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Orientadora: Profª. Drª. Marilene Loewen Wall / Coorientadora: Profª. Drª. Silvana Regina Rossi Kissula Souza / Dissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação Mestrado Profissional em Enfermagem. Defesa: Curitiba, 18/11/2016 / Inclui referências : f.93-102 / Resumo: A gestação em idade materna avançada tem se tornado realidade diante das mudanças ocorridas na sociedade nas últimas décadas. Muitos estudos mostram a relação entre idade materna avançada e complicações durante a gestação, porém são poucos os que trazem uma abordagem qualitativa no intuito de conhecer as experiências vivenciadas pelas mulheres em idade avançada. Nesse sentido, o presente estudo tem como questão norteadora: "Qual é a vivência de mulheres na gestação em idade avançada?" e como objetivo: descrever a vivência de mulheres na gestação em idade avançada. Trata-se de uma pesquisa qualitativa, descritiva, para qual se utilizou entrevistas semiestruturadas como técnica de coleta dos dados. A seleção das participantes ocorreu de forma intencional e a coleta de dados foi realizada de dezembro de 2015 a abril de 2016, em sala reservada no Ambulatório de Pré-natal de Alto Risco de um hospital universitário do sul do Brasil. As participantes da pesquisa foram 21 gestantes com idade igual ou superior a 35 anos. Para o processamento dos dados foi utilizado o software Iramuteq que aplica análises estatísticas em dados textuais qualitativos. Dentre os diferentes tipos de análise, empregou-se a Classificação Hierárquica Descendente. A análise dos dados se baseou na proposta de John W. Creswell (2010), que guia a pesquisa com seis passos desde a coleta até a interpretação dos dados. Essa pesquisa faz parte de um projeto maior aprovado por Comitê de Ética em Pesquisa com Seres Humanos sob o Parecer de n. 1.155.166. Os resultados apresentam uma caracterização das gestantes em idade avançada e seis classes temáticas: Ambivalência: do medo à felicidade; O (não) planejamento e o divino; (Re)organização familiar: do apoio a não aceitação; Maturidade como uma facilidade à maternidade; A idade avançada e a percepção do risco; e, A idade biológica do corpo dificultando a gestação. Os resultados refletem a vivência da mulher gestante em idade avançada que experiencia medos, alegrias, questões relacionadas ao planejamento familiar, o apoio da família frente à gestação em idade avançada, as percepções de risco, a maturidade como um facilitador da gravidez nessa idade e as dificuldades relacionadas com as mudanças do corpo cronologicamente "velho" na visão biológica. Percebe-se a necessidade de proporcionar maior atenção e cuidados para as mulheres nessa faixa etária, no sentido de captá-las desde a atenção primária para orientações de saúde reprodutiva e, quando no pré-natal, existir consultas de enfermagem para que o enfermeiro possa abordar questões além da perspectiva de risco. Palavras-chave: Enfermagem. Idade materna. Gravidez. / Abstract: The pregnancy in advanced maternal age has become a fact towards the changes occurred in society the last decades. Many studies reveal the relation between advanced maternal age and some complications during pregnancy, however there are few people who demonstrate a qualitative approach in order to knowing the experiences lived by women in advanced age. Regarding this issue, the current study has as a guiding question: "What is the experience lived by women in advanced maternal age?" and as an intention: to describe the experiences of women in advanced maternal age. It is about a qualitative and descriptive research in which semi instructed interview were applied as a data collection method. The sorting of participants happened through an intentional procedure and the data collection was between December in 2015 and April in 2016, in a private room of a high risk prenatal care first aid post of a university hospital in the south of Brazil. The participants of the research were 21 pregnant women aged 35 years old or even more. It was used an Iramuteq software for the data processing which applies statistics analyses in qualitative textual data. Among the different types of analysis, it was adopted the Hierarchical Descendant Classification. The data analysis was based on de John W. Creswell (2010) proposal which guides the research in six steps since the collection until the data interpretation. This research takes part of a major project approved by the Research Ethic Committee involving human beings belonging to n. 1.155.166 legal opinion. The results present a characterization of the pregnant women in advanced age and six thematic classes: Ambivalence: from fear to happiness; the (un)planned and the divine; The familiar (re)organization: from support to denial; Maturity as an opportunity to maternity; The advanced age and risk perception; and, The body biological age restricting the pregnancy. The results reflect the reality of pregnant woman in advanced age that experiences fears, joy and issues related to family planning, the support of the family regarding the pregnancy in advanced age, the perceptions of risk, the maturity as a pregnancy supporter in this age and the difficulties related to the changes of the chronological "old" body in a biological view. It can be noticed the need of affording a bigger attention and care to the women in this age group in order to call women attention to the reproductive health assistance and when there are prenatal care nursing appointments so that the nurse can discuss issues beyond risk perspectives. Key Words: Nursing. Maternal Age. Pregnancy.

Maternal and newborn health is one of the main indicators of a good health system. The study wished to develop a strategy to improve the referral system for maternal and newborn care. To identify issues for improvement, the researcher explored the appropriateness of referrals, referral pathways and challenges, and provider costs for maternal and newborn care at health centres and hospitals levels. The researcher selected a sequential explanatory mixed method research design. Two primary hospitals and six health centres were purposively selected for participation. The first phase collected quantitative data by reviewing the health facilities’ medical records for services provided and health service costing, respectively. Data collection covered one Ethiopian fiscal year (8 July 2017 to 7 July 2018). Based on the existing human resource arrangement and care needs, the health service costing found that a single midwife at health centre level spent half of the expected time for delivery care. The cost estimates of various types of care delivery care indicated that delivery care at health centre and hospital levels cost $27.5 to $30.2, and $34.7 to $37.8, respectively. The primary hospitals incurred four times the cost for newborn intensive care units and Caesarean sections compared to normal delivery care. In the second phase, the researcher collected qualitative data from 26 purposively selected key informants in interviews. The findings indicated that the selected hospitals and health centres had a referral system, but several factors impeded its effective implementation. Knowledge of referral pathways determined the referral practices at the lower level of the system. The number of inappropriate referrals to primary hospitals indicated a need to mobilize and educate the community on the services available and protocols of care. In general, most referrals could have been managed at health centre level. Emergency medical transportation is a critical component of the referral system; delays in transportation determine the outcome of care at hospital level. Ambulance management was generally poor, lacked a tracking system, and was negatively affected by confusion and lack of coordination between facilities. The available ambulances were not well equipped or well-staffed for emergency management. Moreover, there were frequent breakdowns due to limited budget for maintenance and running costs. The quality of maternal care depends on the quality of the labour monitoring. However, partograph utilization was not consistently practised. Admitted cases were not properly monitored because of the high caseload and limited supervision support. In many cases, healthcare professionals tended to “treat charts” rather than promote evidencebased practice while providing care. The quality of practice was challenged by insecurity in the working environment but strengthened by good teamwork and available consultation support. The implementation of the existing referral system depended on the people involved; the use of performance indicators; follow up by management, and an accountability framework. The findings of the two phases of the study and review of other countries’ experiences on the identified problems, led to the development of draft strategy and then a consultation with relevant experts produced the final strategy. The strategy includes interventions to improve the practices at the sending and receiving facilities as well as suggestions to improve the communication, transportation and overall governance system. Then, taking into consideration all the phases of the study, the researcher makes recommendations for practice and further research. / Health Studies / D. Litt. et Phil. (Healht Studies)

The purpose of this study was to explore and describe the perception of nurses about the implementation of focused ante-natal care services in nine district health facilities of Dar es Salaam. Quantitative, explorative and descriptive research was conducted to determine how the implementation of the focused ante-natal care guidelines was perceived by nurses who provided midwifery health care services. Data collection was done using a structured questionnaire. A simple random sampling method was used to select the respondents. The study sample comprised of nursing officers (n=50), nurse midwives (53) and public health nurses (40). The SAS/Basic and SAS/STAT version 11.1 was used to analyse data. Validity was ensured and the Cronbach’s coefficient reliability test was 0.86.The findings revealed that the greatest area of concern was the shortage of human and material resources for successful implementation of focused ante-natal care to pregnant women and unborn children. / Health Sciences / M.A. (Health Studies)

The purpose of this study was to explore and describe the perception of nurses about the implementation of focused ante-natal care services in nine district health facilities of Dar es Salaam. Quantitative, explorative and descriptive research was conducted to determine how the implementation of the focused ante-natal care guidelines was perceived by nurses who provided midwifery health care services. Data collection was done using a structured questionnaire. A simple random sampling method was used to select the respondents. The study sample comprised of nursing officers (n=50), nurse midwives (53) and public health nurses (40). The SAS/Basic and SAS/STAT version 11.1 was used to analyse data. Validity was ensured and the Cronbach’s coefficient reliability test was 0.86.The findings revealed that the greatest area of concern was the shortage of human and material resources for successful implementation of focused ante-natal care to pregnant women and unborn children. / Health Sciences / M.A. (Health Studies)