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Facilitating and limiting factors for nurses’ role in controlling COVID-19 in childbirth care

Abstract

Objective

to discuss the facilitating and limiting factors of nurses’ performance in controlling COVID-19 in childbirth care.

Methods

a descriptive and qualitative study, with 20 nurse-midwives from public services in the state of Rio de Janeiro. Data were collected from May to July 2021, through semi-structured interviews, and submitted to thematic content analysis.

Results

as facilitating factors there are: physical installations and resources that provide individualized use; protocol implementation; reorganization of collective environment use; and preference for care that does not require instruments or nurses’ continuous presence. As limiting factors, the following stand out: high demand for care; restricted accommodation and inadequate ventilation; lack of resources; resistance to wearing a mask; nurses’ difficulty in maintaining physical distance in care; and increase in interventionist practices among certain professionals.

Conclusions and implications for practice

services that underwent adaptations in environments, with available resources, co-responsibility regarding sanitary measures and where nurse-midwives modified their care process, presented better conditions to protect health and mitigate COVID-19 transmission, with attention to environment, humanization and women’s rights during childbirth.

Keywords:
COVID-19; Humanization of Assistance; Maternity; Natural Childbirth; Nurse Midwives

Resumo

Objetivo

discutir os fatores facilitadores e limitadores da atuação das enfermeiras no controle da COVID-19 na assistência ao parto.

Métodos

estudo descritivo e qualitativo, com 20 enfermeiras obstétricas de serviços públicos do estado do Rio de Janeiro. Os dados foram coletados de maio a julho de 2021, por entrevistas semiestruturadas, e submetidos à análise de conteúdo temática.

Resultados

como fatores facilitadores, têm-se: instalações físicas e recursos que proporcionam o uso individualizado; implementação de protocolos; reorganização do uso de ambientes coletivos; e preferência por cuidados que não requerem instrumentos ou a presença contínua da enfermeira. Como limitadores, apontam-se: a alta demanda assistencial; acomodações restritas e ventilação inadequada; carência de recursos; resistência ao uso de máscara; dificuldades das enfermeiras em manter o distanciamento físico nos cuidados; e incremento de práticas intervencionistas entre determinados profissionais.

Conclusões e implicações para a prática

serviços que passaram por adequações nos ambientes, com recursos disponíveis, corresponsabilização acerca das medidas sanitárias e onde as enfermeiras obstétricas modificaram seu processo de cuidar, apresentam melhores condições para proteger a saúde e mitigar a transmissão da COVID-19, com atenção à ambiência, humanização e aos direitos das mulheres no parto.

Palavras-chave:
COVID-19; Enfermeiras Obstétricas; Humanização da Assistência; Maternidade; Parto Normal

Resumen

Objetivo

discutir los factores facilitadores y limitantes de la actuación de los enfermeros en el control de la COVID-19 en la atención al parto.

Métodos

estudio descriptivo y cualitativo, con 20 parteras de servicios públicos del estado de Río de Janeiro. Los datos fueron recolectados de mayo a julio de 2021, a través de entrevistas semiestructuradas, y sometidos a análisis de contenido temático.

Resultados

como factores facilitadores, se encuentran: instalaciones físicas y recursos que brindan un uso individualizado; implementación de protocolos; reorganización del uso de los entornos colectivos; y preferencia por cuidados que no requieran instrumental o la presencia continua de la enfermera. Como limitantes, se destacan: la alta demanda de atención; alojamiento restringido y ventilación inadecuada; falta de recursos; resistencia a usar mascarilla; dificultades de las enfermeras para mantener la distancia física en el cuidado; y el aumento de las prácticas intervencionistas entre determinados profesionales.

Conclusiones e implicaciones para la práctica

los servicios que sufrieron adaptaciones en los ambientes, con recursos disponibles, corresponsabilidad en las medidas sanitarias y donde las matronas modificaron su proceso de atención, presentan mejores condiciones para proteger la salud y mitigar la transmisión de la COVID-19, con atención al ambiente, la humanización y los derechos de la mujer durante el parto.

Palabras-clave:
COVID-19; Enfermeras Obstetrices; Humanización de la Atención; Maternidades; Parto Normal

INTRODUCTION

The COVID-19 pandemic has brought unprecedented challenges to the world’s population, given the lack of knowledge about the disease and its impacts on health systems.11 Iobst SE, Breman RB, Walker M, Wysong G, Best N, Edmonds JK. Challenges, job satisfiers, and self-care among perinatal nurses in the United States during the COVID-19 pandemic. MCN Am J Matern Child Nurs. 2023 mai/jun;48(3):118-26. http://dx.doi.org/10.1097/NMC.0000000000000912. PMid:36744889.
http://dx.doi.org/10.1097/NMC.0000000000...
In this context, the risk of morbidity and mortality was decisive in defining risk groups, where pregnant and puerperal women were included.22 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de recomendações para a assistência à gestante e puérpera frente à pandemia de COVID-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 out 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_assistencia_gestante_puerpera_covid-19_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
Corroborating this, Brazilian data on the maternal mortality ratio from 2019 to 2021 reveal an increase of 94%, going back to levels of two decades ago.33 Fundo de Populações das Nações Unidas (UNFPA). A razão da mortalidade materna no Brasil aumentou 94% durante a pandemia. Fundo de População da ONU alerta para grave retrocesso [Internet]. Nova York: UNFPA; 2022 [citado 2023 mar 31]. Disponível em: https://brazil.unfpa.org/pt-br/news/razao-da-mortalidade-materna-no-brasil-aumentou-94-durante-pandemia-fundo-de-populacao-da-onu#:~:text=Em%202020%2C%20foi%20de%2071.97,mapeados%20pelo%20Observat%C3%B3rio%20Obst%C3%A9trico%20Brasileiro
https://brazil.unfpa.org/pt-br/news/raza...

In view of this scenario and in order to reduce the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission, recommendations have been established for disease control in obstetric services, including: strict handwashing protocols and mandatory mask wearing for everyone; adoption of standard precautions and contact precautions for health professionals; changes in care routines and physical spaces, with emphasis on offering environments and instruments for individual use, respect for physical distancing in care and maintaining a minimum distance of two meters between beds in childbirth rooms and collective wards.22 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de recomendações para a assistência à gestante e puérpera frente à pandemia de COVID-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 out 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_assistencia_gestante_puerpera_covid-19_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,44 Amorim MMR, Souza ASR, Melo ASDO, Delgado AM, Florêncio ACMCDC, Oliveira TVD et al. COVID-19 e gravidez. Rev Bras Saúde Mater Infant. 2021 mai;21(Supl 2):337-53. http://dx.doi.org/10.1590/1806-9304202100s200002.
http://dx.doi.org/10.1590/1806-930420210...

However, considering the structural weaknesses of many Brazilian maternity hospitals,55 Pasche DF, Pessatti MP, Silva LBRAA, Matão MEL, Soares DB, Caramachi APC. Transição do modelo de ambiência em hospitais que realizam partos na Rede Cegonha. Cien Saude Colet. 2021 mar;26(3):887-96. http://dx.doi.org/10.1590/1413-81232021263.45262020. PMid:33729344.
http://dx.doi.org/10.1590/1413-812320212...
the effects of these recommendations on the environment of obstetric and neonatal care services can be seen, defined as the physical, social, professional environment and interpersonal relationships that is shared by a group of people who exchange experiences of work and care, permeated by values, meanings and belonging.66 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Orientações para elaboração de projetos arquitetônicos Rede Cegonha: ambientes de atenção ao parto e nascimento [Internet]. Brasília: Ministério da Saúde; 2018 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/orientacoes_projetos_arquitetonicos_rede_cegonha.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,77 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Núcleo Técnico da Política Nacional de Humanização. Ambiência [Internet]. 2ª ed. Brasília: Ministério da Saúde; 2010 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/ambiencia_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

In this regard, it involves the organization of environments that promote comfort, acceptance and the production of subjectivities in human interactions in health work that provide comprehensiveness, equity, qualification and safety of care, optimizing resources and guaranteeing users’ and workers’ rights. Thus, a humanized and functional architecture is constituted that provides care spaces for actions, reflections and pleasurable and resolving experiences.77 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Núcleo Técnico da Política Nacional de Humanização. Ambiência [Internet]. 2ª ed. Brasília: Ministério da Saúde; 2010 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/ambiencia_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,88 Almeida RAAS, Carvalho RHSBF, Lamy ZC, Alves MTSSB, Poty NARC, Thomaz EBAF. Do pré-natal ao puerpério: mudanças nos serviços de saúde obstétricos durante a pandemia da COVID-19. Texto Contexto Enferm. 2022 jan;31:e20220206. http://dx.doi.org/10.1590/1980-265x-tce-2022-0206en.
http://dx.doi.org/10.1590/1980-265x-tce-...

From this point of view, nurse-midwives act using environments as facilitators of normal childbirth care and consider the elements that interfere with the relationships between individuals, such as privacy, individuality, physical facilities, light, smell, sound, synesthesia, art and color. In this way, the process of caring for parturient women is configured as a care centered on women, which constitutes a therapeutic and emancipating experience.88 Almeida RAAS, Carvalho RHSBF, Lamy ZC, Alves MTSSB, Poty NARC, Thomaz EBAF. Do pré-natal ao puerpério: mudanças nos serviços de saúde obstétricos durante a pandemia da COVID-19. Texto Contexto Enferm. 2022 jan;31:e20220206. http://dx.doi.org/10.1590/1980-265x-tce-2022-0206en.
http://dx.doi.org/10.1590/1980-265x-tce-...

9 Prata JA, Ares LPM, Vargens OMC, Reis CSC, Pereira ALF, Progianti JM. Tecnologias não invasivas de cuidado: contribuições das enfermeiras para a desmedicalização da maternidade de alto risco. Esc Anna Nery. 2019 mar;23(2):e20180259. http://dx.doi.org/10.1590/2177-9465-ean-2018-0259.
http://dx.doi.org/10.1590/2177-9465-ean-...
-1010 Silva FL, Russo J, Nucci M. Pregnancy, childbirth and postpartum in the pandemic: the multiple meanings of risk. Horiz Antropol. 2021 jan/abr;27(59):245-65. http://dx.doi.org/10.1590/s0104-71832021000100013.
http://dx.doi.org/10.1590/s0104-71832021...

Considering the above, this article aimed to discuss the facilitating and limiting factors of nurses’ performance in COVID-19 control in childbirth care. This research is relevant, because it reveals the daily challenges of obstetric services and the potential of nurse-midwives’ performance in a context that values high health surveillance, offering subsidies for the development of actions to control the spread of COVID-19 in childbirth care and minimize the impacts of the pandemic on the appropriate environment in this area of care.

METHOD

Study design

This is a descriptive and exploratory study, with a qualitative approach, which followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.

Participants

Participants were 20 nurse-midwives, adopting as an inclusion criterion caring for parturient women during the pandemic in obstetric services in the state of Rio de Janeiro. Specialists who have been developing care activities in this area for less than a year and those who work in the private network were excluded.

It should be noted that eight nurses, who met the inclusion criteria, refused to participate in the research, justifying the lack of time due to work overload in times of a pandemic. Furthermore, there were no withdrawals from participation during data collection.

Data collection procedures

Data were collected from May to July 2021 through semi-structured individual interviews carried out by three authors, previously trained resident nurses who took turns conducting the interviews.

To this end, a script was prepared with 06 closed-ended questions about socio-professional data, such as sex, age, academic background, length of experience in nursing-midwifery, employment relationship with the obstetric service and type of health establishment in which they work. In addition to this, the script included the following open questions: tell me about your perceptions about the factors that may influence COVID-19 control in childbirth care. Were environments, resources, people and childbirth care influenced by the pandemic context? How?

To gather participants, the snowball technique was used, in which an individual with the appropriate profile for the research is selected as the first interviewee, called a seed, which indicates other potential participants, with the desired characteristics, and so on until the sampling becomes saturated, i.e., there are no new indications or the suggested names do not add new information.1111 Curtis AC, Keeler C. Sampling design in nursing research. Am J Nurs. 2021 mar;121(3):53-7. http://dx.doi.org/10.1097/01.NAJ.0000737304.14564.51. PMid:33625012.
http://dx.doi.org/10.1097/01.NAJ.0000737...

The study had three intentionally selected seeds, based on the researchers’ network of contacts with residency preceptors, who met the inclusion criteria. Thus, three indication chains were constituted and initial contact with potential participants took place through a message application, for clarification about the research and invitation to participate. Upon acceptance, the Informed Consent Form was shared in electronic form format, and the virtual interview was scheduled.

Faced with the pandemic context, the interviews took place by videoconference on the date chosen by participants and carried out by three authors, resident nurses. The interviews were attended by one of the interviewers and the participant, and lasted an average of 40 minutes. With due consent, they were recorded using a screen and audio recorder application. Subsequently, the material was fully transcribed with the support of a word processor (Word), and sent by email to participants for content validity, without any negative feedback from them.

It should be noted that the instrument was previously tested with the seeds, which were included in the study, as no adjustments were necessary.

Data analysis

Data were submitted to thematic content analysis.1212 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014. In the pre-analysis stage, text skimming was carried out according to the criteria of exhaustiveness, representativeness, homogeneity and pertinence. Next, the recording units (RU) and context of each interview were identified, with the screening of significant clippings, followed by RU grouping into categories, conforming the exploration and categorization stage. Inductive thematic saturation was adopted to finalize the reference chain, i.e., when there was no emergence of new codes or themes in the analysis phase, which was obtained in the eighteenth interview. When conducting two more interviews to confirm saturation, it was ratified and data collection ended.1313 Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018 set;52(4):1893-907. http://dx.doi.org/10.1007/s11135-017-0574-8. PMid:29937585.
http://dx.doi.org/10.1007/s11135-017-057...

This analytical process resulted in the constitution of two analytical categories: “Factors related to the infrastructure of obstetric services”; and “Factors associated with the human component”. Finally, data were interpreted, with researchers’ inferences about what emerged in the researched group, in dialogue with the scientific knowledge already produced.

Ethical aspects

The study was approved by the Research Ethics Committee of the Universidade do Estado do Rio de Janeiro on February 1, 2021, under CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 42419121.0.0000.5282, Opinion 4,518,637.

The research was developed respecting Resolution 466/2012 of the Brazilian National Health Council. The materials transcribed from the interviews are under the custody of one of the authors, stored on a free internet provider for a period of 5 years, and participants’ anonymity was ensured by adopting the letter “N”, referring to “nurse”, accompanied by a number, referring to the order in which the interview was carried out.

RESULTS

Participants are female, and most are aged between 30 and 35 years old as well as obtained the title of specialist through training in the residency modality. About the length working in the specialty, two have been working for up to 5 years; thirteen have been working between 5 and 10 years; and five have worked for more than 10 years. With regard to the employment relationship, twelve are statutory public servants and eight are hired under a CLT (Consolidation of Brazilian Labour Laws) regime, with 15 working in maternity hospitals and 5 in childbirth homes.

Factors related to the infrastructure of obstetric services

This category shows that obstetric services’ physical environments and resources are facilitating or limiting factors in COVID-19 control in childbirth care. In this regard, participants recognize that facilities and material resources available, by providing the individualized use of spaces and care instruments, are factors that contribute to mitigating the risk of contamination.

[...] we have several balls! If one woman is using one ball, we can get the other one on another. (N1)

[…] they are free to choose the shower [warm aspersion] because we have suites with a bathroom and so they have no contact with anyone. (N4)

PPP rooms [pre-childbirth, childbirth and post-childbirth] are private rooms equipped with a bed, with RHU [Radiant Heat Unit] and material for resuscitation. One of these rooms has a bathtub, two have a bathroom with a shower and one has a bathtub next to the bed! (N9)

They are suites with a very large bathroom! They have the [care] technologies, such as: birthing stool, stool, bars. All of this is available in every PPP room [with pre-childbirth, childbirth and post-childbirth beds]. (N13)

On the other hand, the obstetrical nurses point out that the high demand for care, the absence of exclusive-use bathrooms and the fact that the sectors are small, with restricted accommodation and inadequate ventilation conditions, are shown to be limiting factors, as they increase exposure to the new coronavirus:

Our demand is very high, the physical space is very small and is not divided by boxes! We still need to make the separations with the room dividers. (N8)

The childbirth room does not have a suite or exclusive bathroom. So, offering a warm bath is harmed... (N7)

The space is not a facilitator because it is small, with a large number of women giving birth... [...] and the space in the boxes is reduced! (N5)

It is a closed sector, with only two windows! (N1)

Childbirth happens in heat! No air conditioning or any air circulation. (N18)

Added to this scenario is the lack of material resources needed to cope with COVID-19 in childbirth care, highlighting weaknesses in the availability of diagnostic tests, Personal Protective Equipment (PPE) and some instruments used in care adequately sized to the care demand.

I am afraid of the issue of contact with parturient women, as we see a huge number of pregnant women with COVID-19 and we only find out later because there is no test available on the network… (N3)

At the beginning, the unit did not have enough masks for the number of professionals and consultations because, especially in the maternity ward, we are not in the habit of wearing a mask in various procedures. It was a panic in the team. Mask and face shield were not available for everyone! (N13)

We have two stools and a birthing stool, but using them is difficult because you take these instruments to a contaminated environment and then have to decontaminate them. So, we are using less. (N7)

Factors associated with the human component

This category reveals that behaviors, attitudes and conduct of nurses, health professionals, parturient women and companions are factors that contribute to or hinder COVID-19 control in childbirth care. As behaviors that confer health protection, the nurse-midwives in this study refer to PPE use intensification and the guidelines on the importance of using masks with women and companions.

I started using respiratory barriers [precautionary measures], using the N95 type mask and the face shield… (N2)

I advise her to move freely, as long as she wears a mask. I ask the companion to wear a mask and stay close to the bed while they are not there. (N16)

We advise them to understand the importance of preventing themselves [from contagion] through mask use. (N21)

Moreover, they cite changes in childbirth care arising from the implementation of institutional protocols, which include professional attitudes and conduct to avoid crowding, ensure physical distancing and reduce exposure to body fluids. Additionally, they mention changes in their care process, involving the reorganization of collective environment use, encouraging the companion’s participation and the preference for care that does not require instrument use or nurses’ continuous presence:

In order not to generate too much crowding, I go to the bathroom and leave a maximum of three women in a room [specific environment for using care technologies] and they take turns: one is on the ball, the other on the birthing stool [rocking chair] and another on the [childbirth] stool. Sometimes, I take the ball or the stool to the bed so that they are more isolated. (N14)

According to the literature, we stopped manipulating the placenta and amniotic fluid and avoided [baby] exposure to amniotic fluid, with a reduction in possible interventions, such as [amniotic] bag rupture. […] we are using free movement and bathing more because they are things they can do alone and do not need equipment that will have contact with other people. [...] thus, we train the companion and the woman to use the technologies. Thus, we reduce our presence and our touch a little... we keep a distance, but we remain with care. (N4)

We have not assisted childbirth in water, as it is prevented until there is new evidence. We leave the water just for relaxation! (N10)

For the massage, we encouraged more participation of the companion, to reduce our contact, the touch with parturient women (N12)

However, participants identify behaviors, attitudes and conduct that do not favor COVID-19 control in childbirth care, highlighting: resistance of some parturient women to mask use in the parturition process; nurses’ difficulty in maintaining physical distance in the care relationship with women; and increase in interventional obstetric practices by certain professionals.

The woman can’t wear a mask in childbirth! She can’t breathe, feel pain, contract... I can’t do any different! You see that the woman needs a welcome, you go there and give her a hug! There’s no way! It is inherent to the profession! (N10)

I even forgot I had COVID-19! That I had to keep the distance, that I couldn’t have close contact and that I could catch it. It’s a woman in labor who holds your hand and you can’t help but hold your hand because there’s COVID-19! (N11)

I see a lot of unnecessary performance in the pandemic! I can see a lot of anxiety and not giving the woman time [labor]. They come in with drug interventions! I see a lot of the Kristeller maneuver and a lot of episiotomy! (N8)

She [referring to the medical professional] speeds up the delivery a little, even with the patient dilating quickly! Performs cervical reduction from the end of labor until birth… (N9)

DISCUSSION

The results show that different factors interfere positively or negatively in the performance of nurse-midwives regarding COVID-19 control in childbirth care. In this regard, factors related to the infrastructure of obstetric services are evident, covering physical environments and material resources as well as factors associated with the human component, expressed in behaviors, attitudes and conduct of nurses, health professionals, parturient women and companions.

As infrastructure factors that collaborate to mitigate the risk of contamination, the participants point to the sector’s facilities, which have PPP rooms or private suites, with a large bathroom and instruments used in care, such as a bathtub, shower, Swiss ball, birthing stool, stool and support bars. Thus, they recognize that these physical environments and material resources provide individualized use, comfort and safety necessary for the parturition process in times of a pandemic.

From the perspective of obstetric services’ environment, it is recommended that accommodations be designed in the format of PPP rooms, with appropriate dimensions, attached bathroom and equipment that allow parturient women access conditions and choice of active movement, companion participation and non-pharmacological methods of pain relief.55 Pasche DF, Pessatti MP, Silva LBRAA, Matão MEL, Soares DB, Caramachi APC. Transição do modelo de ambiência em hospitais que realizam partos na Rede Cegonha. Cien Saude Colet. 2021 mar;26(3):887-96. http://dx.doi.org/10.1590/1413-81232021263.45262020. PMid:33729344.
http://dx.doi.org/10.1590/1413-812320212...

6 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Orientações para elaboração de projetos arquitetônicos Rede Cegonha: ambientes de atenção ao parto e nascimento [Internet]. Brasília: Ministério da Saúde; 2018 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/orientacoes_projetos_arquitetonicos_rede_cegonha.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
-77 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Núcleo Técnico da Política Nacional de Humanização. Ambiência [Internet]. 2ª ed. Brasília: Ministério da Saúde; 2010 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/ambiencia_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
In the context of COVID-19, this infrastructure contributes to disease control, because, by providing assistance to be developed in individualized spaces, parturient women and companions are prevented from having unnecessary contact with other people and sharing objects, with respect to measures to maintain physical distance and avoid crowds as well as the right of women to respectful and safe childbirth.1414 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo Coronavírus 2019 - Covid-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/coronavirus/guia-de-vigilancia-epidemiologica-covid-19_2021.pdf/view
https://www.gov.br/saude/pt-br/centrais-...
,1515 Royal College of Midwives. Clinical briefing: face-coverings and care in labour for all women [Internet]. Londres: Royal College of Midwives; 2021 [citado 2022 abr 22]. Disponível em: https://www.rcm.org.uk/media/5400/cb-face-coverings-and-care-in-labour-for-all-women.pdf
https://www.rcm.org.uk/media/5400/cb-fac...

On the other hand, exposure and risk of contamination by the new coronavirus increase in institutions that have small sectors with restricted accommodation, inadequate ventilation conditions, without bathrooms for exclusive use or where the lack of care instruments implies sharing them among the parturient women, as identified in participants’ speeches. Unfortunately, this is the reality of many Brazilian institutions, in which childbirth rooms with beds separated by curtains and the absence of individual equipment for non-pharmacological pain management and private bathrooms with shower and hot water persist, especially in obstetric services with a high-risk maternal and fetal care profile.55 Pasche DF, Pessatti MP, Silva LBRAA, Matão MEL, Soares DB, Caramachi APC. Transição do modelo de ambiência em hospitais que realizam partos na Rede Cegonha. Cien Saude Colet. 2021 mar;26(3):887-96. http://dx.doi.org/10.1590/1413-81232021263.45262020. PMid:33729344.
http://dx.doi.org/10.1590/1413-812320212...
,1616 Bittencourt SDA, Vilela MEA, Marques MCO, Santos AM, Silva CKRT, Domingues RMSM et al. Atenção ao parto e nascimento em maternidades da Rede Cegonha/Brasil: avaliação do grau de implantação das ações. Cien Saude Colet. 2021 mar;26(3):801-21. http://dx.doi.org/10.1590/1413-81232021263.08102020. PMid:33729338.
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,1717 Vieira MLC, Prata JA, Oliveira EB, Rodrigues FAB, Almeida BCDS, Progianti JM. Estratégias das enfermeiras obstétricas frente às condições de trabalho em maternidades. Rev Bras Enferm. 2021 mar;74(1):e20200201. http://dx.doi.org/10.1590/0034-7167-2020-0201. PMid:33787793.
http://dx.doi.org/10.1590/0034-7167-2020...

The non-compliance of these places with the recommendations for an adequate environment for childbirth66 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Orientações para elaboração de projetos arquitetônicos Rede Cegonha: ambientes de atenção ao parto e nascimento [Internet]. Brasília: Ministério da Saúde; 2018 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/orientacoes_projetos_arquitetonicos_rede_cegonha.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,77 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Núcleo Técnico da Política Nacional de Humanização. Ambiência [Internet]. 2ª ed. Brasília: Ministério da Saúde; 2010 [citado 2021 mar 16]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/ambiencia_2ed.pdf
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adds to the difficulties faced in the adoption of preventive measures and COVID-19 control in the face of the high demand absorbed by health services in the course of the pandemic, as verified in this study. In this way, it becomes even more challenging to use collective spaces and avoid sharing objects, because in closed environments, normally without adequate ventilation, people interact frequently and in close physical proximity, enhancing airborne and SARS-CoV-2 contact transmission.1414 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo Coronavírus 2019 - Covid-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/coronavirus/guia-de-vigilancia-epidemiologica-covid-19_2021.pdf/view
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Regarding the latter, it should be noted that contamination occurs through direct contact with contaminated objects and surfaces, without subsequent disinfection and hand hygiene.1414 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo Coronavírus 2019 - Covid-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/coronavirus/guia-de-vigilancia-epidemiologica-covid-19_2021.pdf/view
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Corroborating this, studies show that the new coronavirus survives for minutes or hours on porous surfaces and even for weeks on non-porous surfaces, and this ability is influenced by environment temperature and humidity.1818 Chia PY, Coleman KK, Tan YK, Ong SWX, Gum M, Lau SK et al. Detection of air and surface contamination by SARS-CoV-2 in hospital rooms of infected patients. Nat Commun. 2020 mai;11(1):2800. http://dx.doi.org/10.1038/s41467-020-16670-2. PMid:32472043.
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In this regard, the increased risk of contamination by this route in childbirth care is considered, especially in services with inadequate physical environments and a lack of instruments used in care, considering: the materials of these objects, which are made of smooth and porous plastic, fabric and metal;1919 Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017 mai;5(5):CD002006. http://dx.doi.org/10.1002/14651858.CD002006.pub4. PMid:28539008.
http://dx.doi.org/10.1002/14651858.CD002...
the childbirth environment temperature, which should remain around 26º C;2020 Pinheiro JMB. Preventing hypothermia in preterm newborns - simple principles for a complicated task. J Pediatr. 2018 jul/ago;94(4):337-9. http://dx.doi.org/10.1016/j.jped.2017.10.003. PMid:29100745.
http://dx.doi.org/10.1016/j.jped.2017.10...
and humidity inherent to the female body physiology during labor.1010 Silva FL, Russo J, Nucci M. Pregnancy, childbirth and postpartum in the pandemic: the multiple meanings of risk. Horiz Antropol. 2021 jan/abr;27(59):245-65. http://dx.doi.org/10.1590/s0104-71832021000100013.
http://dx.doi.org/10.1590/s0104-71832021...
,1515 Royal College of Midwives. Clinical briefing: face-coverings and care in labour for all women [Internet]. Londres: Royal College of Midwives; 2021 [citado 2022 abr 22]. Disponível em: https://www.rcm.org.uk/media/5400/cb-face-coverings-and-care-in-labour-for-all-women.pdf
https://www.rcm.org.uk/media/5400/cb-fac...

Added to this overview is the global problem of shortages of essential inputs to face COVID-19. It is noted that more solid health systems were successful in surveillance, as in China and South Korea, or in reducing mortality, as is the case in Germany. However, countries with a history of weakening public services were less efficient, resulting in higher rates of illness and death among health professionals.11 Iobst SE, Breman RB, Walker M, Wysong G, Best N, Edmonds JK. Challenges, job satisfiers, and self-care among perinatal nurses in the United States during the COVID-19 pandemic. MCN Am J Matern Child Nurs. 2023 mai/jun;48(3):118-26. http://dx.doi.org/10.1097/NMC.0000000000000912. PMid:36744889.
http://dx.doi.org/10.1097/NMC.0000000000...
,2121 Helioterio MC, Lopes FQRS, Sousa CC, Souza FO, Pinho PS, Sousa FN et al. Covid-19: por que a proteção de trabalhadores e trabalhadoras da saúde é prioritária no combate à pandemia? Trab Educ Saúde. 2020 jul;18(3):e00289121. http://dx.doi.org/10.1590/1981-7746-sol00289.
http://dx.doi.org/10.1590/1981-7746-sol0...

In the Brazilian context, the lack of PPE and the lack of diagnostic tests culminated in low testing of the population and underreporting of cases,1414 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo Coronavírus 2019 - Covid-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/coronavirus/guia-de-vigilancia-epidemiologica-covid-19_2021.pdf/view
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,2222 Menezes MO, Andreucci CB, Nakamura-Pereira M, Knobel R, Magalhães CG, Takemoto MLS. Testagem universal de COVID-19 na população obstétrica: impactos para a saúde pública. Cad Saude Publica. 2020 ago;36(8):e00164820. http://dx.doi.org/10.1590/0102-311x00164820. PMid:32756766.
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and this scenario was recognized by participants as an infrastructure factor that imposes limits on the new coronavirus control in childbirth care. Thus, occupational exposure in Brazilian obstetric services is considered high,2222 Menezes MO, Andreucci CB, Nakamura-Pereira M, Knobel R, Magalhães CG, Takemoto MLS. Testagem universal de COVID-19 na população obstétrica: impactos para a saúde pública. Cad Saude Publica. 2020 ago;36(8):e00164820. http://dx.doi.org/10.1590/0102-311x00164820. PMid:32756766.
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as evidence related to pregnant women, parturient women and postpartum women with COVID-19 shows that: clinical course of the disease is aggravated; risk factors increase the probability of symptomatic conditions;2323 Khan DSA, Hamid L-R, Ali A, Salam RA, Zuberi N, Lassi ZS et al. Differences in pregnancy and perinatal outcomes among symptomatic versus asymptomatic COVID-19-infected pregnant women: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2021 dez;21(1):801. http://dx.doi.org/10.1186/s12884-021-04250-1. PMid:34852783.
http://dx.doi.org/10.1186/s12884-021-042...
a positive diagnosis is consistently associated with adverse outcomes and maternal and fetal deaths;2424 Villar J, Ariff S, Gunier RB, Thiruvengadam R, Rauch S, Kholin A et al. Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: the INTERCOVID Multinational Cohort Study. JAMA Pediatr. 2021 ago;175(8):817-26. http://dx.doi.org/10.1001/jamapediatrics.2021.1050. PMid:33885740.
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and occurrence of asymptomatic infections is common.2525 Abuova G, Ayazbekov A, Nurkhasimova R, Shaimardenova G, Kulbaeva S, Nurmagambet S. Asymptomatic forms of COVID-19 in pregnant women: long-term consequences. Int J Infect Dis. 2022 mar;116:S46. http://dx.doi.org/10.1016/j.ijid.2021.12.110.
http://dx.doi.org/10.1016/j.ijid.2021.12...

Considering the different infrastructure conditions of obstetric services, the relevance of the human component for COVID-19 control can be seen, since behaviors, attitudes and conducts in childbirth care are facilitating or limiting factors in coping with the disease. In this perspective, the intensification of PPE use and guidance on the importance of wearing a mask with parturient women and companions emerged in participants’ statements as behaviors that mitigate the spread of the new coronavirus. However, they envision the risk related to women’s reluctance to use a mask during parturition.

In line with the recommendations for the prevention and control of contamination by SARS-CoV-2, universal mask use in health services is a requirement for professionals, workers and users. In the scope of obstetric care, regardless of whether it is a suspected or confirmed case of COVID-19, teams must adopt standard precautionary measures, including hand hygiene and use of gloves, apron, glasses, mask and face shield, since childbirth care involves exposure to body fluids and respiratory droplets, generated by deep breathing and vocalization of women.22 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de recomendações para a assistência à gestante e puérpera frente à pandemia de COVID-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 out 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_assistencia_gestante_puerpera_covid-19_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,1414 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo Coronavírus 2019 - Covid-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/coronavirus/guia-de-vigilancia-epidemiologica-covid-19_2021.pdf/view
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,1515 Royal College of Midwives. Clinical briefing: face-coverings and care in labour for all women [Internet]. Londres: Royal College of Midwives; 2021 [citado 2022 abr 22]. Disponível em: https://www.rcm.org.uk/media/5400/cb-face-coverings-and-care-in-labour-for-all-women.pdf
https://www.rcm.org.uk/media/5400/cb-fac...

Especially in collective spaces, such as wards and childbirth rooms with several beds, hygiene standards and mask use must be intensified and applied to all parturient women and companions.22 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de recomendações para a assistência à gestante e puérpera frente à pandemia de COVID-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 out 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_assistencia_gestante_puerpera_covid-19_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,44 Amorim MMR, Souza ASR, Melo ASDO, Delgado AM, Florêncio ACMCDC, Oliveira TVD et al. COVID-19 e gravidez. Rev Bras Saúde Mater Infant. 2021 mai;21(Supl 2):337-53. http://dx.doi.org/10.1590/1806-9304202100s200002.
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However, it should be noted that women may not tolerate mask use for reasons related to: rescue from traumatic situations; the exacerbation of respiratory conditions; the impairment of gaseous and metabolic exchanges inherent to the physiology of work; the impairment of communication; and the feeling of discomfort and overheating. In these cases, the benefits and risks must be discussed, without any imposition regarding mask use.1515 Royal College of Midwives. Clinical briefing: face-coverings and care in labour for all women [Internet]. Londres: Royal College of Midwives; 2021 [citado 2022 abr 22]. Disponível em: https://www.rcm.org.uk/media/5400/cb-face-coverings-and-care-in-labour-for-all-women.pdf
https://www.rcm.org.uk/media/5400/cb-fac...

Considering the resistance to preventive measures by a considerable part of the population, health education is essential during the pandemic.2626 Silva PK, Ribeiro CC, Duarte MC. Avaliação do uso de máscaras de acordo com sexo, idade e situação laboral durante a pandemia de COVID-19. Braz J Health Rev. 2021 jan/fev;4(1):465-74. http://dx.doi.org/10.34119/bjhrv4n1-037.
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In this context, nurses play an important role in disseminating scientific information that generates safe behavior for the community, through educational activities and guidance on self-care to promote health and prevent contamination in different environments.2727 Pinheiro PNC, Mondragón-Sánchez EJ, Costa MIF, Rodrigues IP. Reflections on nursing and COVID-19 in light of health education. Rev Bras Enferm. 2022 nov;75(Supl 1):e20201305. http://dx.doi.org/10.1590/0034-7167-2020-1305. PMid:34852036.
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As attitudes and behaviors that promote safety in childbirth care in the face of COVID-19, participants refer to adaptations in their care process, with emphasis on: adoption of rotations in collective room use; provision of equipment close to the bed; encouraging companion participation; and guidance on practices that do not require instruments or continuous professional follow-up, such as free movement in the shower room or bedroom, massage and shower bath with warm water.

Thus, it is noted that these actions are in line with the protocols for the reorganization of health services for COVID-19 prevention and control, which recommend: not to attend childbirths in water;22 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de recomendações para a assistência à gestante e puérpera frente à pandemia de COVID-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 out 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_assistencia_gestante_puerpera_covid-19_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,44 Amorim MMR, Souza ASR, Melo ASDO, Delgado AM, Florêncio ACMCDC, Oliveira TVD et al. COVID-19 e gravidez. Rev Bras Saúde Mater Infant. 2021 mai;21(Supl 2):337-53. http://dx.doi.org/10.1590/1806-9304202100s200002.
http://dx.doi.org/10.1590/1806-930420210...
avoid handling the placenta and amniotic sac;44 Amorim MMR, Souza ASR, Melo ASDO, Delgado AM, Florêncio ACMCDC, Oliveira TVD et al. COVID-19 e gravidez. Rev Bras Saúde Mater Infant. 2021 mai;21(Supl 2):337-53. http://dx.doi.org/10.1590/1806-9304202100s200002.
http://dx.doi.org/10.1590/1806-930420210...
,2828 Tolu LB, Ezeh A, Feyissa GT. Vertical transmission of Severe Acute Respiratory Syndrome Coronavirus 2: a scoping review. PLoS One. 2021 abr;16(4):e0250196. http://dx.doi.org/10.1371/journal.pone.0250196. PMid:33886645.
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limit the number of people in collective spaces and bathrooms; prevent sharing of objects; and respect the distance of one meter between people, especially in indoor and poorly ventilated environments.22 Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de recomendações para a assistência à gestante e puérpera frente à pandemia de COVID-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 out 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_assistencia_gestante_puerpera_covid-19_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
,1414 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo Coronavírus 2019 - Covid-19 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2022 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/coronavirus/guia-de-vigilancia-epidemiologica-covid-19_2021.pdf/view
https://www.gov.br/saude/pt-br/centrais-...

Despite these efforts, maintaining physical distance in the care relationship with the parturient women, associated with extensive PPE use, is a challenge for midwives in this study, since they understand touch and non-verbal communication as bodily-affective attitudes transformed into non-medicated therapeutic actions, which characterize the process of humanistic nursing care11 Iobst SE, Breman RB, Walker M, Wysong G, Best N, Edmonds JK. Challenges, job satisfiers, and self-care among perinatal nurses in the United States during the COVID-19 pandemic. MCN Am J Matern Child Nurs. 2023 mai/jun;48(3):118-26. http://dx.doi.org/10.1097/NMC.0000000000000912. PMid:36744889.
http://dx.doi.org/10.1097/NMC.0000000000...
,99 Prata JA, Ares LPM, Vargens OMC, Reis CSC, Pereira ALF, Progianti JM. Tecnologias não invasivas de cuidado: contribuições das enfermeiras para a desmedicalização da maternidade de alto risco. Esc Anna Nery. 2019 mar;23(2):e20180259. http://dx.doi.org/10.1590/2177-9465-ean-2018-0259.
http://dx.doi.org/10.1590/2177-9465-ean-...
,2929 Alves VH, Grzibowski S, Vieira BDG, Rodrigues DP, Sampaio LBC, Santos MVD. Fenomenologia da vida no cuidado afetivo de enfermagem na pandemia da COVID-19: um estudo de reflexão. Esc Anna Nery. 2021 jun;25(Spe):e20200469. http://dx.doi.org/10.1590/2177-9465-ean-2020-0469.
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and provide a positive experience with childbirth.1515 Royal College of Midwives. Clinical briefing: face-coverings and care in labour for all women [Internet]. Londres: Royal College of Midwives; 2021 [citado 2022 abr 22]. Disponível em: https://www.rcm.org.uk/media/5400/cb-face-coverings-and-care-in-labour-for-all-women.pdf
https://www.rcm.org.uk/media/5400/cb-fac...
,3030 WHO: World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience [Internet]. Genebra: WHO; 2018 [citado 2022 abr 10]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=
https://apps.who.int/iris/bitstream/hand...
However, they recognize that this attitude increases the risk of COVID-19 transmission.

In opposition to care strategies developed by participants, they perceive an increase in interventionist practices by some professionals to shorten work duration, such as prescribing medication and performing invasive procedures, such as cervical reduction, the Kristeller maneuver and episiotomy. Such behaviors, in addition to being obstetric practices of judicious use or that should be abolished in childbirth care,3030 WHO: World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience [Internet]. Genebra: WHO; 2018 [citado 2022 abr 10]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=
https://apps.who.int/iris/bitstream/hand...
interfere with COVID-19 control, as they increase occupational exposure.44 Amorim MMR, Souza ASR, Melo ASDO, Delgado AM, Florêncio ACMCDC, Oliveira TVD et al. COVID-19 e gravidez. Rev Bras Saúde Mater Infant. 2021 mai;21(Supl 2):337-53. http://dx.doi.org/10.1590/1806-9304202100s200002.
http://dx.doi.org/10.1590/1806-930420210...

During the pandemic, health professionals should be even more attentive to good practices, ensuring women’s rights and avoiding excessive interventions.1515 Royal College of Midwives. Clinical briefing: face-coverings and care in labour for all women [Internet]. Londres: Royal College of Midwives; 2021 [citado 2022 abr 22]. Disponível em: https://www.rcm.org.uk/media/5400/cb-face-coverings-and-care-in-labour-for-all-women.pdf
https://www.rcm.org.uk/media/5400/cb-fac...
However, it is noted that the reorganization of health work has had repercussions on the achievements of humanization of childbirth, expressed in the increase in cases of abuse and disrespect against parturient women and in the adoption of practices without scientific support.88 Almeida RAAS, Carvalho RHSBF, Lamy ZC, Alves MTSSB, Poty NARC, Thomaz EBAF. Do pré-natal ao puerpério: mudanças nos serviços de saúde obstétricos durante a pandemia da COVID-19. Texto Contexto Enferm. 2022 jan;31:e20220206. http://dx.doi.org/10.1590/1980-265x-tce-2022-0206en.
http://dx.doi.org/10.1590/1980-265x-tce-...
,1010 Silva FL, Russo J, Nucci M. Pregnancy, childbirth and postpartum in the pandemic: the multiple meanings of risk. Horiz Antropol. 2021 jan/abr;27(59):245-65. http://dx.doi.org/10.1590/s0104-71832021000100013.
http://dx.doi.org/10.1590/s0104-71832021...
,3131 Sadler M, Leiva G, Olza I. COVID-19 as a risk factor for obstetric violence. Sex Reprod Health Matters. 2020 dez;28(1):1785379. http://dx.doi.org/10.1080/26410397.2020.1785379. PMid:32552522.
http://dx.doi.org/10.1080/26410397.2020....

32 Schmid MB, Fontijn J, Ochsenbein-Kölble N, Berger C, Bassler D. COVID-19 in pregnant women. Lancet Infect Dis. 2020 jun;20(6):653. http://dx.doi.org/10.1016/S1473-3099(20)30175-4. PMid:32197098.
http://dx.doi.org/10.1016/S1473-3099(20)...
-3333 Kazemi A, Beigi M, Najafabadi HE. Environmental factors influencing women’s childbirth experiences in labor-delivery-recovery-postpartum unit: a qualitative cross-sectional study. BMC Pregnancy Childbirth. 2023 mar;23(1):169. http://dx.doi.org/10.1186/s12884-023-05488-7. PMid:36915051.
http://dx.doi.org/10.1186/s12884-023-054...

In the scenario of denial and uncertainty that the COVID-19 pandemic is going through in Brazil,3434 Morel APM. Negacionismo da Covid-19 e educação popular em saúde: para além da necropolítica. Trab Educ Saúde. 2021 jan;19:e00315147. http://dx.doi.org/10.1590/1981-7746-sol00315.
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restrictive and interventionist behaviors have been established in health care under the argument of mitigating contamination, but without evidence to support them. In this way, women’s dignity, safety and autonomy are threatened, forming situations of violence that are manifested in practices without obstetric or unnecessary indication, such as the restriction of the right to a companion, cesarean sections, instrumental childbirths and resource use to reduce labor duration.88 Almeida RAAS, Carvalho RHSBF, Lamy ZC, Alves MTSSB, Poty NARC, Thomaz EBAF. Do pré-natal ao puerpério: mudanças nos serviços de saúde obstétricos durante a pandemia da COVID-19. Texto Contexto Enferm. 2022 jan;31:e20220206. http://dx.doi.org/10.1590/1980-265x-tce-2022-0206en.
http://dx.doi.org/10.1590/1980-265x-tce-...
,3131 Sadler M, Leiva G, Olza I. COVID-19 as a risk factor for obstetric violence. Sex Reprod Health Matters. 2020 dez;28(1):1785379. http://dx.doi.org/10.1080/26410397.2020.1785379. PMid:32552522.
http://dx.doi.org/10.1080/26410397.2020....

32 Schmid MB, Fontijn J, Ochsenbein-Kölble N, Berger C, Bassler D. COVID-19 in pregnant women. Lancet Infect Dis. 2020 jun;20(6):653. http://dx.doi.org/10.1016/S1473-3099(20)30175-4. PMid:32197098.
http://dx.doi.org/10.1016/S1473-3099(20)...
-3333 Kazemi A, Beigi M, Najafabadi HE. Environmental factors influencing women’s childbirth experiences in labor-delivery-recovery-postpartum unit: a qualitative cross-sectional study. BMC Pregnancy Childbirth. 2023 mar;23(1):169. http://dx.doi.org/10.1186/s12884-023-05488-7. PMid:36915051.
http://dx.doi.org/10.1186/s12884-023-054...

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The factors that influence nurses’ actions in relation to COVID-19 control in childbirth care refer to the infrastructure and the human component of obstetric services, which can contribute or hinder health protection and contamination prevention.

With regard to infrastructure, physical facilities with PPP rooms or private suites, large bathrooms and adequate sizing of resources allow assistance to be developed with respect for health standards, becoming factors that facilitate disease control. However, small sectors, with collective and restricted accommodation, inadequate ventilation conditions and lack of care instruments, diagnostic tests and PPE, increase the risk of contamination by the new coronavirus.

Regarding the human component, PPE use intensification by professionals and guidance on mask use by parturient women and companions as well as adaptations in the process of caring for nurses are behaviors, attitudes and conducts that mitigate SARS-CoV-2 transmission. However, resistance to mask use during childbirth, the difficulty in maintaining physical distance in the care relationship and the increase in obstetric interventions by some professionals are limiting factors.

These findings reveal the day-to-day challenges of obstetric services and the potential of nurse-midwives’ actions in controlling COVID-19, offering subsidies for the development of actions to minimize the impacts of the pandemic on the appropriate environment for childbirth. However, considering that some elements of environment were not studied in depth in this study, it is recommended to carry out research that explores work environments and interpersonal relationships.

Furthermore, it is considered that the rescue of the notions of vulnerability and risk associated with pregnant women in times of COVID-19 can culminate in the resurgence of the biomedical model in obstetric care, making the paths for consolidating the humanization of care and the realization of women’s human rights in the post-pandemic period even more challenging.

This study makes contributions to the fields of health and nursing, as it provides subsidies for COVID-19 control in childbirth care. In this sense, their results reveal that the obstetric services that underwent adaptations in the parturition environments and have resources, suitably scaled to demand and appropriate to the pandemic context, present better conditions to protect health and mitigate SARS-CoV-2 transmission.

Moreover, the importance of the human component is highlighted, in the sense of making nurses, health professionals, parturient women and companions co-responsible for adopting behaviors, attitudes and conduct guided by science and the appropriate environment for childbirth. From this perspective, the relevance of nurse-midwives’ performance is evident, who respect health standards, ensure the environment of childbirth during the pandemic and offer safe care, from the perspective of health surveillance and scientific evidence, respectful and non-invasive to the female body and physiology, following humanistic principles and women’s human rights.

Regarding the interventionist behaviors identified by participants, it is worth reflecting on the influence of the inclusion of pregnant women, parturient women and puerperal women in the risk group for COVID-19 on health care practices. If, on the one hand, this measure aims to protect maternal and neonatal health, on the other hand, it encourages medicalized practices that reinforce the ideas of risk and vulnerability associated with pregnancy and childbirth, rekindling the medicalized view of the biomedical model in obstetrics, which embodies the female body historical appropriation.

As limitations, the difficulties to understand aspects of participants’ non-verbal communication are pointed out, since data collection took place by videoconference due to the pandemic scenario restrictions. Although the study findings reflect the reality of a specific context, it is believed that similar results can be found in other regions, as the characteristics of nurse-midwives’ care process confer a certain homogeneity to their practices regardless of location.

  • FINANCIAL SUPPORT

    This work was carried out with the support of the Carlos Chagas Filho Foundation for Research Support in the State of Rio de Janeiro (FAPERJ - Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro). Announcement 26/2021 - BASIC RESEARCH ASSISTANCE (APQ1) IN STATE ICTs UERJ, UENF and UEZO -2021. PROCESS SEI-260003/015406/2021 - APQ1.

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ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

  • Publication in this collection
    08 Sept 2023
  • Date of issue
    2023

History

  • Received
    13 Dec 2022
  • Accepted
    22 June 2023
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