Attitudes of interprofessional collaboration in childbirth care of women with high-risk pregnancy

Abstract

The aim was to understand the attitudes of interprofessional collaboration in childbirth care for women with high-risk pregnancy. This is a qualitative study with 19 health professionals from the obstetric center of a university hospital in Rio de Janeiro. Data were collected from February to April 2022 through semi-structured interviews and processed in IRAMUTEQ. Descending hierarchical classification shows that collaborative attitudes are more frequent among professionals in the same category and routines that are in line with interprofessional collaboration. Despite having knowledge about collaborative attitudes, these do not materialize in care, given the weaknesses identified in the four domains of interprofessional collaboration: relational, expressed in hierarchical relationships; procedural, related to communication problems; organizational, given the lack of recognition of this domain by participants; and contextual, manifested in the cooperation perceived only among professionals in the same category.

Keywords
Interprofessional relations; Patient care team; Pregnancy; High-risk; Hospitals maternity; Parturition

Resumo

Objetivou-se compreender as atitudes de colaboração interprofissional na assistência ao parto das gestantes classificadas como de alto risco obstétrico. Pesquisa qualitativa, com 19 profissionais de saúde do centro obstétrico de um hospital universitário do Rio de Janeiro. Os dados foram coletados de fevereiro a abril de 2022, por meio de entrevista semiestruturada, e processados no Iramuteq. Classificação hierárquica descendente mostra que as atitudes de colaboração são mais frequentes entre profissionais da mesma categoria e as rotinas que vão ao encontro da colaboração interprofissional. Apesar de possuírem conhecimentos acerca das atitudes de colaboração, essas não se concretizam na assistência, haja vista as fragilidades identificadas nos quatro domínios da colaboração interprofissional: relacional, expressa nas relações hierarquizadas; processual, relativa aos problemas comunicacionais; organizacional, diante do não reconhecimento desse domínio pelos participantes; e contextual, manifestada na cooperação percebida apenas entre profissionais da mesma categoria.

Palavras-chave
Relações interprofissionais; Equipe de assistência ao paciente; Gravidez de alto risco; Maternidades; Parto

Resumen

El objetivo es discutir los conflictos en los procesos de trabajo y salud-enfermedad relacionados con la estabilidad de empleo de los metalúrgicos con restricciones laborales en la región de Campinas, São Paulo, Brasil. La metodología, caracterizada como construcción compartida de conocimientos, incluyó la realización de entrevistas, análisis documental y observación participante, entre 2019-2022. Los resultados señalan las acciones empresariales para promover la descaracterización del nexo trabajo-enfermedad, impedir el acceso a la estabilidad y despedir a los obreros enfermos. Los trabajadores viven ese proceso de forma penosa, pero, con el apoyo sindical, desarrollan formas de resistencia con el objetivo de mantener la estabilidad y proteger la salud. El estudio brinda contribuciones para las políticas de salud y protección social al destacar la dimensión colectiva de la determinación de la salud-enfermedad laboral, además de la necesidad de movilizar a diferentes instituciones y agentes en la producción de conocimiento y acciones para la lucha por la salud.

Palabras clave
Salud del trabajador; Protección social en salud; Sindicatos; Condiciones de trabajo

Introduction

Interprofessional collaboration is a way of organizing health work where people with different job roles work together in a common activity or in a collective project to meet the health needs and demands of people and communities. In this process, professionals have defined roles and established interdependent relationships in the work environment, analyzing problems from different perspectives, but valuing the different expertise and recognizing the contributions that the various disciplines add to the integrality of care¹-⁴.

From an operational point of view, interprofessional collaboration encompasses four domains, namely: relational, which covers hierarchy, disputes, and relationships between team members; procedural, referring to the work environment and the availability of resources for cooperation; organizational, expressed in management principles that drive collaboration and the sharing of care objectives; and contextual, manifested in aspects that interfere with collaboration among professionals, such as culture and gender issues⁵. In this context, attitudes of interprofessional collaboration permeate clear communication, respect for different knowledge and practices, demonstrations of empathy, trust, civility, resilience and ethics, as well as the sharing of responsibilities and decisions⁶.

However, assuming these attitudes is challenging for managers, who must implement organizational arrangements that promote a culture of communication and cooperation in the team, involving common and clear rules, appropriate information systems and availability of time, space and resources to collectively problematize everyday work situations. On the other hand, professionals need to break down the barriers that separate them, be receptive to familiarize themselves with the knowledge base of the different professions, and negotiate ways of working for the production of health care, without fragmentation, hierarchies, or overlapping functions and tasks⁷.

From this perspective, it is evident that, in many health institutions, hierarchical organizational structures persist, where medical knowledge and practices are more valued and overlap with the knowledge of other professions. This situation can be perceived in Brazilian obstetrics, where obstetric nurses face the hegemony and centrality of the medical category in childbirth care, culminating in the excessive use of interventions, often unnecessary and without the proper consent of women, and in the devaluation of the know-how of obstetric nursing⁸,⁹.

Therefore, the implementation of interprofessional collaboration in this field has faced barriers related to the lack of knowledge of health professionals about the different roles and responsibilities of team members; the deficit of professionals; the short time available for dialogue; the fragmentation of the service; and the difficulties in sharing information7. However, it should be noted that attitudes of interprofessional collaboration in obstetric care are associated with the achievement of favorable maternal and perinatal outcomes and the promotion of woman-centered care, humanization, safety, and positive experiences with pregnancy and childbirth⁶,¹⁰.

In this sense, the relevance of carrying out this organization of health work in the care of high-risk pregnancies is understood, since 10% to 20% of pregnant women may present complications in pregnancy and childbirth and require care from different professional categories, to provide sensitive and comprehensive care, to maintain maternal and fetal well-being, prevent complications and avoid unfavorable obstetric and neonatal outcomes⁸,¹¹.

In view of these comments and of the gap in Brazilian scientific production on the subject in the obstetric field, this study aimed to understand the attitudes of interprofessional collaboration in childbirth care of women with high-risk pregnancy.

Methodology

This is a qualitative research that followed the recommendations of the Consolidated criteria for Reporting Qualitative research (COREQ) checklist.

The study scenario was the obstetric center of the maternity of a university hospital in Rio de Janeiro, RJ, Brazil, a reference in the care of women with high-risk pregnancy and in need of tertiary care, being a space for training health professionals and developing scientific research.

The research participants were 19 health professionals, who work in the aforementioned sector. As inclusion criteria, the following were considered: to be assigned to the obstetric center and to develop work activities in the sector for at least one year, as it is understood that this is a minimum period for the worker to adapt to the dynamics of the service. Professionals on leave or on vacation during the period of data collection, as well as residents and students of any course and level of training, were excluded, since these agents work temporarily in the institution.

Data collection took place from February to April 2022. For data collection, the individual interview technique was used, following a semi-structured script, divided into two parts: the first contained questions to collect data about the participants (sex, age, professional category, employment relationship, and time working in obstetrics, in the care for high-risk pregnancies, and in the sector); and the second consisted of four open questions, namely: “What do you mean by interprofessional collaboration? What collaborative attitudes do you identify/perceive in your work environment? What factors influence these attitudes? How can these attitudes impact obstetric care for high-risk parturient women?”.

The professionals were intentionally recruited during their work shift, through the face-to-face approach to clarify the research, followed by the invitation to participate in the study. After expressing their interest, a date was scheduled for the face-to-face interview, according to the participant’s availability.

This process was carried out by two authors previously trained, who were graduates at the time. They took turns conducting the interviews, which took place in the presence of one of them and the professional, in a room of the sector with the necessary privacy and without interfering in the care routine. With the authorization of the participants, the interviews were recorded using an audio recorder application, had an average duration of 25 minutes and were later transcribed in full. This material was sent to the participants, who validated the transcribed content of their interviews.

It should be clarified that a pilot test was carried out, which indicated the adequacy of the instrument and, therefore, the interview was included in the study. During data collection, we could not schedule the interview with three participants after a few attempts, and one doctor cancelled the interview, stating that only the head of the sector would be able to answer the instrument. Also, to close the data collection, inductive thematic saturation was used, when the participants did not add new information to the research, which was identified in the seventeenth interview and confirmed by conducting two more interviews.

The data were processed by IRAMUTEQ ® (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires - version 0.7 alpha 2), and analyzed by Descending Hierarchical Classification (DHC), which, through statistical calculations, categorizes the Text Segments (TS) from the words present in the corpus, separating them based on the frequency (f) of their reduced forms and the chi-square values (x2)¹².

Thus, of the 19 texts processed by the software, 217 TS were obtained out of a total of 244, resulting in the use of 88.93%, higher than the minimum retention recommendation of 75%12. This corpus was divided into four classes so that the first partition generated two sub-corpora that comprised two thematic blocks, which were interpreted and discussed in the light of scientific production on the topics of interprofessional collaboration and obstetric care, since the study did not use a specific theoretical framework.

The preparation of the corpus, its processing in the software and the analysis of the DHC were developed by the two authors who conducted the interviews and transcribed the material, and these steps were reviewed by two other authors, professors holding doctorate and with experience in qualitative research.

The study was conducted in accordance with the ethical guidelines and was approved by the Research Ethics Committee through opinion number 5,222,054 of February 3, 2022. The ICF was obtained from all individuals involved in the research, with the guarantee of voluntary participation and anonymity, which was preserved with the use of the letter E, related to the term “entrevistado” (interviewee), accompanied by a digit, which represents the order of the interview, the gender of the participant, their age and, finally, their professional category.

Results

Nineteen health professionals participated in the research, of which seven are nurses, six are doctors, and six are nursing technicians. Most are female (16) and over 40 years old (16). Regarding the time working in high-risk obstetric services, twelve participants work between one and 15 years and seven develop activities in this area of care for more than 16 years. Ten professionals have worked in the study scenario between nine and 16 years, six between one and eight years, and three for more than 16 years. Regarding the employment relationship with the study’s institution, fifteen are public servants, and four participants did not specify the type of relationship.

The analysis of DHC gave rise to four classes that were organized into two thematic blocks, according to the dendrogram represented in Figure one, where the values of the chi-square test (x2/ p<0.0001) show the strength of association of lexicons with the class.

Figure 1
Dendogram of class divisions and the most significant lexicons according to CHD, Rio de Janeiro, Brazil, 2022.

The first partition divided the corpus into two blocks. The first block generated class 1, represented by 36.41% of the material and composed of 79 TS, and class 4, with 22.12% and 48 TS. Concomitantly, in the second block, class 2 appeared, with 24.42% and 53 TS, and class 3, with 17.05% and 37 TS.

Based on the contents and lexicons of each class, thematic block 1, entitled “The reality of interprofessional collaboration in childbirth care of women with high-risk pregnancy”, covers classes 1 and 4. Thematic block 2, called “Perceptions of the nursing and medical team on interprofessional collaboration”, is composed of classes 2 and 3.

Class 1 - Attitudes of interprofessional collaboration and its barriers in daily work

The TS reveal that attitudes of collaboration are more frequent within the same professional category, and this perception prevailed among nurses and nursing technicians, in line with the most representative lexicon of this class (“nursing”, “more”, “also”, “only”, “participate” and “medicate”).

However, they recognize that these attitudes are present in the relationship with some doctors, who are more collaborative, empathetic and listen to other opinions, while, for these professionals, the attitudes of collaboration in daily work are expressed in the possibility of disagreements about the performance and in the dynamics of the night shift, where they are responsible for the emergencies.

Nurses help each other. We see that doctors also help each other. But interprofessional help is a little bit harder!

(E7 *female *57 *nursing_technician)

This is much more common among the nursing team! I think the personal characteristics, how the person was raised, how the person deals with other people...

(E2 *female *36 *nurse)

This is more related to the doctor-nurse relationship. For example, during labor, in which one may disagree with the other regarding the performance at that time.

(E5 *male *52 *doctor)

At night, we end up being more available for emergencies and I end up relying more on the nursing sector.

(E18 *male *45 *doctor)

Doctors collaborate a lot with us and together with the nurses.

(E16 *female *45 * nursing_technician)

There are people who have more empathy. There are people who do not care about listening to the opinion of the others.

(E1 *female *38 *nurse)

At the same time, they report attitudes, behaviors, and routines that oppose interprofessional collaboration, namely communication problems, hierarchy, care routines without defined roles and responsibilities, and clinical discussions between doctors without the participation of nursing.

And also, vocational training. We see categories that do not know how to deal with the multidisciplinary team in a cohesive, coherent, and equitable way...

(E2 *female *36 *nurse)

I only see more demands or task delegation, stating that this is the role of nursing.

(E4 *female *50 *nurse)

The routine of the sector, which should be more specific about the roles of each one and the leadership as well.

(E4 *female *50 *nurse)

Not only doctors, but nurses too! If necessary, psychologists, physical therapists... Everyone should participate in a round for the patient’s benefit. For the best for the patient!

(E15 *female *42 * nursing_technician)

Class 4 - Factors associated with attitudes of interprofessional collaboration

Regarding the most significant lexicons of this class (“thing”, “here”, “to be”, “to examine”, “to happen” and “stress”), the TS show that, in the daily life of high-risk pregnancy care, participants perceive that attitudes of interprofessional collaboration favor the timely identification of errors and complications. However, they show the overlapping roles as a factor that generates stress for hospitalized women.

So, I think that’s basically it… When the nurse comes and says: “I think there’s something wrong here!”.

(E17 *female *50 *doctor)

They listen when we tell them that something is happening. When we do not agree with some methodology that they are applying, at least the doctors here.

(E11 *female *42 *nurse)

It also facilitates everyone being together because everyone will do the same thing: they will examine.

(E6 *female *40 * nursing_technician)

They are already very different because, here, we have a resident, technician, staff...

(E2 *female *36 *nurse)

They [patients] have more doubts. Sometimes, the information is confusing! One says one thing, then another says another. (E4 *female *50 *nurse)

Class 2 - Knowledge of attitudes of interprofessional collaboration

The lexicons of greatest association with this class were “working together”, “well-being”, “to collaborate”, “assistance”, “good” and “set” so that the TS show the knowledge of the participants about the attitudes of interprofessional collaboration, which comprise the sharing of care and decisions between professionals of different categories, where team members work together with the patient’s well-being as a common objective. In this sense, they emphasize that professionalism, respect, unity, good relationship, and recognition of the functions of each one are fundamental aspects.

Professionalism and respect for work. A team that collaborates, which wants to work together and is united, is a team that will probably provide pregnant women with better care.

(E19 *female *54 *doctor)

I think it’s when professionals from various areas… Whether it’s teaching activities, work activities… They choose to work together aiming at the well-being of their clientele.

(E9 *female *53 *nursing)

The main thing is the good relationship of professional teams. And the doctor understands that the other teams are as important in their roles as the doctor in patient care.

(E5 *male *52 *doctor)

I think that when you have a multidisciplinary team, what you set as an objective, of conduct, the treatment is shared, and all the members of each team collaborate so that the objective is met.

(E8 *female *50 *nurse)

Class 3 - Understanding of interprofessional collaboration

The most expressive lexicons of this class were “collaboration”, “to think”, “colleague”, “inside”, “to understand” and “team” revealing that the participants’ TS show their understanding of interprofessional collaboration. From this perspective, they point out that these are professionals from the same area and from different areas who work as a single team, establish relationships of support and help, with empathy, and communicate to achieve a common goal in care.

I understand collaboration when we work in an environment where co-workers, professionals from the same area and from different areas communicate to achieve a common goal.

(E13 *female *45 *nursing)

I understand it works like this: we should be a single team, try to help each other, being a single team, always thinking about one another.

(E17 *female *50 *doctor)

Everyone in the team should think that the final objective of everything is the resolution, both regarding the technical side or the human side of the patient.

(E18 *male *45 *doctor)

Discussion

The results of this study show that the participants understand interprofessional collaboration as a way of working in which professionals from different areas work as a team and share decisions, with the common objective of the well-being of high-risk parturient women.

This understanding is in line with the concept of interprofessional collaboration, which permeates the empathic, harmonic, and interdependent relationship between professionals with different backgrounds, who learn and work together, engaging in a shared work process from the perspective of the expanded clinic. To this end, they use cooperation, communication, and negotiation, with commitment, responsibility, trust, dialogue, respect, and sharing of resources, knowledge, experiences, and powers, to achieve collective objectives¹-³.

Thus, this way of organizing care transcends teamwork, defined as the performance of a small group of professionals who identify the demands of individuals and collectivities, acting through integrated actions within a singular care project. At the same time, it also goes beyond the notion of collaborative practice, conceived as health actions where the skills of each professional category are synergistically put into practice, with partnership and collective responsibility, without competition between the different areas³,⁶.

The dynamics of interprofessional collaborative work allow a complex view of the situations to be faced¹,⁶, necessary for the care of high-risk pregnancies, since it deals with conditions resulting from obstetric complications and health problems, which can result in unfavorable maternal and neonatal outcomes¹³.

In this context, which requires intensive care from various fields of knowledge, interprofessional collaboration emerges as a way to reduce opioid abuse and ensure the provision of qualified care to women, according to a study carried out at a hospital in the United States¹³. In addition, an investigation in 61 health units in Tanzania found that the implementation of interprofessional collaboration was effective in the management of severe hemorrhagic situations and other conditions of risk to maternal and perinatal health, also favoring the reduction of costs and the satisfaction of women and their families¹⁴.

It should be noted that the association between interprofessional collaboration and the development of care centered on women reverts to improving the quality of care and decision-making capacity, provides opportunities to problematize the use of available resources and oral and written communication, stimulates the skills of professionals, and the adoption of practices based on scientific evidence¹³,¹⁵.

In the daily life of health work from the perspective of interprofessional collaboration, the essentiality of respectful attitudes stands out, based on the recognition of the roles and specificities of each category, which permeates the understanding that professional autonomy is relative to the interdependence of the knowledge and practices of each area to perform the integrality of care¹,⁴.

Although the participants did not identify the recognition of the work of the other as an attitude of interprofessional collaboration, they understand the importance of symmetrical power relations and mutual respect as facilitating factors of collaborative work in the studied scenario, which provides the identification of errors and complications in obstetric care, as evidenced in other research⁸,¹⁵,¹⁶.

On the other hand, their speeches reveal communication problems between the medical and nursing teams, expressed in clinical discussions between doctors without the participation of nursing, as well as in the existence of hierarchy between professions and care routines without clearly defined roles or responsibilities. This configuration reveals the limiting factors of interprofessional collaboration, which are ratified by the fact that nurses and nursing technicians recognize that these collaborative attitudes are more frequent among nursing professionals and that, with doctors, it depends on the individual characteristics of each one, which shows that interprofessional collaboration in the scenario of this research is more said than done.

These findings are similar to those found in investigations carried out in Turkey, Botswana, and the Netherlands, which found a fragile level of collaboration between doctors and nurses due to the lack of understanding of the roles and responsibilities of each one, ineffective coordination of resources, power struggles, and poor collaborative leadership17-19. In addition, it is common for nurses to be more favorable to collaborative attitudes, as found in research carried out in a basic health unit in Brazil³ and in hospitals in Jordan²⁰, Iran²¹,²², Lebanon²,²³ and the Netherlands¹⁹.

Corroborating this, a US study of medical residents found that specialty professionals more focused on procedures had less collaborative attitudes²⁴. At the same time, the autonomy of nursing seems to be more fragile in surgical units and maternity hospitals, when compared to the performance of these professionals in clinical ward sectors of a hospital in Saudi Arabia²⁵.

Thus, it is evident that the implementation of interprofessional collaboration in the scope of obstetrics has been challenging and configured as a stressful factor, including for parturient women. Among the main limitations, the following stand out: the deficit of human resources; the short time available for dialogue; the fragmentation of the service; and the difficulties in sharing roles, responsibilities, and information⁷, as reported by the nurses and nursing technicians of this study.

It should be noted that interprofessional collaboration is organized into four domains, namely: relational, procedural, organizational, and contextual. The first covers interprofessional relationships, permeating power, and hierarchy⁵, aspects considered as challenges by the nursing team of this research, as they report that doctors delegate and give orders to other team members.

The procedural domain deals with the complexity of the work environment and tasks, their interfaces with the practices of professionals, and how they affect team work⁵. From this perspective, the fragility of this domain is evident among the study participants, who recognize the importance of the collaborative environment and dialogue. However, most of the interviewees are nursing professionals who identify problems in communication with the medical team, which does not have the same perception, which is in line with the findings of other studies¹⁹,²⁵.

Regarding the organizational domain, which encompasses the importance of the institution’s organizational structures to boost the agreement of common care objectives and interprofessional collaboration⁵, the participants do not recognize them as an influential factor in collaborative attitudes, since none of the prominent lexicons refers to the management of the service.

The contextual domain, on the other hand, involves the cultural, political, social, and economic aspects that influence cooperative behaviors among health professionals⁵. From this perspective and considering that the results show the predominance of cooperation among participants in the same category, it is inferred that this dimension of interprofessional collaboration is also weakened in the scenario of this study, possibly due to issues related to the historical configuration of the Brazilian obstetric field, as a hierarchical place where doctors, holders of masculine and biomedical knowledge, and nurses, with humanized practices that value feminine knowledge, fight to impose their worldview⁸,¹⁶.

At the same time, the training model prevalent in higher education institutions reproduces the individualistic logic of health work, as professionals isolate themselves in disciplinary nuclei, resulting in a uniprofessional and fragmented teaching and learning process that does not provide opportunities for formative experiences of interprofessional collaboration³,²⁶.

In view of these notes, weaknesses are found in all domains of interprofessional collaboration, and it is necessary to carry out investigations with managers, to explore the involvement of these agents with the encouragement of changes in obstetric care based on interprofessionality.

On the other hand, as a positive factor that can corroborate the effectiveness of interprofessional collaboration in the care reality of the scenario of this research, the fact that professionals have conceptual notions about this way of organizing health work is emphasized, although the recognition of the obstacles to the realization of collaborative attitudes in the daily care of women with high-risk pregnancy is more evident in nursing discourses.

In this sense, the dynamics of the teams studied is similar to that of teamwork but does not add the interprofessional attribute of collaborative practices, as the participants lack relationships of recognition, reciprocity, sharing, interdependence, and mutual respect. This finding associated with the absence of institutional protocols reveals the critical points to be addressed in continuing education activities.

Thus, the findings of this study offer subsidies to problematize the work dynamics, focusing on the lack of communication and hierarchical relationships, which were the main limiting factors of interprofessional collaboration identified. In addition, as it is a university hospital, reflections on health training also emerge, which needs to advance to incorporate interprofessional experiences in the teaching and learning processes of undergraduate and graduate courses, thus promoting the development of collaborative attitudes in future professionals of different categories.

In view of the gap in the production of knowledge about interprofessional collaboration in Brazilian obstetric care, this research is innovative and has potential to strengthen scientific production on the subject, especially in the field of nursing.

As limitations of the study, we highlight the work overload of obstetric center professionals and the difficulty of having doctors come back after the initial recruitment as issues that interfered with the adherence of all team members to the research. In addition, the results represent a sector of a single university hospital; therefore, it is necessary to carry out new studies on the attitudes of interprofessional collaboration between obstetric care professionals from other sectors, hospitals with different care profiles and other locations, to portray the potential and challenges of collaborative work, especially in the context of high-risk pregnancy, where the performance of different professional categories is fundamental.

Conclusion

Attitudes of interprofessional collaboration in the care of high-risk pregnant parturient women are more frequent among the nursing team and with doctors, given the problems in communication, hierarchy, and care routines without defined roles and responsibilities. Thus, the knowledge of the participants shows an ideal scenario, if the work was developed from the perspective of interprofessionality. On the other hand, the attitudes reveal a real scenario, with the challenges that interfere in the implementation of interprofessional collaboration.

• Prata JA, Braga LL, Dias MO, Gioia LG, Silva MCSR. Attitudes of interprofessional collaboration in childbirth care of women with high-risk pregnancy. Interface (Botucatu). 2025; 29: e250338 https://doi.org/10.1590/interface.250338

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Edited by

• Editor
  Roseli Esquerdo Lopes

• Associated editor
  Gustavo Antonio Raimondi

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  2025

History

• Received
  13 Nov 2024
• Accepted
  14 May 2025