Purpose: According to the Peruvian health laws and the associated regulations, the care for pregnant women is provided by the gynecologist-obstetrician. When admitted to a public hospital, this responsibility is transferred to the non-nurse midwife, called an “obstetriz.” In Peru, the obstetriz is a non-nurse healthcare provider prepared at the bachelor level. However, the educational curriculum for the obstetriz in Peru is not consistent with the World Health Organization Global Standards for the Initial Education of Professional Nurses and Midwives. Furthermore, the obstetriz works under the direct supervision of a physician within the biomedical model. Despite the need to provide pregnant women with evidence-based, comprehensive, and person-centered care, this might not be possible in the public hospitals where financial and human resources are limited. The voices, discourses, and experiences of primigravida women laboring in Peruvian public hospitals have not been reported in the literature. The aim of this study was to understand the experiences of laboring primigravida women who received obstetric care from an obstetriz in the labor and delivery area of a large public hospital located in Northern Peru.
Methods: The qualitative case study methodology provides researchers with the ability to study complex phenomena within their natural contexts. This method is particularly important to study poorly understood phenomena in order to develop theory, to evaluate programs and practices, and to construct interventions. For this study, qualitative data from semi-structured interviews were collected, transcribed, and analyzed using content analysis to identify issues, concepts, and themes. Pregnant women were recruited through snowball sampling, over three months from a large maternity unit in a public hospital in Northern Peru with about 12,000 births annually. Interviews were conducted in a private place to preserve women’s intimacy and to promote a deep discourse. The study was approved by the hospital ethics committee.
Results: The point of data saturation was achieved with twelve interviews. Four themes emerged from the data, including: 1) feeling excluded from the decision-making; 2) getting ready for delivery; 3) giving birth alone; and 4) needing the presence of the husband. The four themes explain the general labor experience from the woman’s perspective. In the Peruvian context, the birthing process is contextualized with the focus on using the technologies and implementing the procedures and tasks linked to medicine. The emotional and spiritual aspects of the birthing process, those most important to the woman, are largely ignored or replaced by the more important focus of the obstetriz or physician. The medicalization results in the dehumanization of childbirth and becomes a traumatic experience in the trajectory of motherhood. The therapeutic plan is generally made by physicians or implemented though protocols by an obstetriz. The women verbalized feeling ignored and uninvited to participate in their labor plan. One woman explained: "They came in [the obstetriz] and touched my vagina to know how dilatation was going but didn’t tell me anything else. They just said, ‘wait a second’, as they were annoyed with my questions. I guess they said that to all women… I decided to keep still and silent" (J-35). Getting ready for labor means a complex combination of medical procedures, such as being shaved and needing to fast, despite the fact the national health standard (Norma Técnica del Ministerio de Salud) recommends avoiding these practices. One of the interviewees said: "One of most disgusting things I had to suffer was being trimmed down there [vagina]. I was so scared they might cut me. I already trimmed myself at home, but they insisted it was not good enough, they insisted this needed to be done" (R-28). Medicalizing birth forces the woman to experience solitude, and generated feelings and emotions that impacted the whole process. They became scared and even sad about their delivery and concerned about the safety of their baby. One woman said, "When I was left alone and in pain, I was scared about my little baby. I thought he could suffer if I didn't know what to do when the contractions came" (A-30). To return the focus of childbirth from medicine to the expecting mother, all the women asked to be treated as humans. They insisted they needed humanized care to meet their needs. Their expectation for a beautiful event, or childbirth, was replaced with a medicalized procedure to remove the baby. One woman stated, "When contractions became stronger, I called for the obstetriz and she just kept telling me, that is, you keep breathing and she left me alone without teaching me how to do it. It was sad that I didn’t have anyone helping me to understand what to do, and helping to comfort me... I really felt alone and very sad. The staff must be more human" (R-28). Finally, the national health standard permits the woman to be accompanied by their family and the father or partner; but, all the women complained their desire to have the father and/or family present was ignored. The women repeated that they were forced to be alone and with great sorrow. One woman said, "My pregnancy was complicated, and my husband always came with me [to visits]; but the day of birth they did not allow him to be with me. And, this was when I needed him the most" (O-36).
Conclusion: Overall, this study describes the vulnerability and lack of empowerment primigravida women experience during childbirth. All the women vividly recall the laboring process as a negative medicalized procedure centered on the needs of the physician, obstetriz, and the hospital through the strict adherence to self-serving rules and regulations. The medicalized practices, such as unwanted shaving, fasting, and the family not being allowed to present, as well as the restrictions, such as dietary and visitors, were described by the women as disappointing, depressing, and dehumanizing. Particularly, the hospital policies regarding visiting hours and the prohibition of family participation in childbirth forces women to experience the dilatation period alone; generating feelings of fear and sadness that resulted in their claims of no humanized care from health professionals. The birthing experience places the woman in a vulnerable state where their preferences are not respected, their questions are unanswered, and their need for human contact is ignored. The women are even denied their fundamental rights as explicated in the national health standard. Local norms, including approaches to care and preferences for procedures, shift childbirth to the removal of the baby, a medicalized event and dehumanized process. The women all reported feeling alone, sad, and almost abandoned. The laboring pregnant woman received care from an obstetriz which was neither person-centered nor multidisciplinary.
Recommendations: This study needs to be replicated at other public hospitals in other regions of Peru, to understand if the findings are transferable. At the provincial level, where the study hospital is located, there needs to be a public policy discussion about how to protect the already defined rights of the women and family when giving birth at a public hospital in Peru. At the hospital level, where this research was conducted, the etiology for the medicalization of birthing as a procedure needs to be identified, the root causes for the dehumanizing behaviors need to be defined, and multiple strategies to provide humanized care to the women and the families need to be developed and implemented. A multidisciplinary quality improvement team needs to be convened to shift the paradigm from childbirth as an isolated medical procedure accompanied by dehumanizing behaviors to childbirth as a natural process, part of motherhood, accompanied by humanized care. The focus needs to include meeting the needs and expectations of the woman and her family.
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