Abstract

This article analyzes the environment of birth places, considering the presence of PCP room (Prepartum, Childbirth, and Postpartum) in 575 hospitals that deliver in Sistema Único de Saúde (Unified Health System) within the scope of Rede Cegonha. The data were extracted from a survey called Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha (Assessment of childbirth and birth care in the Rede Cegonha maternity units), carried out in 2017 by UFMA and ENSP, in partnership with the Ministry of Health. The PCP room model combines care for parturient women in a single space, favoring the role of women and the exercise of good practices in childbirth and birth care. The information was obtained by direct observation in the services, and assessment considered the presence and adequacy of PCP rooms and their distribution according to the pre-childbirth environment, which were compared with specific characteristics of these hospitals. Collective rooms for childbirths prevail and only 16.8% of beds are PCP rooms. This picture suggests difficulties in resource management, resistance to changes and insufficiencies in institutional support, which have hampered the transition from the childbirth environment model in Brazilian hospitals. The Brazilian obstetric and neonatal field has lived a fertile period, but it is necessary to build and sustain political-institutional disposition to advance the changes.

Key words
“Rede Cegonha”; Childbirth rooms; Childbirth; Humanization; Delivery assistance

Introduction

The Brazilian model of care for childbirth and birth is characterized by the excessive use of obstetric and neonatal interventions that, when used without a scientific evidence base, may be related to unfavorable maternal and perinatal outcomes¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):17-32.. Among the various initiatives to modify this model, in the 2000s, the Ministry of Health (MoH) created the Humanization Program for Prenatal and Birth (PHPN - Programa de Humanização no Pré-Natal e Nascimento). Humanizing childbirth assistance encompasses several dimensions, including environment, established as one of the Brazilian National Humanization Policy²2 Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. Brasília: Editora do MS; 2010. (PNH - Política Nacional de Humanização) guidelines. In the field of attention to childbirth and birth, environment includes the transformation of the hospital space into a welcoming and favorable environment for the implementation of good obstetric care practices and with the active participation of users. The concept values environment as a contributor to changes in processes and work relationships based on collective and participative construction.

Based on this conception, new operating standards for the Obstetric and Neonatal Care Services were instituted in ANVISA Resolution 36 of 06/03/2008³3 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC nº 36, de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Diário Oficial da União 2008; 4 jun. (RDC 36/2008), and later incorporated into the strategy of Rede Cegonha (RC)⁴4 Brasil. Ministério da Saúde (MS). Portaria nº 1.459, de 24 de junho de 2011. Diário Oficial da União 2011; 27 jun., launched in 2011.

Among the new structures introduced, the transformation of delivery environments was established, traditionally composed of rooms shared by several women in a PCP room (Prepartum, Childbirth, and Postpartum). PCP is a private space for labor, childbirth and immediate puerperium, with attached bathroom, sufficient dimensions for the movement of parturient women and use of non-pharmacological methods of pain relief and for the presence of a companion. This environment, in addition to stimulating the overcoming of the traditional model, which artificially segments childbirth in stages of prepartum, childbirth and postpartum, provides differentiated attention with the purpose of guaranteeing the woman the conditions to choose different positions in labor, leading role, and autonomy⁵5 Brasil. Ministério da Saúde (MS). Orientações para elaboração de projetos arquitetônicos Rede Cegonha: ambientes de atenção ao parto e nascimento [recurso eletrônico]. Brasília: MS; 2018..

In order to transform the Brazilian reality of deficient facilities in health services that deliver and often inadequate to provide quality care⁶6 Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, Arantes SL, Leal MC. Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento. Cad Saude Publica 2014; 30(Supl. 1):S208-S219., numerous MoH initiatives have been developed in the process of implementing RC. In addition to providing financial resources to adapt the environment, measures were taken to facilitate the management of resources, such as the transfer of investment funds to funds⁷7 Brasil. Lei Complementar nº 141, de 13 de janeiro de 2012. Regulamenta o § 3o do art. 198 da Constituição Federal para dispor sobre os valores mínimos a serem aplicados anualmente pela União, Estados, Distrito Federal e Municípios em ações e serviços públicos de saúde; estabelece os critérios de rateio dos recursos de transferências para a saúde e as normas de fiscalização, avaliação e controle das despesas com saúde nas 3 (três) esferas de governo; revoga dispositivos das Leis nos 8.080, de 19 de setembro de 1990, e 8.689, de 27 de julho de 1993; e dá outras providências. Diário Oficial da União 2012; 16 jan.; the adoption of the Differentiated Public Procurement Regime for engineering works and services within SUS⁸8 Brasil. Lei nº 12.462, de 4 de agosto de 2011. Institui o Regime Diferenciado de Contratações Públicas - RDC; altera a Lei nº 10.683, de 28 de maio de 2003, que dispõe sobre a organização da Presidência da República e dos Ministérios, a legislação da Agência Nacional de Aviação Civil (Anac) e a legislação da Empresa Brasileira de Infraestrutura Aeroportuária (Infraero); cria a Secretaria de Aviação Civil, cargos de Ministro de Estado, cargos em comissão e cargos de Controlador de Tráfego Aéreo; autoriza a contratação de controladores de tráfego aéreo temporários; altera as Leis nºs 11.182, de 27 de setembro de 2005, 5.862, de 12 de dezembro de 1972, 8.399, de 7 de janeiro de 1992, 11.526, de 4 de outubro de 2007, 11.458, de 19 de março de 2007, e 12.350, de 20 de dezembro de 2010, e a Medida Provisória nº 2.185-35, de 24 de agosto de 2001; e revoga dispositivos da Lei nº 9.649, de 27 de maio de 1998. Diário Oficial da União 2011; 10 ago.; the creation of SISMOB (Sistema de Monitoramento de Obras -Construction Monitoring System). At the same time, MoH provided architectural projects that could be adopted by managers and carried out training processes for architects and engineers from the health departments, expanding the diffusion of the concept of environment⁹9 Pessatti MP. Estratégias para a ambiência na humanização de Partos e Nascimentos. Brasília: MS; 2014. (Caderno Humanizasus).

Research on the environment of birthplaces is scant and there are no studies that specifically address the concept of environment in obstetrics¹⁰10 Dias PF, Miranda TPS, Santos RP, Paula EM, Bem MMS, Mendes MA. Formação do conceito ambiência para trabalho de parto e parto normal institucionalizado. Rev. Bras. Enferm. 2019; 72(Supl. 3):348-359.^. It is in this context and scenario that this article is inserted. This article seeks to contribute to the debate on the qualification of obstetric care based on the availability and adequacy of PCP rooms in Brazil and in large regions in hospitals that deliver SUS in the context of RC. The research findings were analyzed in the light of reflections that have been made in the field of public health in order to better understand the current picture of the environment of birth places.

Method

This is a normative evaluation research with qualitative and quantitative design and the use of the Participatory Rapid Appraisal technique. All public and private hospitals that, in 2015, were located in a health region with an RC Action Plan, totaling 606 establishments distributed in all states of Brazil were eligible. Data collection was carried out in 2016/2017.

Three methods of data collection were used: 1 - personal interview with key informants: managers; health professionals and puerperal women to check the perception of the management model and the attention to labor and birth; 2- documental analysis verified the availability of norms, protocols and process indicators and results of assistance during labor and birth. Data on hospital care were extracted from the medical records of women and newborns; 3- on-site observation collected data on care processes, infrastructure conditions, physical plant, materials, equipment and through a specific questionnaire counted the available obstetric and neonatal beds. The instrument developed was based on RDC36³3 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC nº 36, de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Diário Oficial da União 2008; 4 jun., RDC50¹¹11 Agência Nacional de Vigilância Sanitária. Resolução RDC no 50, de 21 de fevereiro de 2002. Regulamento técnico para planejamento, programação, elaboração e avaliação de projetos físicos de estabelecimentos assistenciais de saúde. Diário Oficial da União 2002; 20 mar. and Ordinance 930/2012¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):17-32. ²2 Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. Brasília: Editora do MS; 2010.. The evaluator, accompanied by an employee designated by the hospital’s management and most of the time with the presence of a representative of the State Health Secretariat and/or the Municipal Health Office, visited all maternity environments, from the entrance and reception doors even rooming-in, including the neonatal unit. At the end of the on-site observation, the obstetric and neonatal bed counting questionnaire was signed by the evaluator and hospital employee and representative of the health department. For the present analysis, only the information collected in the on-site observation is used.

The research team included the national coordination composed of researchers from the Brazilian National School of Health of Fundação Oswaldo Cruz (Oswaldo Cruz Foundation), Universidade Federal do Maranhão (Federal University of Maranhão) and MoH technicians in women’s health. Each Brazilian state had a coordinator who participated in the organization of the fieldwork and in the selection of the team of evaluators for the state’s research. Altogether, 107 evaluators were distributed across the country. All were health professionals with experience working in maternity hospitals. The training of the 27 state research teams was carried out locally, in a standardized manner, for five consecutive days, including reading the questionnaire instrument, practical application of the questionnaire in hospitals and sending the collected data to REDCap. More information is available in Vilela at al.¹³13 Vilela MEA, Leal MC, Thomaz EBAF. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

Hospitals were classified according to the country’s major regions, location (capital, outside capital), legal nature of the establishment (public and private) and type of management (municipal, state and dual). As private establishments, those listed in the National Register of Health Establishments were classified into the following categories: business, nonprofit, and individual organizations. Hospitals were classified according to the volume of births registered in Sistema de Informação sobre Nascidos Vivos (Sinasc - Live Birth Information System), categorized as low (up to 999 births per year), medium (from 1,000 to 2,999 per year) and high (from 3,000 and more births per year); the existence of a neonatal ICU; and to be a reference for high-risk delivery¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):17-32. ⁴4 Brasil. Ministério da Saúde (MS). Portaria nº 1.459, de 24 de junho de 2011. Diário Oficial da União 2011; 27 jun..

Among the structure requirements required by Brazilian legislation, the type of prepartum environments offered was verified (collective room without separation between beds, collective room with separation by curtains, PCP room and/or both types of environment). The percentage of provision of a PCP room among labor beds was also calculated. Furthermore, the existence of an exclusive bathroom with shower and hot water directly connected to a PCP room and at least one equipment (gymnastic ball, birthing stool, folding step stool ladder, etc.) for non-pharmacological pain relief was examined.

The analysis included the distribution of the relative frequency of the variables studied according to large regions. Finally, data on hospitals’ characteristics were observed according to the presence of at least a PCP room in the assessed hospital.

The research complies with Resolution 196/96 of the Brazilian National Health Council (Conselho Nacional de Saúde) and was approved by the Research Ethics Committee with Human Beings at Universidade Federal do Maranhão and the Brazilian National School of Escola Nacional de Saúde Pública Sérgio Arouca (Public Health Sérgio Arouca), CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 56389713.5.3001.5240, on December 14, 2016 All precautions have been taken to ensure the confidentiality and confidentiality of information.

Results

The present analysis comprises 575 hospitals (95.0% of the total assessed). Table 1 shows that of the total health facilities investigated, 37.4% are located in the Southeast, followed by the Northeast with 28.9%, the North and the South with 13.0% and the Center-West (6.6 %). Regarding the legal nature, 57.7% were public, and the rest were private (42.3%). When analyzing by large regions, it is observed that in the North almost two thirds of the total of hospitals were public, a figure that is reduced to around 60% in the Northeast, the Southeast and the Center-West and comprises a little more than a third in the South. It is noted that for the North, the Northeast and the Southeast, around 30% of establishments are located in the capital; however, the pattern changes for the Center-West and the South, and in the first, most hospitals are located in the capitals (63.2%), while in the South, it comprises 16.5%. Regarding the type of management, the predominance of municipal establishments (65.7%) is striking, and in the South, there is also double management in 26.6% of hospitals. For the country, establishments with an average birth volume (between 1,000 and 2,999 births per year) predominate, with little variation between large regions. Table 1 also shows that hospitals with availability of Neonatal ICU beds ranged from 28.6% in the Northeast to 69.3% in the Southeast. In Brazil, around one fifth of hospitals are a reference for high risk, with the lowest percentage found in the North (7.8%) and the highest in the Southeast (28%).

Table 2 shows that in more than two thirds of hospitals in the country, labor is performed in a collective room, a figure that rose to the North (80.6%), the Northeast (77.7%), and the South (76.0%). The collective room without separation between the beds prevails in the North (49.4%) and in the Northeast (45.8%). The exclusive availability of a PCP room does not reach 12% of the assessed hospitals and is practically nonexistent in the South (2.5%), being the best scenario found in the Center-West, with 26.3%. In 17.2% of hospitals, both types of environments are adopted; the largest presence is found in the Southeast (27.4%), and the smallest in the North (3.9%) and the Northeast (9.0%).

Table 3 shows that 3,358 beds are used for labor. On average, each maternity hospital has 5.8 beds for labor, ranging from 4.7 beds in the North to 6.7 in the Northeast. The proportion of PCP rooms was 16.8% of the total number of beds for labor, with the lowest frequency seen in the South (8%) and the highest in the Center-West (31%). The South (14.3%) and the North (22.2%) had the lowest percentages of PCP rooms that have an exclusive bathroom with hot water in the shower. The availability of non-pharmacological pain relief equipment was found in 91.9% of PCP rooms with little variation between regions.

Table 4 shows that hospitals with at least one PCP room are more frequent in the capitals (37.5%) among hospitals with state management (27.5%), which perform more than 3,000 births per year (38.0%) and greater complexity measured by the presence of Neonatal ICU (34.0%) and being a reference for high-risk pregnant women (34.2%).

Discussion

The overview of the PCP room availability and adequacy is one of the important aspects in assessing the potential of the health system to respond to the care needs of women and newborns during childbirth and birth.

Although all processes involved in assisting the childbirth and birth of the selected maternity hospitals were not considered in this article, the evidence of the association between adequate environments in safe care for women and their newborns and the occurrence of favorable results reaffirm the importance of assessing the structure, even in isolation¹⁵15 Costa JO, Xavier CC, Proietti FA, Delgado MS. Avaliação dos recursos hospitalares para assistência perinatal em Belo Horizonte, Minas Gerais. Rev Saude Publica 2004; 38(5):701-708.. The research findings, using the room PCP as a model of childbirth care, show that the adequacy of the delivery environment is an important liability for the qualification of Brazilian obstetric care, especially in the perspective of expanding the frequency of good practices, many times impossible to be exercised without restraint in collective rooms.

The transition from the childbirth and birth environment model that segments and separates the prepartum and childbirth in specific environments, to the PCP room model, representing an enormous challenge, despite more than a decade of RDC 36/2008³3 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC nº 36, de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Diário Oficial da União 2008; 4 jun. and almost one of RC⁴4 Brasil. Ministério da Saúde (MS). Portaria nº 1.459, de 24 de junho de 2011. Diário Oficial da União 2011; 27 jun.. The presence of collective rooms is a reality in most of the assessed hospitals and the exclusive adoption of a PCP room is still timid. A small portion of hospitals also adopt mixed models, initiating some process of changing the environment. RC hospitals accounted for almost half of deliveries in the country and 61.2% of SUS deliveries in 2017¹⁶16 Datasus. Sinasc - Sistema de Informações de Nascidos Vivos. Arquivos de declarações de nascido vivos. [acessado 2020 Jun 20]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=060702
http://www2.datasus.gov.br/DATASUS/index... . It is likely that public hospitals and/or SUS-affiliated hospitals not covered by the RC Action Plan have even less availability of PCP rooms.

The results show that a significant number of the assessed hospitals do not have an exclusive bathroom with hot water in the shower; this is an indication that an important portion of women did not have access to this technology, nor their privacy, a fundamental aspect for the good development of female physiology. The presence of equipment for non-pharmacological pain relief is found in most hospitals, which shows that even though the delivery environment is not adequate, efforts to incorporate this equipment and care technologies have been carried out¹⁷17 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JA, Gama SGN, Domingues RMSM, Vilela MAE. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018..

Hospitals located in capitals, in general with greater delivery volume, with Neonatal ICU and reference for high-risk pregnancies had a greater number of maternity hospitals with at least a PCP room installed. A similar observation was pointed out by Magluta et al.¹⁸18 Magluta C, Noronha MF, Gomes MAM, Aquino LA, Alves CA, Silva RS. Estrutura de maternidades do Sistema Único de Saúde do Rio de Janeiro: desafio à qualidade do cuidado à saúde. Rev. Bras. Saude Mater. Infant. 2009; 9(3):319-329. and Bittencourt et al.⁶6 Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, Arantes SL, Leal MC. Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento. Cad Saude Publica 2014; 30(Supl. 1):S208-S219., who found that hospitals of greater complexity have better levels of adequacy in the assessed structural dimensions. Our study has the advantage that the data used were based on the direct observation of trained evaluators, thus reducing the uncertainties regarding the reliability of the collected data.

Although the study on childbirth environment has been restricted to checking the structure of health services and has not verified the reasons that make the transition from childbirth environment practically stagnant in the country, it is important to understand the different aspects involved, pointing out, even if limitedly, alternatives to modify the permanence of the traditional model of childbirth care.

The low availability of PCP room and its different stages of implementation according to large regions may be associated with the context of structural underfunding of SUS and, more recently, the ceiling and cut in public spending¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):17-32. ⁹9 Pessatti MP. Estratégias para a ambiência na humanização de Partos e Nascimentos. Brasília: MS; 2014. (Caderno Humanizasus), which may have made it impossible to carry out reforms of maternity hospitals’ physical spaces as well as managers’ difficulties in not executing the financial resources released by MoH to adapt the environment.

MoH data²⁰20 Brasil. Ministério da Saúde (MS). Sistema de Propostas do Fundo Nacional de Saúde (SISPROFNS), Sistema de Monitoramento de Obras (SISMOB), Gestão de Consultas e Normas (GESCON). Brasília: MS; 2019. demonstrate that the funds released, especially until 2015, were not fully implemented by subnational spheres and the funds raised took time to transform into new services and renovated spaces. In the period between 2011 and 2018, 481 proposals for works in a Birth Center (BC), Casa da Gestante, Bebê e Puérpera (CGBP, a special facility for high-risk pregnant women, mothers and their newborns) environment of childbirth and birth care services, construction and expansion of new maternity hospitals and structuring of specialized care units were approved and committed by MoH. Of these proposals, 211 (44%) were related to environment, totaling R$51,878,795.02 (about 4,454 US dollars)²⁰20 Brasil. Ministério da Saúde (MS). Sistema de Propostas do Fundo Nacional de Saúde (SISPROFNS), Sistema de Monitoramento de Obras (SISMOB), Gestão de Consultas e Normas (GESCON). Brasília: MS; 2019.. By the end of April 2019, considering the current proposals (committed and not canceled by MoH), only 46 of them (21%) were completed. Among the 124 proposals approved in 2013, only 59% (46 works) were completed by the end of 2018, after which a period of 5 years had passed. The small number of projects presented also indicates that the transformation of care practices for women and children has not been taken as a priority, so there would be no reason to invest in the delivery environment²¹21 Silva CN. Ergonomia aplicada na qualificação da ambiência do espaço de nascer. Sustinere 2018; 6(1):150-174..

Resistance to change is recognized²²22 Rattner D. Humanização na atenção a nascimentos e partos: ponderações sobre políticas públicas. Interface (Botucatu) 2009; 13(Supl. 1):759-768. by health service managers and teams to preserve what has become institutionalized as a culture of care in the organization. In more hardened scenarios, where relations of knowledge-power are more asymmetrical, changes tend to form forces around conservation, perpetuating a series of situations, such as the continuity of carrying out unnecessary interventions, neglected by those known to be beneficial²2 Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. Brasília: Editora do MS; 2010. ³3 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC nº 36, de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Diário Oficial da União 2008; 4 jun.. However, it is important to highlight that although the modification of the environment has reached a restricted coverage, advances were observed in the care model recommended by RC as highlighted by articles that compared the evolution of good practices and unnecessary interventions in assistance to women and newborns in the same SUS maternity hospitals in 2011 and the current 2016/2017 RC assessment²⁴24 Leal MC, Esteves-Pereira AP, Vilela MEA, Alves MTSSB, Neri MA, Queiroz R, Santos YRP, Silva AAM. Redução das iniquidades sociais no acesso às tecnologias apropriadas ao parto na Rede Cegonha. Cien Saude Colet 2021; 26(3):.^,2525 Bittencourt SDA, Vilela MEA, Oliveira MC, Santos AM, Silva CKRT, Domingues R, Reis AC, Santos GL. Atenção ao Parto e Nascimento em Maternidades da Rede Cegonha: Avaliação do grau de implantação das ações. Cien Saude Colet 2021; 26(3):801-822.. Such movements of change in the ways of caring coexist at the same historical time with the presence of inappropriate practices of care for childbirth and birth, placing Brazil before a paradoxical scenario that mixes innovation and conservation, often conforming hybrid processes that amalgamate conservation-transformation elements.

Changes in health care models do not result from the continuous introduction of new rules at work, not even from governmental strategies of a systemic nature, such as RC. However, the chances of sustaining the innovations emerging from these formulations are greater when they result from collective bargaining processes in the workplace²2 Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. Brasília: Editora do MS; 2010. ⁶6 Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, Arantes SL, Leal MC. Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento. Cad Saude Publica 2014; 30(Supl. 1):S208-S219., that would translate into protocols and technical regulations as well as projects to change the environment for childbirth based on a new work ethic.

It was from this understanding that the institutional support recommended by RC took the PNH method²⁷27 Vasconcelos MFF, Martins CP, Machado DO. Apoio institucional como fio condutor do Plano de Qualificação das Maternidades: oferta da Política Nacional de Humanização em defesa da vida de mulheres e crianças brasileiras. Interface (Botucatu) 2014; 18(Supl. 1):997-1011., - inclusion of subjects and the effects of that inclusion - hence the materialization of principles and guidelines in devices, which are work technologies. It would be a question of implementing an institutional action model that would make it possible to produce consensus on ways of managing and caring that would result in new work contracts, new ways of doing, in new work spaces. Thus, the RC implementation process counted on the participation of supporters, RC guiding groups and technical coordination of the state and municipal health departments, which started to subsidize maternity teams in introducing and sustaining changes in planning, assessment processes, and work agendas, as evidenced in Caderno HumanizaSUS (a set of documents focusing on the humanization of childbirth and birth)²⁸28 Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Brasília: MS; 2014.. Moreover, it supports the training of architects and engineers⁹9 Pessatti MP. Estratégias para a ambiência na humanização de Partos e Nascimentos. Brasília: MS; 2014. (Caderno Humanizasus) committed to developing Co-managed Projects of Environment²2 Brasil. Ministério da Saúde (MS). HumanizaSUS: Documento base para gestores e trabalhadores do SUS. Brasília: Editora do MS; 2010. ⁹9 Pessatti MP. Estratégias para a ambiência na humanização de Partos e Nascimentos. Brasília: MS; 2014. (Caderno Humanizasus), where care processes and the needs for changes in work environments are delimited by the concept of environment.

The intensive way³⁰30 Paulon SM, Elahel ALS. A construção de um observatório de práticas da política nacional de humanização do Sistema Único de Saúde: a experiência do Rio Grande do Sul. In: Brasil. Ministério da Saúde (MS). Política Nacional de Humanização. Formação e intervenção. Brasília: MS; 2010. p. 141-156. of supporting supporters in training processes and in mobilizing management teams and workers, certainly did not become broadened throughout SUS. Achieving it through an intensive mode of action raises the question of the strategies and the political time for its realization. In many health services, the intensive effects were important, but in others, it is likely that RC, as a new ethics of care, did not even arrive, leaving the environments and modes of care unchanged. Even in those where support was achieved, the reports are difficult to implement changes²⁸28 Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Brasília: MS; 2014..

Modifications in the environment demand to combine efforts so that the changes ‘in the state of things’ trigger processes of changes in the models of care in line with the assumptions of humanization of childbirth and birth. These processes, however, are of a different nature, and the ‘transformation of things’ goes hand in hand with ‘people reform³3 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC nº 36, de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Diário Oficial da União 2008; 4 jun. ¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):17-32., demanding time and conditions for the emergence of new processes of subjectification. Thus, it is necessary to build and sustain political-institutional disposition to change work dynamics, which in turn call for subjective repositioning, given the ontogenetic nature of human work³²32 Pasche DF, Passos E, Hennington E. Cinco anos da política nacional de humanização: trajetória de uma política pública. Cien Saude Colet 2011; 16(11):4541-4548.. It is in this measure that we understand, in part, the difficulties to implement changes in the environment model of hospitals that deliver by SUS.

These issues should be understood as challenges for the Brazilian scientific community, professional organizations, managers of SUS, MoH and the Ministry of Education and for the Brazilian society as a whole. Overcoming this reality, in which the inadequate environment, is an analyzer, because it makes it explicit, presupposes a cultural advance towards the conformation of a new social project, in which life and full living are imperative ethical references.

However, even in the face of this scenario of a slow transition of the childbirth environment, the Brazilian neonatal obstetrics field has been experiencing a “fertile and promising period in terms of the possibility of revising concepts, values and (...) care practices”³³33 Gomes MASM. Compromisso com a mudança. Cad Saude Publica 2014; 30(Supl. 1):S41-S42., which can already be seen by Leal et al.¹⁷17 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JA, Gama SGN, Domingues RMSM, Vilela MAE. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.. They point to a “significant increase in access to appropriate technology for childbirth and birth (...) with an increase in the proportion of use of beneficial practices and reduction of practices considered harmful”. Experimenting with new ways of managing and caring in the neonatal obstetrical field is an important space to build the foundations of a social project that puts life at its center. Brazilian experiences already show us this and also show that public policies such as RC are fundamental stakes and achievements for improving women’s and child health.

Acknowledgments

We would like to thank Esther Vilela and Sonia Duarte de Azevedo Bittencourt for their generous contributions in the discussion process, which brought enriching elements to the approach and analysis of the theme.

References

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