CHALLENGES OF MANAGEMENT AND CARE IN NORMAL BIRTH CENTERS: QUALITATIVE STUDY WITH OBSTETRIC NURSES^*

ABSTRACT

Objective:

To understand obstetric nurses’ challenges in managing work and care in normal birth centers.

Method:

A qualitative study was carried out in normal birth centers in Ceará, Brazil. Thirteen nurses and obstetric care coordinators were interviewed between April and July 2020. The thematic categories were organized in Nvivo 12 Pro® software and discussed using the theoretical-philosophical framework of the Sociology of Professions.

Results:

care practices, such as comfort massages, are carried out in conjunction with elements of work management, such as the sizing of the nursing team. It emerged that there are important skills for acting as autonomy and leadership of the nursing team, but elements such as fragile trust and interaction limit the full development of activities.

Final considerations:

there are challenges for management and care in normal birth centers, such as consolidating autonomy and building trust with the health team.

KEYWORDS:
Health Management; Birthing Centers; Nurse Midwives; Natural Childbirth

RESUMO

Objetivo:

compreender os desafios para a gestão do trabalho e do cuidado em centros de parto normal por enfermeiras obstétricas.

Método:

estudo qualitativo realizado em centros de parto normal no Ceará, Brasil. Participaram 13 enfermeiros e coordenadores da assistência obstétrica, por entrevista, no período de abril a julho de 2020. As categorias temáticas foram organizadas no Software Nvivo 12 Pro® e discutidas com referencial teórico-filosófico da Sociologia das Profissões.

Resultados:

práticas de cuidado, como massagens de conforto, são realizadas associadas aos elementos da gestão do trabalho, como o dimensionamento da equipe de Enfermagem. Evidenciou-se que há habilidades importantes para atuar como autonomia e liderança da equipe de Enfermagem, mas elementos como a frágil confiança e a interação limitam o pleno desenvolvimento das atividades.

Considerações

finais: existem desafios para a gestão e o cuidado nos centros de parto normal, como a consolidação de autonomia e construção de confiança com a equipe de saúde.

DESCRITORES:
Gestão em Saúde; Centros de Assistência à Gravidez e ao Parto; Enfermeiras Obstétricas; Cuidado; Parto Normal

RESUMEN

Objetivo:

Comprender los desafíos para la gestión del trabajo y la atención en los centros de parto normal por parte de las enfermeras obstétricas.

Método:

estudio cualitativo realizado en centros de parto normal de Ceará, Brasil. Un total de 13 enfermeros y coordinadores de atención obstétrica participaron en entrevistas de abril a julio de 2020. Las categorías temáticas se organizaron en el Software Nvivo 12 Pro ^® y se discutieron con el marco teórico-filosófico de la Sociología de las Profesiones.

Resultados:

las prácticas de cuidado, como los masajes de confort, se realizan asociadas a elementos de la gestión del trabajo, como el dimensionamiento del equipo de enfermería. Se evidenció que existen habilidades importantes para actuar como autonomía y liderazgo del equipo de enfermería, pero elementos como la confianza frágil y la interacción limitan el desarrollo pleno de las actividades.

Consideraciones finales:

existen desafíos para el manejo y la atención en los centros de parto normales, como la consolidación de la autonomía y la construcción de confianza con el equipo de salud.

DESCRIPTORES:
Gestión de la Salud; Centros de Atención al Embarazo y al Parto; Enfermeras Obstétricas; Cuidado; Parto normal

HIGHLIGHTS

Autonomy and confidence are the skills required to consolidate leadership.

Humanizing practices promote women’s satisfaction and empowerment.

Cooperation is needed to achieve favorable results.

INTRODUCTION

The development of technocratic obstetric models in Brazil has influenced the use of unnecessary interventions without scientific criteria, contributing to the medicalization of childbirth, high rates of maternal and child morbidity and mortality, and a reduction in the quality of obstetric care, contrary to the recommendations of Agenda 2030 of the United Nations Sustainable Development Goals^1-2.

In order to reduce these unfavorable rates in the country, important health policies with promising results have been implemented, most notably the Stork Network strategy in 2011 and the implementation of Normal Birth Centers (NBC) through its labor and birth component. These spaces are considered propitious instruments for changes in maternal and child health, with the use of more humanized and participatory practices through the work of obstetric nurses who promote the role of women and their families during labor and birth^1,3. In the global context, these health institutions are consolidated in many places, such as Canada and Japan, with promising health results^4-5.

As a leading professional category in this scenario in Brazil, the obstetric nurse profession was used in this research as a driving force for discussion, as their work has contributed to reducing maternal and perinatal morbidity and mortality in the country^1,3. This study aimed to understand this process and the challenges that prevent obstetric nurses from fully working with this instrument in the Brazilian public health system. It also aimed to find out how work management and care take place in normal birth centers to expand their implementation.

It is important to understand the professional power processes involved in Brazilian maternal and child care models that contribute to the rates considered compromising in health to encourage change and thus achieve levels of satisfaction and excellence in labor and birth, especially in a country like Brazil considered to have one of the highest cesarean section rates in the world⁶. This study aimed to understand obstetric nurses’ challenges managing work and care in normal birth centers.

METHOD

This qualitative study uses Content Analysis as a guideline for data analysis⁷ in 2020.

The study settings were seven type II in-hospital NBCs and one peri-hospital authorized by the Ministry of Health in Ceará. Of the 40 NBCs authorized by the Ministry of Health in Brazil during the period, this location was chosen because it has the largest number of these legally recognized services that use health models with obstetric nurses caring for parturients⁸. The CPNs were located in the municipalities of Iguatu (one participant), Maracanaú (three participants), Tianguá (one participant), Crateús (two participants), Fortaleza (three participants), Sobral (two participants), Limoeiro do Norte (one participant) and Itapipoca (one participant).

The inclusion criteria were working for at least six months in the selected NBC and specializing in Obstetric and/or Neonatal Nursing. Exclusion criteria were failure to answer the phone after five attempts with a two-day interval between each, no response via the messaging app, and disconnection from the NBC for at least six months. 27 nurses were contacted, 14 obstetric nurses and coordinators agreed to participate in the research, and 13 refused for institutional and personal reasons.

A 12-question open-ended script was used for the interview on the role of the NBC with high-risk pregnant women, using key questions such as: What work management practices do you carry out at NBC? What care actions are carried out at NBC? Some questions for further study were used, such as: Could you elaborate on this?

An individual telephone interview was used as the data collection tool from April to July 2020, lasting an average of 31 minutes. All of them were audio-recorded and transcribed in full. The participants were approached using the snowball technique, which made it possible to choose key informants from a list of obstetric nurses made available by the Brazilian Association of Obstetricians and Obstetric Nurses of Ceará (ABENFO-CE)⁷. Theoretical saturation meant that the sample was closed after the thirteenth interview⁹.

After all the transcriptions had been made, Content Analysis was carried out using Nvivo® Pro 12 software to determine the categories of analysis. The process involved six stages¹⁰. The first stage consisted of familiarizing ourselves with the testimonies by reading them, reflecting on the interviewees’ statements, and identifying potential codes and themes. The second stage involved generating the initial codes, documenting the meetings with triangulation by the researchers, and building the coding structure. The next step was to look for themes and make notes detailing the development and hierarchy of concepts and themes. The researchers and the referential adjustments analyzed these themes, and sub-themes were made in the fourth stage. The fifth step involved the triangulation of the researchers, with the team agreeing on the themes, ending with the documentation of the thematic nomenclature. The final stage consisted of verification by the researchers, with a description of the complete coding process and its detailed analysis, describing the context, and ending with the generation of a complete report of the theoretical foundation and methodological and analytical choices.

Two thematic categories emerged, and the results were relevant through the links between the categories that emerged, the statements, and the objective.

The theoretical framework for the discussion was based on the Sociology of Professions, specifically, the reading carried out by the Portuguese sociologist Maria de Lurdes Rodrigues, which involves the following domains: Knowledge and autonomy, Credentialism, Division of labor, Labor market, Value framework¹¹.

These concepts were used to characterize the obstetric nurse profession, encompassing the mechanisms that allow them to rise professionally, consolidate their position in the NBC, and contribute to improving care in women’s labor and birth. This allows us to address the possibilities of this professional in the area of maternal and child health and public health policies, the consolidation of power within the professional group and society, as well as its main challenges, built historically and socially through the induction of state policies such as the Stork Network strategy.

All participants approved the study before each interview, and the consent form was sent by e-mail and messaging app. To maintain the confidentiality of the participants, alphanumeric coding was used with the letters EO and the respective numbers. All the information collected was kept confidential, and the transcripts of the interviews were sent to each participant by e-mail or messaging app. The Research Ethics Committee approved the study and complied with Brazil’s ethical recommendations under opinion no. 3.829.582¹².

RESULTS

About socio-occupational information, five interviewees were male and eight female, aged between 29 and 53 years (average 35.6 years), all with a specialization in Obstetric and/or Neonatal Nursing and having worked in the area for between two and 14 years (average 5.3 years). Table 1 shows the participants’ information:

Table 1
Socio-occupational characteristics of obstetric nurses. Fortaleza, CE, Brazil, 2022.

Code	Gender	Age	Time at work
EO01	Male	40	2 years 4 months
EO02	Male	38	4 years
EO03	Male	29	2 years
EO04	Female	30	2 years 2 months
EO05	Female	32	5 years
EO06	Female	38	9 years
EO07	Male	42	14 years old
EO08	Female	39	5 years
EO09	Female	29	2 years 8 months
EO10	Female	28	3 years 3 months
EO11	Male	32	7 years
EO12	Female	32	6 years
EO13	Female	54	6 years

• Source: Prepared by the authors (2022).

Based on the thematic analysis, categories were determined: “Management of obstetric nurse care practices for professional consolidation in normal birth centers” and “Skills and competencies for the autonomy of obstetric nursing in labor and birth”. Chart 1 describes the process of constructing the categories:

Chart 1
Coding based on the thematic content analysis process. Fortaleza, CE, Brazil, 2022.

Themes	Sub-themes	Categories
• Coordination and organization of care in normal birth centers. • Practice management for obstetric nurses in childbirth.	• Coordination • Organization • Watch out • Management • Obstetric practices • Obstetric nurse • Childbirth	Management of obstetric nurse care practices for professional consolidation in normal birth centers.
• Interaction and support from the obstetric nursing team during labor and birth • Respect, trust, and competence for the autonomy of professional obstetric nurses.	• Interaction • Nursing • Childbirth • Birth • Respect • Confidence • Autonomy • Support • Competence	Skills and competencies for autonomy in obstetric nursing during labor and birth

• Source: Prepared by the authors (2022).

Management of obstetric nurse care practices for professional consolidation in normal birth centers

In this thematic category, the initial testimonies listed good obstetric practices as one of the elements for providing quality care in the NBC, associated with the coordination and organization of the sector. At this point, management elements such as the coordination of the nursing team are essential for harmonizing the unit and achieving humanized childbirth care.

We’re there to monitor vaginal touches and the progress of labor, guiding the pregnant woman through comfort massages, ball exercises, and walking. And we coordinate the team. (EO1)

I can say that the obstetric nurse has the autonomy to act, to provide care following the legislation; we carry out the whole experience through good practice in labor and birth care, per the most up-to-date scientific evidence. (EO7)

The good childbirth care practices described in the study are recommended nationally and internationally, which, if combined with work management tools such as team sizing, make it possible to promote qualified care in this context and encourage women to take back decision-making during the childbirth process. Dividing up the work process is necessary for effective care and cooperation between the obstetric and neonatal nursing teams responsible for caring for labor, birth, and the newborn. This division is not fragmented and helps ensure that care is carried out with greater expertise by professionals trained in maternal and newborn health.

On the other hand, some of the testimonies showed a persistence of dissociative reasoning between the management of labor in NBC and obstetric care to achieve good labor and birth care practices. As noted, some reports describe the complexity of managing the work of coordinating the nursing team alone.

We need to differentiate and divide up the team, who will be with the babies and helping with the birth. We look at this issue in terms of size and division. (EO13)

It’s just a question of managing the nursing team, the team of nursing technicians. (EO4)

Those of us in the care sector are hardly ever involved, specifically with management. (EO3)

Among the thematic points raised, vulnerability and risk in maternal and child health were described by organizing the care flow through risk classification management associated with the unit’s bed management. This management is permeated by dialogue and qualified listening based on humanized welcoming policies, enabling dynamic and appropriate care for each parturient. It is an instrument of access to the Brazilian health system and the care network for pregnant women. It makes it possible to implement the integrative and universal health model, with a reduction in women’s peregrinations and unfavorable results in maternal and perinatal health.

We have a group of high-risk pregnant women, which was a strategy we implemented to reduce deaths because we have a lot of high-risk pregnant women here in our region who can’t access high-risk prenatal care, and fetal deaths were increasing. (EO5)

I have a nurse who helps me with the administration to monitor the indicators, but I continue to manage the service. (EO5)

[Briefly] organizing medical records and bed management because we always have to organize so that the flow doesn’t stop, so it’s not idle or crowded. (EO11)

Regarding team coordination, I think bed management is also the responsibility of nursing. (EO12)

Another sub-theme refers to managing the supplies, obstetric technologies, and materials necessary for the development of labor and birth care. The testimonies described the interconnected work routine dimensions that collaborate in realizing good care practices within NBC. Thus, they stressed the importance of managing equipment and instruments during labor and delivery, as well as building institutional care routine models for care:

We get there and see how these birthing boxes are because there are so-called birthing boxes if each room has a working bed, a birthing stool, a working Swiss ball, and a working exercise horse if the shower has hot water. (EO2)

Generally speaking, when managing staff and supplies, nurses always have to have this in mind to manage their supplies and try to provide them. (E09)

Skills and competencies for professional autonomy in labor and birth

This thematic block initially looked at professional cooperation and collaboration within the NBCs. The interviewees reported aligned care, which requires interaction between the Obstetric and Neonatal Nursing team and medical professionals. One of the essential skills for maintaining a less interventionist model was the autonomy of obstetric nurses in conducting good labor and birth practices associated with supervising the nursing team and promoting labor and birth care.

So, it’s more the assistance part, monitoring deliveries, carrying out normal deliveries, caring for newborns, and providing immediate care, sometimes helping the doctors with more complicated deliveries. (EO11)

Our routine there is nursing care, care for normal-risk labor, and we supervise the technicians in general, the kind of service we normally do. (EO8)

We follow the partogram; we accompany the patient; we put her on the stroller; we offer her non-pharmacological pain relief materials; we have the stool; we talk to the patient about normal childbirth; we guide the companion. (EO9)

Another sub-theme mentioned was the reception of the parturient for maternal and fetal assessment, which are important elements in the development of quality care in NBC and are allied to women’s empowerment. Empowerment is key in rescuing women’s protagonism in achieving a humanized childbirth with as few interventions as possible.

We assist in childbirth, striving for a humanized birth, a birth where the woman has a free choice of position and the way she wants to give birth to this baby. (EO2)

It’s a nurse for triage, for assistance, for the care itself, for monitoring births, dealing with the bureaucracy. (EO12)

We do all the normal-risk births, admissions, discharges, assessments, suturing, and RN care. (EO10)

The last sub-theme refers to institutional protocols as a tool for aligning good childbirth care practices. The development of health protocols and routines was considered to be of fundamental importance for constructing the line of care based on scientific health evidence. In addition, these elements were considered as recommendations for the professional collaboration of the Nursing team in the guidelines to ensure humanized obstetric care for women in labor and delivery.

We do everything according to the norms and protocols of the institution we work for, and all the care we take with the newborn and pregnant woman during childbirth is all within the norms. (EO6)

I feed the indicators; I manage the staff. (EO9)

Obstetric nurses carry out 90% of my births. It’s 10% or even less for doctors. (EO07)

DISCUSSION

The management of work and care in NBC is an essential interrelationship for developing activities related to the increase of practices favorable to maternal protagonism in labor and birth, fostered by nurses through leadership skills, decision-making power, and autonomy in the development of their activities. It should be emphasized that to have autonomy in care practices in the NBC, it is necessary to have knowledge based on scientific evidence, experience in professional functions, and expertise in the care of women in labor¹³.

From the theoretical perspective of the Sociology of Professions, in which Knowledge and Autonomy¹¹ are essential for carrying out childbirth care and assistance activities and are present in the reports obtained, it is configured as an element for the management of work and care of this health equipment to be carried out in Brazil.

National and international literature highlights the role played by health professionals such as nurses in care activities during labor, delivery, and the postpartum period, satisfactorily evaluated by parturients, their companions, and families, with actions permeated by attention, understanding, and resolution^1,3-4.

Corroborating these testimonies, a study on the care practices carried out by obstetric nurses in NBCs in Bahia showed that those effectively recommended by the World Health Organization (WHO) were implemented regarding the physiology of childbirth and female protagonism, which consolidate childbirth in the humanized model in Brazil¹⁴. The reports of this study describe the use of good practices in labor and birth care by obstetric nurses as a tool in the obstetric care line of the NBCs analyzed.

To achieve full performance and decision-making power in the actions developed in the NBC, it is necessary to acquire skills through training and updates such as specializations, residency in Obstetric Nursing, or other training as mechanisms for professional qualification¹⁵. Regarding the training of the professional responsible for childbirth in the NBC, there are guidelines for childbirth and postpartum care. Still, it is necessary to understand which skills and responsibilities are important and necessary to achieve autonomy and respect within the health team^1,16.

This study emphasizes that the duality in training versus professional experience must be overcome to build training bases aimed at parturient women, rich in humanized knowledge, and with the deconstruction of unnecessary practices that contribute to an increase in compromising results in the childbirth experience^15,17.

The study under discussion shows that all the participants specialize in Obstetric and/or Neonatal Nursing, consolidating their knowledge with their practice in NBC to develop competencies that enable them to achieve quality in obstetric care and health work management.

When reflecting on the professional actions that contribute to less interventionist obstetric models in the NBC, the reports show concepts of Credentialism¹¹, as there is an inducement by the state for obstetric nurses to expand their scope of practice in the NBC. The regulations that deal with this equipment require the presence of this professional as the person responsible for the line of care developed¹³. There is much evidence that nurses are better trained, have greater professional sensitivity when accompanying the parturient during labor, and perform fewer interventions in the parturition process^1,3,5,13.

In a study carried out in the southeast of Brazil, the cost of cesarean section was 32% higher than for normal risk deliveries, also impacting greater maternal and perinatal repercussions in the more interventionist obstetric model¹⁸.

Regarding the management of labor in NBC, the development of the obstetric nurse’s actions involves much more than the administrative management of the supplies necessary for their work and that of the nursing team during labor, birth, puerperium, and with the newborn¹⁶.

Processes such as the flow of care and admission of parturient women, aspects of health education, also relating to the environment, equipment, and technologies necessary for their work, as well as epidemiological health data and information, are also considered to be activities inherent to the management of NBC work in Brazil and around the world^3,5,14,19.

The International Confederation of Midwives stresses that the development of skills such as autonomy, responsibility, supervision of care, practice based on evidence from research, guaranteeing essential rights for women and families, ensuring interprofessional communication, as well as facilitating labor and guaranteeing women’s decision-making power is paramount¹⁶.

Regarding autonomy and building trust within the health team and with women, a study carried out in São Paulo described that professional conflicts regarding areas of activity should be well delimited, and knowledge, expertise, and creative capacity can enhance performance as the main professional in carrying out care practices for habitual risk childbirth in the NBC, and thus reduce indications for cesarean deliveries²⁰.

From this perspective, the deficiencies shown in competencies, such as technical and practical skills, specific knowledge of the area, and the power to act about other health categories, are examples of obstacles that obstetric nurses, as managers of work and care, can face^1,20.

On this premise, regarding the Division of Labor¹¹, the testimonies show professional delimitations mainly between the obstetric nurse and the obstetric doctor, as well as the division of care between the nursing team for the woman in labor and the newborn carried out by nursing technicians. The definition of the professional boundaries between doctor and nurse is evident in the reports collected, with nurses providing normal childbirth care and only requesting a doctor in the event of complications. The division of care by the nursing team for women during childbirth and the newborn is referred to as necessary to achieve a higher quality of care and division of tasks.

A study in the United States described that professional interactions between nurses and doctors responsible for childbirth are still fragile, with little interest in developing, for example, collaborations between the two professionals²¹. An essential element for the division of labor in the NBC, autonomy of action must be linked to the appropriate responsibilities, duties, and rights that make it possible to obtain trust, engagement, and commitment with the health team²².

To corroborate this information, the interviewees described that the professional relationships established, as well as the delimitation of functions, the construction of interactions and cooperation between the nursing team and other actors in the health team, contribute to the care of parturients and how these actions impact on women’s satisfaction.

Going through the professional discussions on the power of action and decision-making in labor and birth care practices in the NBC, in the concept of the Labor Market¹¹, it is reflected that competencies and skills associated with qualified knowledge are required for obstetric nurses to be able to manage work and care within the NBC, as this has been demanded in hiring by health institutions.

It also implies achieving greater quality in the care processes developed for women and their families, such as the use of good childbirth practices, as well as the use of soft, soft-hard, and hard technologies such as communication, sensitivity, the nurse-parturient-family relationship, standards and protocols, tools and equipment used in care^16,19,23.

These requirements result from training processes involving two types of education: three years of midwifery training or one-and-a-half year postgraduate nursing programs¹⁷. The interviewees in this study are linked to the second training model, being nurses with a postgraduate degree in Obstetric and/or Neonatal Nursing.

Within this theoretical framework, in the concept of the Framework of Values¹¹, to obtain the competence and skills to carry out their activities, obstetric nurses in Brazil have the prerequisite for professional qualification of having carried out at least 15 prenatal nursing consultations, 20 deliveries with complete monitoring of labor, delivery and the puerperium, and 15 visits to the newborn²⁴. This process fosters the development of humanized knowledge in the care provided, such as the WHO’s good practices in labor and birth care, as well as building relationships of trust in the care processes with parturients and their families at the NBC^14,19,22.

Professional valorization is identified in other studies carried out in Brazil and around the world. A study carried out in northeastern Brazil, using the words of puerperal women and professional nurses, showed that autonomy, active participation, and female protagonism occur, driven by the practices of obstetric nurses¹³. A survey conducted in Ghana, Africa, found that both family members and women recognized the positive professional attributes of nurses and midwives. However, there was also little publicity about the professional roles of each²².

The study’s limitations are related to snowball sampling and telephone contact, as it was difficult for professionals to explain the research and then agree to take part.

However, this technique made it possible to reach obstetric nurses at the site of the study with a glimpse of the practices developed in the NBCs in place.

FINAL CONSIDERATIONS

It was found that significant advances in work management practices associated with the development and implementation of care practices developed by obstetric nurses were made in the NBCs observed. Negotiations and agreements were made between these professionals and the other members of the hospital team to obtain autonomy and leadership of the team. However, there are still ambiguities among professional nurses about the concepts of managing the work they do and the care they provide.

The conclusion is that understanding the challenges and facilities of this health professional’s work contributes to changes in practice and encourages criticism of the interventionist technocratic obstetric models in force in Brazil to implement more humanized models that involve women and their families.

Nurses, as managers of care practices and work in the NBC, need to have autonomy to carry out their duties, to build trust and recognition as responsible for this piece of equipment in the Brazilian maternal and child health care network, promoting the best results for women during labor and birth.

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  » https://doi.org/10.1590/1413-81232018244.06962017
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  » https://doi.org/10.1371/journal.pone.0256600
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  » http://dx.doi.org/10.1136/bmjopen-2021-053636
• ²¹
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  » https://doi.org/10.1111/jmwh.13201
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• ²³
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• *
  Article extracted from the master’s: “Desafios da gestão e cuidado desenvolvido pelo enfermeiro obstetra em centro de parto normal”, Universidade Estadual do Ceará, Fortaleza, CE, Brasil, 2020.

Edited by

Associate editor:

Dra. Tatiane Trigueiro

Publication Dates

• Publication in this collection
  18 Mar 2024
• Date of issue
  2024

History

• Received
  01 Aug 2023
• Accepted
  06 Oct 2023