Background: An increasing proportion of Canadian women are experiencing a Caesarean section (CS) and a subsequent repeat CS. While CS can be necessary and lifesaving for mothers and their infants in some situations, it is also associated with greater morbidity risks to women and infants than vaginal birth. Clinical practice guidelines recommend the involvement of pregnant women in making decisions about mode of birth and shared decision making improves the informed consent process. This research examines the factors that influence mode of birth after a previous CS. Methods: Two cross sectional descriptive studies and a prospective pre-post cohort study with control were conducted to investigate the high use of repeat CS at the levels of health care providers, maternity care clients, and the organizational structure of a birthing unit. 1. Interviews and surveys with obstetricians, family physicians, midwives, and nurses were conducted to investigate the attitudes, values, and perceptions that guide their care practices for clients with a previous CS. The specific research question was: What are the factors that influence the practices of maternity care providers (obstetricians, family physicians, midwives, and nurses) regarding mode of birth after a previous CS? Data was analyzed using iterative deductive and inductive coding. 2. Interviews and surveys were conducted during pregnancy and after giving birth with healthy women who have had a previous CS to explore their decision making processes regarding mode of birth after a previous CS. The specific research question was: How do women eligible for a VBAC make decisions about their upcoming mode of birth? A thematic framework approach was used for data analysis. 3. Data from the Better Outcomes Registry and Network (“BORN”) Ontario was analyzed to examine the effectiveness of a hospital based strategy on overall proportions of CS and within Robson groups 1, 2a, and 5. The Caesarean section reduction (CARE) strategy includes interventions that target health care providers, pregnant women, and hospital policies. Results: 1. Maternity care providers would recommend a vaginal birth after CS (VBAC) for healthy pregnant women with a previous CS. They had different perceptions of the safety of birth to the health of women and infants and different approaches to engage in decision making during consultation. Providers believed women make their decision about mode of birth outside of the clinical consultation and often prior to their subsequent pregnancy. 2. The main themes that influenced the decisions of maternity care clients about mode of birth were mothers’ experiential reasoning regarding mode of birth and recovery, experiential knowledge from significant others, scheduling of CS regardless of the mode of birth decision, rating and prioritizing risks, fear of risks, and decisional conflict. When women discussed the factors that impacted their decisions about mode of birth six to eight weeks after they had given birth, the main themes were the recovery experience and fear related to the mode of birth. A lack of time during consultation was identified as a major barrier inhibiting shared decision making, specifically among clients of obstetricians. Other barriers included reliance on routine obstetric practices that are not evidence based. 3. Proportions of CS decreased at the intervention hospital by 3.9% (p=0.0006), from 30.3% (n=964) in 2009/10 to 26.4% (n=803) in 2012/13. During the same time frame, proportions of CS in the control group were stable with 28.1% (n=23,694) in 2009/10 and 28.2% (n=23,683) in 2012/13. Within the Robson classification system, the proportions of repeat CS among all low risk women with a previous CS decreased at the intervention hospital by 5.6% (p=0.0044) from 84.3% to 78.7%. In the control group, also fewer women had a repeat CS over the study period, but the decrease was smaller with 3.9% (p<0.0001) from 84.5% to 80.6%. Conclusion: A true shared decision making process addresses the power imbalance between providers and women through an incorporation of the clinical expertise of providers and the experiential expertise of pregnant women before reaching a decision about mode of birth. The use of routine obstetric practices that are not evidence based inhibited women to make decisions about their mode of birth. The introduction of the CARE strategy to a hospital birthing unit was associated with improvements in proportions of CS and VBAC among low risk women.

The aim of this research was to know the demands identified by health care team professionals of Family Health Care Strategy, focusing on adolescence. Such study contemplates on its theoretical review a presentation of the Health System and the Family Health Care Strategy, as well as the public policies for adolescents proposed by the Health Ministry (PROSAD). There is a specific chapter about adolescence, in which changes experienced in such period of development are approached, including physical, psychic and social aspects, as well as the importance of the family relationships as regards the adolescents. Such study aimed to understand, through the Bioecological Theory of Human Development, the relation between the adolescent and his context, establishing interferences among microsystems and their effects on the adolescent‟s health. In order to reach the aim of the study, a qualitative approach was used. Data collection consisted of semi-structured interviews carried out with professionals of five teams of Family Health Care Strategy in Santa Maria/RS. Results were understood through the analysis of multiple cases and analyzed through content analysis. The reports of the professionals indicate the fragility of actions directed to the adolescent public, but also point out important problems presented in such group. Among them, the results highlight pregnancy in adolescence, violence, drugs and family problems. The professionals point out the absence of projects directed to the adolescent public, what could increase the risk concerning the problems previously described. The health care professionals have no knowledge of the existence of Adolescent Health Care Program (PROSAD), and such aspect enables understanding the difficulties referred concerning assistance of the adolescent public. Moreover, aspects regarding working instability related to the maintenance of the health care teams were pointed out by the professionals. Such aspects interfere on the bonds established with the community, as well as on the investment concerning new actions and/or projects. The final considerations highlight the importance of making improvements in the working process of the teams of Family Health Care Strategy, emphasizing the proposal to strengthen the implementation of ideas present in PROSAD, which includes the main questions highlighted by the professionals as part of their communities. Without the consolidation of specific actions for the adolescents, risks seem to increase within such group. Thus, health care promotion and prevention become increasingly urgent and necessary. / O objetivo desta pesquisa foi conhecer as demandas identificadas por profissionais de saúde das equipes de Estratégia de Saúde da Família, com foco na adolescência. O estudo contempla em sua revisão teórica uma apresentação do Sistema Único de Saúde e Estratégia de Saúde da Família, assim como o resgate das políticas públicas, direcionadas aos adolescentes, propostas pelo Ministério da Saúde (PROSAD). Encontra-se no estudo um capítulo específico sobre adolescência, no qual se procurou dar enfoque às mudanças vivenciadas nesta etapa do desenvolvimento, incluindo aspectos físicos, psíquicos e sociais, assim como a importância das relações familiares para os adolescentes.O estudo buscou compreender através da Teoria Bioecológica do Desenvolvimento Humano, a relação do adolescente com seu contexto, estabelecendo as interferências entre esses microssistemas e seu efeito sobre a saúde do adolescente. Para atender ao objetivo proposto, o estudo foi de caráter qualitativo. Foram entrevistados, através da técnica de entrevistas semi-estruturadas, profissionais de cinco equipes da Estratégia de Saúde da Família da cidade de Santa Maria/RS. Os resultados foram compreendidos através da proposta de casos múltiplos, e analisados através da análise de conteúdo. Os resultados evidenciados através das falas dos profissionais indicaram a fragilidade das ações direcionadas ao público adolescente, mas, também apontaram para importantes problemáticas presentes neste grupo. Entre elas destaca-se a gravidez na adolescência, a violência, as drogas e os problemas familiares. Os profissionais apontaram para a ausência de projetos direcionados ao público adolescente, o que aumentaria o risco para as problemáticas anteriormente descritas. Os profissionais de saúde não têm conhecimento da existência do Programa de Saúde do Adolescente (PROSAD), aspecto que possibilita compreender as dificuldades referidas na atuação junto ao público adolescente. Foram apontados, ainda, pelos profissionais, aspectos referentes à instabilidade no trabalho com relação à manutenção das equipes, aspecto que interfere nos vínculos estabelecidos com a comunidade, bem como no investimento em novas ações e/ou projetos. As considerações finais destacam a importância de incrementar o trabalho das equipes de Estratégia de Saúde da Família, fomentando a proposta de forma a fortalecer a implantação das idéias presentes no PROSAD, que inclui as principais questões destacadas pelos profissionais, presentes em suas comunidades. Sem a consolidação de ações específicas para os adolescentes percebe-se o aumento de riscos presentes neste grupo, razão pela qual a promoção de saúde e a prevenção se tornam cada vez mais urgentes e necessárias

NEPOMUCENO, Léo Barbosa. Para atuar com a comunidade: estudo sobre a relação entre participação comunitária e estratégia de saúde da família do SUS no Bairro Terrenos Novos em Sobral, Ceará. 2009. 206 f. Dissertação (Mestrado em Psicologia) – Universidade Federal do Ceará, Departamento de Psicologia, Programa de Pós-Graduação em Psicologia, Fortaleza-CE, 2009. / Submitted by moises gomes (celtinha_malvado@hotmail.com) on 2012-01-23T14:35:57Z No. of bitstreams: 1 2009_dis_LBNepomuceno.PDF: 1311410 bytes, checksum: a700d7975da9a8944af2fe46241cacd0 (MD5) / Approved for entry into archive by Maria Josineide Góis(josineide@ufc.br) on 2012-01-27T15:30:21Z (GMT) No. of bitstreams: 1 2009_dis_LBNepomuceno.PDF: 1311410 bytes, checksum: a700d7975da9a8944af2fe46241cacd0 (MD5) / Made available in DSpace on 2012-01-27T15:30:21Z (GMT). No. of bitstreams: 1 2009_dis_LBNepomuceno.PDF: 1311410 bytes, checksum: a700d7975da9a8944af2fe46241cacd0 (MD5) Previous issue date: 2009 / The research part of the finding, based in several studies, that the Family Health Care Strategy (ESF), established as Primary Health in the National Public Health (SUS) in Brazil, has not encouraged a significant community participation. Supports the idea that community participation is essential to the advance of ESF work, and bring elements to enrich the debate on the theme of social participation in SUS. Studies the relationship between the Family Health Care Strategy (ESF) and community participation in Terrenos Novos neighborhood, in Sobral-CE. Analyzes the understanding of the group of users and professionals in the ESF about community participation, the ESF work and the relationship between them; evaluates community participation, the work of the ESF and the relationship between those in the community studied, presents and create proposals, with residents and professionals of the municipal health system of Sobral, to strengthen community participation and the ESF. Its theoretical mark is the Community Psychology and its interfaces with the Social Psychology of Health, Community Health and Public Health. Consists an exploratory and field research of qualitative approach. A thematic analysis is performed as the main methodological strategy, like a technique of content analysis of empirical material produced in the culture circles performed with the group of participants. As an additional methodological strategy, analyze the field notes taken and materials in work done by the researcher in the place. The search results are divided into three main themes: community participation, the ESF and the relationship between them. The theme of the Community highlights concepts of community participation related to ideas of solidarity with the other, an involvement and commitment to what is common, a need to collectively seek improvements to the neighborhood. The evaluation of community participation in Terrenos Novos neighborhood points to a "disenchantment" and decline of this process in the place. The theme of the ESF's work points to several conceptions, ranging from visions impregnated with the ideology of the biomedical model to more differentiated views that argue defends an attention focused on the family health and in tune with the reality of the territory-community. The evaluation of the work of the CSF studied mainly points to weaknesses in the health care. The discussion of the topic of the relationship between community participation and ESF highlights the importance of this relationship to the advancement of health work and the need to improve the relationship between these processes. Several relevant factors were identified in the relationship between ESF and the Community, among them: the professional commitment, the ability of social reading of the professionals, the need to resize the work process for health promotion; the power relationship between professional and user, the ability to practice the co-responsibility with the user, and need to create permanent spaces of dialogue between the CSF and the community. / A pesquisa parte da constatação, colocada por vários estudos, de que a Estratégia de Saúde da Família (ESF), constituída como Atenção Primária em Saúde no Sistema Único de Saúde (SUS) do Brasil, não tem fomentado uma significativa participação comunitária. Defende a idéia de que a participação comunitária é fundamental para o avanço do trabalho da ESF, e traz elementos para enriquecer o debate sobre o tema da participação social no SUS. Estuda a relação entre Estratégia de Saúde da Família (ESF) e participação comunitária no bairro Terrenos Novos, em Sobral-CE. Analisa a compreensão que um grupo formado por usuários e profissionais da ESF tem a respeito da participação comunitária, do trabalho da ESF e da relação entre estes; avalia a participação comunitária, o trabalho da ESF e a relação entre estes na comunidade estudada; problematiza e constrói propostas, junto com moradores e profissionais do Sistema Municipal de Saúde de Sobral, para o fortalecimento da participação comunitária e da ESF. Tem como marco teórico a Psicologia Comunitária e suas interfaces com a Psicologia Social da Saúde, Saúde Comunitária e Saúde Pública. Constitui-se como pesquisa de campo exploratória de abordagem qualitativa. Como estratégia metodológica principal, realiza análise temática, como técnica de análise de conteúdo, de material empírico produzido em círculos de cultura realizados com o grupo de participantes. Como estratégia metodológica complementar, analisa anotações de campo realizadas, bem como materiais produzidos em trabalhos realizados pelo pesquisador no local. Os resultados da pesquisa dividem-se em três temas principais: a participação comunitária, a ESF e a relação entre estes. O tema da participação comunitária destaca concepções de participação comunitária ligadas a idéias de solidariedade com outro, de um envolvimento e compromisso com o que é comum, de uma necessidade de buscar coletivamente melhorias para o bairro. A avaliação feita sobre a participação comunitária no bairro Terrenos Novos aponta para um “desencantamento” e enfraquecimento desse processo no lugar. O tema do trabalho da ESF aponta para diversas concepções que vão desde visões impregnadas com o ideário do modelo biomédico até visões mais diferenciadas que defendem uma atenção em saúde voltada para a família e sintonizada com a realidade do território-comunidade. A avaliação feita do trabalho do CSF estudado aponta principalmente para fragilidades na atenção à saúde. A discussão do tema da relação entre participação comunitária e ESF destaca a importância de tal relação para o avanço do trabalho em saúde e para a necessidade de se melhorar a relação existente entre esses processos. Foram apontados vários elementos relevantes na relação entre ESF e participação comunitária, dentre eles: o compromisso do profissional; a capacidade de leitura social dos profissionais; a necessidade de redimensionar o processo de trabalho para a promoção da saúde; a relação de poder entre profissional e usuário; a capacidade de praticar a co-responsabilização com o usuário; e a necessidade de criação de espaços permanentes de diálogo entre o CSF e a comunidade.