Orientador: Aarão Mendes Pinto Neto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-14T08:21:34Z (GMT). No. of bitstreams: 1 CardosoDelMonte_MeireCeleste.pdf: 1822486 bytes, checksum: 5ef969ace185af2a5bc1edb9dc948b68 (MD5) Previous issue date: 2009 / Resumo: Objetivo: Identificar a taxa de incidência de infecção do sítio cirúrgico (ISC) e fatores associados ao aparecimento desta infecção, em pacientes submetidas à cesárea em um hospital público, de ensino e terciário, através da vigilância pósalta. Sujeitos e Métodos: Foram admitidas no estudo 204 mulheres que realizaram cesárea no Centro de Atenção Integral à Saúde da mulher no período de maio de 2008 a março de 2009 e que possuíam telefone para contato. A pesquisadora abordava as mulheres durante sua internação e preenchia uma ficha para registrar os fatores associados às infecções pós-cesárea. Após a alta hospitalar, a pesquisadora ligava para essas mulheres 15 e 30 dias após a cirurgia, preenchendo um questionário para obter dados relativos à infecção pós-operatória. A análise estatística foi feita com o programa SAS versão 9.02, usando-se os testes qui-quadrado e exato de Fisher para variáveis categóricas e Mann-Whitney para variáveis numéricas. Um modelo de regressão logística para riscos de COX (RR), com critério de seleção de variáveis stepwise, foi utilizado para identificar os fatores associados a ISC. O RR e seu intervalo de confiança foram calculados e p<0,05 foi considerado significativo. Resultados: A amostra final foi de 187 mulheres. Dessa amostra 44 apresentaram uma ISC, correspondendo a uma taxa de 23,5%. Em 42 mulheres (95%) a ISC manifestou-se após a alta, sendo que em 39 delas (93%) a ISC manifestou-se dentro dos primeiros 15 dias. Na análise bivariada foram observadas como significantes para ISC as variáveis: número de consultas pré-natal = 7 e hipertensão arterial. Na análise multivariada foi observada significância apenas para hipertensão arterial. Conclusão: A vigilância pós-alta é fundamental para não subestimar as ISC em cesáreas, e neste estudo um acompanhamento de 15 dias pós-alta foi suficiente para detectar o aparecimento dessas infecções. A hipertensão arterial foi associada à ISC. / Abstract: Objective: To identify the rate of surgical site infections (SSI) and factors associated with their occurrence by performing postdischarge surveillance of patients following Cesarean section at a public university teaching hospital. Subjects and Methods: A total of 204 women, who had undergone Cesarean section at the Center for Women's Integrated Healthcare (CAISM) between May 2008 and March 2009 and who were able to be contacted by telephone, were admitted to the study. The women were approached during hospitalization and a form was completed on factors associated with post-Cesarean section infections. Following discharge from hospital, the women were contacted by telephone 15 and 30 days after surgery to complete a questionnaire on the presence of postoperative infection. Statistical analyses were performed using the SAS statistical software program, version 9.02. The chi-square test and Fisher's exact test were used to analyze categorical variables and the Mann Whitney test for numerical variables. Cox proportional hazards regression model with stepwise variable selection was applied to determine the relative risks (RR) and respective confidence intervals of factors associated with SSI. Significance was established at p<0.05. Results: The final sample consisted of 187 women. SSI was detected in 44 cases (23.5%). In 42/44 women (95%), SSI appeared following discharge from hospital, becoming evident within the first 15 days following surgery in 39/44 cases (93%). Bivariate analysis indicated the following variables as being significantly associated with SSI: number of prenatal visits =7 and hypertension; however, only hypertension remained significant in the multivariate analysis. Conclusion: Postdischarge surveillance is essential for ensuring accurate estimates of post-Cesarean section SSI; nevertheless, the present findings suggest that a 15-day post discharge follow up is sufficient to detect these infections. Hypertension was associated with SSI. / Universidade Estadual de Campi / Ciencias Biomedicas / Mestre em Tocoginecologia

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2016-05-19T14:13:30Z No. of bitstreams: 2 Dissertação - Natália de Carvalho Borges - 2015.pdf: 1625922 bytes, checksum: 6294a0cb41556811cefca60e606a9b4a (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-05-19T14:14:51Z (GMT) No. of bitstreams: 2 Dissertação - Natália de Carvalho Borges - 2015.pdf: 1625922 bytes, checksum: 6294a0cb41556811cefca60e606a9b4a (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2016-05-19T14:14:51Z (GMT). No. of bitstreams: 2 Dissertação - Natália de Carvalho Borges - 2015.pdf: 1625922 bytes, checksum: 6294a0cb41556811cefca60e606a9b4a (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2015-07-08 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / Postoperative pain is a frequent and multidimensional event, which is influenced by biopsychosocial factors. Little is known about pain after cesarean section, currently one of the most practiced surgeries, which requires a rapid recovery and is held at a time of a woman’s life in which various physical and emotional changes occur. The aim of this study was to estimate the incidence, characteristics and predictive factors for moderate, strong and worst pain post-cesarean section. This is the data analysis part from the prospective cohort study, conducted in a private hospital in the municipality of Goiânia, Brazil, between February 2014 and May 2015, with a sample of 947 women that had undergone cesarean section. Data were collected at the pre and immediate postoperative moments. The outcome variable was postoperative pain of moderate, strong and worst intensity (≥5 on a numerical scale from 0-10). The predictor variables included sociodemographic and clinical factors. The intensity of the pain were assessed through the Numeric Pain Rating Scale of 11 points (NPS), where zero (0)=no pain; 1,2,3 and 4=mild pain; 5 and 6=moderate pain; 7, 8 and 9=severe pain and 10=worst possible pain; and pain quality through the McGill Pain Questionnaire (MPQ-SF). The Hospital Anxiety and Depression Scale (HADS) was used to investigate symptoms of anxiety and depression and the STAI-trait for anxiety symptoms. For the statistical analysis, the chi-square test, t-test and multivariate regression analysis were used. The mean age of the women was 25.3 years (sd=5.7). Married women (43.9%) and those that had completed high school (50.3%) were prevalent. All the women underwent spinal anesthesia with the use of heavy bupivacaine 0.5% and morphine. The incidence of postoperative pain was 92.2% (CI: 95%:90.0%-93.9%) and the incidence of women who reported pain of moderate, strong and worst intensity was de 79,2%(CI:95%:76,5%-81,6). The descriptors most frequently chosen to characterize the pain were “aching”, “tender” and “throbbing”, from the sensory-discriminative category of the MPQ-SF. Performing tubal sterilization together with the cesarean section (OR: 2.26; 95%CI 1.12-4.57), duration of surgery over 30 minutes (OR 1.26; 95%CI 1.11-2.18), presence of preoperative pain (OR: 1.54; 95%CI 1.05-2.26) and medium and high levels of trait anxiety (OR: 1.50; 95%CI 1.04-2.09) emerged as predictors of postoperative pain of moderate, strong and worst intensity. The performance of previous cesarean sections emerged as a protective factor for postoperative pain (OR: 0.65; 95%CI 0.46-0.92). High intensity postoperative pain is a highly frequent event in women undergoing cesarean section, described in words that indicate the multidimensionality of the pain. The perioperative evaluation of women should include negative behaviors such as anxiety, the presence of preoperative pain and the performance of surgeries that require greater exposure and manipulation of tissues, in order to reduce impairments in post-operative recovery. / El dolor pos operatorio es un caso frecuente, multidimensional e influenciado por factores bio-psico-sociales. Aun se sabe poco sobre el dolor después de una cesárea, una de las cirugías mas practicadas en la actualidad, que exige una rápida recuperación y es realizada en un momento de la vida de la mujer en que ocurren diversos cambios de orden físico y emocional. El objetivo de este estudio fue estimar la incidencia, características y los factores que predicen el dolor pos operatorio de intensidad moderada, fuerte y peor possible en mujeres sometidas a cesárea. Se trata del análisis de datos de un estudio de cohorte prospectiva, realizado en un hospital privado del Municipio de Goiânia, Brasil, entre febrero del 2014 y mayo del 2015, con una muestra de 947 mujeres sometidas a cesárea. Los datos fueron colectados durante el periodo pre y post cirurgía inmediatos. La variable de desenlace fue el dolor pos-cirugía de intensidad moderado, fuerte o peor posible (≥5 en la escala numérica de 0-10) Las variables predictorias incluyeron las sociodemograficas y clinicas. La intensidad y tipo del dolor fueron evaluados por medio de la Escala Numérica del Dolor de 11 puntos (END), em que 0(cero)=sin dolor; 1,2,3 e 4= dolor leve; 5 y 6=dolor moderado; 7, 8 y 9=dolor fuerte e 10=peor dolor posible; y la calidad por el Test de Dolor de McGill (MPQ-SF). La Escala de Ansiedad y Depresión Hospitalaria (HADS) fue usada para investigar los síntomas de la ansiedad y la depresión y el IDATE-rasgo a los síntomas de ansiedad. Para el análisis estadístico, fueron utilizados los testes chi-cuadrado, teste t y análisis multivariada. La edad media de las mujeres era de 25,3 años (DP=5,7). Prevalecieron las casadas (43,9%) e que habian completado la escuela secundaria (50,3%). Todas las mujeres fueron sometidas a anestesia raquidea, con el uso de bupivacaína pesado 0,5% y morfina. La incidencia del dolor pos-operatorio fue de 92,2% (IC: 95%:90,0%-93,9%) y la incidencia de mujeres que reportaron dolor de intensidad moderada, fuerte y el peor posible fue de 79,2%(CI:95%:76,5%-81,6). Los descriptores más frecuentes escogidos para caracterizar el dolor fueron: “dolorosa”, “dolorida à palpación” e “palpitante”, del grupo sensorial-discriminativo del MPQ-SF. Surgieron como factores predictores del dolor pos-operatorio de intensidad moderada, fuerte y peor posible la realización de esterilización en conjunto con la cesárea (OR: 2,26; IC95% 1,12-4,57), la duración de la cirugía por más de 30 minutos (OR: 1,26; IC95% 1,11-2,18), presencia del dolor pre-operatorio (OR: 1,54; IC95% 1,05-2,26) y los niveles medios y altos de ansiedade-rasgo (OR: 1,50; IC95% 1,04-2,09). La realización de cesárea previa surgió como un factor de protección para el dolor pos operatorio (OR: 0,65; IC95% 0,46-0,92). Dolor post-cirugía de alta intensidad es un evento altamente frecuente entre mujeres sometidas a cesárea, descrito por medio de palabras que indican la multidimensionalidad del dolor. La evaluación perioperatoria de las mujeres debe incluir los comportamientos negativos como la ansiedad, la presencia de dolor pre-cirugía y la realización de cirugías que requieren una exposición más larga y la manipulación de los tejidos, con el fin de reducir las pérdidas en la recuperación post-operatoria. / A dor pós-operatória é um evento frequente, multidimensional e influenciado por fatores bio-psico-sociais. Pouco ainda se conhece sobre a dor após a cesariana, uma das cirurgias mais praticadas na atualidade, que exige rápida recuperação e é realizada em um momento da vida da mulher em que ocorrem diversas mudanças de ordem física e emocional. O objetivo deste estudo foi estimar a incidência, as características e os fatores preditores de dor pós-operatória de intensidade moderada, forte e pior possível em mulheres submetidas à cesariana. Trata-se de análise de dados parte de um estudo de coorte prospectiva, conduzido em um hospital particular do Município de Goiânia, Brasil, entre fevereiro de 2014 e maio de 2015, com amostra de 947 mulheres submetidas à cesariana. Os dados foram coletados no período pré e pós-operatório imediatos. A variável de desfecho foi a dor pós-operatória de intensidade moderada, forte e pior possível (≥5 na Escala Numérica de 0-10). As variáveis preditoras incluíram as sociodemográficas e clínicas. A intensidade da dor foi avaliada por meio da Escala Numérica de Dor de 11 pontos (END), em que 0(zero)=sem dor; 1,2,3, e 4=dor leve; 5 e 6=dor moderada; 7, 8 e 9=dor forte e 10=pior dor possível; e a qualidade pelo Questionário de Dor de McGill (MPQ-SF). A Escala Hospitalar de Ansiedade e Depressão (HADS) foi usada para investigar sintomas de ansiedade e depressão e o IDATE-traço, para sintomas de ansiedade. Para a análise estatística, foram utilizados os testes qui-quadrado, teste t e análise de regressão multivariada. A média de idade das mulheres foi de 25,3 anos (dp=5,7). Prevaleceram as casadas (43,9%) e que haviam concluido o ensino médio (50,3%). Todas as mulheres foram submetidas à raquianestesia, com uso de bupivacaína pesada 0,5% e morfina. A incidência de dor pós-operatória foi de 92,2% (IC:95%:90,0%-93,9%) e a incidência de mulheres que referiram dor de intensidade moderada, forte e pior possível foi de 79,2% (CI:95%:76,5%-81,6%). Os descritores mais frequentemente escolhidos para caracterizar a dor foram “dolorida”, “dolorida à palpação” e “latejante”, do agrupamento sensitivo-discriminativo do MPQ-SF. Emergiram como fatores preditores de dor pós-operatória de intensidade moderada, forte e pior possível a realização de esterilização tubária em conjunto com a cesariana (OR: 2,26; 1,12-4,57), a duração da cirurgia acima de 30 minutos (OR: 1,26; 1,11-2,18), presença de dor pré-operatória (OR: 1,54; 1,05-2,26) e níveis médios e elevados de ansiedade-traço (OR:1,50;1,04-2,09). A realização de cesariana mostrou ser um fator de proteção para dor pós-operatória (OR: 0,65; 0,46-0,92). Dor pós-operatória de elevada intensidade é um evento altamente frequente entre mulheres submetidas à cesariana, descrita por meio de palavras que indicam a multidimensionalidade da dor. A avaliação perioperatória das mulheres deve incluir os comportamentos negativos como a ansiedade, a presença de dor pré-operatória e a realização de cirurgias que demandam maior tempo de exposição e manipulação de tecidos, com vistas à redução de prejuízos na recuperação pós-operatória.

O Brasil é um dos países do mundo onde mais se realiza cesarianas, muitas delas são realizadas de forma eletiva em idades gestacionais diversas entre 37 e 41 semanas. Cesarianas eletivas realizada em idades gestacionais muito precoces aumentam a o risco de eventos neonatais adversos. Objetivo: Avaliar a relação entre a idade gestacional em que a cesariana eletiva foi realizada e os resultados neonatais em mulheres atendidas no setor privado de saúde. Metodologia: Estudo de coorte retrospectivo entre mulheres assistidas no setor privado de saúde do sul do Brasil, avaliando desfechos neonatais em cesarianas eletivas. No período de janeiro de 2015 a dezembro de 2016. Utilizaram-se os seguintes critérios de elegibilidade: foram incluíram gestantes primíparas e secundíparas com uma cesariana prévia, com idade gestacional entre 37 e 39 semanas (grupo I) ou ≥39 semanas (grupo II) submetidas à cesariana eletiva. Mulheres com indicações médicas para cesariana e gestantes que apresentavam comorbidades associadas foram excluídas, assim como menores de 18 anos, gestações com fetos malformados e gestantes que apresentavam rupreme. Os desfechos neonatais foram comparados entre os dois grupos de idade gestacional. Resultados: Ocorreram 8480 nascimentos de fetos vivos no Hospital Moinhos de Vento durante o período do estudo. Destes, 6542 cesarianas foram excluídos e 1938 cesarianas foram elegíveis para o presente estudo: 625 no grupo I e 1313 no grupo II. A mediana de gestações e abortamentos anteriores foram maiores 14 no grupo I (p≤0,0001 para ambos). A média de idade das mulheres nos dois grupos foi de 34 anos. Não houve variação significativa em relação à etnia, onde a média das mulheres estudadas foi de 97,8% de brancos nos dois grupos. Cerca de 72% das mulheres eram casadas ou moravam com companheiros e 26,1% do total de mulheres eram solteiras ou moravam sem companheiro em ambos os grupos. O índice de massa corporal médio em ambos os grupos foi de 28,7kg / m2. A internação na Unidade de Tratamento Intensivo (UTI) neonatal e a hiperbilirrubinemia foram positivamente associadas ao grupo I em relação ao grupo II (Teste Qui-quadrado com análise residual ajustada, p≤0,0001 e p = 0,049, respectivamente). Nas análises de Spearman observamos que a cesariana realizada ≥39+0 semanas gestacionais (grupo II) foi negativamente relacionada à admissão na UTI Neonatal (rS=-0,091, p≤0,001), à hipoglicemia com necessidade de intervenção terapêutica (rS=-0,047, p=0,039) e eventos de hiperbilirrubinemia (rS=-0,051, p=0,023). Conclusão: A cesariana eletiva realizada antes de 39 semanas completas aumenta o risco de desfechos neonatais adversos. / Brazil is one of the countries in the world where caesarean sections are most frequently performed, many of which are performed electively at different gestational ages between 37 and 41 weeks. Elective cesarean sections performed at very early gestational ages increase the risk of adverse neonatal events. Objective: To evaluate the relationship between the gestational age at which elective cesarean section was performed and the perinatal outcomes in women treated in the private health sector. Methodology: Retrospective cohort study among women assisted in the private health sector of southern Brazil, evaluating neonatal outcomes in elective cesarean sections. From January 2015 to December 2016. The following eligibility criteria were used: primiparous and secondary infants with a previous cesarean section, gestational age between 37 and 39 weeks (group I) or ≥39 weeks (group II) submitted to elective caesarean section. Women with medical indications for cesarean section and pregnant women with associated comorbidities were excluded, as well women under 18 years old and those who presented amoniorexe. Neonatal outcomes were compared between the two gestational age groups. Results: There were 8480 births of live fetuses at Hospital Moinhos de Vento during the study period. Of those, 6542 cesareans were excluded and 1938 cesareans were eligible for the present study: 625 in group I and 1313 in group II. The median of previous pregnancies and abortions were higher in group I (p≤0,0001 for both). The mean age of women in both groups was 34 years. There was no significant variation in relation to ethnicity, where the average of the 16 studied women was 97.8% whites in both groups. About 72% of the women were married or lived with partners and 26,1% of the total women were single or lived without a partner in both groups. The mean body mass index in both groups was 28.7 kg / m2. Neonatal Intensive Care Unit (ICU) and hyperbilirubinemia were positively associated with group I in relation to group II (Chi-square test with adjusted residual analysis, p≤0,0001 and p = 0.049, respectively). In the Spearman analyzes, we observed that cesarean section performed ≥39 + 0 gestational weeks (group II) was negatively related to admission to the neonatal ICU (rS = -0.091, p≤0.001), to hypoglycemia requiring therapeutic intervention (rS = -0.047, p = 0.039) and hyperbilirubinemia events (rS = -0.051, p = 0.023). Conclusion: Elective caesarean section performed before 39 completed weeks increases the risk of adverse neonatal outcomes.

Die Kaiserschnittrate erhöhte sich in den letzten Jahrzehnten in zahlreichen geburtshilflichen Kliniken. Diese Entwicklung ist problematisch, weil damit eine erhöhte pulmonale Morbidität der Neugeborenen verbunden sein kann. Die vor­ liegende Arbeit untersucht die Anpassung von späten Frühgeborenen (34,0–36,6 SSW) und 2 Gruppen von reifen Neugeborenen (37,0–37,6 und 40,6–40,6 SSW) in einem Level 1 Zentrum in Abhängigkeit vom Geburtsmodus. Eingeschlos­ sen wurden primär gesunde Kinder, die im Verlauf eines Jahres geboren wurden. Ausge­ schlossen wurden Kinder mit nachgewiesener angeborener Anomalie und Kinder mit einer schweren Anpassungsstörung (Apgar 5‘<6). Die Kaiserschnittrate lag bei 22% und war am höch­ sten bei späten Frühgeborenen (39%) im Ver­ gleich zu Kindern der 37. (30 %) und der 40. SSW (11%). Die Rate der Kinder, die mit CPAP behan­ delt werden mussten fiel von 88 % in der 34. SSW auf 17% in der 37. und 8% in der 40. SSW. Kinder nach Kaiserschnitt mussten im Vergleich zur spontan geborenen Kindern signifikant häufiger mit CPAP therapiert werden (50 vs. 12%). Dieser Unterschied war für späte Frühgeborene deutlich (82 vs. 36 %) und lag niedriger bei in der 37. (33 vs. 9 %) und 40. (26 vs. 6 %) SSW geborenen Kindern. Der deutlichste Unterschied fiel bei in der 36. SSW geborenen Kindern auf (66 vs. 9%). Die Ergebnisse der Analyse dokumentieren, dass ein Kaiserschnitt bei primär gesunden Kindern zu einer schlechteren respiratorischen Anpassung führt. Dies gilt besonders, jedoch nicht nur, für späte Frühgeborene und dort besonders für Kinder, die in der 36. SSW geboren werden. Die weltweit wachsende Rate von Kaiserschnittent­ bindungen sollte immer wieder kritisch hinter­ fragt werden. Eine Kaiserschnittentbindung ohne klare Indikation führt zu einer erhöhten Rate an respiratorischen Anpassungsstörungen, zur neo­ natologischen Aufnahme der Kinder und damit verbunden zu einer Störung der Mutter­Kind­Bindung, sowie zu einer unnötigen finanziellen Belastung des Gesundheitssystems. Es ist zu wünschen, dass die Daten der Studie benutzt werden, um in der Diskussion zwischen Eltern, Geburtshelfern und Neo­ natologen immer den besten Geburtsweg für das Kind zu finden. / The rates of delivery by Cesarean section (CS) have been trending upwards in recent decades, perhaps leading to higher rates of dysfunction in respiratory adaptation in newborns. We present epidemiological data for pulmonary adaptation by mode of delivery for healthy late preterm and term infants born at a regional tertiary care center. The overall CS rate was 22 % with the lar­ gest proportion of these in late preterms (39%). This drops to 30% in infants born after 37 weeks gestation and to 11% for those born after 40 weeks. Infants needing respiratory support de­ creased significantly as gestational age increased: 88% at 34 weeks, 67% at 35 weeks, 28% at 36 weeks, 17% at 37 weeks and 8% at 40 weeks. The risk of respiratory morbidity following CS as compared to vaginal delivery (VD) was substan­ tially higher. 50% of infants born by CS needed respiratory support compared to only 12% fol­ lowing VD. 82% of all late preterm infants born by CS developed respiratory morbidity compared to 36 % following VD. Comparable data for infants born after 37 and 40 weeks gestation were 33% compared to 9 % and 26 % compared to 6 % respec­ tively. Late preterm infants born after 36 weeks gestation showed the most marked difference by mode of birth with 66 % needing respiratory sup­ port following CS as compared to only 9 % follow­ ing VD. Our data could be useful in counselling parents about risk associated with delivery by Cesarean section. A critical view should be taken of increasing CS rates worldwide because of a clear correlation in increased morbidity in infants, especially late preterm infants.

<p>Until 1976, women in Alabama could choose to make use of a midwife when they gave birth. In that year, the Alabama state legislature outlawed the practice. This dissertation explores the consequences of that decision as well as the efforts of contemporary non-nurse midwives, also known as Certified Professional Midwives (CPM’s), to re-establish the practice as an option available to birthing women in the state.</p><p> In order to address the consequences of outlawing non-nurse midwives in the state of Alabama a mixed methodology approach is applied. Two years of ethnographic data collection approached with a feminist and cultural anthropology lens, reveal that the lack of medical infrastructure within the state of Alabama prohibits the ability for CPM’s to practice safely. This is owed to historically grounded stigma in racism and classism. As a result, the current CPM community within the state of Alabama, along with their clientele, is predominantly white. This is reflected in the case studies within the dissertation as all the families and care providers, regardless of clinical expertise, are all white. An examination of cesarean rates via quantitative analysis supports the historical and ethnographic findings. Cesarean rates are highest within counties that have a low median household income, and a population that is predominately African American.</p><p> The dissertation features five case studies of women who gave birth attended by a CPM. By relating the experiences of the birthing mothers, a CPM, and certified medical professionals, the dissertation offers evidence of the kind of supplemental medical care and knowledge that can be offered by practitioners of midwifery. At the same time, while contemporary midwives such as the one featured here offer important medical service to their clients, they are not equipped to or knowledgeable about political work necessary to push for the re-legalization of midwifery. This dissertation thus sheds light on the challenges facing midwives who would prefer to work openly and legally in the state.</p><p> Ultimately what is revealed is the value of supplementary healthcare networks within the state. While care and birth services provided by CPM’s is not readily accessible to all, those giving birth in Alabama can find support within the current system through supplementary healthcare networks. These networks include doulas, lactation support groups, babywearing groups, etc. It is a piecemeal system to be sure, but it is a piecemeal system that is working diligently to unlearn biases, and support women and birthing families. However, it is important to understand that the supplemental networks cannot fully address the larger structural crisis that is a lack of infrastructure within the state’s medical system. Ideally, a system that utilizes Obstetricians, Nurse Midwives, and Non-nurse Midwives, all with mutual respect for their own expertise, would exist to provide quality care to women throughout the state.</p>

Thesis (M. A. (Nursing)) -- University of Limpopo, 2021 / Indigenous practices are performances that occur naturally in a region or a growing living environment. Most women believe in indigenous practices because of their cultures and social structure. In South Africa regardless of the availability and accessibility of maternal and child health services, 50% of women were found that they still consult traditional birth attendants as their first choice during pregnancy, labour, delivery, and postnatal care. The purpose of the study was to determine the indigenous practices of women during pregnancy, labour and puerperium amongst cultural groupings at selected hospitals in Limpopo Province, South Africa. A Convergent parallel mixed method design was used in the study to collect both qualitative and quantitative data at the same time. Non-probability purposive sampling was used to select 15 participants and Probability simple random sampling was used to select 125 women who were pregnant, in labour and puerperium using slovin’s formula. Data were collected through a semi-structured interview with a guide for qualitative strand and a self-administered structured questionnaire for quantitative srtand. Data were analysed qualitatively using tech’s open coding method and quantitatively using Statistical Package for the Social Sciences (SPSS) Version 25 with the assistance of the University of Limpopo’s Bio-statistician. The results of the study showed that most women use indigeneous practices for protection against witchcraft, fear of giving birth in caesarian section and many other reasons.THPs and church leaders are regarded as the most principled people in their community. Indigenous women are aware of the sign and symptoms during pregnancy, labour, and puerperium which may determine consultation to healthcare practitioners, but they choose THPs and church leaders. Most women still rely on their religious beliefs to assist during their labour. Pregnant women, those in labour and puerperium should be supported to practice their religious beliefs and practices. THPs and church leaders are obliged to teach their clients and ensure that they know the names and components of the traditional medicines and church rituals they use.The nursing education should include indigenous practices in the curriculum so, that healthcare practitioners know about the indigenous practices and can serve as assistance in the training and development of health practitioners who continuously care for women during pregnancy, labour, and puerperium and as a result, may reduce maternal and child morbidity and mortality in Limpopo Province, South Africa.

Trots att det i sjukvården betraktas som normalt att föda barn vaginalt väljer en del kvinnor att föda sina barn med hjälp av kejsarsnitt utan att det föreligger någon medicinsk indikation, varken för mor eller barn (elektivt sectio). Den medicinska vetenskapen visar att det både är säkrare och bättre i de flesta fall att föda vaginalt, men antalet elektiva kejsarsnitt ökar årligen. Kunskap om vad som driver kvinnor att önska elektivt kejsarsnitt kan öka möjligheten att minska kejsarsnitt som görs utan medicinsk indikation. Kunskapen är viktig för barnmorskor som kan hjälpa gravida kvinnor att i högre grad välja att föda sitt barn vaginalt då det inte föreligger indikation för kejsarsnitt. Syftet med arbetet var att beskriva kvinnors önskan om att föda sitt barn med hjälp av  elektivt kejsarsnitt utan att det föreligger någon medicinsk indikation för kejsarsnitt. En litteraturstudie har genomförts där sökningar efter artiklar gjorts i databaserna PubMed, CINAHL och APA PsychInfo. Till studiens resultat har 20 vetenskapliga artiklar, både kvalitativa och kvantitativa artiklar använts. De publicerade studierna är genomförda i  olika länder, en del i höginkomstländer och en del i medelinkomstländer enligt måttet bruttonationalprodukt per person och år, vilken beskriver ett lands produktion utifrån dess befolkningsutveckling (BNP per capita). Samtliga artiklar är publicerade mellan åren 2009-2019, och är etiskt godkända.  Kvinnors anledning att önska elektivt kejsarsnitt utan medicinsk indikation sammanfattas i detta arbete med två övergripande teman: Vaginal förlossning ett hot och Kejsarsnitt garanterar hälsa och trygghet. Kvinnornas rädsla för vaginal förlossning var en framträdande anledning till att önska kejsarsnitt. Rädslan hade sitt ursprung i egna eller andras negativa erfarenheter av vaginal förlossning. Rädslan grundades också i en oro för att kvinnans utseende och hennes relation skulle påverkas av en vaginal förlossning. Önskan om kejsarsnitt utan medicinsk indikation grundades i en tro om att ingreppet skulle garantera hälsa och trygghet för mor och barn, något som vaginal förlossning inte kunde erbjuda.  Den mest framträdande anledningen till att kvinnor önskade kejsarsnitt utan medicinsk indikation var en intensiv rädsla för en vaginal förlossning. Kvinnorna hade uppfattningen att ett kejsarsnitt skulle garantera säkerhet för mor och barn. Det kan inte uteslutas att önskan om elektivt kejsarsnitt kan bero på brist på kunskap.  Det finns ytterligare behov av forskning på ämnet, förslagsvis på interventioner från sjukvården som fokuserar på att utbilda födande kvinnor om vinsterna med vaginal förlossning.

Survey on maternal satisfaction in receiving spinal anesthesia for Cesarean section / A quantitative descriptive and cross-sectional study was conducted. The purpose of the study was to evaluate the maternal satisfaction after the experience of spinal anaesthesia for Caesarean section in one public hospital of Gauteng Province in South Africa. Data were collected by administering a questionnaire which included the demographic profile and satisfaction score in terms of perioperative elements to 82 women in their postoperative period. Analysis of data was performed by The Statistical Package for the Social Sciences (SPSS) version 13 and Excel 2010 was used for tabular and graphical illustrations. The findings revealed that the majority of women studied were black (95,1%), not married (73,2%) and unemployed (64,6%). The levels of maternal satisfaction in terms of intraoperative, postoperative and other perioperative elements were high, at 94,4%, 90,3% and 85,4% respectively. The lowest percentage (76,8%) was found for the maternal satisfaction about the preoperative explanation. The overall level of maternal satisfaction in this study was 86,7%. The majority of women (82,9%) would opt for spinal anaesthesia in future, while 6,1% would not accept it and 11,0% were not sure if they would opt for it or not. / Health Studies / M.A. (Public Health)

Survey on maternal satisfaction in receiving spinal anesthesia for Cesarean section / A quantitative descriptive and cross-sectional study was conducted. The purpose of the study was to evaluate the maternal satisfaction after the experience of spinal anaesthesia for Caesarean section in one public hospital of Gauteng Province in South Africa. Data were collected by administering a questionnaire which included the demographic profile and satisfaction score in terms of perioperative elements to 82 women in their postoperative period. Analysis of data was performed by The Statistical Package for the Social Sciences (SPSS) version 13 and Excel 2010 was used for tabular and graphical illustrations. The findings revealed that the majority of women studied were black (95,1%), not married (73,2%) and unemployed (64,6%). The levels of maternal satisfaction in terms of intraoperative, postoperative and other perioperative elements were high, at 94,4%, 90,3% and 85,4% respectively. The lowest percentage (76,8%) was found for the maternal satisfaction about the preoperative explanation. The overall level of maternal satisfaction in this study was 86,7%. The majority of women (82,9%) would opt for spinal anaesthesia in future, while 6,1% would not accept it and 11,0% were not sure if they would opt for it or not. / Health Studies / M. A. (Public Health)

Introdução - No Brasil mais da metade dos nascimentos ocorrem por meio de cesariana. As pacientes atendidas pelos planos e seguros saúde têm maior chance de passar por uma cirurgia. Embora seja um recurso que salva vidas, a cesárea sem indicação clínica acarreta riscos de saúde imediatos e de longo prazo. Objetivo - Analisar a regulação orientada à redução das cesarianas sem indicação clínica expedida pela Agência Nacional de Saúde Suplementar (ANS) através das Resoluções Normativas RN 368/2015, RN 387/2015 e RN 398/2016 da ANS. Esta tese é uma pesquisa qualitativa com base documental e entrevistas com representantes de entidades relevantes para a formulação de políticas de saúde materna e para a regulamentação dos planos e seguros de saúde. Resultados - Questões relacionadas à regulação das profissões, do modelo assistencial e da relação entre os agentes estão presentes nas causas do problema e não são suficientemente atendidas pelas resoluções normativas. Conclusão - A regulação da assistência obstétrica na saúde suplementar exige ação coordenada de agentes, instituições e entidades que atuam no mercado e na regulação dos planos de saúde, estabelecimentos hospitalares e profissões de saúde, de modo a promover o desenvolvimento de um plano de ação integrado / In Brazil, more then a half of childbirths are delivered by cesarean section. Healthcare insurance system\'s patients have a higher chance to experience surgery. Although an important resource to save lives, cesareans without clinical justifications may cause immediate and in long-term health risks. Objective - Analyse ANS obstetric regulation focused on reducing no clinical indicated cesareans as issued in RN 368/2015, RN 387/2015 and RN 398/2016. The present thesis is qualitative research based on documents and maternal health policies stakeholders interviews. Results - Professional rules and standards, the maternal health assistance model and the relationship between obstetric actors and entities are issues related to the problem causes and not efficiently developed and solved by ANS normative resolutions. Conclusion - Obstetric assistance regulation in Brazilian private health insurance and plans demands action by the Health Ministry coordinating all authorities responsible for healthcare plans, hospitals, and professionals in obstetric assistance as a means of developing an integrated solution plan