"Parto ideal": medicalização e construção de uma roteirização da assistência ao parto hospitalar no Brasil em meados do século XX / "Ideal childbirth": medicalization and construction of a hospital delivery assistance script in Brazil in mid-20 th century

Resumo No Brasil, as práticas de parto e nascimento passaram por profundas transformações e intenso processo de medicalização, sobretudo em meados do século XX. Os partos, que ainda aconteciam em sua maioria nos domicílios com assistência de parteiras, passaram cada vez mais a ocorrer nos hospitais, assistidos por médicos obstetras, com intervenções, práticas e rotinas próprias. A partir da análise de 31 artigos publicados em periódicos científicos brasileiros da área da obstetrícia entre os anos de 1930 e 1970, procuramos compreender as ideias em torno do processo de construção de uma rotina "ideal" para o parto hospitalar e os argumentos que sustentavam a consolidação da figura do médico como profissional mais habilitado para a assistência ao parto. O debate de obstetras acerca de uma roteirização da assistência ao parto, incluindo intervenções e práticas obstétricas que deveriam ser realizadas como rotina, lançam luz sobre os primórdios do processo de medicalização do parto no Brasil. Com a justificativa de um dever médico de diminuir o tempo e as dores do parto, e não deixar a natureza "agir sozinha", as intervenções foram apresentadas como fruto de um novo conhecimento médico-científico que constituiria a obstetrícia moderna.

Abstract In Brazil, childbirth practices underwent deep changes and an intense medicalization process, especially in the mid-twentieth century. Childbirth, which by then still mostly took place at home with midwives' assistance, began to increasingly occur in hospitals, assisted by obstetricians with their own interventions, practices and routines. Based on the analysis of 31 articles published in Brazilian obstetrics scientific journals between the 1930s and 1970s, we sought to understand the ideas about the process of constructing an "ideal" routine for hospital delivery and the arguments that supported the consolidation of the physician's role as the most qualified professional for childbirth care. The obstetricians' discussion about a scripting of childbirth care, including interventions and obstetric practices that should be performed routinely, shed light on the early stages of the medicalization process of childbirth in Brazil. Justified by the medical duty of reducing time and pain of normal birth and to not let Nature "act alone", the interventions were presented as the result of a new medical-scientific knowledge that would constitute the modern obstetrics.

Diferenciais no comportamento reprodutivo das mulheres Brasileiras: uma análise a partir dos grupos ocupacionais / Differences in reproductive behavior among Brazilian women: an analysis based on occupational groups / Différences de comportement reproductif chez les femmes Brésiliennes: une analyse à partir des groupes professionnels

The aim of this study was to analyze reproductive behavior based on women's occupation in the work market. The hypothesis is that given occupations are associated with different strategies by women in relation to fertility, resulting in different reproductive histories. The study used the database from the Population Census for 2000 conducted by the Brazilian Institute of Geography and Statistics (IBGE). Women's birth histories were reconstructed, and demographic tools were used to perform a descriptive analysis of the relationship between women's reproductive behavior and their occupation. According to the findings, women in more highly qualified occupational groups tended to have fewer children and postpone motherhood longer.

Dans cette étude, on cherche à examiner le comportement reproductif à partir de la profession des femmes sur le marché du travail. On part de l'hypothèse que certaines professions sont associées aux différentes stratégies utilisées par les femmes quant à la fécondité, dont résultent des régimes reproductifs différents. On a utilisé les données du recensement brésilien de l'Institut Brésilien de Géographie et de Statistique (IBGE) en 2000. On a reconstitué l'histoire des naissances de ces femmes et, par le moyen d'instruments démographiques, on a effectué une analyse du rapport entre leur comportement reproductif et leurs emplois. On a vérifié que les groupes professionnels les plus qualifiés sont ceux où les femmes ont le moins d'enfants et retardent le plus la maternité.

Infant feeding practices and child health in Bolivia.

The effects of breast-feeding and supplementation practices on recent diarrhoea occurrence and stunted growth are modelled using logistic regression techniques. Data from the Demographic and Health Survey of Bolivia, 1989, show that, among children aged 3-36 months at the date of interview, the benefits of breast-feeding to child health were most pronounced among children living in rural poverty. Reduced breast-feeding among these children increased the likelihood of diarrhoea and stunted growth. In addition, the introduction of solid foods to currently lactating infants negatively influenced child health.

PIP: This study assesses, in two models, the effects of infant feeding practices on stunted growth and diarrhea incidence among breast fed children aged 3-36 months in Bolivia. Data were obtained from the 1989 Demographic and Health Survey, which included 1143 breast-fed children. About 38% of the children were stunted. Stunting increased with age and parity. In the bivariate analysis, breast feeding increased stunting, and maternal characteristics were related. Stunting increased with maternal age and indigenous ethnicity. Stunting was associated with blue collar and agricultural households and households in the rural Altiplano and Valles regions. About 33% of the children had experienced an episode of diarrhea. Bivariate analysis revealed that only maternal education and having waste removal were related to the occurrence of diarrhea. Logistic models show that the positive effects of breast feeding were more prominent in impoverished environments. Cessation of breast feeding among infants 6 months or less and living in households with extreme rural poverty increased the risk of stunting fourfold. Children with birth intervals of 2-3 years were at 1.5 times lower risk. Children in rural areas were less likely to be stunted than children in urban areas, when socioeconomic status was controlled. Children who had diarrhea were 40% more likely to be stunted. Diarrhea decreased with maternal education. Diarrhea increased with the number of household members. Food supplementation introduced at about 6-9 months, when most infants are fed solids, increased the risk of stunting by about 75%. Introduction earlier or later had no significant impact on child growth. Only 30% of infants received solids before the age of 4 months. Personal living conditions or socioeconomic status were key explanatory factors in stunting and diarrhea.

Misinformation, mistrust, and mistreatment: family planning among Bolivian market women.

Results of an ethnographic study suggest that, despite stereotypes to the contrary, urban Aymara women in Bolivia want to regulate their fertility, and sociocultural norms support fertility regulation. However, the norms also make such regulation difficult to achieve. One barrier is a deep suspicion of modern medicine and medical practitioners, who are not seen as reliable sources of information. This suspicion is reinforced when the quality of health services is inadequate. Among urban Aymara, the level of acceptability of most modern methods of contraception is low. Many would prefer to use traditional methods, even when use of these methods entails considerable sacrifice and risk of conflict with their partners, unwanted pregnancies, and recourse to unsafe abortion.

PIP: Ethnographic data were used to examine fertility control in 1993 among Aymara urban women in Bolivia. Data were gathered from in-depth interviews on family planning (FP) with 30 women, from similar interviews with eight men, from 38 other household interviews, and from FP service clients. Most of the Bolivian population is composed of members of the Aymara or Quechua indigenous groups. About 50% of total population is urban. Interview responses indicated that most women wanted to control their fertility so that they could improve their economic situation by selling items in the market. Cultural norms and beliefs were compatible with fertility control and women's work. Women were expected to control reproduction through rhythm or a form of abstinence. Barriers to fertility control included a lack of communication about sexual and contraceptive matters with friends, family, or spouses. This pattern of silence was handed down from their mothers. Almost 66% of the 30 women had never received information on menstruation or reproduction when growing up. The message was that sexuality was dangerous and shameful. Almost 33% engaged in a living arrangement with a sexual partner at the age of 14-16 years, and the remaining had done so by 17-20 years. Marriage occurred accidentally or by force (25%). Voluntary cohabitation occurred in about 50% of cases. After sexual contact occurred, parents strongly urged marriage. Women eventually learned about contraception through women's clubs, clinics, church groups, husbands, or friends. When fertility control failed, women resorted to extreme abstinence, abortion, infanticide, or modern methods. Modern methods were viewed as dangerous and with harmful side effects; modern medicine was viewed similarly. Contraceptive use could be associated with promiscuity. Women feared being touched by health personnel. Although abortion was illegal, women conveyed a desire to end an unwanted pregnancy or acted with systematic neglect to end an unwanted birth. Recommendations were made for providing culturally sensitive services which involved men.

[The nature of the preceding birth technique]. / La naturaleza del metodo del hijo previo.

PIP: The author applies the preceding birth technique of infant mortality estimation to World Fertility Survey birth history data from a number of developing countries. (SUMMARY IN ENG)^ieng

An experiment using a month-by-month calendar in a family planning survey in Costa Rica.

Recent demographic surveys have incorporated a month-by-month calendar for the five-year reference period before the survey for the recording of fertility-related events (sexual unions, contraceptive use, pregnancies, and breastfeeding). In the 1986 survey of Maternal and Child Health and Family Planning in Costa Rica, approximately one-half of the 3,527 women interviewed were administered a questionnaire with traditional fertility and family planning questions; the other half were asked virtually the same questions, but the women's responses were entered in a month-by-month calendar. The assignment of questionnaire type was randomly alternated by cluster. Comparisons of the number of events (live births, pregnancy losses, and contraceptive use) showed that more events were recorded among the women in the calendar group. Significantly less erroneous superposition of events (contraceptive use in the last trimester of pregnancy and hormonal contraceptive use in the first month postpartum) was noted when the calendar was used.

PIP: There are many approaches to obtaining data on reproductive events. The World Fertility Survey uses a detailed pregnancy history questionnaire and family planning use for the last birth interval. The Demographic and Health Surveys use a live birth history and family planning method use for as many as 2 methods during each birth interval in the prior 5 years. The 1965 National Fertility Survey in the US used a chart or calendar to code respondent's reproductive status and events for each month in the reference period. This report is a comparison of data collection methods for the Costa Rica Maternal and Child Health-Family Planning Survey in 1986. The reference period for respondents' pregnancy history, family planning events, and marital and employment history was 5 years. Out of 322 clusters, the calendar method and the traditional questionnaire are alternated. Questionnaires and interviewer training were the same. The criteria for comparing data quality were established as 1) the higher number of events recorded, 2) the extent of conflicting events for contraception and pregnancy and for contraception and lactation, and 3) extent of method choice data missing from the calendar method. The results showed high response rates for both groups (95%). In the calendar questionnaire the mean number of pregnancy losses was significantly higher (by 17%) and the number of contraceptive use segments was higher (by 11%). A greater proportion of women reported with the calendar method at least 1 event for all variables. Inconsistency was reported for 10% of women in the traditional questionnaire on overlaps between pregnancies of 4 months and contraceptive use. Sometimes the overlapping continued through the entire pregnancy. Only 1% of women reported inconsistencies in reported pregnancy and contraception using the calendar method. Inconsistencies of lactation and contraceptive use occurred with 7% of traditional questionnaire reports and only 3% of calendar reports. 8.6% of women using the traditional questionnaire reported multiple method use. In the calendar method only the most effective method was indicated where there was multiple use. The recording of more events with the calendar method was confirmed by comparison conducted in Peru but not in the Dominican Republic.

High fertility of Old Colony Mennonites in Mexico.

Old Colony Mennonites in Mexico appear to demonstrate natural fertility, using no form of artificial birth control and apparently not attempting to limit family size. The resulting fertility is nearly as high as that of the Hutterites, although the Mennonites lack the communal economic system of the latter. Most Mennonites in Mexico migrated from Canada in the 1920s, and the largest single settlement, called the Manitoba Colony, is one of four in the state of Chihuahua. A 1967 partial census obtained data from 38% of the Mennonite households. Family size in the sample was close to that in a local survey taken in the same year. Available church records matched with census forms permitted verification of and corrections to 560 female reproductive histories. The median number of live births to women over age 45 years was 9.5, compared with 10.4 in the Hutterites. Age-specific marital fertility rates and birth intervals closely resembled those of the Hutterites.

PIP: Old Colony Mennonites in Mexico appear to demonstrate natural fertility, use no form of artificial birth control, and are apparently not attempting to limit family size. The resulting fertility is nearly as high as that of the Hutterites, although the Mennonites lack the communal economic system of the latter group. Most Mennonites in Mexico migrated from Canada in the 1920s and the largest single settlement, called the Manitoba Colony, is 1 of 4 in the state of Chihuahua. A partial census in 1967 obtained data from 38% of the Mennonite households. Family size in the sample was close to that of a local survey taken in the same year. Available church records matched with census forms permitted verification of and corrections to 560 female reproductive histories. The median number of livebirths to women over age 45 was 9.5 compared with 10.4 in the Hutterite community. Age- specific marital fertility rates and birth intervals closely resembled those of the Hutterites.

Women's status and infant mortality in rural Colombia.

This paper investigates the effects of maternal demographic characteristics and social and economic statuses on infant mortality in rural Colombia. Demographic characteristics include the age of the mother, parity and length of preceding interbirth interval, and sex of infant. Measures of women's status at the time of birth include education, wage labor and occupation, economic stratum, place of residence, and whether the mother is living with a husband. The life history data for the study (involving 4,928 births) were collected in 1986 from a representative sample of two cohorts of women resident in rural central Colombia. Overall differentials in infant mortality by measures of women's status are small and are in good part associated with the differing reproductive behaviors of the women and variations in breastfeeding practices. The sharp declines in infant mortality recorded in rural Colombia in recent years appear less related to improved status of women than to reductions in fertility that enhance infant survivorship and to public health interventions shared by all segments of the population.

PIP: As part of the demographic transition that has been unfolding in Colombia over the last 5 decades, both urban and rural areas have experienced substantial declines in infant mortality. This decline is generally attributed to extensive countrywide health campaigns during the 1950s and 60s aimed at the prevention of disease, government-supported child immunization campaigns during the 1970s and 80s, and improvements in the population's educational level. To investigate the dynamics behind the sharp decline in infant mortality, life history data were collected in 1986 from a representative sample of 2 cohorts of women living in rural central Colombia. 4928 births were available for analysis. The cohorts included women born in 1937-46, who were of reproductive age in the early 1960s when fertility began its decline, or 1955-61, who entered their reproductive period in the 1980s after the sharp decline in fertility. Measures of women's status and demographic characteristics at the time of each birth were reconstructed for the analysis. A total of 207 children born to the study subjects died before their 1st birthday, yielding a 0.042 probability of infant death. Substantial declines in this probability were observed over time, with 0.072 of infants born before 1960 dying compared to 0.050 of those born in 1960-72 and 0.033 of infants born after 1972. Logit model analysis of the life history data indicated that changes in the status of women, including educational attainment, have had only a slight impact on the sharp declines in infant mortality in rural Colombia. More important have been reductions in fertility that have cut the number of high parity and closely spaced births and the prevalence of breastfeeding among rural mothers.

Fertility change in Costa Rica 1960-84: analysis of retrospective lifetime reproductive histories.

Lifetime reproductive histories of a 1984-85 nationally representative sample of 870 women aged 25-59 years provided data to describe the evolution of fertility, contraception, breast-feeding, and natural fecundability in Costa Rica between 1960 and 1984. The contraceptive prevalence rate increased from 23% in 1965 to 58% in 1975 and 66% in 1984. Duration of breast-feeding was stable during the 1960s, decreased in the early 1970s, and increased after about 1976. Fecundability among women who did not practise contraception was lower than expected and declined between 1960 and 1975, probably because of selection effects. Despite a high consistency between estimations from the reproductive histories and other sources of data, some suggestion of omissions of short periods of contraceptive use in the distant past was detected. The survey may have reduced recall errors by using a calendar that summarizes major life events together. The analysis demonstrated the feasibility and usefulness of asking for lifetime reproductive histories in fertility surveys in developing countries.

PIP: Lifetime reproductive histories of a 1984 through 1985 nationally representative sample of 870 women aged 25 through 59 years provided data to describe the evolution of fertility, contraception, breast feeding, and natural fecundity in Costa Rica between 1969 and 1984. The contraceptive prevalence rate increased from 23% in 1965 to 58% in 1975 and 66% in 1984. Duration of breastfeeding was stable during the 1960s, decreased in the early 1970s, and increased after about 1976. Fecundability among women who did not practice contraception was lower than expected and declined between 1960 and 1975, probably because of the selection effects. Despite a high consistency between estimations from the reproductive histories and other sources of data, some suggestion of omissions of short periods of contraceptive use in the distant past was detected. The survey may have reduced recall errors by using a calendar that summarizes major life events together. The analysis demonstrated the feasibility and usefulness of asking for lifetime reproductive histories in fertility surveys in developing countries. Retrospective information gathered on 900 women permitted reconstruction of the results in a a period of dramatic changes. However, Costa Rica may be somewhat exceptional among developing countries because of its high levels of literacy. Some of the few, older, illiterate women may have found a life history calendar difficult to decipher, but others seemed to grasp the approach as easily as did the literate men.

[A comparison of complete and truncated birth histories to measure fertility and child mortality]. / Comparacion entre las historias completas y truncadas de nacimientos para medir la fecundidad y la mortalidad de la ninez.

"During the latter part of 1986, national probability sample surveys of women of reproductive ages were carried out in... Peru and the Dominican Republic. These surveys were made as part of the Demographic Health Surveys project (DHS). In each country, one survey was conducted with the standard core questionnaire developed for DHS; the other survey was based on an experimental questionnaire. The major difference between the two questionnaires is the inclusion in the experimental one of a monthly calendar, which records pregnancies, contraceptive use, reasons for contraceptive discontinuation, breastfeeding, post-partum amenorrhea, post-partum abstinence, women's employment and place of residence for the period 1981-1986. This paper presents results from the first stage of the analysis of the Peruvian data: a comparison of basic characteristics of the two samples and an assessment of the completeness of reporting of recent births and infant and child deaths, i.e., a comparison of information in the truncated and full birth histories." (SUMMARY IN ENG)

[The previous birth technique: the Latin American experience]. / El procedimiento del hijo previo: la experiencia latinoamericana.

PIP: The author describes the use of the previous birth technique, developed by Brass and Macrae, in Latin American countries. The technique involves the estimation of infant and child mortality using data on the survivorship of previous children. The focus is on the experiences of CELADE in collecting data in maternity hospitals in Argentina, Bolivia, the Dominican Republic, and Honduras. The inclusion of survey questions related to dates of birth and death of the previous child is evaluated. (SUMMARY IN ENG)^ieng

[Estimating child mortality using the previous child technique, with data from health centers and household surveys: methodological aspects]. / Estimacion de la mortalidad de la ninez mediante la tecnica del hijo previo con datos provenientes de centros de salud o de encuestas de hogares: aspectos metodologicos.

PIP: 2 trials of the previous child or preceding birth technique in Bamako, Mali, and Lima, Peru, gave very promising results for measurement of infant and early child mortality using data on survivorship of the 2 most recent births. In the Peruvian study, another technique was tested in which each woman was asked about her last 3 births. The preceding birth technique described by Brass and Macrae has rapidly been adopted as a simple means of estimating recent trends in early childhood mortality. The questions formulated and the analysis of results are direct when the mothers are visited at the time of birth or soon after. Several technical aspects of the method believed to introduce unforeseen biases have now been studied and found to be relatively unimportant. But the problems arising when the data come from a nonrepresentative fraction of the total fertile-aged population have not been resolved. The analysis based on data from 5 maternity centers including 1 hospital in Bamako, Mali, indicated some practical problems and the information obtained showed the kinds of subtle biases that can result from the effects of selection. The study in Lima tested 2 abbreviated methods for obtaining recent early childhood mortality estimates in countries with deficient vital registration. The basic idea was that a few simple questions added to household surveys on immunization or diarrheal disease control for example could produce improved child mortality estimates. The mortality estimates in Peru were based on 2 distinct sources of information in the questionnaire. All women were asked their total number of live born children and the number still alive at the time of the interview. The proportion of deaths was converted into a measure of child survival using a life table. Then each woman was asked for a brief history of the 3 most recent live births. Dates of birth and death were noted in month and year of occurrence. The interviews took only slightly longer than the basic survey of coverage for the expanded program of immunization to which the questions were added. Information from the trial clarified some important problems that should be taken into account in future surveys to measure recent early mortality trends in countries with incomplete registration. Collection of data on early childhood mortality in brief household interviews has been proven feasible . All women able to bear children should be interviewed if possible. The minimum questions on child mortality include the Brass questions on live born and surviving children and dates of birth and death of the 2 most recent births. The data should be analyzed based on each birth rather than each women. Use of the previous child method applied to regularly collected data offers a potentially rewarding method of discovering recent mortality trends.^ieng

Childhood mortality estimated from reports on previous births given by mothers at the time of a maternity: preceding-births technique.

PIP: This paper demostrates that, by using the Preceding-Births technique (Brass 1969), data can be collected to determine indices of the most recent childhood mortality using a totally different approach independent of the age of the mother reporting on the survivorship of previous children. This method is particularly simple since it requires only 1 question on the registration or notification form: is your last child still alive? No complex analysis and no dependence on other data sources or model life tables are necessary. An advantage of this method is the low % of selection bias. These techniques are concerned with the limited use of only that part of the maternity history data concerning mortality of recent births. Their use is recommended particularly for monitoring trends and evaluating intervention. In the interim before full registration exists in less developed countries, this is a valuable and viable means of estimating childhood mortality. Model tables describe distributions of intervals between live births reported from Colombia, Italy, USA, England and Wales; mortality schedules taken from African standards; and an estimation of proportion dead by the Preceding-Births technique in the Solomon Islands.^ieng