Promoting Low-Intervention Childbirth in Paraguay: Assessing the Role of Midwives Open Access
Dickerson, Anissa Elizabeth (2012)
Published
Abstract
Background: The midwifery model of care is based on the
principal that pregnancy and
birth are naturally occurring events in a woman's life. Birth has
become increasingly
medicalized with the routine use of oxytocin, episiotomies, and
forceps-assisted
deliveries. Midwives provide low-cost, low-intervention care for
women throughout the
world. Midwives, known as obstetras in Paraguay, deliver 32%
of babies in hospitals in
Paraguay; yet limited research exists about the role of midwives in
the health care team.
Objective: The purpose of this study is to assess the role
of midwives in the Paraguayan
health system, their perspectives on birth and their potential for
promoting low-
intervention care.
Methods: Qualitative methods were used to gather data
May-August 2011. Focus group
discussions were conducted with midwives and midwifery students.
In-depth interviews
were also used to gather data from midwives and physicians who work
with midwives in
public hospitals. Key informant interviews and participant
observation also carried out.
Results: Participants feel that low-intervention care is
better for women but they do not
think that this is a realistic option in the current health care
system. Some of the major
obstacles to low-intervention birth include lack of prenatal care
preparation, scheduling
of non-medically indicated cesarean sections in the prenatal
period, limited human and
infrastructural resources, and fear or uncertainty around natural
birth. Additionally,
midwifery students have a more holistic view of care than providers
and see a need to
offer women choices around pregnancy, labor, and birth.
Discussion: The role of the midwife is becoming increasingly
limited, either due to
physician-dominated institutions or the lack of sufficient
resources to be able to provide
women with more comprehensive midwifery care. Independent of the
midwife's role, it
is apparent from the evidence presented that women delivering in
public hospitals are
being left out of the decision making process of their own labor
and delivery. Findings
suggest that there is a need for provider training around
evidence-based practice and low-
intervention birth. Other intervention strategies to consider
include a pilot program for a
midwifery model of care and the development of prenatal care
educational materials for
all pregnant women.
Table of Contents
Table of Contents
Chapter 1: Introduction
...................................................................................................
1
Introduction and rationale
............................................................................................
1
Problem statement
.......................................................................................................
2
Purpose statement and research questions
....................................................................
2
Significance statement
.................................................................................................
3
Definition of terms
......................................................................................................
3
Chapter 2: Literature Review
..........................................................................................
5
The definition of a midwife
.........................................................................................
5
Midwifery in South America
.......................................................................................
6
Midwifery and reproductive health in Paraguay
........................................................... 8
Paraguay
...................................................................................................................
10
Medicalization of birth
..............................................................................................
12
Cesarean sections
....................................................................................................
12
Episiotomies
...........................................................................................................
13
Other interventions
..................................................................................................
14
Low-intervention birth and the role of midwives
....................................................... 16
Humanized birth
........................................................................................................
17
Chapter 3: Methods
.......................................................................................................
20
Research
design.........................................................................................................
20
Recruitment and eligibility
........................................................................................
21
Data collection
..........................................................................................................
23
Small group discussion and interview guide development
......................................... 23
Small group discussions and in-depth interviews with midwives
............................... 24
Small group discussions with
midwives.....................................................................
24
In-depth interviews (IDI) with midwives
...................................................................
25
Small group discussions with midwifery students
...................................................... 25
Interviews with physicians
........................................................................................
26
Key informant interviews
..........................................................................................
26
Participant observation
..............................................................................................
26
Ethical
considerations................................................................................................
27
Data management and analysis
..................................................................................
27
Limitations
................................................................................................................
28
Data collection for midwifery profile
.........................................................................
29
Chapter 4:
Results..........................................................................................................
30
Profile of midwives
...................................................................................................
30
Findings from qualitative data
...................................................................................
34
Participant observation
..............................................................................................
35
Perspectives of birth
..................................................................................................
38
Natural birth
...........................................................................................................
39
Fear and uncertainty of natural and low-intervention birth
............................................ 40
Humanized birth
.....................................................................................................
43
A different view from students
..................................................................................
45
Barriers and facilitators to low-intervention
birth.......................................................
47
Lack of prenatal education and preparation
.................................................................
47
Preparation for possible complications
.......................................................................
48
Prenatal care provided by physicians versus midwives
................................................. 49
Unwarranted cesarean sections
..................................................................................
50
Lack of resources
....................................................................................................
53
The influence of family on birth
................................................................................
54
Lack of support by physicians for low-intervention birth
.............................................. 56
Facilitators of low-intervention birth
..........................................................................
57
Role of the midwife
...................................................................................................
58
Views on midwifery roles at physician-dominated hospitals
......................................... 59
Views on midwifery role at team-based hospitals
........................................................ 63
Differences in the role of the midwife in Asunción
versus outside of Asunción ............... 64
Residents................................................................................................................
66
Space/place of the midwife
.......................................................................................
58
Professional conflict with
nursing..............................................................................
69
Chapter 5: Discussion
...................................................................................................
71
Conclusions
...............................................................................................................
71
Recommendations
.....................................................................................................
75
Training providers in evidence based practice for low-intervention
care ......................... 75
Midwifery model of care
..........................................................................................
76
Development of prenatal education materials for all pregnant women
............................ 78
Policy recommendations
..........................................................................................
79
Limitations and need for further
research...................................................................
80
References
.....................................................................................................................
82
List of Appendices
Appendix A - Focus Group Discussion Guide - Midwives
............................................ 86
Appendix B - Focus Group Discussion Guide - Midwifery Students
............................. 88
Appendix C - In-depth Interview Guide - Midwives
..................................................... 90
Appendix D - In-Depth Interview Guide - Physicians
................................................... 92
Appendix E - Codes and Code Definitions
....................................................................
93
List of Tables
Table 1 - History of Assistant at Delivery in Chile
.......................................................... 8
Table 2 - Country Indicators
.........................................................................................
30
Table 3 - MDG and Reproductive Health Indicators
...................................................... 31
Table 4 - Midwifery Workforce and Education in Paraguay
.......................................... 32
Table 5 - Regulation of Midwifery in Paraguay
.............................................................
33
Table 6 - Midwifery Professional Associations in Paraguay
.......................................... 33
Table 7 - Maternal and Newborn Policies
......................................................................
34
Table 8 - Paraguayan Public Hospitals visited by PI, June-July 2011
............................ 35
List of Figures
Figure 1 - Maternal Mortality Trends in Paraguay, 1987-2009
...................................... 30
Figure 2 - Trends in Total Fertility Rate and Contraceptive
Prevalence, 1990-2008 ....... 31
Figure 3 - Delivery Location, 1998-2008
......................................................................
31
Figure 4 - Birth Attendants by Provider and Risk
.......................................................... 32
Figure 5 - % of Cesarean Section Deliveries by Area and
Socioeconomic Status ........... 34
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