Prenatal care policies: when the "outcome is unexpected"
Políticas de atenção ao pré-natal: quando o "desfecho é inesperado"
Ludmila Fontenele Cavalcanti
Nucleus of Studies and Actions in Reproductive Health and Feminine Labor, Social Service School of Rio de Janeiro Federal University. email@example.com
The "unexpected outcome" suggested as the title for this debate underscores what can arise from an ineffective and inefficient healthcare policy and what the tests conducted on pregnant women can reveal. Both situations can lead to an unexpected outcome. The debate about giving "bad news" in this sense, places the communication process squarely within the field of health policies.
The quality of prenatal healthcare is a historical concern in Brazilian healthcare policies (PAISM and PHPN), which define such care as a set of clinical and educational procedures designed to promote health and ensure the early identification of risks for the pregnant mother and unborn child1.
In Brazil, prenatal care is usually the responsibility of municipal services and is of strategic importance in comprehensive healthcare for women. The National Policy for Comprehensive Healthcare for Women2 sought to consolidate advances in the field of sexual and reproductive rights and also noted the improvement in the coverage of prenatal healthcare.
The comprehensive care approach seeks a complex focus on the motherhood process and, therefore, includes social, cultural and economic factors that affect pregnancy and its multiple aspects. From this perspective, the effectiveness of prenatal care is primarily related to the possibility that women are well informed about their situation and about their baby, are ready to give birth and are aware about possible complications.
In this respect, the communication of "bad news" as part of the right to information during prenatal care should be part of an interdisciplinary approach, incorporating a comprehensive approach to various fields of knowledge, visions and practices of women (prenatal care subjects) in order to ensure their autonomy in the experience of motherhood.
Healthcare professionals must provide support, guidance and information on reproductive health to the pregnant woman, which does not mean "medicalizing" and "pathologizing" their condition. The philosophy of care is that no woman should be treated as a "technical object," but as a subject, an individual and a person. And this is achieved by a personalized exchange of information that can reduce the suffering of women and families in situations where the bad news is inevitable. Therefore, prenatal healthcare, besides the technical quality of care, falls within the context of humanization that emphasizes the link between professionals and service users.
However, among professionals working in prenatal care, especially physicians, one detects a marked difficulty in dealing with issues that are not related merely to the biomedical rationale. In this context, issues related to fetal anomalies and complications in pregnancy are often obfuscated behind technical discourse3. This ultimately makes the professional responsible for the examination, diagnosis, preparation for "bad news" and guidance regarding future decisions. This difficulty in establishing qualified sensitivity capable of creating adequate rapport is explained in part by perceptions regarding the professionals' role vis-à-vis the outcomes of pregnancy, but also the shortfalls in their exclusively technical training.
This situation is aggravated when the outcome involves the interruption of pregnancy, because in Brazil, today, abortion is only permitted by law in cases of risk of life to the mother and in cases of pregnancy resulting from sexual violence. It is also legally accepted in some cases of fetal anencephaly. However, the search by women for services that perform abortions tends to exacerbate their suffering, due to the lack of preparation and prejudice of the health professionals who by not guaranteeing their human rights foster a form of institutional violence.
Thus, the need for effective institutional responses and a critical and comprehensive overview of the professionals about the reality of the population who are seeking prenatal care, and are attended by public healthcare, pose two major challenges for vocational training: the inclusion of debate on sexual and reproductive rights; and an interdisciplinary approach to interaction with the Unified Health System patients as an important component in humanized practices.
1. Cavalcanti LF. Ações da assistência pré-natal voltadas para a prevenção da violência sexual: representação e práticas dos profissionais de saúde [tese]. Rio de Janeiro: Instituto Fernandes Figueira, Fundação Oswaldo Cruz; 2004.
2. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília: Ministério da Saúde; 2004.
3. Mitjavila M, Echeveste L. Sobre a construção social do discurso médico em torno da maternidade. In: Costa AO, Amado T, organizadores. Alternativas escassas: saúde, sexualidade e reprodução na América Latina. São Paulo: Prodir/Fundação Carlos Chagas; Rio de Janeiro: Editora 34; 1994. p. 283-300.