Promoting Low-Intervention Childbirth in Paraguay: Assessing the Role of Midwives Público

Dickerson, Anissa Elizabeth (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/5t34sk02q?locale=pt-BR
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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