Delivery in adolescents: qualitative factors of care

Abstracts

O estudo buscou conhecer o que as adolescentes entendem como assistência adequada ao parto. Dados coletados através de entrevista individual com as adolescentes que tiveram seu parto em um Hospital Universitário do sul do Brasil, entre julho de 2008 e outubro de 2009Foi efetuada uma análise temática, que se baseou nas preconizações do Ministério da Saúde sobre o parto humanizado. Despontaram núcleos temáticos relacionados à necessidade de atenção, de orientação e de respeito. A atenção apareceu como elemento significativo e primordial, caracterizada pela compreensão, diálogo e participação ativa no processo de parir, assinalada pelo pronto atendimento às solicitações, compreensão pelo fato de desconhecerem as rotinas e procedimentos, interação com a equipe, sem serem simplesmente visualizadas como sujeitos passivos.

Adolescente; Parto, Parto humanizado; Enfermagem obstétrica

ARTIGO ORIGINAL

Delivery in adolescents: qualitative factors of care

Parto de adolescentes: elementos cualitativos de la atención

Cleci de Fátima Enderle^I; Nalú Pereira da Costa Kerber^II; Lulie Rosane Odeh Susin^III; Bruna Goulart Gonçalves^IV

^IMaster in Health Sciences, Universidade Federal do Rio Grande. RN, Hospital Universitário Dr. Miguel Riet Corrêa Jr. Member of the Research Group Viver Mulher with the Program for Graduate Studies in Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IIRN. Ph.D. in Nursing. Faculty of the School of Nursing and the Graduate Program in Nursing, Universidade Federal do Rio Grande. Head of the Research Group Viver Mulher. Rio Grande, RS, Brazil. [e-mail]

^IIIPhysician. Ph.D. in Medical Sciences, Universidade Federal do Rio Grande do Sul. Faculty of the College of Medicine and the Master in Health Sciences Course, Universidade Federal do Rio Grande. Member of the Research Group Viver Mulher, of the Graduate Program in Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IVMaster's Student of the Graduate Program in Nursing, Universidade Federal do Rio Grande. CAPES Fellow. RN, Hospital Santa Casa. Member of the Research Group Viver Mulher of the Graduate Program in Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. brunaggonç[e-mail]

^{Correspondence addressed}

ABSTRACT

The objective of this study was to learn what adolescents understand as appropriate delivery care. Data were collected through individual interviews with adolescents who delivered at a University Hospital in southern Brazil, between July 2008 and October 2009. A thematic analysis was performed, based on the recommendations of the Ministry of Health regarding humanized delivery. Theme nuclei emerged related to the need for care, guidance and respect. Care appeared as a significant and primordial factor, characterized by understanding, dialogue and an active participation in the delivery process, marked by a timely attention to their needs, understanding their unfamiliarity with the routines and procedures, having a good interaction with the team and not being seen as passive subjects.

Descriptors: Adolescent; Parturition; Humanizing delivery; Obstetrical nursing

RESUMEN

El estudio buscó conocer lo que las adolescentes entienden como atención adecuada al parto. Datos recolectados a través de entrevista individual con adolescentes que tuvieron su parto en un Hospital Universitario del sur de Brasil, entre julio 2008 y octubre 2009. Fue efectuado un análisis temático, que se basó en las recomendaciones del Ministerio de Salud sobre parto humanizado. Asomaron núcleos temáticos relacionados a la necesidad de atención de orientación y de respeto. La atención apareció como elemento significativo y primordial, caracterizada por la comprensión, diálogo y participación activa en el proceso de parto, señalada por la rápida atención a las solicitudes, comprensión por el hecho de desconocer las rutinas y procedimientos, interacción con el equipo, sin ser simplemente visualizadas como sujetos pasivos.

Descriptores: Adolescente; Parto; Parto humanizado; Enfermería obstétrica

INTRODUCTION

The Brazilian Ministry of Health, through the Adolescent Health Program (Programa de Saúde do Adolescente - PROSAD), defines adolescence as a period in life characterized by growth and development manifested by anatomical, physiological and psychosocial changes, within the ages of 10 and 19 years. Adopting a chronological criterion makes it easier to identify the requirements that guide an epidemiological research, as well as to create policy strategies for collective development and to plan social and public health services⁽¹⁾.

The age of sexual initiation has been decreasing systematically, and it often occurs in considerably unfavorable social situations. The effect of this condition is that the sexual experience is often followed by pregnancy. Multiple causes are associated with the frequency of pregnancy in adolescence. The following are the most discussed in the literature: early sexual maturation; starting sex life earlier; lack of knowledge regarding contraception; getting married at an older age; weak family guardianship; and an accelerated urbanization process, with a significant change in lifestyle⁽²⁾.

A large number of adolescents have experienced pregnancy, as confirmed by the data reported by the Brazilian Ministry of Health in 2005, which states that 21.8% of the deliveries performed in the national public health system (Sistema Único de Saúde - SUS) were of adolescents with between 10 and 19 years of age⁽¹⁾, and the adolescent fertility rate, in 2006, increased in 0.14 in the lowest social classes⁽³⁾. In the city of Rio Grande, data from 2007 show there were 2,584 hospital births, 506 (19.9 %) of which were of women younger than 20 years of age. This mean rate was maintained in 2008, with 2,506 births with 516 (20.2%) being of women of ages between 10 and 19 years⁽⁴⁾.

Based on these considerations, it becomes clear that it is important to establish public policies aimed at this particular clientele, with the purpose of providing contextualized, quality care founded on the principles of health care humanization.

The Brazilian Ministry of Health, seeking to improve humanized obstetrical and neonatal care, established, in the year 2000, a program for the humanization of prenatal care and birth (Programa de Humanização no Pré-Natal e Nascimento - PHPN), with the objective to guarantee better accessibility to coverage and quality of prenatal follow up, and care during delivery and the postpartum period. This document focuses mainly on women and on rescuing their dignity during the labor and delivery process, aiming to effectively change the model of care that is used during pregnancy, delivery, and in the postpartum period⁽⁵⁾.

The implementation of the PHPN program for the humanization of prenatal care and childbirth is considered a landmark, a watershed event, because it permitted to address the change of behaviors and procedures used at health care services, once the program prioritizes on vaginal delivery, non-medicalization, and on reducing surgical interventions. The program adopts a critical attitude towards procedures that cause a depersonalization of women, and performing unnecessary cesareans, while encouraging the process of active delivery as a physiological event⁽⁶⁾.

Although the PHPN program is a promising health care policy in the sense of improving the quality of health care from prenatal to delivery, it does not consider the specificities of the adolescent parturient. We observed there is a gap regarding studies developed directly with this clientele, considering that a small number of authors address this issue.

One of the located studies aimed at understanding the meaning that humanized delivery had for the adolescents and found how important it is to act with respect and dignity toward others⁽⁷⁾. It highlights the role of the health team in this process, including in the search for reducing the number of rules and routines that, according to the authors, are found to be excessive in health institutions.

In another investigation, performed with the objective to understand the experience of adolescent primiparae regarding delivery, the statements demonstrated that the strange environment of the pre-delivery and delivery rooms increase their feelings of loneliness and their fear of pain⁽⁸⁾. The claimed that health care professionals keep a distance from adolescents, in the sense of understanding the meaning of this type of experience, valuing technical aspects over their relationship with the subjects.

Taking into consideration the particularities inherent to this category, in addition to the situation in Rio Grande, and with the purpose to guarantee that every adolescent can have a safe delivery, with all their rights assured by health care policies, the objective of this study was to learn what adolescents understand by appropriate delivery care.

METHOD

The present study is an except from the database of the multicenter macro research, involving Universidade Federal do Rio Grande (FURG), Universidade Federal de Pelotas (UFPEL) and Faculdade Santa Clara in Santa Maria (FASCLA). The macro research uses a quanti-qualitative approach to investigate the delivery care to adolescents at the University Hospitals of the referred institutions, with data collection performed from July 2008 to October 2009. The databank is comprised of semi-structured interviews performed with the adolescents who were cared for during labor at the SUS (national public health system) Birthing Center (BC), with their relatives or companions present at the hospital, waiting for the end of the birth process, with health care workers of the BCs, their administrators, and also data collected through a survey of the medical records of the adolescent subjects. We inform that the adolescents were excluded from the study in case there was stillbirth, aiming to preserve their emotional integrity.

The present study used a qualitative approach and considered data there were collected using interviews with adolescents had childbirth at the BCs of the University Hospital of Universidade Federal do Rio Grande, with a total 269 interviews. All the interviews comprising the databank were read to find consistency between the answers, in order to make a trustworthy reproduction of the population of pregnant adolescents in face of the addressed issue. Because of the significant number of subjects, we chose to present the frequency of the answers so the reader can have a better view of the significance of the statements.

We used the following question from the research instrument: What do you consider to be ideal, quality care in the moments while a pregnant woman stays in the birthing center? Based on the reports provided by the women, subjects of the care, about how they would like to be treated in this health care setting, it is possible to think about how they understand the humanization of childbirth.

The macro research, from which the present study originates, was approved by the Research Ethics Committee at Universidade Federal do Rio Grande (document number 31/2008). The adolescent and her legal guardian were informed about the study, and that their names would be kept confidential and they could withdraw from the study at any time. All subjects provided written consent by signing the Free and Informed Consent Form.

The data was subjected to thematic analysis, following the recommended steps of repeated reading, organizing and ordering of data, in order to find consistency between the findings⁽⁹⁾. As a way to facilitate the visualization of these findings, the data with a greater frequency of repetition were organized into categories and, then, grouped by similarity into the following themes: need for attention, need for guidance, and need for respect. Therefore, the analysis was performed according to the recommendations of the Brazilian Ministry of Health and listed on the PHPN program, which emphasize confirming the women's rights, proposing humanization as a strategy to improve the quality of health care.

RESULTS

Before starting the presentation of the themes, we chose to provide a clear view of the categories that stood out when reading the statements. They are presented in Table 1.

By combining the categories according to their similarity, the referred themes stood out, showing the specific needs mentioned in the adolescents' statements. To improve the presented results, some of the statements were transcribed with the purpose of illustrating each aspect.

NEED FOR ATTENTION

This theme comprises the needs for attention and the presence of a companion or having someone near. As shown in Table 1, most adolescents (26.4%) reported attention as the number one item of importance in delivery care.

Oh, they have to give us attention, because, sometimes, we ask and they don't come (AF032).

(...) understand that we are scared and give us attention (AF123).

Attention, calm us down, because it is a difficult moment (AF221).

The presence of a companion during the labor and delivery process was reported by about 13% of the adolescents as an important factor of health care, which makes them feel more secure, and supported both physically and emotionally.

Oh! In this case I think they should let my mother come in, they really should. We should be allowed to have a companion (AF004).

(...) we should be allowed a companion, a relative, especially because we are minors (AF018).

Oh! I think a relative should be allowed to stay here as a companion, because the person leaves us, we feel pain, I think this is the only problem (AF033).

Other subject reported the importance of having someone near (4.5%), holding her hand, being there, so they can talk, and not feel lonely. The following statements illustrate this finding:

What I liked there was that there was always someone near, there was a nurse who would tell me that's how it really was supposed to be, so I calmed down a little, I wasn't so insecure (AF011).

Preferably a nurse by my side would be good, I don't know why, but it would be good (...) (AF040).

Having someone next to you to explain what is going on (AF103).

NEED FOR GUIDANCE

The statements reveal that the parturients have a need to feel they are part of the care process, that they are true participants. In Chart 1, it is observed that 15.5% of the adolescents associated ideal care to the right to information and guidance.

The ideal condition would be for them to explain better, talk more about it. They just leave you there and go do other things, and you are left there wondering what you should expect. I think they should explain better: "Now you are going to stay here, then you are going there...", so they don't make you anxious (AF060).

There should always be someone there to give you information, when examining me they should give me information, like: there is dilation, there isn't dilation, more dialogue (AF069).

I think that explaining how you are, inform you (AF194).

The requested information also refers to the relatives who are waiting for news. The parturients' insecurity about their relatives receiving news about their condition and the evolution of the labor and delivery process, about how long it will take until the baby is born, if it will be a natural childbirth or cesarean, increases their anxiety, because being separated from their relatives makes them want to know what is going on, so they can feel supported and secure.

Regarding my relatives, they should receive more attention because they are nervous out there on the street (...). They could at least go to the door and give them some news every once in a while, that way they wouldn't come knocking at the door all the time (AF027).

(...) they shouldn't leave relatives without any news (AF234).

NEED FOR RESPECT

To better translate the adolescents' opinions about this theme, the categories patience, respect, asking for their opinion, and privacy were joined in this single group, accounting for 23.2 % of the interviewees.

Being patient appears in the statements outlining an association with their fear of the unknown, and their lack of preparation in face of the eminent delivery. Labor pain appears as something very strong and difficult to overcome. They expect more affection and understanding in view of their lack of preparation and the many doubts they have regarding the evolution of labor and delivery.

I whish they would be a little more patient with us, and that they would answer what we ask them. Even the doctor, I told him I was in pain, that I couldn't take it anymore (...) and he ways on the bed, watching TV (...) he couldn't even say to me: calm down, little girl (...) (F013).

To make us calmer and show more understating (...) (AF065).

I wish people wouldn't keep yelling at us. They should be calm, patient (AF 122).

According to the subjects' statements, in their experience as parturients they did not see any respect from health team members. In fact, in the following statements it is observed that the adolescents were actually mistreated in a moment of their lives considered so delicate and important.

The ideal situation would be if they had treated me with more respect, I am sure it would have been better (...) (AF006).

(...) aside from the rudeness of the doctors the rest was fine, I just think the doctor could be more polite (AF039).

Treating well and not swearing ( AF119).

The parturients stress the fact that there were never consulted about the procedures that the team would perform on their body, neither did they ask their opinion and collaboration in the delivery process.

(...) If they had asked my opinion, they did whatever they wanted and never asked my opinion (AF006).

(...) I'm a first-time mother and they didn't inform me about anything, about what they were going to do with me; they just told me I had to push, but I didn't feel any contraction, I didn't even feel pain (AF018).

(...) they don't explain anything to us; I even thought I was going to die because they took me to get a cesarean and only then they told me I couldn't give birth naturally. I didn't even know what was going on. They should explain things better (AF257).

Regarding privacy, few adolescents stated this issue as being important during the delivery. However, those who did state this factor where very emphatic about it, stating they felt uncomfortable when their privacy was not respected.

(...) there should be fewer people in the delivery room, I don't know, I think there were like eight people in there, and then they called in another doctor (AF018).

I don't even know, because it was my first time (...), all I know is there were too many people (AF056).

To complete the presentation of the results, it is necessary to state that, during the interview, some adolescents (17%) preferred not to express their opinion about what they consider to be ideal, quality care while they were at the birthing center. Some said that the way they were cared for was appropriate, but did not know what to say about it. This part of the subjects, therefore, did not make any contributions for the study objective.

DISCUSSION

As observed in the interviews, the factor that stands out in the statements is lack of attention in delivery care. The clients realized this need when they called out to the health care professionals working at the BC and were not immediately answered. On the other hand, it is demonstrated that the health team sees pain as natural, and assume that nothing can be done to reduce it. In this sense, the women state that they could only wait for the baby to be born so their suffering could be reduced.

When pain increases, the sensation perceived by the adolescents is that the baby is about to be born, and they feel lonely, because the health care professionals are busy with other activities and act as mere spectators of the labor process. It appears that the professionals do not realize that this type of situation, common in their daily work environment, is far from being common to these young women, who realize they are scared in face of the moment they are living. The interpersonal relationships established while following the labor and delivery process are capable of reducing the mothers' stress, comparable to medical and pharmacological resources⁽¹⁰⁾.

The statements reveal that the greatest desire of these parturients is, simply, to have "someone" to hold their hand, calm them down, and help them feel secure and comfortable. It is extremely important that health professionals stay close to them, tailoring the care⁽¹¹⁾.

The care that the adolescents receive from the professionals was highlighted in one study, as a reference of health care quality, in almost every report⁽¹⁰⁾. Similarly, the adolescents reported that being continuously accompanied by someone was a care differential.

It is also necessary to discuss the health professionals' reactions to the women losing control when in pain, with reprimanding attitudes, or being impersonal, and determined pre-established conducts and behaviors, and practices proven to be harmful. The delay to adopt measures that minimize pain and discomfort in the prepartum period appears to be associated with the quality of the interpersonal relationships with health care professionals^(8,12).

In fact, there is a group of factors that intensifies the need for attention as referred by the adolescents: strange environment; strange people; too much pain; observing other women in labor, some expressing pain and suffering through screams, thus favoring the appearance of fear.

In this sense, another aspect emerges, which is considered indispensible to guarantee the quality of care: the presence of a companion. The companion is seen as a person who, by being constantly at her side, could offer support, calm, and encouragement during labor. The adolescents understand that, this way, they would not feel lonely, and this could reduce their fear of being in a strange environment. The presence of companion chosen by the patient is a right protected by law⁽¹³⁾, guaranteed to every woman. Regarding pregnant adolescents, the Children and Adolescents Statute (Estatuto da Criança e do Adolescente - ECA) guarantees the presence of a companion, identified as their legal guardian, while the health care is being provided⁽¹⁴⁾.

Regarding the presence of a companion, some studies^(11,15) discuss about the initial resistance of the team to accept their presence. The professionals state several reasons, which include emotional and social aspects associated to the companion and the patient's condition, not including any problem caused by functional or structural limitations of the institution, which demonstrates the lack of preparation of the staff.

It is a general understanding that a woman in labor should be accompanied by people she trusts, which whim she feels comfortable and safe, such as her partner, mother, best friend or a doula. We emphasize that the BC of the institution where the present study was performed is small, with a collective prepartum room, with beds separated only by curtains as a way to preserve the parturients' privacy. This factor can be a drawback to guarantee the right to having a companion.

The presence of the companion in the delivery room surpasses all physical barriers, and health care professionals must be aware of their role, be prepared to establish a relationship with that new client, which demands them to review their concepts⁽¹⁶⁾.

The statements of the adolescents soon included the need for information/guidance, for them to feel included in the care, becoming true participants of the process, and not mere spectators. The interaction established through the relationship with the professionals has a strong influence on their satisfaction with the delivery. The team has an important role in helping to reduce the women's fear and anxiety, promoting the necessary tranquility and permitting them experience the emotion of birth⁽¹⁵⁾.

Another role of the health care professionals, which is extremely relevant, is to prepare the parturients by providing information, which established the necessary condition for women to make choices, and be free to choose or refuse any procedure involving their bodies, provided this choice is pertinent and consistent with her well-being. The right to decide and give opinions appropriately will cease to exist if the information is not provided or of poor quality⁽¹⁷⁾.

The need for information and explanations is extensive to relatives, who are waiting for news, and because they do not receive any, become uncomfortable, unsure and insecure, as do the pregnant adolescents. It is understood that in cases there are truly no chances to guarantee the presence of a companion, as in cases of structural problems at the service, the staff should maintain a continuous channel of communication with the relatives, thus guaranteeing they receive information about the health care process that is taking place in the BC.

The adolescents in labor are weakened, and need to be welcomed with calm and understanding. In their statements, they report thee need for the team to be more patient, and to respect each adolescent's timing regarding contraction pain. Many professionals are unable to understand the lack of preparation of these women when they arrive to give birth to their children and lose their patience when they do not correspond or collaborate with what is proposed, i.e., routines and protocols. Treating the puerperae well and meeting their needs through conversation and interactivity are the main aspects of humanization⁽¹⁸⁾.

Regarding their need for respect and privacy, which was considered to be an important factor because it causes discomfort and insecurity when not observed from the team, it is important to contextualize the study location where the interviews were performed, i.e., a University Hospital, with the continuous presence of students in their learning process, and thus makes this aspect of privacy more apparent. Another aspect referring to the need for respect is implied in the decision-making process, in which the parturients are not include, and, in their opinion, the act of sharing decisions and valuing their opinion is indispensible to guarantee quality and satisfactory care.

Respecting also involves listening to what others have to say, respecting their beliefs and values, considering the principles of bioethics and the beneficence and non-maleficence⁽¹⁹⁾. Bioethical principles help and guide actions in health care so that patients are respected in a more natural way⁽²⁰⁾. Working with respect implies to perform humanized actions, seeing human beings as biopsychosocial and spiritual agents.

In their statements, health professionals usually emphasize that the woman's help in the labor is welcome, but, in reality, they act as if they remained hostages of the technique because they depend on the care⁽⁶⁾. The author also states that the view of health care professionals is that women can help without interfering or giving their opinion; and, therefore, silence them and maintain them isolated and do not include them as participants.

The good relationship between the pregnant women and the team professionals is essential for the humanization process, characterized by communication, empathy, knowledge, and respect for others⁽¹⁷⁾.

Women must be welcomed with respect, and given the opportunity to ask questions, and get the answers. They must be recognized as someone who has their own will and opinion, and can share their joys, fears and uncertainties regarding the pregnancy with the staff. Humanized delivery should be seen as an event filled with meanings for women, their family and for the professional assisting them, and not as a medical procedure⁽²¹⁾.

The process of humanization and the changes that occur in delivery care were only possible due to the imposition of public policies. It is believed that, for these actions to be successful, there must be a change in paradigms, in which women are the center of the process⁽²²⁾ and it appears there is still a long road to achieving that goal.

Finally, regarding the adolescents that chose not to express their opinion, some factors that might explain this attitude is their emotional state, the stress of the moment, the weakness inherent to their young age. We believe that one motivating factor of the adolescents' difficulty to answer may be associated with a possible constraint to give their opinions while still hospitalized. The user satisfaction survey, when performed within the institution when the health care took place should take into consideration the bias by factors such as fear of the team, or their overestimation of a happy outcome⁽¹⁵⁾. On the other hand, it is worth recalling that the proximity with the moment of health care is favorable to details. Therefore, it is understood that it was possible to reach a view based on the reports of the other participants, by means of the diversity of analysis elements they presented.

CONCLUSION

It is understood that the adolescents, weakened by the situation of being hospitalized for the delivery, did not receive a good welcome, with patients, attention and affection, they were not given the minimal information and did not feel respects as subjects with rights. Therefore, we understand that the evolution of labor becomes difficult for all those involved, because the adolescents' collaboration is of utmost importance for the outcome of the birth.

Most adolescents reported that attention is a significant and key element of ideal care, which is characterized by answering request immediately, understanding the fact that they are unaware of the routines and procedures, interacting with the team, talking, participating, contributing with the birth process, and not simply being passive subjects.

We understand that when talking about humanization of childbirth, it is important to provide women control over their body, let the physiological nature act, follow the birth with the minimal intervention possible, while always offering support, orientation, and information, always being next to these women. Allowing them to assume the leading role of heir child's birth, because even in cases of inexperienced adolescents, it is observed that they with to become active participants of their deliveries.

In conclusion, the care that the adolescents desire is one in which delivery care is also centered on the individuality of each parturient. Professionals should believe in each woman's potential to conduce labor provided they receive the appropriate orientation, with patience, affection, and understanding. This way, health care can be less focused to accomplishing norms and routines, and more founded on the individual needs of each adolescent, taking their individual specificities and characteristics into consideration.

This study permitted to learn what the adolescent patients understand by an ideal delivery care, i.e., they desire attention, guidance and respect. Having hold of this information, it is possible to identify the weaknesses of the service in view of the recommendations of the Brazilian Ministry of Health for the humanization of childbirth, and it is understood that it is necessary to get the whole health team involved so they learn the study results and can help make the necessary changes, so this policy can be effectively implemented.

The implementation of policies and governmental programs aimed to improve the quality and humanization of childbirth is increasing in Brazil, and the number of studies on this issue is also on the rise. This demonstrates the importance of this theme and the interest towards it, although most studies have a broad approach, and do not aim specifically at adolescents.

Studies about the humanization of childbirth have made great contributions to reviewing and criticizing the current technocratic, curative, and specialist health care model. They propose changes to the technical-scientific paradigm in health practice and education, permitting to review attitudes towards human rights and the power relationships between health care professionals and clients.

REFERENCES

1. Brasil. Ministério da Saúde; Secretaria de Atenção à Saúde; Departamento de Ações Programáticas Estratégicas. Pré-natal e puerpério: atenção qualificada e humanizada [Internet]. Brasília; 2005 [citado 2010 nov. 12]. Disponível em: http://dtr2001.saude.gov.br/editora/produtos/livros/pdf/05_0151_M.pdf

2. Federação Brasileira das Associações de Ginecologia e Obstetrícia (FEBRASCO). Gravidez na adolescência: manual de orientação. São Paulo; 2009.

3. Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais [Internet]. Rio de Janeiro; 2010 [citado 2010 dez. 12]. Disponível em:

http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/indicadoresminimos/

sinteseindicsociais2010/default.shtm

4. Rio Grande do Sul. Secretaria da Saúde; Núcleo de Informações em Saúde. Estatísticas de nascimento [Internet]. Porto Alegre; 2007 [citado 2010 nov. 12]. Disponível em: http://www.saude.rs.gov.br/wsa/portal/index.jsp? menu=organograma&cod =746

5. Brasil. Ministério da Saúde. Portaria GM/MS n. 569, de 1º de junho de 2000. Institui o Programa de Humanização no Pré-Natal e Nascimento no âmbito do Sistema Único de Saúde [Internet]. Brasília; 2000 [citado 2010 nov. 13]. Disponível em:

http://www.saude.mg.gov.br/atos_normativos/legislacao-sanitaria/estabelecimentos-de-saude/

atendimento-humanizado/Portaria_569.pdf

6. Griboski RA, Guilbem D. Mulheres e profissionais de saúde: imaginário cultural na humanização ao parto e nascimento. Texto Contexto Enferm. 2006;15(1):107-14.

7. Oliveira ZMLP, Madeira AMF. Vivenciando o parto humanizado: um estudo fenomenológico sob a ótica de adolescentes. Rev Esc Enferm USP. 2002;36(2):133-40.

8. Silva MO, Lopes RLM, Diniz NMF. Vivência do parto normal em adolescentes. Rev Bras Enferm. 2004;57(5):596-600.

9. Minayo MC. O desafio do conhecimento: pesquisa qualitativa em saúde. 10ª ed. São Paulo: Hucitec; 2007.

10. Rodrigues AV, Siqueira AAF. Sobre as dores e temores do parto: dimensões de uma escuta. Rev Bras Saúde Matern Infant. 2008;8(2):179-86.

11. Nagahama EEI, Santiago SM. Práticas de atenção ao parto e os desafios para humanização do cuidado em dois hospitais vinculados ao sistema único de saúde em município da região Sul do Brasil. Cad Saúde Pública. 2008;24(8):1859-68.

12. Almeida CAL, Tanaka OY. Perspectiva das mulheres na avaliação do Programa de Humanização do Pré-Natal e Nascimento. Rev Saúde Pública. 2009;43(1):98-104.

13. Brasil. Lei n. 11.108, de 7 de abril de 2005. Altera a Lei no 8.080, de 19 de setembro de 1990, para garantir as parturientes o direito a presença de acompanhante durante o trabalho de parto e pós-parto imediato, no âmbito do Sistema Único de Saúde – SUS [Internet]. Brasília; 2005 [citado 2010 nov. 13]. Disponível em: http://www.planalto.gov.br/ccivil_03/_Ato2004-2006/2005/Lei/L11108.htm

14. Brasil. Lei n. 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências [Internet]. Lei Brasília; 1990 [citado 2010 out. 14]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/L8069.htm

15. Queiroz MVO, Jorge MSB, Marques JF, Cavalcante AM, Moreira KAP. Indicadores de qualidade da assistência ao nascimento baseados na satisfação de puérperas. Texto Contexto Enferm. 2007;16(3):479-87.

16. Longo C, Andraus L, Barbosa M. Participação do acompanhante na humanização do parto e sua relação com a equipe de saúde. Rev Eletr Enferm [Internet]. 2010 [citado 2010 set. 23]; 12(2):386-91. Disponível em: www.revistas.ufg.br/index.php/fen/article/view/5266/6945

17. Machado NXS, Praça NS. Centro de Parto Normal e Assistência Obstétrica centrada nas necessidades da parturiente. Rev Esc Enferm USP. 2006;40(2):274-9.

18. Queiroz MVO, Silva AO, Jorge MSB. Cuidado de enfermagem à puérpera em uma unidade de internação obstétrica: perspectivas de humanização. Rev Baiana Enferm. 2003;18(1/2): 29-37.

19. Anjos MF. Dignidade humana em debate. Bioética. 2004;12(1):109-14.

20. Barbosa IA, Silva MJP. Cuidado humanizado de enfermagem: o agir com respeito em um hospital universitário. Rev Bras Enferm. 2007;60(5):546-51.

21. Dias MAB, Deslandes SF. Expectativas sobre a assistência ao parto de mulheres usuárias de uma maternidade pública do Rio de Janeiro, Brasil: os desafios de uma política pública de humanização da assistência. Cad Saúde Pública. 2006;22(12):2647-55.

22. Castro JC, Clapis MJ. Parto humanizado na percepção das enfermeiras obstétricas envolvidas com a assistência ao parto. Rev Latino Am Enferm. 2005;13(6):960-7.

Correspondence addressed to:

Cleci de Fátima Enderle

Rua General Vitorino, 174 - Centro

CEP 96200-310 - Rio Grande, RS, Brasil

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  23 Feb 2011
• Accepted
  13 July 2011