The thesis "Addictive Substances and their Possible effect on Child Development" deals with the effects of addictive drugs used by pregnant women on their child's development. Firstly, the text focuses on common valid definitions and characteristics of addictive substances. The addictive substances are divided into two categories - illegal and legal drugs. Initially, key groups of addictive substances are described and then their individual representatives are portrayed briefly. Furthermore, the thesis focuses on the period of prenatal development, which will serve as a comprehensive overview on the subject and will logically connect individual chapters. Another part of the thesis focuses on the characteristics of drug-addicted mothers, describes the specific traits of drug addicted pregnant women. Moreover, in this part pregnant women with dual diagnosis are described. Last but not least, the theoretical part of the thesis will explain complications that arise in infants right after childbirth, especially the fetal alcohol spectrum disorder (FASD), neonatal abstinence syndrome (NAS) or infection. There will also be discussed the long-term consequences such as disorders associated with attention, behavior disorders, learning or congenital malformation. This work aims to find out whether children of...

Le Cambodge est l'un des neuf pays au monde à avoir atteint l'OMD 5 des Nations Unies, c'est-à-dire à avoir diminué de trois quarts le taux de mortalité maternelle au niveau national entre 1990 et 2015. Ce taux est ainsi passé de 1020 à 161 décès maternels pour 100 000 naissances au cours de ces 25 années. Ce succès est le résultat de politiques publiques volontaristes : une politique de planification familiale, la mise en place de systèmes de financements de la santé, la formation puis le déploiement de milliers de sages-femmes sur le territoire. Cette réussite s'explique également par une mutation sociologique de premier plan : l'accouchement, qui était historiquement un événement avant tout social et qui se déroulait dans l'intimité de la maison, est devenu un événement public pour la femme et sa famille. Alors qu'en 2000 moins de 10% des femmes accouchaient dans une structure médicalisée, elles étaient plus de 80% dans cette situation en 2014, traduisant ainsi la biomédicalisation massive et soudaine de l'accouchement dans tout le pays. Cette recherche sociodémographique remet en question la vision idéalisée des Nations Unies concernant la santé maternelle au Cambodge en rendant visibles et en observant les pratiques obstétricales « par le bas » à partir d'une enquête empirique sur plusieurs terrains à Phnom Penh et en Kandal (milieu rural). La méthodologie développée conjugue une observation participante, à des entretiens semi-directifs auprès de soignants et de non soignants (hommes et femmes), des questionnaires auprès de femmes enceintes puis accouchées (cohorte), ainsi qu'une collecte de données médicales dans quatre maternités de Phnom Penh. Les résultats montrent que certains hôpitaux et cliniques pratiquent des épisiotomies systématiques, ce qui est contraire aux recommandations internationales, et que le taux de césariennes dans la capitale a presque triplé en quinze ans, dépassant depuis le début des années 2000 le seuil de 10% recommandé par l'OMS. Enfin, une pratique répandue de périnéorraphies visant à resserrer fortement le vagin de femmes jeunes et en bonne santé après des accouchements par voie basse, sans indication médicale, est courante dans la capitale. Ces pratiques obstétricales, historiquement construites, vont alors fréquemment être détournées de leur usage médical pour répondre à une demande sociale. Le corps des femmes a été appréhendé dans cette recherche comme un corps social et politique, révélateur des rapports sociaux, sur lequel se jouent de nombreux enjeux de pouvoirs. La thèse a révélé que ces trois pratiques obstétricales faisaient système en se renforçant les unes les autres. A l'intersection entre corps, genre et biomédecine, la recherche a montré que ces différentes pratiques obstétricales pouvaient être conçues comme des instruments de domination. Le genre, tel qu'il est pensé dans la société, va contribuer à fabriquer un sexe féminin, mais aussi à construire un corps féminin de façon plus générale. Mais la thèse a dévoilé également que certaines de ces pratiques vont être saisies par les femmes, afin d'accroître leur attractivité sexuelle, leur permettant de renégocier les rapports de genre, et de maintenir l'harmonie et la stabilité du couple. / Cambodia is one of the nine countries worldwide to have reached the United Nations - MDG 5. A reflection of this achievement is a 75% drop in the national maternal mortality ratio from 1020 to 161 deaths for 100 000 live births between 1990 and 2015. This success is the result of voluntary public policies i.e. a family planning policy; the set-up of health care financing systems; and the training of thousands of midwives across the country. A deep sociological transformation can also help to explain this success. While childbirth in Cambodia used to be a private event, which took place at home, it has now become a public event for women and their families. In 2000, less than 10% of women were giving birth in a medicalized structure. By 2014, this number rose to over 80%, showing the sudden and massive biomedicalization of childbirth across the country. This socio-demographic research challenges the idealized vision of the United Nations regarding maternal health in Cambodia by showing and observing obstetrical practices on the ground, from an empirical study led in several setups in Phnom Penh and in Kandal province (rural sector). This mixed method research draws from participant observation, semi-structured interviews with healthcare professionals and patients (men and women), questionnaires with pregnant women (pre- and post- childbirth), as well as examination of medical records from four Phnom Penh maternity wards. The results show that episiotomies are systematically performed in some hospitals and clinics, in contradiction with international recommendations. Furthermore, the number of caesarean sections in Phnom Penh has almost tripled in fifteen years, and since the beginning of the 2000s it is above the 10% threshold recommended by the WHO. Finally, in the capital city, a common practice is observed: perineorraphy, which aims at tightening the vagina of young and healthy women shortly after a vaginal delivery without any medical indication. These three obstetrical practices have historical roots and are now frequently used outside of their medical purpose, as a response to a rising social demand. In this research, women' body has been considered as a social and political object that reveals social relationships, where many power negotiations occur. The thesis shows that these three obstetrical practices are interconnected and form a system. At the intersection between body, gender and biomedicine, these different obstetrical practices can be understood as tool of domination that seeks to shape the female body according to social expectations. In this way, the perception of gender in a society shapes the female body, and more precisely, the female sexual organs. Nevertheless, some of these practices are nowadays consciously chosen by women to increase their erotic capital, in an attempt to renegotiate gender relationships and preserve marital harmony.

“Förlossningsvården behöver i ännu större utsträckning än idag även bestå av känslomässigt stöd och trygghetsskapande omvårdnad.” Citatet ovan finns i boken Trygg förlossning (2017) och är vägledande i mitt examensarbete. Idag är det säkert att föda i Sverige och mödra- och barnadödligheten är bland den lägsta i världen. Trots detta lider många av förlossningsrädsla. Studier, bland annat från Socialstyrelsen, visar att platt ryggläge är den förlossningsställning som är mest ofördelaktig, för både föderska och barn. När föderskan rör på sig och om hen dessutom har en upprätt förlossningsställning kan den upplevda smärtan minska, eftersom utsöndringen av endorfiner ökar. Trots detta har de flesta en liggande ställning under förlossningen. Det finns uppenbarligen glapp mellan den medicinska kunskapen och förlossningspraktiken. Därför undersökte jag befintliga hjälpmedel och produkter inom förlossningsvården, som dessutom inte är utvecklade för ett förlossningsarbete, utan inlån från andra sjukvårdsavdelningar. Jag har utvecklat ett designförslag som ska uppmana till upprätta förlossningsställningar för en tryggare förlossning. / “Maternity care needs to be comprised of emotional support and reassuring nursing practices, even more so than it does today.” This quotation, from the book Trygg förlossning (2017), has been a big influence in my degree project. Today, it is regarded as safe to give birth in Sweden with maternal and child mortality being amongst the lowest in the world. Despite this, many suffer from a fear of childbirth. Studies from Socialstyrelsen, amongst others, show that a back-lying position during childbirth is disadvantageous for the mother and child. If the mother moves and has an upright position, the perceived pain may decrease as the release of endorphins increases. Despite this, most people continue use a back-lying position during childbirth. There is obviously a gap between medical knowledge and childbirth practice. Therefore, I have investigated existing aids in maternity care, many of which are not developed for childbirth, but borrowed from other healthcare departments. I have developed a design proposal that will encourage an upright childbirth position for a safer delivery.

Introdução: Informação qualificada no período pré-natal pode contribuir para o conhecimento das mulheres sobre práticas realizadas no parto, o que pode colaborar para melhores resultados maternos e perinatais, incluindo a integridade perineal. Objetivo: Avaliar se o programa de educação em saúde e apoio às mulheres (PRENACEL) contribui para a redução das lesões no períneo durante o parto de mulheres atendidas na rede pública de saúde de Ribeirão Preto, sudeste brasileiro. Métodos: Análise secundária do estudo PRENACEL, um ensaio aleatorizado por conglomerados implementado na cidade Ribeirão Preto. Participaram do estudo todas as mulheres com 18 anos ou mais que iniciaram acompanhamento pré-natal de risco habitual antes da 20ª semana gestacional, em uma das 20 unidades de saúde selecionadas. Para avaliar o desfecho perineal foram incluídas as mulheres que pariram por via vaginal em uma das quatro maternidades que oferecem atendimento público. A intervenção PRENACEL correspondeu ao oferecimento, via telefonia celular, de um pacote de mensagens curtas de texto (SMS) contendo informações essenciais ao acompanhamento do pré- natal e parto de baixo risco. Este programa de educação em saúde foi oferecido como um complemento ao cuidado pré-natal ofertado pelo Sistema Único de Saúde. A aleatorização dos conglomerados foi realizada em duas etapas através de sorteios aleatórios simples. A primeira etapa correspondeu à formação de dois grupos que, na segunda etapa, foram alocados em grupos intervenção ou controle. No grupo intervenção foi utilizada inscrição passiva para incluir as mulheres no programa. As participantes do grupo controle foram incluídas no momento da coleta de dados nas maternidades. Não foi adotada estratégia de mascaramento. O risco relativo e seu intervalo de confiança foram calculados, considerando um nível de significância de 5% para os testes. Resultados: Dez unidades de saúde participaram do grupo intervenção e dez do grupo controle. Para avaliar o desfecho principal foram consideradas 704 mulheres. A integridade perineal foi relatada por aproximadamente 30% das mulheres e a episiotomia foi um procedimento utilizado em aproximadamente 15% dos partos. Não foi encontrada diferença significativa relacionada ao desfecho perineal entre as participantes dos grupos. Conclusão: O uso de SMS, como uma proposta de educação em saúde oferecida no pré-natal, não foi associada à redução de traumas perineais durante o parto, apesar dos seus benefícios comprovados na atenção pré-natal. O estudo PRENACEL está catalogado no Registro Brasileiro de Ensaios Clínicos (ReBEC, RBR-54zf73). / Introduction: Qualified information in the antenatal period can contribute to women\'s knowledge about practices performed during childbirth, which may to improve maternal and perinatal outcomes, including perineal integrity. Objective: To evaluate whether the health education and support programme for women (PRENACEL) contributes to the reduction of perineal trauma of women attended in the public health system of Ribeirão Preto, Southeastern Brazil. Methods: Secondary analysis of the PRENACEL study, a cluster randomized trial implemented in the city of Ribeirão Preto. All women aged 18 years or more who started antenatal care at usual risk before the 20th gestational week, in one of the 20 selected health units participated in the study. To evaluate the perineal outcome, women who had a vaginal birth in one of the four participating maternity hospitals were included. The PRENACEL intervention corresponded to the offer, by mobile phones, of a package of short text messages (SMS) containing essential information about low-risk pregnancy and childbirth and related care. This health education programme was a complement to standard antenatal care offered in public health system (Sistema Único de Saúde). Cluster randomization was performed in two steps through simple random sweepstake. The first stage corresponded to the formation of two groups that, in the second stage, were allocated in intervention or control group. In the intervention group, passive enrollment was used to include women in the programme. Participants in the control group were included at the moment of data collection in the maternity hospitals. No masking strategy was adopted. The relative risk and the confidence interval were calculated, considering a level of significance of 5% for the tests. Results: Ten health units participated in the intervention group and ten in the control group. To evaluate the main outcome, 704 women were considered. Perineal integrity was reported by approximately 30% of women and episiotomy was a procedure used in approximately 15% of deliveries. No significant difference was found related to the perineal outcome between the participants of the groups. Conclusion: The use of SMS, as a proposed health education offered in antenatal care, was not associated with the reduction of perineal traumas during childbirth, despite its benefits in antenatal care. The PRENACEL study is included in the Brazilian Registry of Clinical Trials (ReBEC, RBR-54zf73).

Centros de parto normal (CPN) têm como finalidade a assistência à mulher no parto normal sem complicações. Podem ter localização intra-hospitalar, peri-hospitalar ou extra-hospitalar (autônomo). Os objetivos foram: identificar os fatores de risco para transferência materna de um CPN para o hospital; elaborar um modelo de risco para transferência intraparto baseado nos fatores identificados e analisar os desfechos maternos e neonatais das transferências. Estudo do tipo caso-controle, com coleta de dados retrospectiva, em um centro de parto extra-hospitalar (Casa do Parto de Sapopemba - CPS) e no Hospital Estadual de Vila Alpina (HEVA), na cidade de São Paulo. Os casos foram todas as mulheres transferidas da CPS para o HEVA, de março de 2002 a dezembro de 2009. Os controles foram mulheres não transferidas que deram à luz na CPS no mesmo período, selecionadas aleatoriamente, sendo quatro controles para cada caso. Os fatores de risco para transferências maternas intraparto foram analisados primeiro pelo teste Qui-Quadrado. Na análise múltipla, incluíram-se as variáveis com p<0,20. Elaborou-se a seguir o modelo de regressão logística múltiplo pelo processo stepwise forward selection; variáveis com p<0,05 foram fatores independentes associados às transferências maternas. Transferências maternas pós-parto tiveram análise descritiva, em razão do reduzido número (13). Variáveis identificadas como fatores de risco independentes para transferência intraparto: nuliparidade (OR 5,6; IC 95% 2,9-10,9), idade materna 35 anos (OR 5,0; IC 95% 2,0-12,7), não ter companheiro (OR 2,7; IC 95% 1,4-5,1), ser admitida na CPS com cervicodilatação 3 cm (OR 2,0; IC 95% 1,1-3,4), realizar 5-12 consultas na CPS (OR 3,3; IC 95% 1,6-6,7) e peso do RN de 4.000-4.600 g (OR 3,5; IC 95% 1,1-11,2). Adequação entre altura uterina e idade gestacional baixa (OR 0,3; IC 95% 0,2-0,6) foi fator de proteção para a transferência. Apresentou-se modelo de risco para transferência intraparto, com probabilidade de transferência estimada de acordo com as variáveis identificadas como fatores de risco. Nos desfechos das transferências maternas: taxa de transferência intraparto: 4,1%; pós-parto: 0,5%; não houve óbitos entre as mulheres que deram à luz na CPS ou no HEVA e entre os RN da CPS; houve óbito de dois RN do HEVA (taxa de mortalidade perinatal: 0,73/1.000 nascidos vivos). Causas de transferência intraparto: maternas (57,6% falha no progresso do trabalho de parto); fetais (28% líquido amniótico meconial e traçado cardiotocográfico alterado); outras (14,4%); via de parto das mulheres transferidas: 49,5% parto normal; 44,1% cesariana; 4,5% fórceps e 1,8% vácuo extrator. Entre os RN de mães transferidas: 25,2% e 4,5% tiveram Apgar <7 nos 1º e 5º minutos, respectivamente; unidade de internação: 10,8% na UTI neonatal, 9,0% unidade de cuidados intermediários, 0,9% setor de observação e 79,3% alojamento conjunto. Causas de transferência no pós-parto: retenção placentária (38,5%); outros problemas (30,8%); sangramento vaginal aumentado (15,4%) e febre materna (15,4%); 46,1% necessitaram de curetagem e 38,4% de transfusão sanguínea. Concluiu-se que identificar os fatores de risco para transferência materna contribui para refinar os critérios de admissão de mulheres atendidas em CPN, ao auxiliar na identificação de casos que podem resultar em complicações. / Birth centers (BC) aim to provide care to women in normal birth without complications. They may have in-hospital, alongside or freestanding (autonomous) locations. The objectives were to identify risk factors for maternal transfer from a BC to the hospital, to develop a risk model for intrapartum transfers using the identified factors and to analyze the maternal and neonatal outcomes of transfers. It was a case-control study, with retrospective data collection in a freestanding birth center (Sapopemba Birth Center - SBP) and the State Hospital Vila Alpina (HEVA), in São Paulo. The cases were all women transferred from SBP to HEVA, from March 2002 to December 2009. The controls were not transferred women who gave birth in CPS in the same period, randomly selected, four controls for each case. Risk factors for maternal intrapartum transfers were primarily analized by the Chi-square test. In the multivariate analysis, the variables with p <0.20 were included. The multiple logistic regression model was build by stepwise forward selection process; variables with p <0.05 were factors independently associated with maternal transfers. Postpartum maternal transfers had descriptive analysis, due to the small number (13). Variables identified as independent risk factors for intrapartum transfer: nulliparity (OR 5.6, 95% CI 2.9 to 10.9), maternal age 35 years (OR 5.0, 95% CI 2.0 to 12. 7), no partner (OR 2.7, 95% CI 1.4 to 5.1), admission to the CPS with cervical dilation 3 cm (OR 2.0, 95% CI 1.1-3.4), number of appointments on SBC 5-12 CPS (OR 3.3, 95% CI 1.6 to 6.7) and newborn weight 4000-4600 g (OR 3.5, 95% CI 1.1 to 11.2). The low result for fitting uterine height and gestational age (OR 0.3, 95% CI 0.2-0.6) was a protective factor for transfer. A model of risk for intrapartum transfer was presented, to estimate the probability of transfer according to the variables identified as risk factors. The outcomes of maternal transfers were: intrapartum transfer rate: 4.1%; postpartum transfer rate: 0.5%; there were no deaths among women who gave birth in SBC or HEVA or between the newborns who were born on SBC; there were two deaths of newborns born in HEVA (perinatal mortality rate: 0.73 / 1,000 live births). Causes of intrapartum transfer: maternal (57.6% failure to progress in labor), fetal (28% meconium stained amniotic fluid and cardiotocographic trace changes), others (14.4%); mode of delivery of the transferred women: 49, 5% normal delivery, cesarean section 44.1%, 4.5% forceps and 1.8% vacuum extractor. Among infants of mothers transferred: 25.2% and 4.5% had Apgar score <7 at 1st and 5th minutes, respectively; unit admission of newborns: 10.8% in the neonatal intensive care unity, 9.0% intermediate care unit, 0, 9% observation rooms and 79.3% rooming-in unity. Causes of postpartum transfer: retained placenta (38.5%), other problems (30.8%), increased vaginal bleeding (15.4%) and maternal fever (15.4%); 46.1% required curettage and 38.4% blood transfusion. It was concluded that identifying risk factors for maternal transfer contributes to refine the criteria for admission of women attending BC, as it can be useful in identifying cases that may lead to complications.

University of Macau / Faculty of Arts and Humanities. / Department of Chinese

Exclusive breastfeeding for at least 6 months provides numerous infant and maternal benefits. Yet mothers with risk factors, such as lower education, lower socioeconomic status, younger maternal age, planned cesarean birth, and anxiety and depression, are more likely to stop breastfeeding in the early postpartum period. Few studies have focused on perinatal depression as a risk factor for breastfeeding cessation. To tailor effective interventions, nurses must first understand the lived experience of breastfeeding for mothers at risk for perinatal depression. A descriptive phenomenological study was conducted to elucidate the experience of breastfeeding for mothers with perinatal depression. The study was grounded in Swanson’s middle-range theory of caring. After university Institutional Review Board approval, a purposive sample of 10 women was recruited from various organizations. Participants completed a demographic questionnaire and the Edinburgh Postnatal Depression Scale, and semistructured, audiorecorded face-to-face or telephonic interviews were conducted. The researcher transcribed the data which was transformed into constituents of the mothers’ lived experience by utilizing Giorgi’s descriptive phenomenological method. Five constituents emerged: choosing selflessness, harboring inadequacy, deliberate persevering, discerning meaning, and cherishing intimacy. The constituents embodied the essence of the mothers’ thoughts and feelings connected to breastfeeding. By daily choosing selflessness, mothers consciously decided to breastfeed despite physical or psychological struggles. They often were harboring inadequacy due to ongoing struggles which led to incessant thoughts of maternal incompetence. Yet they successfully breastfed for at least 2 weeks after birth by deliberate persevering. Through breastfeeding, they were discerning meaning to realize their value as mothers. Finally, they reveled in purposeful moments of togetherness with their babies through cherishing intimacy. The study findings inform recommendations for nursing education, practice, research, and policy. Nursing education must include basic breastfeeding and perinatal mental health knowledge in prelicensure curricula and up-to-date lactation management techniques and perinatal mental health awareness training in continuing education. Practicing maternal-child nurses must provide education and support to mothers about advantages and difficulties of breastfeeding throughout the perinatal period. Future research includes determination of support needs for women with perinatal depression with subsequent development and evaluation of therapeutic actions to promote breastfeeding success. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2017. / FAU Electronic Theses and Dissertations Collection

Introdução: Informação qualificada no período pré-natal pode contribuir para o conhecimento das mulheres sobre práticas realizadas no parto, o que pode colaborar para melhores resultados maternos e perinatais, incluindo a integridade perineal. Objetivo: Avaliar se o programa de educação em saúde e apoio às mulheres (PRENACEL) contribui para a redução das lesões no períneo durante o parto de mulheres atendidas na rede pública de saúde de Ribeirão Preto, sudeste brasileiro. Métodos: Análise secundária do estudo PRENACEL, um ensaio aleatorizado por conglomerados implementado na cidade Ribeirão Preto. Participaram do estudo todas as mulheres com 18 anos ou mais que iniciaram acompanhamento pré-natal de risco habitual antes da 20ª semana gestacional, em uma das 20 unidades de saúde selecionadas. Para avaliar o desfecho perineal foram incluídas as mulheres que pariram por via vaginal em uma das quatro maternidades que oferecem atendimento público. A intervenção PRENACEL correspondeu ao oferecimento, via telefonia celular, de um pacote de mensagens curtas de texto (SMS) contendo informações essenciais ao acompanhamento do pré- natal e parto de baixo risco. Este programa de educação em saúde foi oferecido como um complemento ao cuidado pré-natal ofertado pelo Sistema Único de Saúde. A aleatorização dos conglomerados foi realizada em duas etapas através de sorteios aleatórios simples. A primeira etapa correspondeu à formação de dois grupos que, na segunda etapa, foram alocados em grupos intervenção ou controle. No grupo intervenção foi utilizada inscrição passiva para incluir as mulheres no programa. As participantes do grupo controle foram incluídas no momento da coleta de dados nas maternidades. Não foi adotada estratégia de mascaramento. O risco relativo e seu intervalo de confiança foram calculados, considerando um nível de significância de 5% para os testes. Resultados: Dez unidades de saúde participaram do grupo intervenção e dez do grupo controle. Para avaliar o desfecho principal foram consideradas 704 mulheres. A integridade perineal foi relatada por aproximadamente 30% das mulheres e a episiotomia foi um procedimento utilizado em aproximadamente 15% dos partos. Não foi encontrada diferença significativa relacionada ao desfecho perineal entre as participantes dos grupos. Conclusão: O uso de SMS, como uma proposta de educação em saúde oferecida no pré-natal, não foi associada à redução de traumas perineais durante o parto, apesar dos seus benefícios comprovados na atenção pré-natal. O estudo PRENACEL está catalogado no Registro Brasileiro de Ensaios Clínicos (ReBEC, RBR-54zf73). / Introduction: Qualified information in the antenatal period can contribute to women\'s knowledge about practices performed during childbirth, which may to improve maternal and perinatal outcomes, including perineal integrity. Objective: To evaluate whether the health education and support programme for women (PRENACEL) contributes to the reduction of perineal trauma of women attended in the public health system of Ribeirão Preto, Southeastern Brazil. Methods: Secondary analysis of the PRENACEL study, a cluster randomized trial implemented in the city of Ribeirão Preto. All women aged 18 years or more who started antenatal care at usual risk before the 20th gestational week, in one of the 20 selected health units participated in the study. To evaluate the perineal outcome, women who had a vaginal birth in one of the four participating maternity hospitals were included. The PRENACEL intervention corresponded to the offer, by mobile phones, of a package of short text messages (SMS) containing essential information about low-risk pregnancy and childbirth and related care. This health education programme was a complement to standard antenatal care offered in public health system (Sistema Único de Saúde). Cluster randomization was performed in two steps through simple random sweepstake. The first stage corresponded to the formation of two groups that, in the second stage, were allocated in intervention or control group. In the intervention group, passive enrollment was used to include women in the programme. Participants in the control group were included at the moment of data collection in the maternity hospitals. No masking strategy was adopted. The relative risk and the confidence interval were calculated, considering a level of significance of 5% for the tests. Results: Ten health units participated in the intervention group and ten in the control group. To evaluate the main outcome, 704 women were considered. Perineal integrity was reported by approximately 30% of women and episiotomy was a procedure used in approximately 15% of deliveries. No significant difference was found related to the perineal outcome between the participants of the groups. Conclusion: The use of SMS, as a proposed health education offered in antenatal care, was not associated with the reduction of perineal traumas during childbirth, despite its benefits in antenatal care. The PRENACEL study is included in the Brazilian Registry of Clinical Trials (ReBEC, RBR-54zf73).

Este estudo, de natureza qualitativa, buscou apreender o sentido da arte de partejar para cinco parteiras tradicionais que atuaram, ou ainda atuam, no distrito de Regência, ES, como a única possibilidade de assistência ao parto na região. Ao longo deste trabalho, buscou-se uma fundamentação teórica sobre o tema e que permitiu reconhecer, na história da parturição, até meados do século XX, que foram as parteiras quem sempre fizeram o parto e auxiliaram as mulheres em doenças especificamente femininas. Mesmo nos dias atuais, em regiões afastadas dos grandes centros e em zonas rurais, as parteiras continuam constituindo a única fonte da população para resolver seus problemas de saúde, especialmente na assistência do parto, realidade também constatada no presente estudo.A entrevista semi-estruturada foi utilizada como instrumento para coleta de dados. Histórias de vida oral temática foram obtidas, mediante os relatos das entrevistadas, os quais foram gravados em fitas cassete e transcritos, para desenvolvimento da análise de conteúdo. Todas as parteiras entrevistadas são pessoas simples, com nenhum ou pouco estudo e que, apesar de viverem com poucos recursos, orgulham-se de nada cobrarem pelos serviços prestados, aceitando somente alguns presentes, muitas dependendo da ajuda dos filhos para sua sobrevivência. A análise da trajetória dos sujeitos da população de estudo revelou que o ofício de parteira tem o sentido de missão de vida, decorrente do dom de que são portadores, dom este descoberto diante do inesperado, de uma demanda concreta, e que se desenvolve pela própria experiência, a serviço da coletividade, muitas vezes, sem nenhuma estrutura de apoio do sistema oficial de saúde. Diante dessa constatação, fica evidente a necessidade de uma articulação efetiva entre as parteiras e o sistema de saúde da região, visando a uma assistência de melhor qualidade à população local, respeitados os princípios do SUS. / This qualitative study tried to catch the art of midwife practice of five ladies who have been exercising it in Regência, ES, as the only possibility of helping pregnant women at baby delivering in that region. During this essay, a theorical embasement was searched, which allowed to recognize the role of midwives, until mid 20th Century, as the only assistance for delivery as well as specifically feminine diseases. Even nowadays, in the countryside or faraway counties, midwives still are the only resource to turn to in health cases or baby delivery assistance, as verified in the present study. The half-structured interview was used as a data collection tool. Verbal thematic stories of lives where obtained, by means of reported stories of the interviewed, which where recorded in cassette tapes and transcripts, for content analysis development. All the interviewed midwives are from humble background, with little or none education who, despite living short of money, feel proud of not charging anything for the job. Most depend on their own children’s help to survive financially. Sometimes, they accept gifts in return but never money. The analysis of the subjects of this study reveals that the craft of midwives is faced as a mission in life, due to the natural gift they were given, which was discovered in an unexpected situation, or a real demand and, eventually, was developed by experience itself, as a service to the community, most of the times, with no structural support on behalf of the official Healthy system. Aware of this, it becomes more and more evident that there is need for effective engagement among midwives and the Regional health system, having in mind a qualified and better assistance to the local population, respecting the principles of SUS (Unified Health System).

Esta tese é o resultado de um estudo que pretendeu colocar em análise as estratégias do Programa Trabalhando com Parteiras Tradicionais e suas repercussões para um grupo de mulheres Krahô. A entrega do kit da parteira é um ícone do programa, uma presunção de que uma nova prática alinhada ao saber hegemônico terá início a partir de então. Nesse sentido, o estudo buscou analisar como as mulheres Krahô compreendem sua participação no programa e se apropriam e ressignificam os objetos do kit da parteira no contexto do parto domiciliar. A tese está estruturada em formato de quatro artigos, cada qual representando momentos distintos do estudo. Os dois primeiros são anteriores ao trabalho de campo e frutos de questionamentos vivenciados tanto na etapa de desenvolvimento do programa de parteiras quanto no percurso para aprovação nos comitês de ética. Os dois últimos são provenientes do trabalho de campo e contaram com a antropologia e o método etnográfico como suportes principais. Os trâmites para aprovação ética do estudo mostraram-se tortuosos e excessivamente burocráticos, a experiência indicou que é nos processos singulares e subjetivos que as posturas éticas ou não éticas podem ser experimentadas, a despeito do que possa estar registrado em formulários. Os resultados apontam um descompasso entre o discurso e a prática de valorização do saber tradicional e um nítido viés etnocentrado do programa ao ofertar instrumentos fora da lógica de cuidado das mulheres e pressupor um impacto nos indicadores de saúde a partir da aquisição do saber hegemônico. Os objetos foram apropriados e ressignificados no cotidiano das aldeias, mas não encontraram um lugar claro no contexto do parto domiciliar. Traços de violência simbólica emergiram e a categorização das mulheres Krahô como “parteiras” trouxe impactos e prejuízos na relação social de algumas mulheres. Sugere-se o resgate da dimensão intercultural na formulação e execução de políticas públicas direcionadas a esse público como um caminho profícuo, sob pena de se engendrar num ciclo alienado e alienante, desperdiçando recursos e adiando discussões importantes como o fortalecimento da rede de atenção à saúde no entorno das mulheres indígenas. / This thesis is the result of a study that sought to analyze the strategies of the Working with Traditional Midwives Program and its repercussions on a group of Krahô women. Midwife kit delivery is an icon of the program, a presumption that a new practice aligned with hegemonic knowledge will begin there after. Thus, the study sought to analyze how Krahô women view their participation in the program and take ownership of and resignify midwife kit objects in the home birth context. The thesis is structured in four papers, each representing different moments of the study. The first two occurred prior to fieldwork and result from issues raised during the development stage of the midwifery program and throughout the process of approval by ethics committees.The last two stem from fieldwork and were mainly supported by anthropology and the ethnographic method. The procedures for the ethical approval of the study were tortuous and overly bureaucratic. Experience has indicated that ethical or unethical stances can be experienced in the singular and subjective processes, regardless of what may be recorded in forms. Results point to a mismatch between the discourse and the practice of recognizing traditional knowledge and a clear ethnocentric bias of the program when offering tools outside the rationale of women care and assuming an impact on health indicators from the acquisition of hegemonic knowledge. The objects were appropriated and resignified in the daily life of villages, but they failed to find a clear place in the context of home birth. Symbolic violence traits emerged and the categorization of Krahô women as "midwives" brought impacts and losses in the social relationship of some women. We suggest reviving the intercultural realm in the formulation and implementation of public policies directed to this public as a profitable pathway, under penalty of engendering an alienated and alienating cycle, wasting resources and delaying important discussions such as the strengthening of the health care network around indigenous women.