The pilgrimage in reproductive period: a violence in the field of obstetrics

Abstract

Objective:

To describe and analyze the perceptions of women about obstetric care in reference to the attendance of their right of access to health care during the process of labor and birth.

Method:

Descriptive and exploratory study. Were interviewed 56 women in sets of four public hospitals in Metropolitan Region II of Rio de Janeiro State, developed in 2014. Data analysis were the thematic content mode.

Results:

Showed a recurring problem for women, the pilgrimage, which has three connotations about the law, lack of care and feelings experienced by women who searches service care. These points are interconnected by the logic of failure with action to ensure sexual rights, reproductive and human, in addition to unpreparedness of the institutions in providing quality care.

Conclusion:

It was found the need for changes in obstetric care paradigms, valuing respect, care to women in behalf of your health.

Keywords:
Human Rights Abuses; Patient Rights; Obstetrics; Women's Health

Resumo

Objetivo:

Analisar as percepções das mulheres acerca da assistência obstétrica no que se refere ao atendimento de seus direito de acesso ao serviço de saúde durante o processo de parto e nascimento.

Métodos:

Pesquisa descritiva, exploratória realizada 56 mulheres nos alojamentos conjuntos de quatro maternidades públicas da Região Metropolitana II do Estado do Rio de Janeiro, desenvolvida em 2014. A análise dos dados foi na modalidade temática do conteúdo.

Resultados:

Mostraram um problema recorrente para as mulheres, a peregrinação, que traz três conotações a respeito do direito, da ausência de cuidado e dos sentimentos vivenciados pela busca de atendimento. Esses pontos estão interligados pela lógica do descumprimento de ações que assegurem os direitos sexuais, reprodutivos e humanos, além do despreparo das instituições em oferecer uma assistência de qualidade.

Conclusão:

Constatou-se a necessidade de transformações nos paradigmas assistenciais obstétricos, valorizando o respeito, o cuidado à mulher em prol da sua saúde.

Palavras-chave:
Violação dos Direitos Humanos; Direitos do Paciente; Obstetrícia; Saúde da Mulher

Resumen

Objetivo:

Describir y analizar las percepciones de las mujeres acerca de la atención obstétrica en relación con el cuidado de su derecho de acceso a la asistencia sanitaria durante el proceso de parto y el nacimiento.

Métodos:

Descriptivo, exploratorio celebró 56 mujeres en grupos de cuatro hospitales públicos especiales Metropolitana Región II del Estado de Río de Janeiro, desarrollado en 2014. El análisis de datos fue el modo de contenido temático.

Resultados:

Mostró un problema recurrente para las mujeres, la peregrinación, que tiene tres connotaciones acerca de la ley, la falta de atención y sentimientos experimentados por el servicio de búsqueda. Estos puntos están interconectados por la lógica del incumplimiento de las medidas para garantizar los derechos sexuales, reproductivos y humanos, además de la falta de preparación de las instituciones en la prestación de una atención de calidad.

Conclusión:

Se encontró la necesidad de cambios en los paradigmas de atención obstétrica, valorando el respeto, la atención a las mujeres por el bien de su salud.

Palabras-clave:
Violaciones de los derechos humanos; Derechos del paciente; Obstetricia; Salud de la mujer

INTRODUCTION

In Brazil, from December 27, 2007, Law Nº 11,634, regulates the right of pregnant women to know and link maternity clinics which receive assistance under the Unified Health System (SUS), and to know and link referential maternity clinics, health services must provide women with obstetric beds at the time of birth process, avoiding the pilgrimage during antepartum and labor^1,2. However, pilgrimage remains a serious public health problem directly related to the obstacles in the quality of obstetric care and maintenance of maternal mortality rates in the country, as well as contributing to the failure of the Millennium Development Goals³ particularly to paragraph 5 (improve the quality of obstetric care).

The precariousness of care, together with the inequalities in the provision of obstetric beds becomes evident mainly by lack of investment in women's health, that prevent the construction of new hospitals and the expansion/adaptation of existing ones, resulting in difficulty of hospitals in receiving women⁴.

The implementation of the Program for Humanization of Prenatal and Birth (PHPN) in 2000, aimed to meet social demands for better quality of delivery and birth care, a theme that has been the subject of attention in various regions of the country. The aim was to promote a broad discussion⁵.

The regulation of the Stork Network, in 2011, brought up a proposal for quality of care to women, with investments of states and municipalities for the construction or suitability of maternity according to Board Resolution Nº 36 of the National Health Surveillance Agency (ANVISA), effective in obstetric services, in favor of binding assurance and women's access to maternity hospitals³. However, even with this government proposal the pilgrimage of women in the reproductive process is still present in daily hospitals⁶. Thus the quality of obstetric services becomes an important indicator for the health of women⁷.

It is possible to consider the pilgrimage of women as obstetric violence⁸ because it is directly related to its reproductive process and the annulment of their rights³. This type of violence results from the precariousness of the health system, which greatly restricts access to services offered. Thus causing many women in labor to experience a real journey in search of a place in the public hospital network. They are wandering until they experience situations bringing serious risk to their lives and those of their fetuses should this service does not occur in a timely manner⁹, favoring the negative outcomes of delivery and the increase in maternal and neonatal mortality rates.

Considering these circumstances, and with the prospected advance in the construction of knowledge on obstetric care in the country, this study aimed to describe and analyze the perceptions of women about obstetric care in relation to the care of their right of access to health services during the process of labor and birth.

METHODS

A descriptive, qualitative, exploratory study, performed in sets of four public hospitals within the Metropolitan Region II of the Rio de Janeiro State, with fifty-six participating women, being fourteen in each maternity.

In accordance with Resolution Nº 466 of 12 December 2012, the Research Ethics Committee (CEP) of the Faculty of Medicine of the University Hospital Antônio Pedro (HUAP), and the Federal Fluminense University (UFF), under Protocol Nº 375,252/2013, approved the National Health Council (CNS)¹⁰ this study.

Inclusion criteria were: be in postpartum; be at least eighteen years; have performed vaginal birth in public hospitals with greater permanence than or equal to twelve hours in shared living environment; show no physiological or psychological changes impeding participation. Exclusion criteria were: have remained in the labor room, nursing mothers, obstetric center and rooming high risk in public hospitals; have undergone caesarean section; having presented pathological postpartum and post-abortion be in situation.

Those that initially met the inclusion criteria were invited to participate and selected by simple random process, and those in obstetric beds were odd-numbered. Then these potential participants received a new invitation, explaining the subject of research and its objectives. After agreeing to participate, all signed the Informed Consent (IC) conditioning their participation, ensuring anonymity and confidentiality of information, confirmed by using an alphanumeric code (PS1... PS56), and allowed the application of data collection instrument containing open and closed questions concerning the process of access/pilgrimage aimed at labor and delivery. The technique used was the semi-structured interview and testimonies of interviewees. They were recorded on a digital handset with prior authorization, fully transcribed and validated, ensuring the reliability of what they said. The data were subjected to content analysis in the thematic mode¹¹.

We used the Registration Unit (UR) from the subject as an organization strategy for interview contents. Colorimetry made it possible to identify each UR and group them in related units, enabling an overview of the subject. The interviews gave the following UR: wave shortage and gap obstetric beds; pilgrimage process of women; women's rights; not host; lack of support on the safe transport; treatment and value judgment; negative feelings and safety in childbirth; fear of child birth on the way to motherhood; inhuman and disrespectful treatment; pain and safety in childbirth; unpreparedness of health facilities.

These UR underlie the construction of the following thematic categories: 1) The institutionalization of the pilgrimage as an obstacle to accessibility to health services: a matter of obstetric violence; 2) The pilgrimage in search of obstetric care: a violence in the care of women field; 3) Expressions and feelings of women from the pilgrimage: the experiences of the obstetric violence.

RESULTS AND DISCUSSION

The Metropolitan Region II of the State of Rio de Janeiro covers the following municipalities: Niterói, São Gonçalo, Marica, Itaboraí, Tanguá, Rio Bonito and Silva Jardim. And the Stork Network implemented since 2011, proposes a shift in attention to obstetric health, with investment from the federal government, in conjunction with the technical area of ​​women's health, the State of Health of Rio de Janeiro Secretariat and women's health coordinators from the municipalities in the implementation of the Stork Network³.

The care network for obstetric components of Metropolitan II of the State of Rio de Janeiro offers a whole of: university hospital, state hospital and six municipal hospitals in the region. The Stork Network has as one of its strategic principles the wife contacting the reference unit for labor and birth, when not guaranteed with pregnancy, pilgrimage of antepartum and delivery contacts^6,12.

The institutionalization of the pilgrimage as an obstacle to accessibility to health services: a matter of obstetric violence

The Universality described in Law 8,008/1990 means ensuring equal access to health services, and a citizen's right and duty of the State to ensure equal access. The Equity ensures the actions of health services at all levels of complexity. This concept seeks equality, since all are equal before the law; therefore, their rights should be guaranteed equally. Already Integrality conveys the concept of comprehensive care of the health user, promotion, protection and recovery, a system that meets an integral, that is a biopsychosocial being^13,14.

In this context, the term Accessibility represents an important component of a health care system, at the time of realizing the process of seeking and obtaining care. This way, health services allow its resources to be more easily used by the user¹⁵. This accessibility is related to the concepts of equity and completeness, principles that govern the guidelines of the Unified Health System (SUS), which should ensure accessibility conditions and solving the population, considering the society's health problems⁶.

Unfortunately, it is still possible to observe the pilgrimage of pregnant women due to lack of vacancy or obstetric bed in hospital units. This reality is the experiences of these women, making it a major public health problem in the network of maternal health care, as has been said. The following are statements on this respect:

When the pain was beginning, a different and increasing pain, I went to the hospital and did they not meet me and then went to another, in another city, and they also did not meet me and I came to this maternity. (PS32)

I asked to look for another maternity, and had no vacancy for admission (...) was a lack of respect to me, they would have to meet me and have a vacancy and look for another hospital (...) was a chaos (...) . And I never want to go through this situation again, I could not get a vacancy for lack of beds. (PS50)

Indeed, two factors become decisive in relation to access: the first refers to the structural conditions of the health unit of origin of this woman, the second relates to the pilgrimage to get care at a specialized clinic. It is known that the greater the distance to be covered by the woman, the harder it is access to services, and these conditions often labor in process becomes complicated and high-risk¹⁶.

A network of health care services, comprising polyarchic organizations of health services sets in which all health care points are equally important and relate horizontally; implying continuous attention at primary, secondary and tertiary levels, should determine the care for women. They are linked together by a single mission, common goals and a cooperative and interdependent action, allowing offering a continuous and comprehensive care to a given population, coordinated by the primary health care provided on time and in right place, with the cost and certain quality and humane way, and with health and economic responsibility for this population¹⁷.

In this sense, the lack of vacancies in hospital units that can not absorb their demand, caused by a shortage of obstetric beds, committed to effective care in the woman care line, for health services should be articulated horizontally, interacting with each other correlating and cooperating with actions in care during the birth process. In other words, instances of municipal, state and federal levels should be coordinated in responsibility, with knowledge, resources and technologies in support of both mother and newborn.

The dissatisfaction of some women caused by the lack of vacancies and obstetric beds, coupled with the absence of a specific line of care, makes them seek their rights. However, even as a matter of law and police support, they do not always achieve collateral assistance, as explained in the following lines:

I called the police and the girl explained that the hospital was too full, they even had people up in the chair, and I had to go to another maternity. (PS7)

Look, they have to meet me on the time, at the place and have a vacancy for me. That is my right, I pay my taxes and all but when I need a service I am entitled. (PS25)

The dissatisfaction of women is influenced by expectations they have about the care they receive, not specifically depicting the quality of care directed to them¹⁸. However, the lack of vacancies in obstetric care, the pilgrimage and not meeting their needs, says this dissatisfaction and increases the vulnerability of these women and their children. Therefore, there appears to obstetric violence to the extent that the constitutional and institutional law⁸ was not granted to them.

The pilgrimage was featured in the testimonies of the respondents who had as a reason for refusal of care on the part of health professionals, that they are not "inhabitants of the municipality." The following speeches allow characterization of the denial of care as violence against women:

The doctor said that they do not give preference to other municipalities, only to those living in the city, and the downstairs staff found it utterly absurd, he sent the police and all, as I was in labor he had more to attend me. (PS26)

When I went to another one they did not leave and did not answer me because I did not live in the city, and they could not attend me because I did not live there. I was very angry because it is a public service, and even me being of another municipality, they had to meet me and they did nothing and said that they could not meet me because it was not part of the women's council. (PS45)

It is noteworthy that the municipal health management should not only embrace a woman, but deliver services in events of imminent danger, even when not on integral demand of the municipality where she is seeking care. If the unit does not have vacancies at the time, the service should provide women with safe transportation and refer to another health unit, as the Stork Network³ Health management has the obligation to provide a place at the woman in labor, with the slogan "Always a Vacancy." Institutional violence is established to create obstacles on access to the woman's right⁸ and when the health service denies answering, it does not integrate the council's demand. By doing so, the service also denies the right to health care of women, which is constitutional and should be free from any obstacles.

The women pointed out that the condition of "being poor" was a social stigma that also posed a predisposing factor to the cancellation of their citizenship with regard to lack of access to health services:

Health is like that, we have to pass hard times for those who have no health insurance, the poor end up being that way, suffering a disregard for the people, they think of us we are thieves, and we stay that way, with nothing. (PS31)

For I have no health insurance, and would have the first opportunity, but as I have no need of it, is thus a neglect of the poor people, the same disregard, was in their hands. (PS56)

The lack of health services impedes women's access to them, violating their citizenship as it faces obstacles to enjoy the universal right to health, provided for in the Constitution of 1988. The reasons for this to occur are complex: the services may not be available or affordable, and women may be unable to find a suitable service¹⁹. Note that citizenship refers to the exercise of civil rights and social and political duties, set forth in the Constitution of the country, featuring the full awareness of the rights and obligations of every citizen. It constitutes a major achievement of reference of humanity by those who have always sought to ensure rights, freedom, best individual and collective guarantees, not conforming fronts of domination, whether of the same or of other institutions. Nevertheless, in Brazil, citizenship is far from many Brazilians, for the achievement of civil, political and social rights can not hide the drama of millions of individuals, especially women seeking access to health care²⁰.

One of the strongest rules perceived by the user on the level of practical consciousness, though often vehemently rejected in the discursive level, is that the SUS health services are seen as a sort of favor to the population, far from being an exercise in the right to citizenship. This becomes concrete through the perception of a significant disregard for them in the various interfaces with health services. Thus, the PHS users point to the fact that the image prevails that they are not seen as citizens, rights holders, but as dispossessed to which those who are in "power" do a favor^3,21. Then the pilgrimage in obstetric care becomes an ideology of accessibility in institutional violence, as a condition of citizenship is disrespected as legal guarantee.

The pilgrimage in search of obstetric care: a violation in the care of women

Failure hosts in assisting reflects the (lack of) care from professionals when they refuse to provide appropriate assistance to women:

I have not seen a hospital responsibility because they [professionals] thought I needed to be hospitalized. (PS22)

They would not suit me (...) and I could not care, they were some stupid with me (...) and did not help me at all, really not at all (...) I came to seek help and denied me service. (PS31)

This (lack of) care portrays negligence, passivity, breach of trust or duty; fail to carry out what should be done; indifferent health professionals; breach of duties imposed on the performance of any act, even refusal of assistance to the individual, all occurring when the subject does not act appropriately to protect safety³.

The carelessness, disrespect and denial of service can be observed in the daily practice of some health professionals^8,9. A reality of obstetric care in health services constitutes setting up an institutional nature of violence, caused by the lack of support in the care of women, noted in (lack of) care against the pilgrimage process⁶.

This leads to think that the host does not necessarily go through carelessness, conducting in ways punishable by the Code of Ethics of each professional. As a result, it appears that women pilgrim because of (lack of) care, ultimately negating their rights to quality care.

The disrespectful treatment, abuse and value judgments, can be seen in the experiences of women during the search process for care in hospitals, according to their reports:

The height of absurdity was the doctor talking tough with me, giving me a scolding for this situation, and in the end I think I came out as guilty, but then I left there and went with a friend to another hospital because there would have no attention from anyone. A neglect. (PS36)

And I started to complain and the nurse began to repress me and insulting me, saying he had to see it before, and how I would see it? A thick, disrespect me because of my weakness, I felt guilty at the time, more then I thought they were wrong, not me. (PS39)

According to PNHP, the host translates into cordial and respectful reception to the user seeking health services, as from her arrival, and be fully responsible for her, hearing her complaints, allowing her to express her concerns. This implies the providence of care and resolution, co-responsibility and, as appropriate, guiding her and her family, ensuring coordination with other health services for continuity of care when necessary. Desiring a transversal process, permeating all areas of service and the network, the host should be seen by all teams as an opportunity to better listen to and serve the unique needs of women^6,22 instead of uttering power related statements that make her feel guilty as a result of judgments about the lack of care.

Although power relations of inequality mark the professional/user interaction, involving various health professionals in general, inequality can be transformed into related violence because they are women, annulling them as subjects of rights, particularly sexual, reproductive and human rights. This form of violence may be constituted by acts of neglect, physical abuse, psychological, verbal and even sexual violence. In such cases, violence means an exercise of power and authority, set up by the dominant ideology, with rules to determine social roles for men and women based on the sexual difference²³. Which is in line with the statements mentioned above.

The institutional violence experienced during the pilgrimage goes through the omission of maternal care⁸, exacerbated by insults, humiliations, insults, disrespect, discrimination and scapegoating, which occur because of this unequal relationship²³, featuring a sort of unjustified violence. Moreover, the gap of skilled obstetric care offered to women, can be seen in their statements about the lack of commitment to maternal health, as the unit does not accept responsibility for the safe transport provided to the unit that has an available seat, passing the measures related to this initiative to the women themselves and their families:

Because I had to take a taxi and had no money and had to borrow, it was an inconvenience. (PS2)

But it does not occur, it must be with us all running after service, paying cabs without help from anyone, no ambulance to take us, she was in pain and it would help. (PS20)

The search for care by a woman at birth makes her go through various health services to achieve it. This occurs due to lack of vacancies in those units that, in most cases, are specialized, and the woman ends up wandering in search for a maternity making use of own resources, favoring the rise in rates of complications during childbirth²⁴ as a result of stress. Note that transportation to the referral center for obstetric care should be carried out by secure transport, and monitored by trained health workers, as recommended by the Stork Network³.

Expressions and feelings of women from the pilgrimage: the experience of obstetric violence

Women, along the way, experienced numerous negative feelings like fear, anger, anxiety, apprehension, stress and nervousness, among others that directly affect the physiology of labor, such as security, and could make it an unsafe event:

It was horrible this feeling, because I could have my son right there (...) It was horrible because there is no hospital near (...) if I had my son he would be born close to home (...) I was nervous, afraid, for I knew not where my son would be born. (PS1)

Scared, anxious, I was very nervous, and when I came here, it took a while to calm down, and I calmed me to have my daughter, only after the end of suffering. (PS30)

Psychological order effects experienced during the pilgrimage directly contribute to a process of unsafe childbirth, especially by the action of adrenaline produced by the body when under stress. In this case, there is a negative impact on labor and delivery, since the female organism inhibits hormone release of endogenous oxytocin for adrenergic action, preventing the woman to have a safer delivery and a pleasurable and quieter experience²⁵. This hormone acts directly in the uterine contractility, favoring the effacement and dilation of the uterus, but in the presence of these feelings of insecurity occurs inhibition of oxytocin by adrenergic action, contributing to an unsafe labor birth, especially in the second stage of labor.

The pilgrimage linked directly to stress, as described in the testimonies of women, favoring the uncertainty about where they would give birth, a fact that becomes an obstetric psychological violence, carried out due to an institutional conduct that caused feelings of abandonment, insecurity and emotional instability⁸, highly damaging factors to a safe delivery. In addition to the disrespect, women complained of inhumanity to which they were subjected as a result of the pilgrimage process as reported:

I felt humiliated! (...) Ah!, We are human beings and not animals, an animal (...) so I think that they should have attended me the first time I went, but it did not happen. (PS8)

Let us start like a waste, do not give legal service, and this delay in deciding what to do was agonizing, I waited about three hours with no available bed as the nurse told me at the end that had no vacancy. (PS36)

The disrespectful treatment prevails in unethical conduct of many health professionals, contrary to the principles of Humanization of Assistance Policy, and is an assault to sexual, reproductive and human rights⁹ characterizing as obstetric violence^3,8 of psychological character for causing emotional instability in women, in such a special moment of life. The sense of abandonment they experienced during the pilgrimage^23,26 provides opportunities for negative feelings, leaving them vulnerable to a hostile practice, violent and full of humiliation^3,26 in addition to directly affect the physiology of labor and may result in unfavorable outcomes for labor and birth:

And I disrespected, my situation was fragile [cry] with a lot of pain and despair to have my daughter in hospital and then the second was even more desperate (...) a horrible feeling not getting what you wanted, be admitted to have your child, and the pain only increasing and increasing. (PS13)

And when he said they [do not have room] I almost died of despair [crying], I felt such great anguish, the pain increased and I was not admitted, and I came here and to have the support that others had denied me. (PS29)

As stated, the hormone oxytocin inhibition of the action of adrenaline on the woman's body, makes her feel more pain during the birth process. The intensity of pain depends on the ability of each individual to support it, but during the process of labor and birth, can characterize fetal distress, making childbirth an unsafe event caused by the inhibitory action of birth hormones. In addition, it is important that women's pain during childbirth can be enhanced on the occurrence of stress, discomfort, fear and insecurity, among other negative feelings, especially if they come to light as a result of the pilgrimage, considered a psychological character of violence^3,8,25,27.

Therefore, it is necessary to reflect on the care offered to women, but also about the infrastructure and obstetric logistics processes, which will certainly contribute to a safe obstetric care, without pilgrimage and violence, thus ensuring sexual, reproductive and human rights for women.

CONCLUSION

At present, obstetrical care offered during the birth process is seen as a challenge to public policy in the field of women's health, especially with regard to their rights established in relation to equal access to obstetric health services. As a result, the pilgrimage during the process of labor and birth, allows to experience a veiled violence occasionally conniving with the cancellation of their rights before a quality of care, with the guarantee of admission and meet their needs, beyond carefully targeted based on a cozy logical, humane and responsible to mother and newborn.

The woman's pilgrimage to delivery care is proving to be a real public health problem because of the lack of vacancies and obstetric beds, impediments to a qualified and problem-solving assistance. The solution to this problem permeates the change in investment pact of instances of network care, care co-responsibility, and respect for women's rights.

It is necessary for health services to ensure pregnant women's access to necessary assistance as well as security of birth and reduction of maternal and perinatal mortality processes. This should be done with the accountability of care; so in case there is no place in the institution at the time the pregnant woman need, it is necessary to provide safe transportation to another unit, ensuring accountability for ensuring her place.

The importance of a continuous evaluation of obstetrical care offered by the services is understood, but this should be monitored from the implementation of policies directed to humanization of obstetric care, passing the prevention and minimization of situations of violence during the reproductive period. The continuous and ongoing evaluation of obstetric care will allow the improvement of maternal morbidity and mortality indicators, and also portray the main problems to be focused on like a prioritization policy and humanization of obstetric care.

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Publication Dates

• Publication in this collection
  Oct-Dec 2015

History

• Received
  21 Sept 2015
• Accepted
  23 Nov 2015