Individual birth planning as a teaching-learning strategy for good practices in obstetric care

ABSTRACT

Objective

To verify students’ knowledge about individual birth planning and learn their opinion about the use of this teaching-learning strategy for good obstetric practices.

Method

This is a descriptive study conducted with midwifery students who made primary health care internships. Data collection was performed digitally from 01/2017 to 05/2017 through the Google Forms^®Platform. The analysis was performed by descriptive categorization statistics of statements. The study followed the required ethical standards.

Results

The form was sent to 97 students and answered by 40% of them. All respondents reported knowing the birth planning, and 87% applied it during prenatal care. The most frequent (45%) points about the birth plan were those that promoted women’s empowerment and autonomy. The most cited methodological suggestions for its application were to focus on content (76%) and increase the number of meetings (50%). Individual birth planning was recognized by 79% of the participants as an important teaching strategy.

Conclusion

In addition to knowing birth planning and applying it, the students consider it very relevant for teaching and learning good obstetrical practices.

Humanizing Delivery; Education, Higher; Evidence-Based Practice; Obstetric Nursing

RESUMO

Objetivo

Verificar o conhecimento de estudantes sobre o plano individual de parto e conhecer sua opinião a respeito da utilização dessa estratégia de ensino-aprendizagem e das boas práticas obstétricas.

Método

Estudo descritivo, com alunos de Obstetrícia que cursavam estágios na atenção básica. A coleta dos dados realizada de 01/2017 a 05/2017, por meio digital, na Plataforma Google Formulários^®. A análise foi realizada por estatística descritiva de categorização de enunciados. O estudo seguiu os padrões éticos exigidos.

Resultados

O formulário foi enviado a 97 discentes e respondido por 40% deles. Todos os respondentes informaram conhecer o plano de parto, e 87% aplicaram-no durante o atendimento de pré-natal. Os apontamentos mais frequentes (45%) acerca do plano de parto foram os que promoviam empoderamento e autonomia à mulher. As sugestões metodológicas mais citadas para a sua aplicação foram focar o conteúdo (76%) e aumentar o número de encontros (50%). O plano individual de parto foi reconhecido por 79% dos participantes como importante estratégia de ensino.

Conclusão

Além de conhecerem o plano de parto e aplicá-lo, os estudantes o consideram muito relevante para o ensino e a aprendizagem das boas práticas obstétricas.

Parto Humanizado; Ensino Superior; Prática Clínica Baseada em Evidência; Enfermagem Obstétrica

RESUMEN

Objetivo

Verificar el conocimiento de estudiantes acerca del plan individual de parto y conocer su comprensión respecto de la utilización de dicha estrategia de enseñanza aprendizaje y de las buenas prácticas obstétricas.

Método

Estudio descriptivo, con alumnos de Obstetricia que cursaban pasantías en la atención básica. La recolección de datos fue realizada de 01/2017 a 05/2017, por medio electrónico, en la Plataforma Google Formularios^®. El análisis fue llevado a cabo por estadística descriptiva de categorización de enunciados. El estudio siguió los estándares éticos exigidos.

Resultados

El formulario fue enviado a 97 discentes y respondido por el 40% de ellos. Todos los respondedores informaron conocer el plan de parto, y el 87% lo aplicaron durante la atención de prenatal. Los planteamientos más frecuentes (45%) acerca del plan de parto fueron los que promovían empoderamiento y autonomía a la mujer. Las sugerencias metodológicas más citadas para su aplicación fueron enfocar el contenido (76%) y aumentar el número de encuentros (50%). El plan individual de parto fue reconocido por el 79% de los participantes como importante estrategia de enseñanza.

Conclusión

Además de conocer el plan de parto y aplicarlo, los estudiantes lo consideran muy relevante para la enseñanza y el aprendizaje y de las buenas prácticas obstétricas.

Parto Humanizado; Educación Superior; Práctica Clínica Basada en la Evidencia; Enfermería Obstétrica

INTRODUCTION

The theoretical-practical teaching-learning process of the Midwifery Program of the Arts, Sciences and Humanities School of the University of São Paulo ( EACH-USP – Escola de Artes, Ciências e Humanidades da Universidade de São Paulo ) is developed in several practice internships scenarios, with the basic health units of the East Zone of the city of São Paulo among them, at which time students develop essential competencies to promote health in the primary care context and to provide care to women and families experiencing the pregnancy-puerperal cycle.

In this care context, one of the strategies used by teachers and students to enable greater empowerment and autonomy of women during the childbirth process is Individual Birth Planning (IBP) during prenatal care, an experience which has been put into practice since the year 2014. As a result, it is empirically observed that pregnant women who elaborated their birth plan and later presented it at the time of admission to the maternity hospital reported their contribution to understanding the care and received better provided service according to their wishes, meaning that IBP has the potential to enable appropriating information which promotes benefits in both terms of women’s autonomy and role, as well as the awareness of health professionals who provide care to them. On the other hand, and unfortunately, there are still reports of hostility and even sometimes violence on the part of professionals against those who want to exercise their rights of choice.

IBP should contribute to humanizing care, since it is defined as a written document of a legal nature in which the pregnant woman, after receiving information and considering her personal values, personal desires, expectations and needs, must combine with the primary and maternity care professionals on which alternatives she prefers during the labor and delivery process under normal conditions¹ and based on good obstetric practices.

The recommendation report published by the Ministry of Health, called the National Care Guidelines for Normal Childbirth² , which is based on the standards of the National Institute for Health and Care Excellence (NICE) of the United Kingdom Public Health System (NHS), stresses that women in labor should be treated with respect, have access to evidence-based information and be included in decision-making. For this, the professionals who provide care to them should establish an intimate relationship, asking them about their desires and expectations, and reading and discussing their delivery plan. However, few Brazilian health services have managed to implement the delivery plan, and many professionals do not even know the meaning of this terminology.

This deficiency can also be explained by the lack of research on the subject in Brazil³ . Among the few studies, one which was carried out in a birth center in the city of Rio de Janeiro points out that elaboration of the birth plan in prenatal care contributes to favorable labor development⁴ . Another study carried out in the city of Belo Horizonte, Minas Gerais, with 106 pregnant women, found that 74% of them did not receive any information about IBP during the prenatal period, even though their workbook contained a birth plan⁵ , which evidences the low value of this instrument by primary care professionals.

IBP used in the curricular internships of the Midwifery Program was prepared by teachers and students and presents information about good obstetrical practices, and it is expected that the student will be able to apply it in a well-founded way to the woman and family during care. In this context, IBP in the Midwifery Program has fostered discussions about the need for training and improvement by primary and hospital health care professionals regarding their use.

In addition to its original purpose, the use of the document aims to make the pedagogical experience of its application unique and fundamental in training health professionals, be they doctors, nurses, midwives, or others. From this assumption, it is questioned whether the students of the Midwifery Program understand IBP as an instrument for learning the good practices of obstetric care during the internship that they perform in primary health care. Thus, the objectives of the present investigation were to verify students’ knowledge about IBP and to learn their opinion about it and its use in theoretical and practical teaching and learning of good obstetric practices.

METHOD

STUDY DESIGN

This is a descriptive study, carried out from January to May 2017.

STUDY POPULATION

The study population was composed of students of the Direct-entry Midwifery Program of the University of São Paulo.

SELECTION CRITERIA

The adopted selection criteria were: students already enrolled in the Integrated Curricular Internship I and II, in which they had the opportunity to provide prenatal care in the primary care context in Basic Health Units of the city of São Paulo, and consequently use IBP.

DATA COLLECTION

A data collection form was first elaborated containing six open questions and two closed questions, perfected from pilot test performed with students who were about to graduate. The closed questions were about knowing and applying IBP. The open questions asked the students to give their opinion about the birth plan, to indicate the methodological procedures used for its application in the primary care internship, to give methodological suggestions for its application, to indicate if they considered themselves to have the theoretical and practical ability to use it, to indicate if the instrument constituted a strategy to learn good practices in obstetric care, and finally to comment on IBP and its use during the primary care internships.

We chose to use the digital form in the Google Forms Platform^®as it was difficult to collect face-to-face data. Eligible students were identified by listing the university’s undergraduate service and were contacted face-to-face or through social networking, applications, and e-mail. The digital form was sent to 97 students, except for those who participated in the aforementioned pilot test, defining a maximum deadline of 60 days for the response, when they were reminded of the importance of their participation in the research. Therefore, it was defined that the deadline for submitting the forms to the researchers would be 60 days.

DATA ANALYSIS AND PROCESSING

The objective information was inserted in spreadsheets and analyzed through descriptive statistics. The answers to the open questions were inserted in worksheets of the Microsoft Excel^®program, read by three researchers for content appropriation, categorized and described by similarity, and finally analyzed by descriptive statistics.

ETHICAL ASPECTS

The study followed the guidelines and regulatory norms of research involving human beings according to Resolution no. 466/2012 of the National Health Council. Eligible students were invited to collaborate with the research, leaving them free to participate through the Informed Consent Form (ICF), which assured them confidentiality and anonymity. In this sense, it is observed that the ICF preceded completion of the form, meaning that only those who agreed to participate in the study had access to the questions.

Data collection was initiated after approval by the EACH-USP Ethics Committee on Research Involving Human Beings, under Opinion no.1.885.451/2017.

RESULTS

Despite several attempts to stimulate greater participation, only 38 (40%) students responded to the form. All of them said they knew about IBP, and 33 (87%) reported having had the opportunity to apply it during their basic care training activities. The presented results correspond to the students’ answers who had practical experience with the childbirth plan. When asked what they thought about the birth plan, the students expressed several opinions, which constituted five categories, and are presented and described in Chart 1 . It is noteworthy that some discursive responses were contemplated and counted in more than one category.

Chart 1
– Opinions of Midwifery course students about birth plan – São Paulo, SP, Brazil, 2017.

CATEGORY	DESCRIPTION	FREQUENCY (N=33)
Promotes empowerment and autonomy	It addresses the possibility of IBP promoting the autonomy and empowerment of women in the pregnancy, labor and childbirth process.	45%
Promotes sexual and reproductive rights	It focuses on the power of the instrument in providing women with knowledge about their rights.	39%
Guidance on interventions in childbirth	Describes IBP as a care plan for women in the obstetric care setting.	24%
Promotes health education	It points out IBP as a facilitator and/or mediator in the process of building knowledge that permeates the usual care practice in childbirth care.	16%
Defends women from obstetric violence	It identifies IBP as a protective tool for violence against women in the childbirth/labor setting.	8%

When questioned about the procedures they used to apply IBP in the primary care stage, 68% of the students described that they presented and explained the instrument content item-by-item in individual prenatal consultations performed in the third gestational trimester, which clarified doubts and pointed out the benefits and harms of possible behaviors in the labor and childbirth scenario. Another 11% indicated the same method applied to groups of pregnant women for whom they used didactic-pedagogical materials such as videos, illustrations and obstetric models.

When asked about how the birth plan should be applied, the students made several methodological suggestions which comprised 10 categories, and are presented and described in Chart 2 . It is worth noting that some discursive responses were contemplated and counted in more than one category.

Chart 2
– Methodological suggestions of Midwifery course students to elaborate birth plan – São Paulo, SP, Brazil, 2017.

CATEGORY	DESCRIPTION	FREQUENCY (N=33)
Focus on content	Indicates that IBP should be presented and explained item-by-item in an informative manner and with clarification of doubts.	76%
Increase the number of meetings	Suggests that it would be ideal to hold the discussion about IBP in more than one meeting and with the presence of the companion.	50%
Apply early	Indicates that IBP should be presented as early as possible in the prenatal period, so that the pregnant woman has the opportunity to appropriate her content and autonomously and safely make choices.	37%
Promote ambience	Suggests that IBP application requires an adequate environment, not always possible in the institutions in which basic care occurs.	29%
Focus on context	Indicates that there is a need to contextualize the current obstetric scenario in the act of elaborating IBP.	26%
Include accompanying person	Points out that IBP discussion requires the presence and active participation of the companion in the choosing process.	18%
Apply close to delivery	Suggests that the plan should be used as close as possible to the delivery date, since the choices and decisions of the woman should be matured throughout the pregnancy.	8%
Use teaching materials	Indicates that IBP application requires complementary didactic-pedagogical material support.	8%
Apply in group	Emphasizes that construction of IBP should be developed in collective activities in which there is sharing of experiences, doubts, anxieties, security and choices by the participants.	8%
Respect for cultural diversity	Points out that professionals must consider and predict the ethnic and cultural particularities of women and their families which are not present in IBP models used by the Midwifery Program.	3%

The majority of the participants (89%) considered themselves able to apply IBP, meaning they have the necessary skills to subsidize the guidelines and clarify doubts. Those who did not consider themselves sufficiently knowledgeable did not indicate their reasons for this deficiency. Most respondents (79%) also identified IBP as a teaching-learning strategy for good obstetric care practices. In this respect, it was found that 16% answered the question negatively, while 5% did not respond.

DISCUSSION

The National Guidelines on Normal Labor Care presents scientific evidence on the effect that communication has on women’s perception of their childbirth experience² . The interventions analyzed in this document included the effect of control, choice and decision-making, including IBP, on the psychological well-being of women in the medium and long term.

The NICE review described in the cited Guideline pointed to 19 studies produced in Europe and the United States, the results of which indicate that the way in which caregivers relate to women strongly influences their experiences with childbirth. The most important factors highlighted in the study were the individualized treatment with respect and affection, and the information based on well-explained and interpreted evidence which makes the woman feel informed, supported, safe and protected throughout the delivery. According to these results, the Brazilian protocol recommends that women in labor be treated with respect and have access to information based on scientific evidence and be included in the decision-making process² .

Among the suggested ways to establish this communication, we indicate the reading and discussion of a birth plan which was previously designed by the woman during pregnancy with the support of the professionals who assist them in this period² . In this sense, it is important that the birth plan is known and used by health professionals in their academic training. The role of the training apparatus in changing the obstetric scenario is thus highlighted, since it fails to reproduce established practices for decades which have proven to compromise the health of women, and consequently to promote teaching recent scientific knowledge which place the woman as the protagonist of the care provided to her⁶ .

The results of the present study show that practical experience with IBP was not possible for all of the investigated students. This is a gap that must certainly be faced by teachers, since they must foster the learning process of the essential attributes for training critical-reflexive professionals, humanists and transformation agents of midwifery care practices.

It is worth mentioning that IBP is the axis of the clinical relationship established between the pregnant woman and the health professional, serving to guide the healthcare provided throughout the process⁷ . As mentioned, this document has proven to be potent in order to provide autonomy and a protagonist role of women in the care provided to them during labor and childbirth, breaking from a care model solely based on biomedical knowledge. Thus, good use of a childbirth plan can contribute to minimize fragmented, impersonal, objectified and technical care, as well as to change the care paradigm and rescuing the protagonism, voice, desires and will of women. In addition, the use of this strategy enables information, decision-making and shared responsibility between the health professional, whether already graduated or in the training process, and the woman.

It is important to say that elaboration (individual or collective) of the birth plan guided by basic care has been unveiled as one of the actions for the quaternary prevention of obstetric violence⁸ . However, the lack of respect for women’s decisions often leads to frustration and antagonism between informed choices and care⁹ , which is also perceived by the students participating in this study.

It should be emphasized that students in the internship field apply IBP after following basic instructions from their teachers supervising them: the document should be read together with the pregnant woman, preferably with the participation of their companion of choice, between the 34^thand the 36^thgestational week; it must be ensured that the pregnant woman and her companion understand the information provided in the document; for this reason, it is recommended to discuss the delivery plan in more than one meeting; the plan can be presented collectively, meaning in groups of pregnant women and companions; however, it must always be individually completed by the woman after clarifying all the questions that are part of it; the team must ensure an effective bond, meaning that the woman has access to additional clarifications whenever she wishes; after that, the document must be signed in two copies, one of which is attached to the pregnant woman’s health card and the other to the medical record; the pregnant woman must present the document to the maternity professionals at the moment of delivery admission; after childbirth, one should evaluate with the woman how the instrument was used, which means how she perceived the process and whether her rights and desires were respected.

However, in addition to highlighting the use of some of these guidelines, the students made some important suggestions such as the use of didactic-pedagogical material and adapting the instrument to multicultural and ethnic characteristics, since cultural diversity influences the care plan, particularly for maternal health¹⁰ . Indigenous, black, and more recently Bolivian, Peruvian and Haitian women from Arab and African countries put the issue of cultural diversity at the center of obstetric care, requiring the education and health system to respect their habits, customs and beliefs.

Regarding the perception of the participants’ aptitude for applying IBP, it is important to question whether learning (for those who have assessed themselves as unfit or only partially fit) in fact did not occur or was not perceived as being important. According to the Significant Learning Theory¹¹ , ideas expressed symbolically substantively interact and also in a non-arbitrary way with what the learner already knows, meaning that new knowledge is re-signified since previous knowledge gains greater cognitive stability in active situations of teaching-learning and those experienced in the care practice described herein.

Success strategies in learning, especially in higher education, not only relate to the developed activities, but especially to the student’s previous repertoire, their motivation needs, the immediate application of the contents, as well as the ability to share experiences. The fear of error and the need for feedback are important characteristics which interfere in the refractoriness of the student to the acquisition of new knowledge; their interest in the subject should increase as they perceive practical application in their reality¹² , which may have occurred with those who did not consider themselves apt to apply IBP or who no longer recognized it as a strategy for teaching good practices.

The change in the national scenario of the maternal and perinatal healthcare situation requires interventions from different perspectives, among them that which promotes quality of care directed to the needs of women, requiring a transformation in the work of the health professional, and therefore in their training process which is continually pursued by the teachers and students of the Midwifery Program¹³ .

Elaborating IBP is not a simple process, and often pregnant women and their companions have difficulties in understanding the choice possibilities present in the instrument. This probably occurs because the biomedical model, under the aegis of which care is historically focused on hospital delivery, does not allow women to make choices about the adopted procedures in the labor and childbirth process. In this sense, it must be remembered that there is a legal framework that legitimates the right of women to prepare and have their IBP respected in the prenatal care and childbirth context in the city of São Paulo¹⁴ - ¹⁶ .

However, in order to implement this public policy, it is necessary to develop strategies for implementing tools such as IBP which facilitate understanding the physiological process of childbirth and the puerperium, as well as the rights of women, the newborn and the family during hospitalization in the maternity, in addition to publicizing the birth plan in the care, academic and decision-making spaces within the health system.

The results of the present study contribute to highlight the importance of implementing tools such as the childbirth plan, which enable humanizing care in the health professional training process. However, limitations cannot be disregarded, since there was low adherence of students to participate. In addition, the study was developed with students of a single undergraduate course in the country, whose origin is justified by the need for professionals to implement the principles of humanization and comprehensiveness in the context of healthcare for women, which does not allow generalizations for the teaching-learning process of other health courses.

CONCLUSION

The results of the present investigation allow to conclude that the majority of the participants know, apply and consider the pedagogical experience of using IBP as fundamental for learning the good practices of obstetric care. Checking students’ knowledge and points of view regarding the instrument and its application leads to important reflections on the meaning of the teaching and application process and improvement in the implemented strategies.

Considering the scarcity of studies that deepen specific questions of IBP in teaching and care, in the students’ reports and in the practice of care it is observed that the birth plan helps women to participate in the decision-making about her childbirth process, giving them the necessary protagonism and autonomy. In addition, the participants emphasized the importance of IBP in preventing obstetric violence and in promoting empowerment of women regarding their sexual and reproductive rights in labor and childbirth.

These results also indicate the need for a theoretical and practical approach of the birth plan in nurses’ training, since they are the main providers of care to women in primary health units. Considering the importance of the relationship between the different care levels for prenatal care, labor and birth, and the professionals who work in them, opportunities must be provided for doctors, nurses and other professionals involved in the care of women to not only use and learn the meaning of IBP, but also to value it as an instrument for improving the care quality and preventing the ignorance of women and families about their commonly neglected rights.

REFERÊNCIAS

• ¹
  Kitzinger S. Sheila Kitzinger´s letter from England: birth plans. Birth. 1992;19(1):36-7. DOI: http://10.1111/j.1523-536X.1992.tb00373.x
  » http://10.1111/j.1523-536X.1992.tb00373.x
• ²
  Brasil. Ministério da Saúde; Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília; 2017.
• ³
  Silva ALNV, Neves AB, S AKG, Souza RA. Plano de parto: ferramenta para o empoderamento de mulheres durante a assistência de enfermagem. Rev Enferm UFSM [Internet]. 2017 [citado 2018 jan. 10];7(1):144-51. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/22531/pdf
  » https://periodicos.ufsm.br/reufsm/article/view/22531/pdf
• ⁴
  Mouta RJO, Silva TMA, Melo PTS, Lopes NS, Moreira VA. Birth plan as a female empowerment strategy. Rev Baiana Enferm [Internet]. 2017 [cited 2018 Mar 14];31(4):e20275. Available from: https://portalseer.ufba.br/index.php/enfermagem/article/view/20275/15598
  » https://portalseer.ufba.br/index.php/enfermagem/article/view/20275/15598
• ⁵
  Silva SG, Silva EL, Souza KV, Oliveira DCC. Perfil de gestantes participantes de rodas de conversa sobre o plano de parto. Enferm Obstétrica [Internet]. 2015 [citado 2017 nov. 10];2(1):9-14. Disponível em: http://www.enfo.com.br/ojs/index.php/EnfObst/article/view/31/23
  » http://www.enfo.com.br/ojs/index.php/EnfObst/article/view/31/23
• ⁶
  Diniz CSG, Niy DY, Andrezzo HFA, Carvalho PCA, Salgado HO. A vagina-escola: seminário interdisciplinar sobre violência contra a mulher no ensino das profissões de saúde. Interface (Botucatu) [Internet]. 2016 [citado 2018 mar. 14]; 20(56):253-9. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832016000100253&lng=en
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832016000100253&lng=en
• ⁷
  Suárez-Cortés M, Armero-Barranco D, Canteras-Jordana M, Martínez-Roche ME. Use and influence of Delivery and Birth Plans in the humanizing delivery process. Rev Latino Am Enfermagem [Internet]. 2015 [cited 2017 Nov10];23(3):520-6. Available from: http://www.scielo.br/pdf/rlae/v23n3/0104-1169-rlae-0067-2583.pdf
  » http://www.scielo.br/pdf/rlae/v23n3/0104-1169-rlae-0067-2583.pdf
• ⁸
  Tesser CD, Knobel R, Andrezzo HFA, Diniz SG. Violência obstétrica e prevenção quaternária: o que é e o que fazer. Braz J Fam Community Med [Internet]. 2015 [citado 2017 nov. 10];10(35):1-12. Disponível em: https://www.rbmfc.org.br/rbmfc/article/view/1013
  » https://www.rbmfc.org.br/rbmfc/article/view/1013
• ⁹
  DeBaets AM. From bith plan to birth partnership: enhancing communication in childbirth. Am J Obstet Gynecol. 2017;26(1):31.e1-31.e4. DOI: https://doi.org/10.1016/j.ajog.2016.09.087
  » https://doi.org/10.1016/j.ajog.2016.09.087
• ¹⁰
  Yajahuanca RA, Diniz CSG, Cabral CS. We need to “ikarar the kuyipados”: intercultural understanding and health care in the Peruvian Amazon. Ciênc Saúde Coletiva [Internet]. 2015 [cited 2018 Mar 13];20(9):2837-46. Available from: http://www.scielo.br/pdf/csc/v20n9/en_1413-8123-csc-20-09-2837.pdf
  » http://www.scielo.br/pdf/csc/v20n9/en_1413-8123-csc-20-09-2837.pdf
• ¹¹
  Ausubel DP. Aquisição e retenção de conhecimentos. Lisboa: Plátano Edições Técnicas; 2003.
• ¹²
  Pazin-Filho A. Característica do aprendizado do adulto. Medicina (Ribeirão Preto) [Internet]. 2007 [citado 2017 out. 20];40(1):7-16. Disponível em: https://www.revistas.usp.br/rmrp/article/view/298/299
  » https://www.revistas.usp.br/rmrp/article/view/298/299
• ¹³
  Narchi NZ, Cruz EF, Gonçalves R. O papel das obstetrizes e enfermeiras obstetras na promoção da maternidade segura no Brasil. Ciênc Saúde Coletiva [Internet]. 2013 [citado 2017 out. 20];18 (4):1059-68. Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232013000400019&script=sci_abstract&tlng=pt
  » http://www.scielo.br/scielo.php?pid=S1413-81232013000400019&script=sci_abstract&tlng=pt
• ¹⁴
  São Paulo. Secretaria de Estado da Saúde. Resolução SS-42, de 06 de maio de 2015. Aprova a nota técnica “Boas Práticas do Parto e Nascimento”, assegurando o direito ao parto humanizado nos estabelecimentos públicos de saúde, no âmbito do Estado de São Paulo e dá providências correlatas [Internet]. São Paulo; 2015 [citado 2017 out. 25]. Disponível em: http://www.saude.sp.gov.br/resources/ccd/homepage/acesso-rapido/documentos-sobre-o-comite-de-mortalidade-materna/2017/resolucao_ss42_06-05-2015_-boas_praticas_do_parto_e_nascimento.pdf
  » http://www.saude.sp.gov.br/resources/ccd/homepage/acesso-rapido/documentos-sobre-o-comite-de-mortalidade-materna/2017/resolucao_ss42_06-05-2015_-boas_praticas_do_parto_e_nascimento.pdf
• ¹⁵
  São Paulo. Lei n. 15.759, de 25 de março de 2015. Assegura o direito ao parto humanizado nos estabelecimentos públicos de saúde do Estado e dá outras providências [Internet]. São Paulo; 2015 [citado 2017 out. 27]. Disponível em: https://www.al.sp.gov.br/repositorio/legislacao/lei/2015/lei-15759-25.03.2015.html
  » https://www.al.sp.gov.br/repositorio/legislacao/lei/2015/lei-15759-25.03.2015.html
• ¹⁶
  São Paulo (Cidade). Lei n. 15.894, de 8 de novembro de 2013. Institui o Plano Municipal para a Humanização do parto, dispõe sobre a administração de analgesia em partos naturais de gestantes da Cidade de São Paulo, e dá outras providências [Internet]. São Paulo; 2013 [citado 2017 out. 27]. Disponível em: https://www.imprensaoficial.com.br/Certificacao/GatewayCertificaPDF.aspx?notarizacaoID=c7c20e03-7a71-4d17-868e-77b433645fd1
  » https://www.imprensaoficial.com.br/Certificacao/GatewayCertificaPDF.aspx?notarizacaoID=c7c20e03-7a71-4d17-868e-77b433645fd1

Publication Dates

• Publication in this collection
  05 Sept 2019
• Date of issue
  2019

History

• Received
  27 Mar 2018
• Accepted
  28 Mar 2019