Women’s autonomy in the process of labour and childbirth: integrative literature review

ABSTRACT

Objective

To identify the available evidence in scientific literature on healthcare practices that interfere with the autonomy of Brazilian women in the labour and delivery process.

Method

The search for papers was conducted in the databases LILACS, Scopus and PubMed, between 1996 and 2015, according to a guiding question and exclusion criteria, resulting in the selection of 22 papers to compose the analytic body.

Results

The main practices that favoured the exercise of women’s autonomy were out-of-hospital care practices; care practices of support and comfort; and educational care practices. By contrast, the practices that limited autonomy were authoritarian care practices; standardised or routine care practices; care practices that intensify the painful sensation of childbirth; and impersonal and cold care practice.

Conclusion

There was an alarming contrast between the daily healthcare routine and ministerial recommendations.

Women’s health; Obstetrics; Parturition; Personal autonomy; Patient preference; Decision making

RESUMO

Objetivo

Identificar as evidências disponíveis na produção científica acerca das práticas de assistência à saúde que interferem no exercício da autonomia das mulheres brasileiras no processo de parto e nascimento.

Método

A busca dos artigos foi desenvolvida nas bases de dados LILACS, Scopus e PubMed, no período entre 1996 e 2015, tendo como eixo orientador a questão norteadora e os critérios de exclusão, sendo selecionados 22 artigos como corpus de análise.

Resultados

Foram evidenciadas como práticas que favorecem o exercício da autonomia feminina: práticas assistenciais extra-hospitalares; práticas assistenciais de apoio e conforto; e práticas assistenciais educativas. Em contrapartida, revelaram-se como práticas limitantes ao exercício da autonomia: práticas assistenciais autoritárias; práticas assistenciais padronizadas ou rotineiras; práticas assistenciais que intensificam a sensação dolorosa do parto; e prática assistencial impessoal e fria.

Conclusão

Revelou-se uma situação de alerta relativa ao grande descompasso existente entre o cotidiano assistencial e as recomendações ministeriais.

Saúde da mulher; Obstetrícia; Parto; Autonomia pessoal; Preferência do paciente; Tomada de decisões

RESUMEN

Objetivo

Identificar la evidencia disponible en la literatura científica acerca de las prácticas de atención de salud que interfieren con el ejercicio de la autonomía de las mujeres brasileñas en el proceso de parto y el nacimiento.

Método

La búsqueda de artículos se desarrolló en las bases de datos LILACS, Scopus y en PubMed, en el período comprendido entre 1996 y 2015, con el principio rector de los rectores criterios de interrogación y exclusión, y seleccionó 22 artículos como un corpus de análisis.

Resultados

Hemos puesto de relieve las prácticas que favorecen el ejercicio de la autonomía de la mujer: las prácticas de atención ambulatoria; prácticas de apoyo y consuelo; prácticas educativas y atención. Por el contrario se han demostrado como una limitación del ejercicio práctico de la autonomía: las prácticas de atención autoritarias; prácticas de cuidados estandarizados o de rutina; cuidado prácticas que mejoran la sensación dolorosa del parto; y la práctica de la atención impersonal y fría.

Conclusión

Se puso de manifiesto una situación de alerta en el gran desajuste entre su vida cotidiana y recomendaciones ministeriales.

Salud de la mujer; Obstetricia; Parto; Autonomía personal; Prioridad del paciente; Toma de decisiones

INTRODUCTION

The birth of a child is associated with the renewal of life, and, for many, it is one of the most intense and significant moments of human existence¹. Due to the specific social, economic, and biological specificities of childbirth, the care provided during this event must focus on the needs of the new mothers, their rights, and their active participation in the process of parturition²-³.

However, these rights and the preconditions for health and citizenship have been gradually violated. The current obstetric care model is characterised by growing dependence on technical and technological interventions and the wide use of C-section as a way of birth, which has expropriated women of the control over their bodies and of their autonomy⁴-⁵.

Since the 1980s, the feminist movement and other sectors of society have been criticising this technocratic obstetric model in the hope of helping women regain their autonomy during childbirth. They mainly questioned the care provided during the gravid-puerperal cycle, the institutionalisation of childbirth, and the routine use of unnecessary interventions. This movement culminated in conferences, documents, and the search for scientific evidence that could combine several fields of knowledge³.

An understanding of the impact of gender relations in women’s health has led to the expansion of health policies from the perspective of comprehensive care. In recent decades, the ministry of health has proposed programmes and policies to guarantee the civil, sexual, and reproductive rights of women and children. The programme for humanisation in the prenatal and birth⁶established in 2000 chiefly aims to improve access, coverage, and the quality of prenatal monitoring, and care during childbirth and the puerperal period for pregnant women and the newborn.

Expanding the vision of childbirth beyond the biological aspects of women and children, while focusing on the recognition of their rights, is considered incontestable. This integrative literature review is based on the need to discuss the role of women in childbirth and their difficulties in autonomously² caring for themselves and their child. The aim of this review is to identify the available evidence in scientific production of healthcare practices that interfere with the autonomy of Brazilian women in the process of labour and birth.

METHOD

This is the study of an integrative literature review according to the proposed six-step methodology⁷. The first step was the selection of the subject and the guiding question: Which healthcare practices interfere in the exercise of autonomy of Brazilian women in the process of labour and childbirth?

In the second step, we defined the inclusion criteria, namely research papers conducted in Brazil that respond to the subject, published in Portuguese, English or Spanish, between 1996 and 2015, and available in full online. We only selected studies conducted in Brazil due to the provided obstetrics care model. Regarding the timeframe, the period from 1996 to 2015 was selected due to the intense humanisation movement and qualification of obstetric care based on the publication by the World Health Organization (WHO) of the “WHO Recommendations – Good Practices for Normal Labour and Delivery”⁸. Since we specifically searched for evidence of healthcare practices in childbirth regardless of the type/method of birth, studies that focused on the method of birth and on the presence of chaperones were excluded.

The search of papers was conducted at the following databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), PubMed, and Scopus. Given the specific characteristics of the selected databases, the search strategies were adapted for each paper based on the guiding question of the review and the inclusion criteria adopted by the researchers.

In the LILACS database, we used the controlled descriptors obtained from the following health sciences descriptors (“DeCS”): “tocologia” or “parto” or “parto humanizado” or “parto normal” or “parto obstetrico” or “trabalho de parto” or “saude reprodutiva” or “cesarea”. These descriptors were combined using the Boolean operator AND with words defined from the concept of autonomy, namely “decisao” or “autonomia” or “direito” or “preferencia” or “escolha” or “participacao”. This strategy was used to increase the possibility of finding evidence to answer the research question.

With the same purpose, in the two databases Scopus and PubMed, the keywords were “midwifery” or “parturition” or “humanizing delivery” or “reproductive health” AND “autonomy” or “patient reference” or “decision”, and the selection of the item “All Fields” for all the keywords. The studies were surveyed in January 2016. When the full text was not available in the database, the search strategies were totally exhausted by contacting the authors and the institutions of origin of the papers. Duplicate studies were analysed only once.

Subsequently, two reviewers independently selected 22 papers to form the body of analysis. In case of disagreements, the papers were analysed by a third reviewer (Figure 1). To minimise potential errors of interpretation, two independent reviewers also performed the searches, evaluations, and analyses of the papers.

Figure 1
– Flow chart of the independent peer selection of studies surveyed in the integrative literature review. LILACS/PubMed/Scopus, 1996-2015

The fourth step was the analysis, for which each paper was classified according to the information that would answer the investigation question and in relation to the level of evidence. The method used to classify the power of evidence proposes three levels, namely: 1 – Intervention or diagnosis; 2 – Prognosis or etiology; and 3 – Meaning. In view of the body of this research, we used the classification of evidence from studies with a clinical question that is directed toward the meaning, with the following hierarchy: I – Meta-synthesis of qualitative studies; II – Qualitative individual studies; III – Summary of descriptive studies; IV – Individual descriptive studies individual; and V – Expert opinion⁹.

Then, the results were presented and discussed in a descriptive manner. Firstly, we described the identification data of the publications (authors, year, state of origin, and institution of the study). Subsequently, the methodological characteristics of studies were evaluated and sorted according to the research design and critical evaluation of the levels of evidence⁹.

In the fifth step, the evidence was grouped by similarity followed by a description of the healthcare practices that interfere in the autonomy of Brazilian women during labour and childbirth. Finally, in the sixth step, based on the discussion and interpretation of the results, we prepared the considerations of obstetric care practices and made research suggestions.

RESULTS

Regarding the quadrennial distribution of the publication frequency, the publications between 2012 and 2105 deserve special attention (Figure 2). In relation to the state of origin, there was a greater concentration in the southeastern (8 papers) and southern (7 papers) states of Brazil. It was noted that 13 studies were conducted in hospitals and 9 were conducted in outpatient treatment institutions (basic health units and delivery units). Of these studies, 15 were conducted in one institution and 7 were conducted in several institutions.

Figure 2
– Chart of the quadrennial distribution of publication frequency of scientific literature on healthcare practices that interfere in the autonomy of Brazilian women during labour and childbirth. LILACS/PubMed/Scopus, 1996-2015

Regarding the authors of the reviewed publications, 18 were authored by nurses only, 1 was written by a physical therapist and nurses, and 2 were written exclusively by physicians. The methodology of all the studies was qualitative research. In relation to the strength of the evidence, the 22 papers belong to the category of meaning and have level 2 evidence.

In relation to the objective of this review, the results of the papers revealed a set of healthcare practices during labour and childbirth according to the positive and negative interference of these practices in women’s autonomy.

The practices that favour the exercise of autonomy of Brazilian women during labour and childbirth were out-of-hospital care practices; care practices of support and comfort; and educational care practices. The practices that limit the exercise of autonomy of Brazilian women during labour and childbirth were defined as authoritarian care practices; standard or routine care practices; practices that intensify the painful sensation of childbirth; and impersonal and cold care practices (Figure 3).

Figure 3
– Evidence of healthcare practices that interfere in the exercise of autonomy of Brazilian women during labour and childbirth. LILACS/PubMed/Scopus, 1996-2015

DISCUSSION

There was a low number of scientific papers related to women’s health and the exercise of women’s autonomy during labour and childbirth. Most of the selected studies focused on the use of good practices recommended during delivery⁸, and there was a deficit of papers that addressed the subject from the perspective of this principle that is the precondition for the health and citizenship of women.

The out-of-hospital care practice was considered beneficial for the protagonism of women during childbirth¹⁰-¹⁶. This practice was heavily associated with the pursuit of specialised care other than the care that is provided in the traditional hospital setting, and it reflects the search for strategies to overcome the lack autonomy and fear that women feel when they have no control over the delivery process.

In this context, the delivery units and home deliveries gain momentum. Based on scientific evidence and a deep respect for the decisions of women, this practice allows out-of-hospital care that focuses on women, especially from the viewpoint of autonomy¹⁰, ¹². Another positive aspect of the out-of-hospital setting is the possibility of non-traditional practices, such as vertical positions during delivery, that are more closely related to the active participation of parturients and assistance by non-medical professionals who believe in the potential of the female body to give birth¹⁴-¹⁵.

Of these professionals, the obstetrics nurse or midwife favours the experience of natural and physiological childbirth that respects women’s autonomy and shared decision making¹¹, ¹³-¹⁴. The care that midwives provide is characterised by dialogue and the appreciation of women’s experiences, which supports female empowerment during childbirth¹⁰, ¹⁶.

The practices of support and comfort of these professionals also promote women’s autonomy during labour and childbirth¹¹, ¹³, ¹⁶-²⁰ since this form of care is not merely technical or procedural. Nursing professionals are considered the main facilitators of this practice, especially because they respect the feelings of women and value their complaints, provide the necessary psychological and emotional support, and apply relaxation techniques recommended by the WHO⁸ to bring relief and comfort to women in labour¹⁶, ¹⁹-²⁰.

Educational practices are also believed to favour the exercise of women’s autonomy, as supported by a large number of studies¹¹, ¹³-¹⁴, ¹⁶, ¹⁹-²⁴. These practices enable the development of human potential and allow the women to perceive themselves as the key subjects of their pregnancy and childbirth, which makes them active decision makers in their own care. The information obtained from the women is not only used to support their choices; it is also used to help them experience the birth of their children as they imagined it regardless of location.

Of the educational activities, the most noteworthy strategies are prenatal care and group activities. Prenatal care provides access to critical information for the autonomy of women and supports decision making related to childbirth¹¹, ¹⁷, ²⁰-²¹. Group activities contribute to the safety and autonomy of the couple, and generate changes in attitudes and behaviour. The educational process in groups has a positive impact on the women and on society as a whole, and could become an instrument to change the current obstetrics scenario¹¹, ¹⁴, ²²-²³.

Information essentially builds a solid basis that grants women the autonomy they need to choose or reject any procedure on their bodies, and provides support for professionals and out-of-hospital care. However, if the women are not sure of their rights or how they can claim these rights, any autonomy becomes a distant possibility. Ignorance about their own bodies and the reproductive processes merely supports the mechanisms of control and oppression assumed by these women in the hospital setting¹¹, ¹³, ¹⁶, ¹⁸-¹⁹, ²⁴.

Contrarily, the model of technical obstetric care was directly tied to practices that restrict the autonomy of Brazilian women in the process of labour and childbirth, as described in all the studies. The basic principle of this model is authoritarian healthcare practices ¹⁴, ¹⁷-¹⁹, ²¹, ²³-²⁷, that is, when the professional assumes a position of authority over the user, who in this case is the woman who is expropriated from the control of her own body.

The predominant idea in this model of care is the existence of an asymmetric relationship between professional and patient¹⁷, ²³-²⁴, ²⁶-²⁷, which becomes visible at the moment of delivery because, even when the women participate in the process, it is only to collaborate with the work of the professional and not to ensure the exercise of their autonomy. Since they not allowed to express their feelings or their opinions about delivery, they remain silent. Their bodies do not belong them, and even when they do speak, the health workers do not seem to listen.

This model of obstetric care includes practices that are not notified or consented¹⁸-¹⁹, ²¹, ²³-²⁴. Some procedures are usually imposed or performed without even notifying the women. The imposition of care practices is considered a violation of the woman’s right to bodily integrity and freedom from abuse. When they are notified, they are not offered the opportunity to participate in the decision that involves their own bodies, which restricts and prevents the exercise of their autonomy. This lack of communication on the part of professionals somehow reveals their neglect regarding the women`s right to information.

Similarly, it was observed that the standard or routine care practices limit the exercise of autonomy of Brazilian women during labour and childbirth¹⁸-¹⁹, ²¹, ²³, ²⁵-²⁷. It is presumed that women in labour are incapable of deciding the care they need, and they are forced to accept the discourse of the health workers. General and ungrounded prescriptions characterise a standardised and authoritarian care where women are thought to have the same bodies.

These individualised practices with no scientific basis include preparation for childbirth, sprinkler baths, hair removal, enema, prolonged fasting, infusion of oxytocin, and episiotomy at childbirth, in which the professionals are unanimous in stating that the decision cannot be made by the women who will undergo these procedures¹⁸-¹⁹, ²¹, ²⁵-²⁷. Similarly, in C-section deliveries, these practices include tying of the women`s hands during surgery, the use of sedatives, and the postponement of the first contact with the newborn, which only reinforces the neglect of health workers regarding the emotional aspects and autonomy of women²⁸.

It is acknowledged that the professionals who are present during delivery are responsible for indicating and performing certain practices since they are qualified to assess the need for interventions and prevent complications. However, standardisation or authoritative imposition and not requesting the informed consent of the women subjugates them and hinders their emancipation as an active agent of the parturition process¹⁹, ²¹, ²³.

It was also observed that the care practices that intensify the sensation of pain in labour negatively interfere in the autonomy of Brazilian women ¹⁷-¹⁸, ²⁰, ²³, ²⁵-²⁶, ²⁹-³⁰. Oftentimes, these obstetrics interventions are not recommended⁸, as in the case of isolation and abandonment in the obstetrics unit, the abusive use of oxytocin, Kristeller’s manoeuvre, and episiotomy¹⁸, ²⁰, ²⁵. The non-use of pain relief methods and analgesia in childbirth only worsens the situation¹⁷, ²⁹.

The suffering caused by pain renders the women powerless, and any attempts to alleviate or minimise the pain allows women to assume control over the process of parturition and become more active and participatory. However, although pain relief techniques during labour are widely recommended, the use of these techniques varies according to the philosophy of the institution²⁰. When the professional trivializes or does not consider physical complaints of the parturients, believing that the pain of childbirth is legitimate, there is no listening and no negotiating, only limitation, imposition, and violence¹⁸, ²³, ²⁶, ³⁰.

A cold and impersonal healthcare practice that is contrary to ministerial recommendations was also considered a barrier to the autonomy of Brazilian women during labour and childbirth¹⁶, ¹⁸, ²¹, ²⁵-²⁶, ³⁰-³¹. It is a reflection of the loneliness, fear, and sadness caused by the abandonment in the obstetrics units. Many professionals fully transfer the responsibility of confronting labour to the women, and distance themselves by giving priority to medical prescriptions during care¹⁶, ¹⁸, ²¹.

During labour, most women prefer the permanent and qualified presence of professionals, especially when they are experiencing painful contractions¹⁸, ²¹. However, when the women do not behave as expected, a heavy tension is generated among the health workers. Consequently, they adopt an attitude of disrespect for the culture of women, and repress and force the women to act according to the rules of behaviour they impose²⁵-²⁶, ³⁰-³¹.

Some long-standing obstetric conducts are understandably difficult to change, and discussions are needed to foster change in the current obstetric scenario²¹. It is necessary to rethink the role of health workers and the implementation of a care model that values techniques that favour human relationships to ensure individualisation, the best care, and the recovery of women`s autonomy to all those involved in the process of pregnancy and childbirth¹⁶, ²⁰-²¹.

CONCLUSIONS

This integrative literature review presented scientific literature on the healthcare practices that interfere with the active participation and decision making of Brazilian women in the process of labour and childbirth. The review showed that out-of-hospital practices, care practices of support and comfort, and educational practice positively affect the exercise of women`s autonomy. The care practices that negatively interfere with women`s autonomy are authoritarian practices, standardised or routine practices, practices that intensify the painful sensation of childbirth, and cold and impersonal healthcare practices.

A possible limitation of this review is the analysis of studies conducted in Brazil only, which prevents a general perspective of obstetric care. However, the review of Brazilian studies is justified since the models of obstetric care used worldwide differ from the models used in Brazil.

Educational practices can potentially serve as strategies to promote the role of women in the obstetric setting and ensure the exercise of their rights. However, the review also revealed a profound disconnection between routine care and ministerial recommendations, and most of the studies highlighted practices that limit the autonomy of Brazilian women in the process of labour and birth. Clearly, there is a setback in the recognition and full implementation of women’s rights that prevents these women from exercising autonomy regarding their own bodies and childbirth.

The results stress the need for greater nursing intervention to ensure the autonomy of women and their active participation in the process of labour and birth. The findings also emphasise the importance of obstetric nursing in this scenario since, in addition to substantiating their care in the precepts of non-medicalisation and the appreciation of physiological birth, obstetrics nurses are growing professionally and becoming highly representative in the field of nursing in general. Therefore, future studies should address the singularities and subjectivities of women, the democratisation of relations between professionals and patients, and the perception of those involved in childbirth regarding the conceptual and ethical aspects of women’s autonomy.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  22 May 2016
• Accepted
  10 Jan 2017