application number CAAE 01918712.6.0000.5553). All participants signed an informed consent form. This study was part of a wider study, entitled Organization, Access, and Continuity of Maternal and Infant Care in SES-DF, and was funded by the Research Support Foundation (Fundação de Apoio à Pesquisa).

Results

The average age of the nurses, nursing residents, doctors, and medical residents was 37.6 ± 8.5, 27 ± 7.3, 43 ± 8.7, and 27 ± 1.9 years, respectively. The professionals were predominantly female in all categories. The majority of the professionals were specialists; however, the frequency of qualifications apart from specialist training was greatest among doctors. Average hours worked per week was above 40 to residents (Table 1).

With respect to labor and childbirth care practices (Table 2), the lowest average scores were obtained for the first dimension (organization of labor and childbirth care): 7.8 ± 12.9, 53.8 ± 12.5, 56.0 ± 13.8, and 57.6 ± 12.5 for nurses, nursing residents, doctors, and medical residents, respectively. Significant differences in scores between nurses and doctors were observed in relation to certain items in this dimension, notably: prior visit for familiarization with the birth location; operating beyond capacity; and participating in antenatal meetings to discuss improvements in antenatal and labor and childbirth care. The scores for the first two items were greater among nurses.

Average scores for the second dimension (evidenced-based practices) were 56.3 ± 7.1, 56.4 ± 7.3, 56.5 ± 8.5, and 56.2 ± 6.6 for nurses, nursing residents, doctors, and medical residents, respectively (Table 3). Seven of the 21 items in this dimension showed significant differences in scores between nurses and doctors, notably: labor and childbirth care (p = 0.01); nonpharmacological pain management (p < 0.01); auscultation of the fetal heart during labor (p < 0.01); informing the mother of progress in labor (p < 0.01); use of intravenous rehydration during labor and childbirth (p < 0.01); encouraging pushing during the expulsion stage (p < 0.01); and performing routine episiotomy (p < 0.01).

Average scores for the third dimension (work process) were 67.4 ± 15.6, 63.7 ± 15.8, 68.2 ± 15.2, and 72.0 ± 11.4 for nurses, nursing residents, doctors, and medical residents, respectively (Table 4). Seven of the nine items showed significant differences in scores between nurses and doctors, notably: providing information to the mother before commencing procedures (p < 0.01); joint clinical decision-making (p < 0.01); team discussion of scientific evidence (p < 001); integrated action between doctors and nurses (p < 0.01); encouraging normal childbirth (p < 0.01); and undergoing periodic training (p < 0.01).

Figure 1 presents the average scores for each hospital. Significant differences were found between the different services across all dimensions (p < 0.01), with scores ranging from 50 ± 3 (hospital H3) to 62 ± 5 (hospital H1). The lowest scores were obtained for dimension 1 (organization of labor and childbirth care) in all the hospitals, with scores ranging from 31 ± 9 (hospital H7) and 49 ± 8 (hospital H1), while the second dimension (evidence-based practices) showed the highest scores, except in hospitals H4 and H9, with scores ranging from 56 ± 7 (hospital H9) and 78 ± 7 (hospital H5). Scores for the third dimension (work process) ranged from 55 ± 10 (hospital H8) and 66 ± 8 (hospital H4).

Figure 1 presents the average scores for each hospital. The scores of the dimension 1 (organization of labor and childbirth care) ranged from 46 ± 9.8 (hospital H6) and 61 ± 8 (hospital H8). The scores of the second dimension (evidence-based practices) ranged from 52 ± 4.8 (hospital H7) and 58 ± 5 (hospital H8). Scores for the third dimension (work process) ranged from 62 ± 18 (hospital H9) and 77 ± 14 (hospital H3) (Figure 1).

Statistically significant differences in scores between hospitals were found in five of the nine items of the first dimension (organization of labor and childbirth care), notably: prior visit for familiarization with the birth location (p < 0.01); educational activities with mothers during prior visits to promote maternal bonding (p = 0.02); and difficulties in performing diagnostic and therapeutic support in other services (p < 0.01).

Significant differences in scores were found in 13 of the 21 items of the second dimension (evidence-based practices), notably: advice on relaxation techniques to help ease pain (p = 0.04); and freedom to choose the position for labor and childbirth (p < 0.01). The average score for these items was over 80 in all hospitals. With respect to the items encouraging women to have a birth companion of her choice and nonpharmacological pain management, only two hospitals failed to achieve scores of over 80 (p < 0.01). It is also important to stress the differences in scores found in the following items related to obstetric interventions: intravenous rehydration during labor and childbirth (p = 0.01); encouraging pushing during the expulsion stage (p < 0.01); performing routine episiotomy (p < 0.01); and performing the Kristeller maneuver when necessary (p < 0.01).

Significant differences in scores across hospitals were found in seven of the nine items of the third dimension (work process), notably: “following ministry of health recommendations on labor and childbirth care”, with average scores of over 80 in all hospitals (p < 0.01).

The last question of the instrument asked whether professionals encouraged normal childbirth among friends or family. Positive responses were obtained from 100% of nursing residents, 91.2% of medical residents, 86.7% of nurses, and 78.1% of doctors

Discussion

The findings reveal significant potential and gaps in labor and childbirth care practices in the hospitals studied. The scores for practices related to organization of labor and childbirth care were low among both professionals and hospitals, signaling inadequate implementation¹⁴14. Costa MAR, Versa GLGS, Bellucci Júnior JA, Inoue KC, Sales CA, Matsuda LM. Admittance of Risk-Classified Cases: Assessment of Hospital Emergency Services. Esc. Anna Nery Rev. Enferm. [Internet]. 2015 [cited 2018 Jan 08]; 19(3):491-497. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452015000300491&lng=pt
http://www.scielo.br/scielo.php?script=s... . Among the hospitals, the findings show gaps in the implementation of ministry of health recommendations, especially for the items relating to maternity care within the defined territory, educational activities, coordination and communication with other birth and low-risk antenatal locations, sufficient staff and bed capacity, and ambience of maternity facilities.

The results of this dimension demonstrate the challenges in changing the organization of healthcare services, which are currently fragmented and isolated, and in adopting an integrated approach. This requires the establishment of horizontal relations between different services in order to develop points of interrelated care with multiple and permanent communication channels¹⁵15. Malheiros PA, Alves VH, Rangel TSA, Vargens OMDC. Labor and birth: knowledge and humanized practices. Texto & Contexto Enferm. [Internet]. 2012 [cited 2018 Jan 10]; 21(2):329-337. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072012000200010&lng=pt
http://www.scielo.br/scielo.php?script=s... . Strengthening primary healthcare services, in this study represented by antenatal services, is critical to ensuring quality care, sharing of clinical information, defining childbirth plans, and familiarization of mothers with birth locations. In this respect, the scores obtained by the services demonstrate clear weaknesses in coordination and communication between points of care¹⁶16. Silva MZND, Andrade ABD, Bosi MLM. Access and user embracement in prenatal care through the experiences of pregnant women in Primary Care. Saúde Debate [Internet]. 2014 [cited 2018 Jan 10]; 38(103):805-816. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042014000400805&lng=en
http://www.scielo.br/scielo.php?script=s... .

In the second dimension (evidence-based practices), implementation was poor in both categories of health professionals and across all hospitals¹1. Leal MC, Pereira APE, Domingues RMSM, Filha Mariza MT, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S17-S32.. The best scores were obtained for the following practices: presence of a companion; nonpharmacological pain management; auscultation of the fetal heart during labor; and informing the mother of progress in labor. The findings also show that the following practices persist: use of intravenous rehydration; encouraging pushing during the expulsion stage; routine episiotomy; the Kristeller maneuver; use of early amniotomy; and use of oxytocin to induce labor. These results show that health professionals only partially adopt best practices and are consistent with the findings of Leal et al.¹1. Leal MC, Pereira APE, Domingues RMSM, Filha Mariza MT, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S17-S32.. There is therefore an urgent need to reshape the labor and childbirth care model, given that many adverse outcomes are directly related the quality of care.

These findings may reflect the professionals’ conceptions of humanized childbirth, a matter widely discussed in training programs. Humanization refers to the process that begins in pre-labor, with actions focusing on the newborn, mother and companion developed by a multiprofessional team¹⁷17. Magalhães Júnior HM. Health Care Networks: towards the integrality. Divulg. Saúde Debate [Internet]. 2014 [cited 2017 Nov 29]; (52):15-37. Available from: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-52.pdf
http://cebes.org.br/site/wp-content/uplo... .

A study conducted in four public hospitals in Tehran that observed 24 mothers during pre-labor, childbirth and after birth and interviewed 100 mothers after birth showed that professionals adopted best practices together with obstetric interventions. The findings show that restrictions persist in relation to oral fluid and food intake during labor, choice of birth position and mobility during labor, and skin to skin contact immediately after birth. It was also shown that practices such as use of early amniotomy, use of oxytocin to induce labor, exerting pressure on the bottom of the uterus, and episiotomy persist¹⁸18. Pazandeh F, Huss R, Hirst J, House A, Baghban AA. An evaluation of the quality of care for women with low risk pregnanacy: The use of evidence-based practice during labour and childbirth in four public hospitals in Tehran. Midwifery [Internet]. 2015 [cited 2017 Nov 28]; Available from: http://dx.doi.org/10.1016/j.midw.2015.07.003
http://dx.doi.org/10.1016/j.midw.2015.07... .

A recent overview of 23 systematic reviews (16 Cochrane and 7 nonCochrane) relating to the most common care practices for the management of normal labor and delivery in the first stage of labor concluded that evidence does not support routine enemas, perineal shaving, early amniotomy, continuous electronic fetal heart rate monitoring, and restriction of fluids and food during labor. It suggests that practices such as continuity of obstetric care, encouraging nonsupine positions, and freedom of movement during labor should be routine. Furthermore, it highlighted that there is insufficient evidence to support routine administration of intravenous fluids and antispasmodics during labor and that more evidence is needed regarding delayed admission until active labor and use of the partograph¹⁹19. Iravani M, Janghorbani M, Zarean E, Bahram M. An overview of systematic reviews of normal labor and delivery management. Iran J Nurs Midwifery Res 2015; 20(3):293-303. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462052/
https://www.ncbi.nlm.nih.gov/pmc/article... .

The third dimension includes practices related to team meetings, joint decision-making, communication between maternity care staff and women in labor, integrated actions conducted by a multiprofessional team, patient satisfaction surveys, recording of information, and the role of nurses in the delivery room. The scores show inadequate implementation of these practices by the health professionals and across the hospitals as a whole.

The findings in this dimension, which refers to attitudes and practices related to the work process, reveal both barriers to and facilitators of change in childbirth care practices. A study conducted in 2007 with professionals from Argentina and Uruguay showed that barriers to change include limited access to information and that participants noted that resistance to change was developed in medical school where they were not trained to view medical knowledge as dynamic²⁰20. Belizan M, Meier A, Althabe F, Codazzi A, Colomar M, Buekens P, Belizan J, Walsh J, Campbell MK. Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study. Health Educ Res [Internet]. 2017 [cited 2017 Nov 29]; 22(6):839-853. Available from: https://academic.oup.com/her/article/22/6/839/641694
https://academic.oup.com/her/article/22/... . A study undertaken in Iran between 2013 and 2014 showed that key barriers to adopting evidence-based practices were lack of knowledge and skills, lack of motivation to change or adopt new behavior, lack of decision-making authority, fear of legal action, and poor health professional-patient communication. Other significant barriers included shortage of equipment and inappropriate physical structure of birth settings and the fact that the decisions taken by doctors often go against the norms of best practice²¹21. Iravani M, Janghorbani M, Zarean E, Bahrami M. Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study. Iranian Red Crescent Medical Journal [Internet]. 2016; [cited 2017 Nov 29] 18(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863155/pdf/ircmj-18-02-21471.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... . Both studies showed that women had limited capacity to influence change²¹21. Iravani M, Janghorbani M, Zarean E, Bahrami M. Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study. Iranian Red Crescent Medical Journal [Internet]. 2016; [cited 2017 Nov 29] 18(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863155/pdf/ircmj-18-02-21471.pdf
https://www.ncbi.nlm.nih.gov/pmc/article...

22. Pasche DF, Vilela MEA, Giovanni M, Almeida PVB, Franco Netto TL. Rede Cegonha: challenges of cultural changes in obstetric and neonatal practices. Divulg. Saúde Debate [Internet]. 2014 [cited 2017 Nov 29]; 52:58-71. Available from: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-52.pdf
http://cebes.org.br/site/wp-content/uplo...

23. Cecatti JG. Beliefs and misbeliefs about current interventions during labor and delivery in Brazil. Cad Saude Publica [Internet]. 2014 [cited 2018 Jan 08]; 30(Supl. 1):S33-S35. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2014001300006&lng=en
http://www.scielo.br/scielo.php?script=s... -²⁴24. Busanello J, Kerber NPC, Mendoza-Sassi RA, Mano PS, Susin LRO, Gonçalves BG. Humanized attention to parturition of adolescents: analysis of practices developed in an Obstetric Center. Rev. Bras. Enferm [Internet]. 2011 [cited 2018 Jan 08]; 64(5):824-832. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672011000500004&lng=pt
http://www.scielo.br/scielo.php?script=s... .

Based on the parameters proposed by Costa et al.¹⁴14. Costa MAR, Versa GLGS, Bellucci Júnior JA, Inoue KC, Sales CA, Matsuda LM. Admittance of Risk-Classified Cases: Assessment of Hospital Emergency Services. Esc. Anna Nery Rev. Enferm. [Internet]. 2015 [cited 2018 Jan 08]; 19(3):491-497. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452015000300491&lng=pt
http://www.scielo.br/scielo.php?script=s... (score between 50 and 62), the implementation of ministry of health guidelines in the hospitals is poor. Scores are influenced by care infrastructure, user profile, management models, and whether the hospital has residence programs. With respect to the latter, the existence of a nursing residence program has been shown to have a particularly strong influence²⁴24. Busanello J, Kerber NPC, Mendoza-Sassi RA, Mano PS, Susin LRO, Gonçalves BG. Humanized attention to parturition of adolescents: analysis of practices developed in an Obstetric Center. Rev. Bras. Enferm [Internet]. 2011 [cited 2018 Jan 08]; 64(5):824-832. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672011000500004&lng=pt
http://www.scielo.br/scielo.php?script=s... .

The findings of this study, together with those published by the Nascer no Brasil (Born in Brazil) survey, raise a number of questions about the quality of obstetric care in Brazil¹1. Leal MC, Pereira APE, Domingues RMSM, Filha Mariza MT, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Supl. 1):S17-S32.,²⁵25. Binfa L, Pantoja L, Ortiz J, Cavada G, Schindler P5, Burgos RY, Maganha e Melo CR, Silva LC, Lima M O, Hernández LV, Schlenker RR, Sánchez V, Rojas MS, Huamán BC, Chauca ML, Cillo A, Lofeudo S, Zapiola S, Weeks F, Foster J. Midwifery practice and maternity services: A multisite descriptive study in Latin America and the Caribbean. Midwifery [Internet]. 2016 [cited 2017 Nov 29]; 40:218-225. Available from: http://repositorio.uchile.cl/bitstream/handle/2250/142284/Midwifery-practice-and-maternity-services.pdf?sequence=1
http://repositorio.uchile.cl/bitstream/h... . The findings also reveal significant weaknesses in health information systems, hindering access to patients’ medical records and sociodemographic information. These factors weaken coordination between different points of care, especially when it comes to sharing of information and resources between health facilities²¹21. Iravani M, Janghorbani M, Zarean E, Bahrami M. Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study. Iranian Red Crescent Medical Journal [Internet]. 2016; [cited 2017 Nov 29] 18(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863155/pdf/ircmj-18-02-21471.pdf
https://www.ncbi.nlm.nih.gov/pmc/article...

22. Pasche DF, Vilela MEA, Giovanni M, Almeida PVB, Franco Netto TL. Rede Cegonha: challenges of cultural changes in obstetric and neonatal practices. Divulg. Saúde Debate [Internet]. 2014 [cited 2017 Nov 29]; 52:58-71. Available from: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-52.pdf
http://cebes.org.br/site/wp-content/uplo... -²³23. Cecatti JG. Beliefs and misbeliefs about current interventions during labor and delivery in Brazil. Cad Saude Publica [Internet]. 2014 [cited 2018 Jan 08]; 30(Supl. 1):S33-S35. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2014001300006&lng=en
http://www.scielo.br/scielo.php?script=s... .

Despite the efforts made by the government and professional associations, the findings show that, as in other parts of Latin America, the prevailing model of care in the capital of Brazil is characterized by the medicalization of childbirth, where best practices and unnecessary interventions coexist²³23. Cecatti JG. Beliefs and misbeliefs about current interventions during labor and delivery in Brazil. Cad Saude Publica [Internet]. 2014 [cited 2018 Jan 08]; 30(Supl. 1):S33-S35. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2014001300006&lng=en
http://www.scielo.br/scielo.php?script=s... ,²⁴24. Busanello J, Kerber NPC, Mendoza-Sassi RA, Mano PS, Susin LRO, Gonçalves BG. Humanized attention to parturition of adolescents: analysis of practices developed in an Obstetric Center. Rev. Bras. Enferm [Internet]. 2011 [cited 2018 Jan 08]; 64(5):824-832. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672011000500004&lng=pt
http://www.scielo.br/scielo.php?script=s... . Nonetheless, the findings also show the adoption of evidence-based practices¹⁶16. Silva MZND, Andrade ABD, Bosi MLM. Access and user embracement in prenatal care through the experiences of pregnant women in Primary Care. Saúde Debate [Internet]. 2014 [cited 2018 Jan 10]; 38(103):805-816. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042014000400805&lng=en
http://www.scielo.br/scielo.php?script=s...

17. Magalhães Júnior HM. Health Care Networks: towards the integrality. Divulg. Saúde Debate [Internet]. 2014 [cited 2017 Nov 29]; (52):15-37. Available from: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-52.pdf
http://cebes.org.br/site/wp-content/uplo...

18. Pazandeh F, Huss R, Hirst J, House A, Baghban AA. An evaluation of the quality of care for women with low risk pregnanacy: The use of evidence-based practice during labour and childbirth in four public hospitals in Tehran. Midwifery [Internet]. 2015 [cited 2017 Nov 28]; Available from: http://dx.doi.org/10.1016/j.midw.2015.07.003
http://dx.doi.org/10.1016/j.midw.2015.07...

19. Iravani M, Janghorbani M, Zarean E, Bahram M. An overview of systematic reviews of normal labor and delivery management. Iran J Nurs Midwifery Res 2015; 20(3):293-303. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462052/
https://www.ncbi.nlm.nih.gov/pmc/article...

20. Belizan M, Meier A, Althabe F, Codazzi A, Colomar M, Buekens P, Belizan J, Walsh J, Campbell MK. Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study. Health Educ Res [Internet]. 2017 [cited 2017 Nov 29]; 22(6):839-853. Available from: https://academic.oup.com/her/article/22/6/839/641694
https://academic.oup.com/her/article/22/...

21. Iravani M, Janghorbani M, Zarean E, Bahrami M. Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study. Iranian Red Crescent Medical Journal [Internet]. 2016; [cited 2017 Nov 29] 18(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863155/pdf/ircmj-18-02-21471.pdf
https://www.ncbi.nlm.nih.gov/pmc/article...

22. Pasche DF, Vilela MEA, Giovanni M, Almeida PVB, Franco Netto TL. Rede Cegonha: challenges of cultural changes in obstetric and neonatal practices. Divulg. Saúde Debate [Internet]. 2014 [cited 2017 Nov 29]; 52:58-71. Available from: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-52.pdf
http://cebes.org.br/site/wp-content/uplo...

23. Cecatti JG. Beliefs and misbeliefs about current interventions during labor and delivery in Brazil. Cad Saude Publica [Internet]. 2014 [cited 2018 Jan 08]; 30(Supl. 1):S33-S35. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2014001300006&lng=en
http://www.scielo.br/scielo.php?script=s... -²⁴24. Busanello J, Kerber NPC, Mendoza-Sassi RA, Mano PS, Susin LRO, Gonçalves BG. Humanized attention to parturition of adolescents: analysis of practices developed in an Obstetric Center. Rev. Bras. Enferm [Internet]. 2011 [cited 2018 Jan 08]; 64(5):824-832. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672011000500004&lng=pt
http://www.scielo.br/scielo.php?script=s... . To improve outcomes, health professionals need to experience healthcare settings in which all aspects of labor and childbirth care, from facility structure to routine practices, favor physiological childbirth. Lack of resources and infrastructure to support interventions has been highlighted as a major barrier to providing humanized childbirth care¹⁹19. Iravani M, Janghorbani M, Zarean E, Bahram M. An overview of systematic reviews of normal labor and delivery management. Iran J Nurs Midwifery Res 2015; 20(3):293-303. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462052/
https://www.ncbi.nlm.nih.gov/pmc/article...

20. Belizan M, Meier A, Althabe F, Codazzi A, Colomar M, Buekens P, Belizan J, Walsh J, Campbell MK. Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study. Health Educ Res [Internet]. 2017 [cited 2017 Nov 29]; 22(6):839-853. Available from: https://academic.oup.com/her/article/22/6/839/641694
https://academic.oup.com/her/article/22/... -²¹21. Iravani M, Janghorbani M, Zarean E, Bahrami M. Barriers to Implementing Evidence-Based Intrapartum Care: A Descriptive Exploratory Qualitative Study. Iranian Red Crescent Medical Journal [Internet]. 2016; [cited 2017 Nov 29] 18(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863155/pdf/ircmj-18-02-21471.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... .

Our findings show that 84.9% of the respondents encouraged normal childbirth among friends or family. Other studies investigating this type of attitude among obstetric care providers were not identified, highlighting the need for further research into the influence of professionals’ beliefs and values on adherence to best practices.

Study limitations include the fact that it was not possible to interview all professionals involved in labor and childbirth care, including nongraduate staff who provide daily assistance to mothers. In this respect, multidisciplinary team working is critical to transforming the obstetric care model and promoting change in practice.

This study provides a valuable contribution to the evaluation of health services, given that it shows the challenges of ensuring compliance with best practices for labor and childbirth care, such as difficulties in maternity settings, relations between care providers, and obstetrics training. The findings therefore constitute an important input to strategies for enhancing obstetric and newborn care in line with the best practices proposed by the WHO in pursuit of the Sustainable Development Goals, which include the reduction of maternal mortality and ending preventable deaths of newborns.

This study can also contribute to the institutionalization of health evaluations encompassing health professionals’ knowledge, attitudes, and practices, given the difficulties in systematizing evaluation tools and obtaining reliable data, documents, and information for this purpose. The findings also indicate a need to change obstetric residency programs, providing more in-depth training and qualification of care providers in order to enhance care management using a holistic, evidence-based approach centered on self-care, humanization, safety, and human rights.

Conclusion

The findings of this study show that strategies are needed to change the obstetric care model and organization of the capital’s healthcare system and care provider work processes and to promote a more innovative and less conservative approach to care. Continuing training of care providers should be strengthened, emphasizing best practices in labor and childbirth, and steps should be taken to enhance integration between services and the definition of territories and the population base covered by maternity facilities.

References

Publication Dates

History