Diálogo com equipes de Saúde da Família sobre parto no pré-natal: uma investigação comunicativa / Diálogo con equipos de salud de la familia acerca del parto prenatal: una investigación comunicativa / Dialogue on Childbirth with Family Health Teams during Prenatal Care: A Communicative Study

RESUMO O diálogo entre gestantes e profissionais de saúde sobre parto pode ser uma importante ferramenta para mudanças na prática de cesáreas no Brasil. Entretanto, a priorização desse tema no pré-natal e a forma como ele é abordado estão diretamente relacionadas à sua valorização e às dificuldades de abordagem. Objetivos: analisar, junto com equipes de saúde da família, os elementos que dificultam a abordagem do parto no pré-natal. Materiais e método: pesquisa qualitativa, que utilizou a metodologia comunicativa para identificar elementos facilitadores e dificultadores para o exercício de uma prática ou benefício. Foram realizados grupos de discussão comunicativos com as equipes, entre 2013 e 2014. Resultados: os elementos dificultadores perpassam a formação profissional, o processo e as condições de trabalho nas unidades, que interferem nas atividades educativas, na falta de articulação entre a atenção básica e a hospitalar, e nas próprias vivências pessoais dos profissionais com o tema, aspectos que influenciam negativamente a abordagem do parto. Conclusões: é necessário investimento na qualificação dos profissionais nas questões referentes ao parto, com espaços de diálogo que permitam explorar as possibilidades de superação das dificuldades institucionais e expressar suas próprias vivências, a fim de desfazer mitos e crenças em relação ao parto.

RESUMEM El diálogo entre gestantes y profesionales de la salud acerca del parto puede ser una importante herramienta para cambios en la práctica de cesarianas en Brasil. Sin embargo, la priorización del tema en el prenatal y la forma como este es abordado están directamente relacionadas a su valoración y a dificultades de enfoque. Objetivos: analizar, junto con equipos de salud de la familia, los elementos que dificultan el abordaje del parto en prenatal. Materiales y método: investigación cualitativa, que utilizó la metodología comunicativa para identificar elementos facilitadores y dificultadores para el ejercicio de una práctica o beneficio. Se realizaron grupos de discusión comunicativos con los equipos, entre 2013 y 2014. Resultados: los elementos dificultadores permean la formación profesional, el proceso y las condiciones de trabajo en las unidades, e interfieren en las actividades educacionales, en la falta de articulación entre la atención básica y la hospitalaria, y en las propias vivencias personales de los profesionales con el tema, aspectos que influencian negativamente el abordaje del parto. Conclusiones: se necesita inversión en la capacitación de los profesionales en cuestiones referentes al tema, con espacios de diálogo que permitan explorar las posibilidades de superación de dificultades institucionales y expresar sus propias vivencias, con el fin de deshacer mitos y creencias en relación con el parto.

ABSTRACT Dialogue between pregnant women and health professionals about childbirth can be an important tool for prompting changes in the practice of cesarean deliveries in Brazil. However, prioritizing this topic in prenatal care and the way it is addressed are directly related to its assessment and to the difficulties concerning the approach. Objectives: Analyze, in conjunction with family health teams, the elements that make it difficult to address the issue of childbirth in prenatal care. Materials and method: This is a qualitative study in which the communicative methodology was used to identify elements that facilitate and/or hamper the implementation of a particular practice or benefit. Communicative discussion groups were held with the teams between 2013 and 2014. Results: The elements that pose difficulty permeate professional training, the process and working conditions in the health units, and interfere in educational activities, in the lack of articulation between basic and hospital care, and in the personal experiences of professionals concerning this subject. All of these aspects negatively influence the approach to childbirth. Conclusions: Investment in professional training on issues related to childbirth is needed, with room for dialogue that makes it possible to explore possibilities for overcoming institutional difficulties and provides professionals with an opportunity to express their own experiences in order to undo myths and beliefs with respect to childbirth.

A cohort study of functioning and disability among women after severe maternal morbidity.

OBJECTIVE: To assess functioning and disability related to severe maternal morbidity (SMM) via the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). METHODS: In a retrospective cohort study, women with or without a history of SMM who delivered at a tertiary public hospital in Brazil between July 2008 and June 2012, completed the WHODAS 2.0 questionnaire by individual interview between August 2012 and November 2013. General WHODAS scores were evaluated by maternal and neonatal characteristics, and specific domain scores according to SMM event. RESULTS: Overall, 638 women were enrolled (315 with SMM and 323 without SMM). The mean general WHODAS score was higher among women with SMM (19.04±16.18) than among women without SMM (15.77±14.46; P=0.015). Domain scores were also higher in the SMM group for mobility (16.00±20.22 vs 11.63±17.51; P=0.003), household activities (26.79±30.16 vs 20.09±26.08; P=0.005), participation (23.55±21.72 vs 17.27±19.17; P<0.001), and work/school activities for women currently studying or working (20.52±26.64 vs 11.66±19.67; P=0.001). Excluding SMM, a parity of two or more was the only factor significantly associated with higher scores overall (P=0.013) and for domain 4 (getting along with people; P=0.017). CONCLUSION: By comparison with women without childbirth complications, SMM impaired self-reported functioning among women 1-5years after delivery.

Does Severe Maternal Morbidity Affect Female Sexual Activity and Function? Evidence from a Brazilian Cohort Study.

OBJECTIVE: to assess Female Sexual Function Index (FSFI) scores and delay to resume sexual activity associated with a previous severe maternal morbidity. METHOD: This was a multidimensional retrospective cohort study. Women who gave birth at a Brazilian tertiary maternity between 2008 and 2012 were included, with data extraction from the hospital information system. Those with potentially life-threatening conditions and maternal near miss episodes (severe maternal morbidity) were considered the exposed group. The control group was a random sample of women who had had uncomplicated pregnancy. Female sexual function was evaluated through FSFI questionnaire, and general and reproductive aspects were addressed through specific questions. Statistical analyses were performed using Mann-Whitney and Pearson´s Chi-square for bivariate analyses. Logistic regression was used to identify variables independently associated with lower FSFI scores. RESULTS: 638 women were included (315 at exposed and 323 at not exposed groups). The majority of women were under 30 years-old in the control group and between 30 and 46 years-old in the exposed group (p = 0.003). Women who experienced severe maternal morbidity (SMM) had statistically significant differences regarding cesarean section (82.4% versus 47.1% among deliveries without complications, p<0.001), and some previous pathological conditions. FSFI mean scores were similar among groups ranging from 24.39 to 24.42. It took longer for exposed women to resume sexual activity after index pregnancy (mean 84 days after SMM and 65 days for control group, p = 0.01). Multiple analyses showed no significant association of FSFI below cut-off value with any predictor. CONCLUSION: FSFI scores were not different in both groups. However, they were lower than expected. SMM delayed resumption of sexual activity after delivery, beyond postpartum period. However, the proportion of women in both groups having sex at 3 months after delivery was similar. Altered sexual response may be evaluated as one of possible long-term consequences after SMM episodes. Further studies on the growing population of women surviving severe maternal conditions might be worth for improvement of care for women.

Sexual life and dysfunction after maternal morbidity: a systematic review.

BACKGROUND: Because there is a lack of knowledge on the long-term consequences of maternal morbidity/near miss episodes on women's sexual life and function we conducted a systematic review with the purpose of identifying the available evidence on any sexual impairment associated with complications from pregnancy and childbirth. METHODS: Systematic review on aspects of women sexual life after any maternal morbidity and/or maternal near miss, during different time periods after delivery. The search was carried out until May 22(nd), 2015 including studies published from 1995 to 2015. No language or study design restrictions were applied. Maternal morbidity as exposure was split into general or severe/near miss. Female sexual outcomes evaluated were dyspareunia, Female Sexual Function Index (FSFI) scores and time to resume sexual activity after childbirth. Qualitative syntheses for outcomes were provided whenever possible. RESULTS: A total of 2,573 studies were initially identified, and 14 were included for analysis after standard selection procedures for systematic review. General morbidity was mainly related to major perineal injury (3(rd) or 4(th) degree laceration, 12 studies). A clear pattern for severity evaluation of maternal morbidity could not be distinguished, unless when a maternal near miss concept was used. Women experiencing maternal morbidity had more frequently dyspareunia and resumed sexual activity later, when compared to women without morbidity. There were no differences in FSFI scores between groups. Meta-analysis could not be performed, since included studies were too heterogeneous regarding study design, evaluation of exposure and/or outcome and time span. CONCLUSION: Investigation of long-term repercussions on women's sexual life aspects after maternal morbidity has been scarcely performed, however indicating worse outcomes for those experiencing morbidity. Further standardized evaluation of these conditions among maternal morbidity survivors may provide relevant information for clinical follow-up and reproductive planning for women.