The process of labor and birth: a view from woman who have private healthcare plans in a social phenomenology perspective

Abstracts

OBJETIVO: Este estudo objetivou compreender o processo de parto e nascimento na perspectiva das mulheres que possuem convênio saúde. MÉTODOS: A partir das questões norteadoras: Como foi o processo de parto? Fale-me da assistência que recebeu. Foi como esperava?, analisou-se os dados segundo o referencial da Fenomenologia Social. RESULTADOS: Os resultados mostraram que essas mulheres puderam opinar sobre o tipo de parto, contar com a presença do marido na sala de parto e confiar no profissional que a assistiram. Para essas mulheres a experiência foi maravilhosa e gratificante. CONCLUSÕES: A vivência do processo de parto e nascimento, na perspectiva das mulheres que possuem convênio saúde difere dos sentimentos vivenciados pelas mulheres que não têm acesso a este tipo de atendimento. No entanto, independente do plano de saúde, não se pode negligenciar nem os direitos das usuárias, nem os deveres de uma assistência digna, que possa viabilizar o atendimento humanizado.

Saúde da mulher; Parto; Tocologia; Trabalho de parto; Parto humanizado

ORIGINAL ARTICLE

The process of labor and birth: a view from woman who have private healthcare plans in a social phenomenology perspective^*

El proceso del parto y nacimiento: visión de las mujeres con convenio salud en la perspectiva de la fenomenología social

Miriam Aparecida Barbosa Merighi^I; Geraldo Mota de Carvalho^II; Vivian Pontes Suletroni^III

^IFree-Lecturer; Professor of the Maternal-infant and Psychiatric Nursing Department at the College of Nursing at University of São Paulo – USP – São Paulo (SP), Brazil

^IIDoctor; Professor and Coordinator of the Course for Specialization in Obstetric Nursing at the São Camilo University Center, São Paulo (SP), Brazil

^IIINurse at the Hospital Real Benemérita Sociedade Portuguesa de Beneficência. São Paulo (SP), Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVE: This is a qualitative study with the goal of understanding the labor and childbirth process in the perspective of women being admitted to a private institution and covered by a health care plan.

METHODS: According to the following directive questions: How did you feel during the delivery process? Tell me about the assistance given to you. Did it take place according to your expectations?, the data was evaluated using the social phenomenology referential.

RESULTS: The results show that these women were able to make a decision about their type of labor, they could count on the presence of their husbands in the delivery room, and that they trusted the professional assisting them. For these women, the experience was wonderful, and gratifying.

CONCLUSIONS: Undergoing the delivery and childbirth process, in the perspective of women who are covered by a health care plan, differ from the feelings of women who do not have access to this assistance. However, we should never neglect the users' rights or the duty to provide suitable assistance, whether women are covered or not by a health care plan, making room for more humanized assistance.

Keywords: Woman's health; Parturition; Midwifery; Labor, obstetric; Humanizing delivery.

RESUMEN

OBJETIVO: En este estudio se tuvo como objetivo comprender el proceso del parto y nacimiento en la perspectiva de las mujeres con convenio salud.

MÉTODOS: A partir de las preguntas norteadoras, ¿como fue el proceso del parto? Hábleme de la asistencia que recibió. Fue como esperaba?, se analizó los datos según el referencial de la Fenomenología Social.

RESULTADOS: Los resultados mostraron que esas mujeres pudieron opinar sobre el tipo de parto, contar con la presencia del marido en la sala de parto y confiar en el profesional que la asistieron. Para esas mujeres la experiencia fue maravillosa y gratificante.

CONCLUSIONES: La vivencia del proceso del parto y nacimiento, en la perspectiva de las mujeres con convenio salud difiere de los sentimientos vivenciados por las mujeres que no tienen acceso a este tipo de atención. Entre tanto, independiente del plan de salud, no se puede negligenciar ni los derechos de las usuarias, ni los deberes de una asistencia digna, que pueda viabilizar la atención humanizada.

Descriptores: Salud de la mujer; Parto; Tocología; Trabajo de Parto; Parto humanizado.

INTRODUCTION

By examining the literature on the subjectivity of the woman who experiences the process of labor and birth, it was possible to verify that such investigations have, as their main focus, women who are users of the Brazilian Public Healthcare System (SUS), receiving care in public hospitals. They are women who are conditioned to see and act in the scopes of health and disease, from their own perspective of social insertion, characterized by their own living conditions and the experience of many economic difficulties^(1-5).

Therefore, we highlight a study performed with this clientele, aimed to reveal the phenomenon of women's healthcare in labor and birth, receiving care in public hospitals. The women's testimonials revealed that receiving care from a team of specialized and experienced professionals is important yet not enough, because emotional factors are not usually seen to. When in labor and childbirth, women submit silently and submissively to rigid hospital routines, living through this moment without any harmony. The need for human contact, information, technical competence, security and participation has shown itself in context, enabling us, health professionals, to reflect on the content of their accounts, when we take the necessary actions⁽⁴⁾.

We also judge that developing investigations on women who have private healthcare plans and that are seen to in private institutions is important.

With this study, we aimed to comprehensively report the accounts of labor and birth, especially when it comes to the meanings that are attributed to experiencing and acknowledging the needs of these women, from their own experiences during labor and childbirth.

The object of the present investigation was to explore the experiencing of the labor process from the woman's own perspective, with the intention of filling the existing void, since most studies, as previously mentioned, did not include women who receive care from a private healthcare plan. It is assumed that women who possess a private healthcare plan have living conditions that help them visualize possibilities, reduce stress, increase security and trust, with a consequent and beneficial repercussion in this important period of their lives. However, such women must also have desires, experience anxiety, fears, sadness and joy, and show expectancy and hope for care.

Wishing to reveal the phenomenon of the woman's experience during labor, this study had the following objectives:

General: Identifying whether the feelings and need for care of women who experienced the process of labor, who have a private healthcare plan and who receive care in private institutions differ from those who are users of the SUS.

Specific: Understanding the meaning that women attribute to the process of labor and childbirth; knowing what these women's healthcare needs are in this stage of their life cycles.

We believe that such knowledge may subsidize healthcare to this clientele and increase learning in the field of women's health.

TECHNICAL-METHODOLOGICAL REFERENCE

The study was developed by the means of a qualitative approach, since this one works with a plethora of meanings, reasons, aspirations, beliefs, values and attributes.

We considered that the phenomenological perspective would be the best way to understand the woman as a subject capable of thinking, acting and reflecting over their life-world and who needs to be understood and helped by those who assist her.

We used the social phenomenology reference, which is based on Alfred Schütz's conception. Such reference aims to understand the intersubjective experience, i.e., the world with others, social relations and focused on the responses to the actions, which have a meaning configured in the social sense, not purely individual⁽⁶⁾.

For the social phenomenology, it is not important to investigate the individual, particular behaviors of every subject. The focus of interest is that which may constitute a typical feature of a social group that is experiencing a given situation⁽⁶⁾.

The aim of this research was to know the reality of a group of parturients, who were within the seven first days after delivery, placing them into a natural attitude, and therefore in their life-world, to understand the many interpretative practices which reality is made of, from a social and personal perspective. We consider that people express the meaning of this experience in their actions that were undergone socially.

To capture the subjective point of view, it is necessary to report to the interpretation that the subjects attribute to the action in terms of projects, available means, reasons and meanings⁽⁷⁾.

By "reason", it can be understood: "A state of things, the intended goal of the action". Thus, reason is the bearing for future actions, and the reason why it is related to past experiences, with the available knowledge⁽⁷⁾.

The reason why a project is referred regarding past experiences is because it is an objective category and accessible to the researcher. The meaning context of the true reason is always an explanation following the event⁽⁶⁾.

We can only capture the living experience of each subject if we find their reason why (anticipated, imagined act, subjective meaning of the action)⁽⁶⁾.

Alfred Schütz developed his studies with the inquietude stemmed from understanding the subjective meaning of action, which will enable the construction of the experienced type. The experienced type is the expression of a structure experienced in the social dimension, a characteristic of a social group, a concept expressed by intelligence, whose experienced nature is essential and invariable. The experienced type is reached through the analysis of social relations⁽⁷⁾.

The experienced type does not correspond to anyone in particular, being an idealization. According to Alfred Schütz, the idealized experienced types are interpretative schemes of the social world that are part of our background knowledge about the world, have a meaningful value, and we always make use of its elements in interpersonal relations⁽⁷⁾.

Many times during pregnancy the woman has something in view, i.e., a projection regarding the method of delivery, anesthesia, assistance, care, among others. It was in this context that we also elected Alfred Schütz's social phenomenology for the analysis of the collected accounts.

METHODS

Women over 18 years of age took part in this research, cared for in private institutions and owners of private healthcare plans, who were in the first post-parturition week, in the hospital or right after leaving the hospital. We considered that this stage in the life of the women is appropriate for the collection of data, since, in the meantime, their feelings are closest to the experienced reality, and as such they may be able to express their meanings in richer testimonials.

When the inquiry group was defined, we did not take profession, socioeconomic situation and instruction level into account, believing that those would not interfere in the labor and birth experience, since our interest was the women's experience.

The data collection for this study did not require the definition of a local. The inquiry region is itself the situation where the phenomenon occurs, the life-world, the pre-reflective of women who experience and suffer the influences of labor and childbirth⁽⁸⁾.

It is worth adding that the approach of the subject, i.e., the contact with the mothers, depended on the knowledge of the researcher and third-party information about their existence, while still pregnant. The interviews were scheduled according to the women's preferences on dates, times and places. Some were done in their own homes, while others were done in the hospitals where they had given birth. The delimitation of the number of subjects was defined when we noticed that the testimonials unveiled the phenomenon under investigation, i.e., when our inquiries had been sufficiently answered.

The ending of the inclusion of new women experiencing the birthing period was decided according to the database collected, which made evident both the breadth and the comprehensiveness of the meanings contained within the testimonials. Thus, twelve reports were considered as good enough to unveil the phenomenon.

The collection of the women's reports was performed in the period from November/2004 to March/2005, with the following guiding questions: How was the birthing experience for you? Tell me about the assistance you have received. Was it the way you expected?

Considering the settings of Resolution 196/96 on directives and ruling norms on research with human beings, the women had been told about the objectives of the research, as well as their right to anonymity and privacy, and their right to take part in it or not. After such clarifying, it was asked of the participants to sign a Term of Free and Clarified Consent in order to take part on the research. In aiming to preserve their anonymity, the women taking part in the study were identified with fictitious names.

RESULTS

For the analysis of the women's speeches, we concentrated attentively on what they had in common, searching in the interviews the convergences or similarities among feelings experienced when they were in labor and when giving birth, and the expectations of the women regarding the assistance they would receive. The feelings and experiences were studied through an analysis of the identified categories after the organization of the testimonials, them being: a wonderful, gratifying and fantastic experience; experiencing high-quality care (sub-categories: having her husband present, trusting the health professional, being able to choose the kind of parturition), and overcoming the expectations they had during their pregnancies.

It is important to remember that it is up to the researcher to describe the social behavior experience, shown in a convergent form in the intentions of the social actors as a unique experienced structure, whose only value of meaning is transmitted through a meaningful language of relationships among people. The experienced type does not correspond to any person in particular, being an idealization; it is interpretative of the social world, being part of our knowledge of the world; it is meaningful and we always use it in our interpersonal relations⁽⁷⁾.

Therefore, the experienced type "being a woman undergoing the process of labor and birth, having a private healthcare plan and receiving care in a private institution" constituted a typical characteristic of said social group which experienced the process of labor and childbirth and the care received in this period, and has presented itself as a wonderful, gratifying and fantastic experience; high-quality care received in this interim, especially by trusting the health professional, being able to have her husband present when delivering the child and being able to choose the kind of delivery. This experience overcame the expectations they had during their pregnancies.

DISCUSSION

The women's statement, subject of this study, showed that this moment was a wonderful, gratifying and fantastic experience, and was described as "unique", "sublime", "hard to put in words", "magical experience", and "a mind-blowing experience".

the delivery experience was wonderful for me. It's hard to put it in words due to the greatness of the feeling (Emerald).

it's a unique situation, a feeling I can't say whether it's love, I think there's no single word to describe what you feel and gets higher each day (Agate).

labor was a unique experience I'd have another for sure, would go through everything again, same pain, everything, stitches, because it's worth it. It's such a great reward that I don't even recall that it hurt. (Aquamarine)

We consider that a comprehensive assistance was a facilitating factor for seeing childbirth as a unique and wonderful experience in the woman's life, where the woman feels comfortable and receives orientation that will help her at that moment of doubt and uncertainty.

Facing the greatness of the feelings experienced in this pregnant-puerperal period, the care received was of high quality, overcoming their expectations, and made this moment even more significant in their lives:

everything went well, thank God, I had really good care, people were patient with me, listened to me, it was better than I expected it to be (Topaz).

the care I received was of excellent quality. The professionals showed competence and dedication. I was well-advised regarding the procedures to be performed, about breast-feeding and the initial care with the baby (Emerald).

Being able to count with the participation of their husbands was frequently pointed out in the testimonials. Scientific evidence shows that the presence of the partner contributes to the improvement of the health markers and the mother's and newborn's welfare. The presence of the partner increases the woman's satisfaction and significantly reduces the percentage of cesareans, the length of labor, the usage of analgesics and oxytocin. It is every woman's right, regardless of owning a private healthcare plan or not:

my husband was in the room with me during delivery and that made me feel secure, it was very good to have him by my side at the time, he gave me much needed strength the doctor let my husband cut the umbilical cord, he did that while he was crying, I thought that was wonderful because my husband experienced the birth with me, he was entirely present. Oh, Samara was in my arms shortly after delivery and I breast-fed her right there, and my husband was still there by my side, and he also got her in his arms. (Topaz)

the father came in and took part in delivery. You can see the father's emotion and this brings more security to the mother... seeing the father does you good. (Opal)

Still as part of high-quality care highlighted by women, some of their accounts mention the importance of trusting the health professional:

I praised the nurses a lot. Until now everybody has been treating me very well. The tranquility and security that they transmitted to me has really helped me. The fact that the doctor who had done my pré-natal oversaw my delivery made me feel safer and calmer, because I knew her and she knew me too. Thus, I was more at ease. (Diamond)

The act of communication aims not only to have someone know about it, but also that its message helps the listener to assume a particular stance or to develop any possible kind of caution⁽⁷⁾; such fact can be verified through verbalization:

the good thing is that you're surrounded by people who are giving you attention, because I think that's a moment when you really feel fragile, isn't it. The nurses and doctors would come to me, I felt really comforted, really comforted. (Tourmaline)

Being able to choose the type of parturition was also mentioned as part of high-quality assistance. Some opted by the type of parturition of their preference, since the existence of a healthcare plan makes this choice possible; others had made a choice that was made impossible by the clinical conditions at the time of delivery:

I chose the type of delivery, I wanted it to be normal, but I had very little dilation, when it came to three fingers of dilation they gave me the serum to see if I could take it, if I couldn't it would have been a cesarean, the doctor talked to me and said "We are trying normal childbirth, but if I see that it won't be good for you or for the baby, I'm doing a cesarean". It was fine with me, we had put that in the admittance papers, but it was my choice to have it normal, and, for me, they helped me a lot while I was in the delivery room, at any time there was a nurse there by my side to check if the bleeding increased, if the density of the bleeding increased, my blood pressure. I was really well cared for all the time, so, delivery was better than I had imagined. And I wanted it normal because I had always been told that recovery is better, the baby is born well, does not suffer so much. Since I'm young I didn't want a cesarean so soon. (Agate)

The analysis of the presented categories allows us to state that, to positively experience such a special moment, it is indispensable to trust the health professional, being able to count on the husband's presence, being able to choose the kind of delivery, being treated with dignity and respect. The bond between professional and client is of utmost importance in the pregnant-puerperal period.

The women in this study reported that their expectations during pregnancy had been overcome, since freedom, respect and dignity had been observed in care. In human coexistence there are elements such as relationships, sharing of ideas, emotions and feelings in the living world. People are worth more than things; they are worth by themselves and not by the position they have, because they possess an inherent character of dignity, since they are human beings⁽⁹⁾.

Isolation and abandonment of women at the moment of birthing are considered a manifestation of institutional violence and a violation of human rights. When women are unaware of the process of parturition, the hospital routine policies and the place where they will give birth, they feel very anxious, fearing the upcoming events, feelings that make such a process highly traumatic.

The woman idealizes how childbirth will be, and, quite often, becomes disappointed when whatever she had idealized happens differently. When facing the unexpected, there are women who not only feel frustrated, but feel also like they are failing, as if they had failed or done everything wrongly. Such feelings are more intense when a rigid ideal is formed around childbirth, not considering unpredictability and the possibility of it happening differently⁽¹⁰⁾. In the following verbalizations are the "reason-whys" of such idealizations:

thank God the expectation that I had of a normal delivery was of pain and of feeling a lot of pain. But nothing like that happened. Everything was great and really calm. Interestingly, it wasn't like I expected, even though it's a very well-known hospital. Sincerely, I didn't expect it to be like that. I overcame it. People here overcame my expectations. (Diamond).

I thought I was going to die, was going to be full of stitches, scars, it was better than I expected, even though it was a cesarean, I'm really afraid of it all, but the doctor is great, even though he irritates me once and again, but he is really great. You can see that it was like I expected it to be, but better. (Aquamarine)

It was much, much better than I expected, I was scared because I had this idea that it would be in a public hospital, but the issue of delivering, I couldn't imagine that it could have been better than this. It was great for me. (Agate)

Childbirth, many times, is seen as a critical moment, marked by a series of significant changes that fill several levels of symbolization, such as imagining malformation of their child or not being able to withstand pain⁽⁵⁾:

well, it was unique and painful because of the contractions. But I imagine that the fact of feeling the contractions and knowing that they would result in this (looks at the baby) is fantastic. Gee, if it were like this all the time, I'd go through lots of contractions. It's great. Delivery itself, my delivery was great, but victory is here and everything went great. (Diamond)

The moment of delivery feels as if it were a "leap into darkness", an indispensable, irreversible, unknown moment over which there is no control⁽¹¹⁾. One of the subjects in this study reports:

everything was really magic, despite the angst, knowing if he'd be born well, how he would be, if it would turn out right, everything was wonderful suddenly I heard Felipe crying, I don't even know how to explain it, it was something that blew my mind. After that, when I saw him, he looked at me, all wrapped up, dark hair, cute my son had been born, everything had turned out right, I didn't believe it, everything was really good, better than anything. (Ruby)

In spite of the technological advances of Obstetrics and despite the more recent aids to childbirth, it is still seen, from an emotional point of view, as an important process, and, to a point, frightening, because of the innumerable meanings that it represents⁽¹²⁾.

Fear and insecurity of the pregnant woman regarding delivery comes from ancient times. Popular tradition has always associated giving birth to the idea of pain, suffering and angst⁽¹⁾.

We agree with the aforementioned authors about the anxiety and expectations of the parturient regarding the process of labor and birth. Expectations that make them to fantasize the action (reason-why) in an insecure, and quite often, negative way:

I felt such an intense happiness, along with a strong anxiety. Anxiety in wanting to know if everything would turn out well when I received the anesthetics, undergoing surgery itself, and especially in knowing whether the baby would be born well and if he would be perfect. I would wonder what his little face would be like. (Emerald)

I really wanted to have a normal childbirth, because I'm really sensitive to pain, I was thinking: "What's going to happen if it has to be a cesarean?" I was really willing to have it normal, but if the doctor said that it would have to be a cesarean, I was prepared for that too. (Turquoise)

The way a woman experiences delivery and birth, the way this experience is perceived, the information she receives about pregnancy throughout her life, may directly affect her perception and beliefs about the events experienced, along with other factors. The available background knowledge is like a "stable structure of the individual's previous subjective experiences, acquired throughout his/her life, through first-hand experiencing or experiences reported by other people"⁽⁷⁾.

It is natural for man to experience the intersubjective world, be it the common-sense world, the world of everyday life or the day-to-day world. This world existed before we were born, had its own history and is given to us in an orderly way. It's primordially the scene and scenery of our actions and intentions; we do not only act in it, but also on it, and we interpret it through typifications. The common-sense world is the scene and scenery of social action, and, as such, intersubjectivity is the key category of human existence⁽⁷⁾.

Having Alfred Schütz's philosophy as a principle, we understand that the parturients are linked to typical meanings of the relationships of their predecessors to issues that permeate living and assistance received in this period of life (reasons-why).

Therefore, the way they experience childbirth and the reasons for each experience are based in their own values and beliefs, which are acquired socially. Even though such knowledge is transmitted from generation to generation of women with changes through time, it keeps the previous generations' structure, however.

As such, women who experience the process of labor and birth use typical actions to solve typified problems faced in their daily social relations, using stock knowledge to understand and project their actions when in labor and birth, and also expectations related to care.

CONCLUSIONS

The analysis of the testimonials, differently from the aforementioned considerations and highlighted in the literature review, allowed us to understand that the feelings of the women who experienced the process of labor and birth, who own a private healthcare plan and are cared for in private institutions, differ from the feelings of women who cannot afford this type of care.

While many times women who do not own private healthcare plans do not have guaranteed availability of childbirth facilities, feel insecure, afraid, anxious for not being able to count on their husbands being present and not knowing the professional that is responsible for the care, those who can afford a private healthcare plan can decide on the type of delivery, count on their husbands being present in the delivery room and trust the professional responsible for their childbirth, since they quite often have a bond with this professional from early on in their pregnancies. They refer to the moments of labor and birth as a wonderful, sublime experience, during which they experienced high-quality assistance that overcame their expectations.

Every woman, regardless of their healthcare plan, has the right to a dignified and respectful assistance. They must be informed about suggested healthcare actions, their risks and alternative benefits; they must have the right to make decisions and express their desires. Likewise, the healthcare professional must also support and assist this moment which is, undoubtedly, of greatest importance in the life of the woman and her relatives.

Neither the rights of the users nor the duties of a dignified assistance can be neglected, which may enable humanized and efficient care in the health actions, according to the needs of the assisted clientele. The object of our study is a person, with feelings and emotions that are independent of owning a private healthcare plan or not.

It is important to look for humanized assistance to labor and childbirth. This means a type of care that goes beyond aiming for normal delivery at any cost, but also to reinstate the woman's central position in the process of labor and birth, respecting their dignity, their autonomy and their control over the situation.

Many times, poorer women tend to "prefer" cesareans to escape the rude treatment they face in public hospitals, painful procedures and lack of sedation. Women receive incomplete information, are not able to manifest their preferences, and are submitted to intense pain and stress. And quite frequently the social differences jeopardize their ability to decide.

The notion of rights is not very concrete for the users of the health services, and much less palpable for those who depend on the SUS. It is necessary to remember that the Brazilian society is divided in a small portion of the population who own a private healthcare plan, while the vast majority depends on the SUS. The private alternative includes a group of reference services, and several healthcare plans guarantee the right of choosing the professional that will assist childbirth.

Among the women who depend on the SUS, being admitted to a hospital while in labor equals to solving the problem, because it means to be included in some formal system of assistance. We do not refer to the quality of such assistance, but to having any kind of assistance, whatever it is.

We believe that labor is a moment of utmost importance in the life of the woman, a rite of passage that must be experienced positively. We also believe that the obstetric nurse is in a privileged position regarding caring for the woman who experiences the process of parturition, because he/she may incorporate the whole science that he/she is able to, and also to translate this impersonal science into a humanistic perspective, presenting proposals of change in the practices of assistance that might take the women's rights to a safe and pleasurable maternity into account.

REFERÊNCES

Received article 12/03/2007 and accepted 25/05/2007

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*

This study was performed in the City of São Paulo in Universidade de São Paulo - USP, São Paulo (SP), Brazil.

Publication Dates

• Publication in this collection
  18 Jan 2008
• Date of issue
  Dec 2007

History

• Accepted
  25 May 2007
• Received
  12 Mar 2007