Women's health during pregnancy, childbirth and puerperium: 25 years of recommendations from international organizationsParada, Cristina Maria Garcia de LimaI
- IUniversidade Estadual Paulista Júlio de Mesquita Filho. Botucatu, São Paulo, Brazil.
Women’s health during pregnancy, childbirth and the puerperium has been a concern of international bodies since the 1994 United Nations International Conference on Population and Development in Cairo, Egypt. This conference had as theme Women’s Health and Safe Motherhood. The rationale for choosing the theme was that pregnancy and childbirth-related complications were among the leading causes of mortality of women of reproductive age in many parts of the developing world, and the great distance between developed and developing countries, when discussing aspects related to maternal morbidity and mortality (1).
In the manual titled Safe Motherhood. Care in Normal Birth: A Practical Guide, 1996, from the World Health Organization (WHO). Based on the best available scientific evidence, he proposed to classify practices related to normal childbirth into four categories taking into account their usefulness, effectiveness and absence of dangerousness. These categories were: practices demonstrably useful that should be encouraged; practices that are clearly harmful or ineffective and should be eliminated; practices for which there is insufficient evidence to support a clear recommendation, and should therefore be used with caution; and practices often misused. This document is a milestone for normal birth promotion based on scientific evidence (2).
In 2001, concerned with caring for women during pregnancy, WHO conducted a randomized multicenter study. It obtained World Bank support to compare the standard Western model of antenatal care, with eight to 12 consultations, and the new basic model that proposed limiting the number of consultations to four; and decrease in the number of prenatal examinations and procedures for eligible pregnant women. The study concluded that there were no differences in maternal and perinatal outcomes between the two models, indicating the implementation of the core component activities of the new model (3-4).
Despite the small number of consultations and examinations proposed, the primary care strategy did not represent a greater opportunity for women to access antenatal care. WHO estimates indicate that overall between 2007 and 2014, only 64% of pregnant women had attended the four recommended consultations. Recognizing the need for review as a result of the possible inadequacy of the model, in 2016 WHO issued a consolidated and updated guideline for routine antenatal care as part of its normative work in supporting public practices and policies (5).
In this guideline, antenatal care is an opportunity to establish effective communication with pregnant women about physiological, biomedical, behavioral and sociocultural issues. Care establishes respectful and effective support, essential not only for saving lives, but also for improving life, using health care and its quality. Women’s positive experiences during prenatal and childbirth can form the basis of healthy motherhood. They propose the adoption of strategies aimed at providing quality care focused on women and their families, based on the timely and appropriate implementation of evidence-based practices. The guideline provides guidance with recommendations related to nutritional interventions related to mother and fetus assessment, preventive measures and interventions for common physiological symptoms and to improve utilization and quality of antenatal care. It proposes 19 interventions applicable to all pregnant women in the context of routine antenatal care (5).
Also in the context of positive experiences, in 2018 WHO publishes the text WHO recommendations: intrapartum care for a positive childbirth experience. These recommendations are aimed at transforming care for women and newborns to improve their health and well-being. The experience of positive childbirth is an outcome that transcends labor. It surpasses the previous personal and sociocultural beliefs and expectations of the woman contemplated by the possibility of giving birth to a healthy baby in a safe environment from the clinical and psychological points of view; and to receive ongoing practical and emotional support from kind and technically competent professionals. Most women wishing to have physiological labor and delivery, and to be included in decision making, even when involving medical interventions was the basic premise (6).
At the 72nd World Health Assembly recently held in May 2019, in a report from the WHO Director-General, the 2016-2030 Global Strategy for Women’s, Children’s and Adolescent Health was released. Regarding the pregnancy-puerperal cycle, the document presents quality antenatal care and access to qualified health professionals during pregnancy and the postnatal period as essential to prevent maternal and newborn deaths. On childbirth, there is a discussion that paradoxically, excessive and inadequate care can have consequences as severe as lack of care. The document reports WHO publications, positive prenatal and childbirth experience, as a basis for planning actions for women and children in the puerperal pregnancy cycle. It proposes that the postpartum period provides an opportunity to initiate or maintain care related to non-obstetric disorders such as chronic noncommunicable diseases and mental disorders (7).
From the foregoing, over the past 25 years, quality prenatal and childbirth care is on the agenda as a crucial strategy to reduce maternal and child morbidity and mortality. Nursing, as an area of knowledge, has much to contribute in this direction, as well as in achieving universal coverage of essential health services. In this sense, the important role of nurses inserted in primary care services is highlighted by the performance and possibility of qualification of antenatal care. Midwives and nurses graduating from lato sensu courses in midwifery also stand out for their training that leads them to make effective changes, especially as they assume that women are the focus of care and promote the reduction of unnecessary interventions in childbirth care.