ABSTRACT

Objective.

To identify potential barriers to the implementation of the National Childbirth Guidelines in Brazil based on the best available global evidence.

Method.

A rapid review of evidence was performed in six databases in March/April 2019. Secondary studies published in English, Spanish, or Portuguese with a focus on barriers of any nature relating to the implementation of the Guidelines were retrieved.

Results.

Twenty-three documents (21 reviews and two practice guides) were included in the review. The barriers identified were grouped into 52 meaning categories and then reorganized into nine thematic clusters: delivery and childbirth care model, human resource management, knowledge and beliefs, gender relations, health care service management, attitudes and behaviors, communication, socioeconomic conditions, and political interests.

Conclusions.

The results show that combined approaches may be required to address different barriers to the implementation of the Guidelines. For successful implementation, it is essential to engage health care leaders, professionals, and users in the effort to change the delivery and childbirth care model. Also necessary is the development of intersectoral initiatives to improve the socioeconomic conditions of women and families and to curtail gender inequalities.

Keywords
Evidence-informed policy; implementation science; practice guidelines as topic; parturition; Brazil

RESUMEN

Objetivo.

Identificar los posibles obstáculos a la aplicación de las recomendaciones formuladas en las Directrices Nacionales para la Atención del Parto Normal en Brasil a partir de la mejor evidencia disponible a nivel mundial.

Métodos.

Entre marzo y abril de 2019 se llevó a cabo una revisión rápida de seis bases de datos. Se seleccionaron estudios secundarios publicados en español, inglés o portugués sobre los obstáculos de cualquier tipo que pudieran estar relacionados con la aplicación de las recomendaciones contenidas en las Directrices.

Resultados.

Se incluyeron 23 documentos (21 revisiones sistemáticas y 2 guías de práctica clínica). Los obs- táculos identificados se agruparon en 52 categorías con base en su semejanza de significado y luego se reorganizaron en nueve grupos temáticos: modelo de atención del parto, gestión de recursos humanos, cre-encias y conocimientos, relaciones de género, gestión de servicios de salud, actitudes y comportamientos, comunicación, condiciones socioeconómicas e intereses políticos.

Conclusiones.

La aplicación de las Directrices puede requerir enfoques combinados para hacer frente a diferentes obstáculos. La participación de los administradores y los trabajadores de la salud en el proceso de cambio del modelo de atención del parto, así como la participación de los usuarios, son fundamentales para que la aplicación de las Directrices sea satisfactoria. Además, se necesitan medidas intersectoriales para mejorar las condiciones socioeconómicas de las mujeres y las familias y para combatir las desigualdades entre los géneros.

Palabras clave
Política informada por la evidencia; ciencia de la implementación; guías de práctica clínica como asunto; parto; Brasil

RESUMO

Objetivo.

Identificar potenciais barreiras à implementação das recomendações das Diretrizes Nacionais de Assistência ao Parto Normal a partir das melhores evidências globais disponíveis.

Métodos.

Realizou-se uma revisão rápida com consulta a seis bases de dados em março/abril de 2019. Foram selecionados estudos secundários publicados em inglês, espanhol ou português sobre barreiras de qualquer natureza que pudessem ser relacionadas à implementação das recomendações das Diretrizes.

Resultados.

Foram incluídos 23 documentos (21 revisões sistemáticas e dois guias de prática clínica). As barreiras identificadas foram agrupadas em 52 categorias por semelhança de significado e, em seguida, reorganizadas em nove núcleos temáticos: modelo de atenção ao parto e nascimento, gestão de recursos humanos, crenças e saberes, relações de gênero, gestão de serviços de saúde, atitudes e comportamentos, comunicação, condições socioeconômicas e interesses políticos.

Conclusões.

Os resultados mostraram que a implementação das Diretrizes pode requerer abordagens combinadas para o enfrentamento de diferentes barreiras. O engajamento de gestores e profissionais de saúde no processo de mudança do modelo de atenção ao parto e nascimento e o envolvimento de usuários são indispensáveis para o sucesso da implementação. São necessárias, ainda, ações intersetoriais para melhorar as condições socioeconômicas de mulheres e famílias e para combater as iniquidades de gênero.

Palavras-chave
Políticas informadas por evidências; ciência da implementação; guias de prática clínica como assunto; parto; Brasil

While recent decades have seen important progress in Brazil in the care of pregnant women, parturient women, and newborns, challenges remain with regard to the quality of childbirth (¹1. Pasche DF, Vilela ME de A, Giovanni M Di, Almeida PVB, Franco Netto T de L. Rede Cegonha: desafios de mudanças culturais nas práticas obstétricas e neonatais. Divulg saúde debate. 2014;52:58–71.). The most visible challenge is the high rate of C-sections, which rose from 15% in 1970 to 56% in 2015, despite the adoption of several policy measures over the last two decades (¹1. Pasche DF, Vilela ME de A, Giovanni M Di, Almeida PVB, Franco Netto T de L. Rede Cegonha: desafios de mudanças culturais nas práticas obstétricas e neonatais. Divulg saúde debate. 2014;52:58–71.–³3. Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341–8.). Examples of recent initiatives by the Ministry of Health include the Rede Cegonha (“Stork Network”, 2012), the Appropriate Childbirth program (2015), and the project on Improvement and Innovation in the Care and Teaching in Obstetrics and Neonatology (ApiceOn, 2017).

In addition to these initiatives, a set of National Care Guidelines for Normal Childbirth in Brazil were developed in 2017 (¹1. Pasche DF, Vilela ME de A, Giovanni M Di, Almeida PVB, Franco Netto T de L. Rede Cegonha: desafios de mudanças culturais nas práticas obstétricas e neonatais. Divulg saúde debate. 2014;52:58–71., ⁴4. Brasil. Ministério da Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida [Internet]. Brasília: Ministério da Saúde; 2017 [citado 2020 jun 2]. Disponível em: https://pesquisa.bvsalud.org/bvsms/resource/pt/mis-39026
https://pesquisa.bvsalud.org/bvsms/resou... ). The Guidelines contain 225 recommendations, divided into eight sections: 1) the place where childbirth care is provided; 2) general care during delivery; 3) pain relief during delivery; 4) care during the first stage of delivery; 5) care during the second stage of delivery; 6) care during the third stage of delivery; 7) immediate postpartum maternal care; and 8) care of the newborn (⁴4. Brasil. Ministério da Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida [Internet]. Brasília: Ministério da Saúde; 2017 [citado 2020 jun 2]. Disponível em: https://pesquisa.bvsalud.org/bvsms/resource/pt/mis-39026
https://pesquisa.bvsalud.org/bvsms/resou... ).

Even though practical clinical guidelines like these are fundamental for ensuring quality health care, they can be underutilized (⁵5. Latosinsky S, Fradette K, Lix L, Hildebrand K, Turner D. Canadian breast cancer guidelines: have they made a difference? CMAJ. 2007;176(6):771–6.) when their implementation is poorly planned or inefficient (⁶6. Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011;6(1):26.). In the planning process, it is important to identify potential barriers that might pose challenges for the various actors involved at the different levels of the health system (⁷7. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented. Heal Res Policy Syst. 2009;7(S1):S6.). Therefore, the objective of the study presented here was to review the best available global evidence for identifying barriers to implementation of the recommendations in the National Care Guidelines for Normal Childbirth in Brazil.

MATERIALS AND METHODS

The present systematic review was conducted under the initiative Embedding Research for the Sustainable Development Goals, led by the Pan American Health Organization (PAHO). This report accompanies another article on the same topic in the current special edition: “Implementation of the National Childbirth Guidelines in Brazil: Barriers and strategies.” A rapid systematic review was conducted using methodological shortcuts to produce a timely synthesis of the best available evidence in order to meet the specific demand for a public health policy (⁸8. Tricco AC, Langlois E V, Straus SE (eds). Rapid reviews to strengthen health policy and systems: a practical guide. Geneva: World Health Organization; 2017.). The protocol for this review is available in the Supplementary Material (page 1).

According to the criteria for inclusion, the articles were secondary studies only (systematic reviews, qualitative evidence syntheses, systematic mappings, narrative reviews, and clinical practice guidelines), published in English Portuguese, or Spanish, which addressed the subject of barriers to the implementation of one or more of the recommendations in the Guidelines.

The searches

The searches were conducted between 21 March and 1 April 2019. There was no limitation on the date when the articles were published. Six data sources were used. In the PubMed database MeSH entry terms associated with parturition (“Parturition,” “Parturitions,” “Birth,” “Births,” “Childbirth,” “Childbirths”) and guideline adherence (“Adherence, Guideline,” “Policy Compliance,” “Compliance, Policy,” “Protocol Compliance,” “Compliance, Protocol,” “Institutional Adherence,” “Adherence, Institutional”). In the Regional Portal of the Virtual Health Library (VHL) (https://bvsa-lud.org/), the health sciences descriptors (DeCS) in Portuguese were “parto normal” and “parto humanizado,” with the search restricted to human subjects and to the Latin American Caribbean Health Sciences Literature (LILACS) and the Brazilian Nursing Database (BDENF). The term “Childbirth alone was used in the following sources: Health Systems Evidence (https://www.healthsystemsevidence.org/), Health Evidence (https://www.healthevidence.org/) and Epistemonikos (https://www.epistemonikos.org/). Further details on the searches are available in the Supplementary Material (page 5).

Data selection and extraction

The selection was done by two reviewers (CFO, AAVR) using the Rayyan QCRI platform (⁹9. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5:210.). Disparities were resolved by consensus. The extraction was done by two researchers (CFO, AAVR) working independently and reviewed by another pair of researchers (MCB, TST), using a spreadsheet to record the data for the study and the barriers identified based on the level of health system organization (⁷7. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented. Heal Res Policy Syst. 2009;7(S1):S6.).

Assessment of methodological quality

The systematic reviews were assessed in duplicate using the AMSTAR I tool (¹⁰10. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):10.) to rate their quality as low (score 0-3), moderate (⁴4. Brasil. Ministério da Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida [Internet]. Brasília: Ministério da Saúde; 2017 [citado 2020 jun 2]. Disponível em: https://pesquisa.bvsalud.org/bvsms/resource/pt/mis-39026
https://pesquisa.bvsalud.org/bvsms/resou...

5. Latosinsky S, Fradette K, Lix L, Hildebrand K, Turner D. Canadian breast cancer guidelines: have they made a difference? CMAJ. 2007;176(6):771–6.

6. Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011;6(1):26.-⁷7. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented. Heal Res Policy Syst. 2009;7(S1):S6.), or high (⁸8. Tricco AC, Langlois E V, Straus SE (eds). Rapid reviews to strengthen health policy and systems: a practical guide. Geneva: World Health Organization; 2017.

9. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5:210.

10. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):10.-¹¹11. Minayo MCS (ed.), Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. Rio de Janeiro, Brasil: Vozes; 2013.). Disparities were resolved by consensus. In addition, when an AMSTAR I assessment was already available in the Health Evidence and Health Systems Evidence databases, the previous assessments were also taken into account. The methodological quality of the non-systematic reviews and clinical practice guidelines was not assessed.

Summary of the findings

The barriers identified were grouped according to the methodological orientation of the thematic analysis (¹¹11. Minayo MCS (ed.), Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. Rio de Janeiro, Brasil: Vozes; 2013.). First, the reports were categorized according to common meanings taking into account the eight areas of the Guidelines and the organizational levels (health care users, personnel, services, and overall systems) (⁷7. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented. Heal Res Policy Syst. 2009;7(S1):S6.). Next, the categories were analyzed again and regrouped according to similar thematic clusters.

RESULTS

The searches retrieved a total of 1,611 documents. In addition, 13 other articles and two sets of clinical practice guidelines, suggested by specialists, were also considered. As a result of the selection process, 42 studies were excluded (with justification), resulting in the inclusion of 23 studies in the synthesis of findings (Figure 1).

Characteristics of the included studies

The final list comprised 10 systematic reviews, 5 qualitative evidence syntheses, 2 narrative reviews, 2 evidence maps, and 2 sets of clinical practice guidelines. The income status of the countries covered broke down as follows: high (36.1%), lower middle (31.8%), upper middle (20.3%), and low (11.8%). Of the systematic reviews, seven were of moderate quality, two of high quality, and one of poor quality (Supplementary Material, page 9).

The included studies addressed barriers that corresponded to five of the eight sections of the Guidelines: 1) place where the childbirth care is provided; 2) general care during delivery; 3) pain relief during delivery; and 4) care during the first stage of delivery; and 5) care during the second stage of delivery. The results related to 25 of the 225 recommendations in the Guidelines (Supplementary Material, page 15). A synthesis of the findings, grouped according to nine thematic clusters and 52 types of barriers, is shown in Table 1. Complete information is available in the Supplementary Material (page 18).

Delivery and childbirth care model

The thematic cluster with the most categories was the model of delivery and childbirth care, with challenges related to the health services and systems. Childbirth care is dominated by the biomedical model, which emphasizes the role of the physician to the detriment of other health professionals and dictates the practices that are followed in the hospital setting (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391.). This asymmetry, which is also influenced by gender bias, obstructs the action of midwives and obstetric nurses. In this environment, the adoption of different care models by professionals gives rise to conflicts or interference in the care provided (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609.–¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143.). Furthermore, the privileged power position of the professionals relative to the users affects the care provided and undermines women’s autonomy (¹⁴14. Gomes ML, Moura MAV. Modelo humanizado de atenção ao parto no Brasil: evidências na produção científica. Rev Enferm UERJ. 2012;20(2):248–53.–¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264.), while the absence of connection between the health professionals and the pregnant woman can impact her choice of childbirth delivery (¹⁸18. Avanci BS, Cortez EA, Barbosa FS, André KM. Papel do enfermeiro na perspectiva do Programa de Humanização do pré-natal, parto natural e nascimento: revisão sistemática de literatura. Rev Enferm UFPE Line. 2009;3(4):1126–33., ¹⁹19. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(1):267.).

The form of health system organization, the legalization of hierarchical relationships, and the lack of financial, human, material, and managerial resources, coupled with a dearth of policies aimed at promoting respectful care, are elements that can contribute to the normalization and legalization of the mistreatment that women experience during delivery and childbirth. Throughout the world, this mistreatment has been shown to include physical, sexual, and verbal abuse; stigma and discrimination; and the adoption of inappropriate standards of care (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁹19. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(1):267., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084.).

The difficulties that stand in the way of adopting evidence-informed practices and a new childbirth care model are related in part to the absence of local protocols that spell out and safeguard these measures (¹⁴14. Gomes ML, Moura MAV. Modelo humanizado de atenção ao parto no Brasil: evidências na produção científica. Rev Enferm UERJ. 2012;20(2):248–53., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.). At the same time, the imposition of rigid protocols and/or standards can also hinder the provision of woman-centered care (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42.). For example, midwives may be required to meet hospital needs that interfere with the needs of the user. Also, the use of protocols may be seen by some midwives as a source of pressure and interference in the care they provide. Difficulty in establishing institutional measures that support practices based on the physiology of birth, respect users, and emphasize woman-centered care leads midwives and obstetric nurses to experience situations of psychological harassment, stress, and burnout (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264., ²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42.).

The hospital environment places high value on the use of technology, active management of childbirth, and strictly technical competencies (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391.). In many places, women are forced to remain in prone position during childbirth, whether for cultural reasons or due to the inability of professionals to attend childbirth in other positions (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²³23. Vargens OMC, Silva ACV, Progianti JM. Non-invasive nursing technologies for pain relief during childbirth—The Brazilian nurse midwives’ view. Midwifery. 2013;29(11):e99–106.).

Human resources management

The difficulties related to human resources management are associated with the organizational levels of the workers and the health services and system in general. Professionals report excessive workloads with long days, no breaks, and many tasks to perform (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084.

21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.-²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42., ²⁴24. Chang Y-S, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between maternity care staff and women in labour: A mixed-methods systematic review. Midwifery. 2018;59:4–16.–²⁶26. Lyberg A, Dahl B, Haruna M, Takegata M, Severinsson E. Links between patient safety and fear of childbirth-A meta-study of qualitative research. Nurs Open. 2019;6(1):18–29.). The shortage of professionals hinders the provision of adequate care (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²⁷27. Long Q, Allanson ER, Pontre J, Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Onsite midwife-led birth units (OMBUs) for care around the time of childbirth: a systematic review. BMJ Glob Health. 2016;1(2):e000096.). These barriers are aggravated by hospital routines that press for faster care, affecting the perception of women in need of pain relief and their choices regarding the technologies used (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁹19. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(1):267.–²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42.).

The inadequate qualification of professionals (¹⁴14. Gomes ML, Moura MAV. Modelo humanizado de atenção ao parto no Brasil: evidências na produção científica. Rev Enferm UERJ. 2012;20(2):248–53.–¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁸18. Avanci BS, Cortez EA, Barbosa FS, André KM. Papel do enfermeiro na perspectiva do Programa de Humanização do pré-natal, parto natural e nascimento: revisão sistemática de literatura. Rev Enferm UFPE Line. 2009;3(4):1126–33., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.) and their low level of compensation (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084.) can be barriers to accessing and adopting new practices. Inadequate education and training of professionals is associated with poor understanding of the rights of users (¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264., ¹⁸18. Avanci BS, Cortez EA, Barbosa FS, André KM. Papel do enfermeiro na perspectiva do Programa de Humanização do pré-natal, parto natural e nascimento: revisão sistemática de literatura. Rev Enferm UFPE Line. 2009;3(4):1126–33., ²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42.) and lack of skill in receiving companions and including them throughout the process (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²⁸28. Hoga LAK, Reberte Gouveia LM, Higashi AB, de Souza Zamo-Roth F. The experience and role of a companion during normal delivery and childbirth: a systematic review of qualitative evidence. JBI Database Syst Rev Implement Reports. 2013;11(12):121–56.). In terms of the workplace, the safety measures that are adopted may focus on basic conditions for professionals and fail to consider the women (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847.).

The barriers at the health system organizational level are related to the education of professionals. The omission of humanization in the academic curriculum (¹⁴14. Gomes ML, Moura MAV. Modelo humanizado de atenção ao parto no Brasil: evidências na produção científica. Rev Enferm UERJ. 2012;20(2):248–53., ²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42.) and the lack of investment in the education and long-term recruitment of midwives and obstetric nurses and their ongoing presence in the services (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391.–¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143.) can contribute to the continuity of inappropriate practices.

Knowledge and beliefs

The knowledge and beliefs of professionals and users can be barriers that impact the care provided during delivery and childbirth. Some women do not wish to receive medical treatment during delivery, which can affect their selection of where to give birth; others expect interventions, which may be understood by professionals as an indication of their passivity and acceptance of the medicalized care model (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847.). Women may have difficulty accepting epidural analgesia for fear of the procedure and its risks (²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.); also, the selection of epidural analgesia as the first method of pain relief can limit the use of non-pharmacological methods (²⁹29. Shaw-Battista J. Systematic Review of Hydrotherapy Research. J Perinat Neonatal Nurs. 2017;31(4):303–16.).

In contexts where the sexual act is seen as sinful, health professionals may feel that abuse and the experience of pain during childbirth are due punishments for pregnant women (¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ³⁰30. Renfrew MJ, Hannah W, Albers L, Floyd E. Practices That Minimize Trauma to the Genital Tract in Childbirth: A Systematic Review of the Literature. Birth. 1998;25(3):143–60.). Differing views on childbirth mean that the use of technology is acceptable for some professionals, while for others only attendance and support are appropriate (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609.). In countries where episiotomy is freely practiced, there may be a belief that it facilitates childbirth (²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²⁵25. Lunda P, Minnie CS, Benadé P. Women’s experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth 2018;18(1):167., ³¹31. Mazzieri SPM, Hoga LAK. Participação do pai no nascimento e parto: revisão da literatura. Rev Min Enferm. 2006;10(3):166–70., ³²32. Miltenburg AS, Roggeveen Y, van Roosmalen J, Smith H. Factors influencing implementation of interventions to promote birth preparedness and complication readiness. BMC Pregnancy Childbirth. 2017;17(1):270.). Women’s lack of knowledge of their rights also affects access to and the type of care they receive, as well as their selection of type of childbirth (¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁸18. Avanci BS, Cortez EA, Barbosa FS, André KM. Papel do enfermeiro na perspectiva do Programa de Humanização do pré-natal, parto natural e nascimento: revisão sistemática de literatura. Rev Enferm UFPE Line. 2009;3(4):1126–33., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084.).

Gender relations

In this thematic cluster, barriers related to attitudes of men and/or health professionals were found at all levels of organization. According to the studies analyzed, men may be unprepared to deal with childbirth and feel powerless and helpless with regard to the pain and suffering experienced by their partner. Some are reluctant to participate in awareness-raising activities about the rights of the women (³³33. George AS, Branchini C, Portela AG. Do Interventions that Promote Awareness of Rights Increase Use of Maternity Care Services? A Systematic Review. PLoS One. 2015;10(10):e0138116.). The partners often feel uncomfortable using the health services, even when they are only accompanying the women (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609.). Despite health policies in place in some countries, such as Brazil, that encourage the participation of partners during gestation, childbirth, and the postpartum period, their health services still have difficulty inserting men in the process (³¹31. Mazzieri SPM, Hoga LAK. Participação do pai no nascimento e parto: revisão da literatura. Rev Min Enferm. 2006;10(3):166–70., ³²32. Miltenburg AS, Roggeveen Y, van Roosmalen J, Smith H. Factors influencing implementation of interventions to promote birth preparedness and complication readiness. BMC Pregnancy Childbirth. 2017;17(1):270.). Also, for some women, the presence of their companion during childbirth can be a stressful factor (²⁵25. Lunda P, Minnie CS, Benadé P. Women’s experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth 2018;18(1):167., ²⁸28. Hoga LAK, Reberte Gouveia LM, Higashi AB, de Souza Zamo-Roth F. The experience and role of a companion during normal delivery and childbirth: a systematic review of qualitative evidence. JBI Database Syst Rev Implement Reports. 2013;11(12):121–56.).

Gender stereotyping by professionals affects the care that women and their companions receive. Women who do not conform to standards and stereotypes of femininity may be mistreated, and women in managerial positions tend to be the subject of discrimination (¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143.). Factors influenced by unequal gender relations include discrimination on the part of physicians toward midwives and obstetric nurses, as well as lack of incentive for these professionals to seek additional training and take autonomous action. Professional women experience work-related strain and receive lower pay. Care-giving, considered to be women’s work, is less valued. For users, their lack of autonomy during childbirth and the violent acts they are subjected to during pregnancy, childbirth, and the puerperium also trace back to cultural gender bias (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143., ²²22. Shakibazadeh E, Namadian M, Bohren M, Vogel J, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG An Int J Obstet Gynaecol. 2018;125(8):932–42.).

Health services management

In the cluster relating to health services and systems management, shortages of medicines and other inputs are a barrier to the provision of adequate childbirth care (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²⁹29. Shaw-Battista J. Systematic Review of Hydrotherapy Research. J Perinat Neonatal Nurs. 2017;31(4):303–16.). Infrastructure problems can jeopardize the woman’s privacy, while inadequate physical space can limit the presence of companions (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁹19. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(1):267., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.).

Infrastructure issues, such as inadequate sanitation and transportation, can hinder access to services (¹³13. Filby A, McConville F, Portela AG. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016;11(5):e0153391., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ³²32. Miltenburg AS, Roggeveen Y, van Roosmalen J, Smith H. Factors influencing implementation of interventions to promote birth preparedness and complication readiness. BMC Pregnancy Childbirth. 2017;17(1):270.). In terms of health system management, difficulties can arise due to lack of financial review, which can impact the hiring and retention of professionals and the upgrading of infrastructure (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.). Challenges related to coordination and referrals between health services also affect the continuity of care (¹⁸18. Avanci BS, Cortez EA, Barbosa FS, André KM. Papel do enfermeiro na perspectiva do Programa de Humanização do pré-natal, parto natural e nascimento: revisão sistemática de literatura. Rev Enferm UFPE Line. 2009;3(4):1126–33., ¹⁹19. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(1):267.).

Attitudes and behaviors

The attitudes and behaviors of professionals toward women, including inappropriate conduct, negligence, and lack of compassion, can affect the care provided and the decisions that women make (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²³23. Vargens OMC, Silva ACV, Progianti JM. Non-invasive nursing technologies for pain relief during childbirth—The Brazilian nurse midwives’ view. Midwifery. 2013;29(11):e99–106., ²⁶26. Lyberg A, Dahl B, Haruna M, Takegata M, Severinsson E. Links between patient safety and fear of childbirth-A meta-study of qualitative research. Nurs Open. 2019;6(1):18–29.). Also, the failure of professionals to engage in trainings that are offered (²⁴24. Chang Y-S, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between maternity care staff and women in labour: A mixed-methods systematic review. Midwifery. 2018;59:4–16.) and their fear of lawsuits may affect their practice (¹²12. O’Connell R, Downe S. A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (Irvine Calif). 2009;13(6):589–609.).

Communication

Communication barriers between professionals, users, and their companions can result in women failing to receive adequate or needed information regarding their childbirth (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁸18. Avanci BS, Cortez EA, Barbosa FS, André KM. Papel do enfermeiro na perspectiva do Programa de Humanização do pré-natal, parto natural e nascimento: revisão sistemática de literatura. Rev Enferm UFPE Line. 2009;3(4):1126–33., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084., ²¹21. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018., ²⁴24. Chang Y-S, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between maternity care staff and women in labour: A mixed-methods systematic review. Midwifery. 2018;59:4–16., ³⁴34. World Health Organization. WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections. Geneva: World Health Organization; 2018.). For example, the absence of interpreters (in the case of patients of other nationalities) and exclusion of family members and companions from the health units reinforce communication barriers (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847., ¹⁹19. Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(1):267.). In addition, the absence or inefficiency of mechanisms for filing claims or lawsuits means that violent situations are not adequately addressed (¹⁶16. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847.).

Socioeconomic conditions

A woman’s low educational level or lack of financial resources can negatively impact her access to care and the type of care she receives (¹⁵15. Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143., ²⁰20. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084.).

Political interests

One of the challenges faced by the health system is the tendency of governments to coopt the interests of nongovernmental organizations involved in government initiatives. Also, partisan disputes within communities can affect girls’ and women’s awareness of their rights (¹⁷17. George AS, Branchini C. Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors. BMC Pregnancy Childbirth. 2017;17(1):264.).

DISCUSSION

In the Brazilian context, the identification of barriers to complying with the recommendations in the Guidelines is an important step in the process of knowledge translation (⁷7. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT Tools for Evidence-informed Policymaking in health 6: Using research evidence to address how an option will be implemented. Heal Res Policy Syst. 2009;7(S1):S6.). The findings revealed the need for decision-makers and other social actors to become involved in considering strategies to change the current technocratic model, with special attention to communication challenges between users and professionals, management of human resources and health services, economic and sociocultural issues, gender violence, and political interests that stand in the way of more widespread adoption of good practices.

The difficulties reported by women in articulating their desires regarding their pregnancy and childbirth with health professionals, as well as in understanding the information given to them, were associated with the users’ low levels of schooling. Also, maternal low level of schooling and low socioeconomic status are associated with reduced adherence to prenatal care and less participation in educational programs (³⁵35. Domingues RMSM, Hartz ZMA, Dias ABM, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425–37., ³⁶36. Costa CSC, Vila VDC, Rodrigues FM, Martins CA, Pinho LMO. Características do atendimento pré-natal na Rede Básica de Saúde. Rev Eletrônica Enferm. 2013;15(2):516–22.). This reality means that the women end up with little knowledge about the physiology of delivery and childbirth or about their rights. Because it affects their expectations regarding the childbirth process and their perceptions of the care they receive, it constitutes an important barrier in the struggle against obstetric violence (³⁷37. Hotimsky SN, Rattner D, Venancio SI, Bógus CM, Miranda MM. O parto como eu vejo… ou como eu o desejo?: expectativas de gestantes, usuárias do SUS, acerca do parto e da assistência obstétrica. Cad Saude Publica. 2002;18(5):1303–11., ³⁸38. Reis CC, Souza KRF, Alves DS, Tenório IM, Brandão W. Percepção das mulheres sobre a experiência do primeiro parto: implicações para o cuidado de enfermagem. Cienc y Enferm. 2017;XXIII(2):45–56.).

Communication barriers between women and professionals can also be associated with the current health care model, where dialogue between women, families, professionals, and managers is virtually nonexistent (¹1. Pasche DF, Vilela ME de A, Giovanni M Di, Almeida PVB, Franco Netto T de L. Rede Cegonha: desafios de mudanças culturais nas práticas obstétricas e neonatais. Divulg saúde debate. 2014;52:58–71.). Is essential to look at the impact of gender bias on obstetric care, which can be seen in the difficulty of involving men in discussions about pregnancy and the childbirth process, in the mistreatment and abuse of pregnant women, in discrimination against women in managerial positions, and in the lack of incentive to train and hire midwives and obstetric nurses for prenatal, childbirth, and puerperium care.

Preliminary results reported by the Rede Cegonha (³⁹39. Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica. 2019;35(7):e00223018.) and the Appropriate Childbirth program show that the presence of a companion during vaginal childbirth has increased from 31.8% to 83.9% in the public sector and from 55.8% to 96.8% in the private sector. However, the data do not show whether the presence of the companions was the women’s first choice, or how the companions were received in the units. Qualitative studies have shown that men have encountered difficulties in these situations, being denied permission to spend the entire time with the woman and being prevented from participating actively in supporting her (⁴⁰40. Souza SRRK, Gualda DMR. A experiência da mulher e de seu acompanhante no parto em uma maternidade pública. Texto Contexto Enferm. 2016;25(1):e4080014., ⁴¹41. Bohren MA, Berger BO, Munthe-Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: A qualitative evidence synthesis. Cochrane Database Syst Rev. 2019;3:CD012449.).

However, there have also been experiences in which fathers have been encouraged to participate in the delivery. These initiatives are important for promoting humanization of the health services and for deconstructing the type of masculinity that has a negative impact on the individual and his relationship with his partner, children, and society in general (⁴²42. Braide ASG, Brilhante AV, Arruda CND, Mendonça FADC, Caldas JMP, Nations MK, Amorin RFD. Sou homem e pai sim!(Re) construindo a identidade masculina a partir da participação no parto. Rev Panam Salud Publica. 2018;42:e190). https://doi.org/10.26633/RPSP.2018.190
https://doi.org/10.26633/RPSP.2018.190... , ⁴³43. Matos MG, Magalhães AS, Féres-Carneiro T, Machado RN. Construindo o Vínculo Pai-Bebê: A Experiência dos Pais. Psico-USF. 2017;22(2):261-271.). It is therefore essential to develop strategies that will guarantee all women the right to have their companion present during childbirth, sensitize professionals and users, make financial resources available, and secure the commitment of managers (⁴⁴44. Kabakian-Khasholian T, Portela A. Companion of choice at birth: factors affecting implementation. BMC Pregnancy Childbirth. 2017;17(265):1-13.). For in fact, studies showed that presence of a companion leads to women’s increased satisfaction with the childbirth process and the adoption of better care practices on the part of professionals (⁴¹41. Bohren MA, Berger BO, Munthe-Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: A qualitative evidence synthesis. Cochrane Database Syst Rev. 2019;3:CD012449., ⁴⁵45. Monguilhott JJDC, Brüggemann OM, Freitas PF, d'Orsi E. Nascer no Brasil: a presença do acompanhante favorece a aplicação das boas práticas na atenção ao parto na região Sul. Revista Saúde Pública. 2018;52(1):1-11.).

The World Health Organization (WHO) recognizes that disrespect toward women in childbirth is a global public health problem. Furthermore, it claims that the problem stems from a foundation of gender stereotypes inherent in the education of health professionals and the organization of health services (⁴⁶46. Diniz CSG, Salgado HO, Andrezzo HFA, de Carvalho PGC, Carvalho PCA, Aguiar C, et al. Violência obstétrica como questão para a saúde pública no Brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção. J Hum Growth Dev. 2015;25(3):377-376.). Seen through this lens, a woman’s body is considered imperfect and also a risk factor because it needs to be attuned and cared for, culminating in the devaluation of women’s sexuality through authoritarian, discriminatory, and iatrogenic attitudes on the part of professionals (¹¹11. Minayo MCS (ed.), Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. Rio de Janeiro, Brasil: Vozes; 2013.).

Another reality in Brazil is the difficulty introducing other actors and ensuring that they stay involved in childbirth care, something that is deeply influenced by gender bias. The number of obstetric nurses in the country is unknown, but the perception is that there are few and that they are often assigned to non-obstetric areas (⁴⁷47. Narchi NZ, de Castro CM, Oliveira C de F, Tambellini F. Report on the midwives’ experiences in the Brazilian National Health System: A qualitative research. Midwifery. 2017;53:96–102.). In 2008, only 8% of normal deliveries were attended by obstetric nurses (⁴⁸48. Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet. 2011;377(9780):1863–76.). Thanks to incentivization by the Rede Cegonha campaign, this percentage increased to 27% in the public sector, though the practice remained virtually nonexistent in the private sector (1.8% in 2017) (³⁹39. Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica. 2019;35(7):e00223018.). To facilitate graduate education in physiologic birth for professional specialists and increase the supply of midwives in the health services, the University of São Paulo (USP) reinstated its degree program in obstetrics in 2005 (⁴⁹49. Narchi NZ, da Silva LCFP, Gualda DMR, Bastos MH. Reclaiming direct-entry midwifery training in Brazil: Context, challenges and perspectives. Midwifery. 2010;26(4):385–8.). However, midwives continue to face challenges to becoming fully active and incorporated in the health services, despite experiences confirming the positive impact of their participation in delivery and childbirth care (⁴⁷47. Narchi NZ, de Castro CM, Oliveira C de F, Tambellini F. Report on the midwives’ experiences in the Brazilian National Health System: A qualitative research. Midwifery. 2017;53:96–102., ⁵⁰50. Lima CF, Soares GCF, Gualda DMR. Midwives’ Experiences: inconsistencies in education vs. clinical practice. Rev Iberoam Educ Invest Enferm. 2019;9(2):7–18.).

The limited number of health workers creates an excessive workload and the problem is aggravated by low wages and unacceptable schedules (⁵⁰50. Lima CF, Soares GCF, Gualda DMR. Midwives’ Experiences: inconsistencies in education vs. clinical practice. Rev Iberoam Educ Invest Enferm. 2019;9(2):7–18.

51. Oliveira RJT, Copelli FHS, Pestana AL, Santos JLG, Gregório VRP, Erdmann AL. Intervening conditions on governance of the nursing practice at an obstetrics centre. Rev Gaúcha Enferm. 2014;35(1):47–54.-⁵²52. Progianti JM, Moreira NJM de P, Prata JA, Vieira MLC, Almeida TA, Vargens OM da C. Job insecurity among obstetric nurses. Rev Enferm UERJ. 2018;26:e33846.). There are also weaknesses in the process of educating and updating professionals. A qualitative study that assessed barriers and facilitators in hospitals of Latin America showed that the reluctance of professionals to change their practices starts with the university curriculum, since they were not trained to see that knowledge is always changing in the field of medicine. Furthermore, they fail to develop sufficient skills to understand the scientific literature (⁵³53. Belizan M, Meier A, Althabe F, Codazzi A, Colomar M, Buekens P, et al. Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study. Health Educ Res. 2007;22(6):839–53.). To achieve fully skilled obstetric practice, the education of health professionals will need to include discussions about the humanization of childbirth, gender, and the rights of women (⁴⁶46. Diniz CSG, Salgado HO, Andrezzo HFA, de Carvalho PGC, Carvalho PCA, Aguiar C, et al. Violência obstétrica como questão para a saúde pública no Brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção. J Hum Growth Dev. 2015;25(3):377-376., ⁵⁴54. Morais LO, Potros FR, Maia PR, Rabelo KLMA, Ribeiro FM, Matos KLA de, et al. O Parto Humanizado no contexto atual: Uma revisão integrativa. Rev Eletrônica Acervo Saúde. 2019;37:e1375.).

Finally, it will not be possible to overcome the barriers identified without proper health services management. Areas that should be examined in the services include infrastructure, adequate professional staffing, basic sanitation, transportation, and resources or budgetary funding.

Limitations of the study

It should be kept in mind that this rapid review used methodological shortcuts that were defined in advance and thoroughly considered by the authors—for example, limitation of the searches and the selection and extraction of articles by a single reviewer. A few important limitations should be kept in mind in interpreting the results. First, the decision to limit the number of databases reviewed was based on the time available to complete the study. Thus, the impact of the coverage of this review should be considered in interpreting the results presented. Second, only secondary studies and clinical practice guidelines were included, which may have resulted in barriers not being identified for several of the recommendations in the Guidelines. Although the confidence level for the evidence in the narrative reviews is lower, they address barriers that appear to be relevant to the Brazilian context, since all are national reports. Third, quality was only assessed for the systematic reviews. Although these reviews represent a large proportion of the included studies, the reliability of the results presented in the remaining types of studies, such as the narrative reviews, is less certain and caution is advised in interpreting them. Finally, the absence of barriers associated with care in the third stage of delivery, maternal care immediately following childbirth, and newborn care may mean that more specific search terms for these stages of care should have been included.

Final considerations

The findings from this rapid review shed light on a problem that is neither new nor unknown. By clearly visualizing barriers to implementation of the Guidelines, we can ensure that the strategies adopted to overcome them are based on solid evidence, clearly delineated, and agreed upon with the actors involved. Childbirth care is clearly complex, and the focus is on promoting natural childbirth, which has been challenged for many years by the medicalized approach to obstetric care in Brazil and throughout the world.

Eliminating the identified barriers to implementation can lead to good care practices, reduce the high rates of unnecessary C-sections and avoidable maternal and neonatal deaths, and help reclaim the transformative potential of the childbirth experience for women, children, and society. Joint action may be necessary to promote ways to raise the financial and educational status of women and families, improve mechanisms for managing health professionals and facilities, and raise awareness to combat gender inequities and the violent acts that stem from them.

Effective implementation of the Guidelines and construction of a model centered on the needs of each woman and family will require a commitment by managers and professionals to embrace good care practices, as well as assurance that health strategies and policies based on incentivization and monitoring, such as the Rede Cegonha, will continue to be supported. Finally, the identified socioeconomic barriers underscore the need for a more just and welcoming society—one that promotes the autonomy of individuals and full respect for them from the moment they are born.

Financing.

This study was financed by the Pan American Health Organization (PAHO), the Alliance for Research in Policies and Health Systems (AHPSR), and the Program for Research and Training in Tropical Diseases (TDR) through a donation to the project “Barriers and Strategies for Implementation of the Care Guidelines for Normal Childbirth in Brazil” [Call for Proposals on Embedding Research for the Sustainable Development Goals (ER-SDG)].” The funding agencies did not have any role in the project design, analysis process, interpretation of the data, or drafting of the manuscript.

Declaration.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or the Pan American Health Organization.

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