Submitted by Gilvan Almeida (gilvan.almeida@icict.fiocruz.br) on 2016-09-26T14:06:06Z No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 144.pdf: 15879405 bytes, checksum: 86f9a988f5f155eb65a3591a1e7766b3 (MD5) / Approved for entry into archive by Barata Manoel (msbarata@coc.fiocruz.br) on 2016-10-20T12:39:36Z (GMT) No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 144.pdf: 15879405 bytes, checksum: 86f9a988f5f155eb65a3591a1e7766b3 (MD5) / Made available in DSpace on 2016-10-20T12:39:36Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 144.pdf: 15879405 bytes, checksum: 86f9a988f5f155eb65a3591a1e7766b3 (MD5) Previous issue date: 2010 / Fundação Oswaldo Cruz. Casa de Oswaldo Cruz. Rio de Janeiro, RJ, Brasil. / A profissionalização do trabalho das parteiras foi um movimento de abrangência internacional. Desenvolvido em maior escala no decorrer do século XIX, a escolarização de parteiras esteve relacionada à consolidação da medicina científica e de reformas sociais voltadas para a saúde e bem-estar da população, com atenção especial para o grupo materno-infantil. No Brasil, a partir dos anos 1920, à medida que a propagação do sanitarismo e a institucionalização da saúde pública ganhavam espaço nos projetos de reformas sociais, podemos observar a emergência de novas profissões sanitárias femininas e o início de uma crise na formação e identidade profissional do grupo das parteiras diplomadas, desde 1832, através das Faculdades de Medicina. Ao mesmo tempo, o treinamento higiênico e as medidas de controle da atuação das parteiras sem certificação, as curiosas, foram assumidas, a partir dos anos 1930, como prioridade pelas autoridades sanitárias. O processo de formação ou treinamento, o modo como os dois grupos de parteiras esteve incluído institucionalmente nas políticas de saúde pública deste período e as suas interelações com os novos grupos de profissionais sanitárias femininas se constituíram na abordagem central desse estudo. A consolidação da enfermagem como uma profissão sanitária importante e especializada contribuiu para o encerramento da formação das obstetrizes no início dos anos 1970, ao passo que as parteiras curiosas permaneciam nos projetos de controle e treinamento dos órgãos sanitários. / The professionalization of midwives was a movement of international scope. Developed on a larger scale during the nineteenth century, the education of midwives was related to the consolidation of scientific medicine and social reforms aimed at health and welfare of the population, with special attention to maternal and child health. In Brazil, from 1920, to the extent that the spread of the sanitarism and the institutionalization of public health took the space in projects of social reform, we can observe the emergence of new women's health professions and the beginning of a crisis in training and professional identity of the group of midwives, who graduated from 1832 through the Faculties of Medicine. At the same time, training public health actions and measures to control the performance of midwifery without certification, the curious, have assumed, from the 1930s, as a priority by health authorities. The process of education or training, how the two groups of midwives was institutionally included in public health policies of this period and their interrelationships with the new groups of female health professionals were formed in the central approach of this study. The consolidation of the nursing as an important and specialized health profession contributed to the closure of the training of midwives in the early 1970s, while popular midwives remained in control projects and training of health authorities.

Maternal mortality is a global health concern but inequalities in utilization of maternal health care are not clearly understood. Severe morbidity (near-miss) is receiving increased attention due to methodological difficulties in maternal mortality studies. The present thesis seeks to increase understanding of factors that impede utilization of emergency obstetric care (EmOC) in Bolivia and Guatemala. Studies I and IV employed qualitative interviews to explore the role of traditional birth attendants (TBAs) and the care-seeking behaviour of women who arrived at hospital with a near-miss complication. Studies II–III documented maternal mortality and near-miss morbidity at the hospital level and investigated the influence of socio-demographic factors and antenatal care (ANC) on near-miss upon arrival. The studies identified unfamiliarity with EmOC among TBAs and a lack of collaboration with formal care providers. A perception of being dissociated from the health care system and a mistrust of health care providers was common among near-miss women from disadvantaged social backgrounds. In the Bolivian setting, 187 maternal deaths per 100,000 live births and 50 cases of near-miss per 1000 were recorded. Causes of near-miss differed from those of maternal deaths. Most women with near-miss arrived at hospital in critical condition: severe preeclampsia, complications after childbirth at home and abortions were mostly encountered among them. Lack of ANC, low education, and rural residence were interactively associated with near-miss. ANC reduced socio-demographic differentials for near-miss. Complementing maternal mortality reviews with data on near-miss morbidity increases the understanding of priority needs and quality of maternal health care. Additionally, focusing on near-miss upon arrival was found useful in exploring pre-hospital barriers to EmOC. The findings identified subgroups of women who seemed especially vulnerable to pre-hospital barriers. They also underscored the need for initiatives to reduce the effect of social marginalization and to acknowledge the influential role of formal and informal care providers on the utilization of EmOC. / La mortalidad materna es un tema de inquietud global, sin embargo la comprensión de las desigualdades en la utilización de los servicios de salud materna es limitada. La morbilidad obstétrica severa (near-miss) está recibiendo creciente atención, producto de problemas metodológicos en los estudios de mortalidad materna. El objetivo de la presente tesis es aumentar la comprensión de factores que impiden la utilización de la atención obstétrica de emergencia en Bolivia y Guatemala. Los estudios I y IV usaron metodologías cualitativas en un esfuerzo por explorar el rol de las parteras tradicionales y las estrategias de las mujeres que arriban a los hospitales con una morbilidad obstétrica severa. Los estudios II–III documentaron la mortalidad materna y la morbilidad obstétrica severa en el marco hospitalario e investigaron el impacto de los factores socio-demográficos y el control prenatal en la llegada a los establecimientos de salud con complicaciones severas. Los estudios identificaron la falta de familiaridad con atención obstétrica de emergencia entre las parteras tradicionales y la falta de cooperación con los profesionales de salud formales. La sensación de estar distanciadas del sistema de salud y la desconfianza hacia los profesionales de la salud eran aspectos comunes entre las mujeres de sectores marginales con experiencias de complicaciones severas. En el contexto boliviano, 187 muertes maternas por cada 100,000 nacidos vivos y 50 casos de morbilidad obstétrica severa por cada 1000 fueron registradas. Las causas de la morbilidad obstétrica severa y las muertes maternas se distinguieron. La major parte de las mujeres con morbilidad obstétrica severa llegaron al hospital en condiciones críticas: preeclampsia severa, complicaciones después de partos domiciliarios y abortos eran causas más frecuentes en esta categoría. Combinaciones del bajo nivel de educación con la falta de controles prenatales o la residencia en zonas rurales fueron asociadas con la morbilidad obstétrica severa. El control prenatal redujo diferencias socio-demográficas en lo concerniente a la morbilidad obstétrica severa. La complementación de estudios de mortalidad materna con datos sobre morbilidad obstétrica severa aumenta la comprensión de las prioridades y de la calidad en la atención de la salud materna. Además, centrándose en la morbilidad obstétrica severa a la llegada al establicimiento de salud, ha sido útil para investigar las barreras pre-hospitalarias en relación a la atención de emergencia obstétrica. Los resultados permiten identificar categorías específicas de mujeres que parecen ser especialmente vulnerables a las barreras pre-hospitalarias. Los resultados, también subrayan la necesidad de iniciativas que reduzcan los efectos de la marginalización social, y que reconozcan el importante rol que tanto el personal de salud formal como informal cumplen en la utilización de los servicios de atención obstétrica de emergencia.