del Hospital Sofia Feldman

FAZENDO ACONTECER: EXPERIÊNCIAS EXITOSAS MAKING IT HAPPEN: SUCCESSFUL EXPERIENCES HACIENDO POSIBLE: EXPERIENCIAS EXITOSAS Humanization of childbirth care: the history of Hospital Sofia Feldman1 Humanização da atenção ao parto e ao nascimento: a história do Hospital Sofia Feldman Humanización de la atención al parto y nacimiento: la historia del Hospital Sofia Feldman Ana Flávia Coelho Lopes2 Erika da Silva Dittz3 Lélia Maria Madeira4 Vera Cristina Augusta Marques Bonazzi5 1 KEYWORDS: Childbirth care. Healthcare Humanization. Obstetric Practices. History. Community Participation. RESUMO ABSTRACT In this paper we describe the elements that express humanization of childbirth care provided to women and newborn babies at Hospital Sofia Feldman. Due to the constant search for an integral approach in healthcare, the hospital has invested in inovative care-giving practices that are reflected on the quality of care provided. Some of these important practices are the inovative management model, the care centered on women’s and their family’s needs, and the continuous investment in training the health personnel that deals with women and babies. Such initiatives evince the effort made by all involved in the history of the Hospital and reinforce their responsibility and commitment to the defense of life. 1 Translated by Marina Melo Arruda Marinho, revised by Daphne Rattner 2 Social Worker, Systemic Family Care Specialist by Pontifícia Universidade Católica of Minas Gerais - [email protected] 3 Ocupational Therapist, PhD in Health Sciences - area of concetration: Children and Adolescent Health – by the Federal University of Minas Gerais (UFMG), member of Hospital Sofia Feldman teams of Perinatal Care and Teaching - [email protected] 4 Nurse, Manager of Hospital Sofia Feldman team of Research and Teaching, PhD in Nursing by the University of São Paulo (USP) - [email protected] 5 Nurse, Specialist in Obstetrical Nursing by the Nursing School of the Federal University of Minas Gerais (UFMG), Technical Manager and Worker´s Support Team Manager of Hospital Sofia Feldman- [email protected] Este artigo apresenta elementos que expressam a humanização da atenção à mulher e ao recémnascido no Hospital Sofia Feldman. A busca constante da integralidade da assistência à mulher e ao recém-nascido tem levado o Hospital a investir em práticas assistenciais inovadoras que se refletem na qualidade do atendimento prestado à população. Destacam-se o modelo de gestão, o cuidado orientado pelas necessidades da usuária e sua família, e o investimento na formação de seus trabalhadores e de outros profissionais para atuarem na atenção à mulher e ao recém-nascido. Tais iniciativas expressam o esforço de todos os sujeitos envolvidos na história do Hospital e reafirma seu compromisso e sua responsabilidade com a defesa da vida PALAVRAS-CHAVE: Atenção ao Parto e Nascimento. Humanização em Saúde. Práticas Obstétricas. História. Participação Comunitária RESUMEN Este artículo presenta elementos que expresan la humanización de la atención a la mujer y al recién nacido en el Hospital Sofia Feldman. La búsqueda constante de la integralidad de la asistencia a la mujer y al recién nacido motivó al Hospital a promover prácticas asistenciales Rev Tempus Actas Saúde Col // 201 innovadoras que se reflejan en la calidad de la atención a la población. Se destaca el modelo de gestión, el cuidado orientado por las necesidades de la usuaria y su familia, y la inversión en la formación de sus trabajadores y de otros profesionales para actuar en la atención a la mujer y al recién nacido. Estas iniciativas expresan el esfuerzo de todos los sujetos relacionados con la historia del Hospital y reafirma su compromiso y su responsabilidad con la defensa de la vida. PALABRAS-CLAVE: Atención al parto y nacimiento. Humanización en salud. Prácticas Obstétricas. Historia. Participación Comunitaria Introduction This text addresses some elements that express the humanization of childbirth care delivered to women and newborns at Hospital Sofia Feldman, bearing in mind that they are the result of a collective construct of the Institution’s personnel during the past years. The Foundation for Integral Health Care of Hospital Sofia Feldman (Fundação de Assistência Integral à Saúde/Hospital Sofia Feldman FAIS/HSF) is a philanthropic institution, located at the outskirts of Belo Horizonte, in Distrito Sanitário Norte, being a reference for approximately 500,000 people1. It is an institution speciazed in providing healthcare services to women and newborn children of the Brazilian Unified Public Healthcare System (SUS). Its history began in 1974, when representatives of Sociedade São Vicente de Paula (SSVP), concerned with the problems faced by homeless patients and very poor people, who needed to be hospitalized but had no access to public hospitals, decided to build this one. At that time, one of the grandsons of Sofia Feldman donated a piece of land in the district of Tupi to build a philantropic hospital, demanding in return that the hospital should 202 // Rev Tempus Actas Saúde Col be named after his grandmother2. Since the land donation, with the support of different partners, the local community got mobilized and built the hospital in their free time. The first unit, the Ambulatory, opened in 1977 and served women and children, providing primary health care services such as immunization, family planning and medical visits. In 1982, the Maternity and Pediatric Wards were inaugurated, with six beds each. The professionals who joined the community project were motivated by ideals based on the Alma-Ata Declaration, which reasserted the proposal of health as a human right and the motto “Health for all by the year 2000” as a goal. The appeal launched in Alma-Ata was a milestone for the initiatives that structured the institution, working always according to the local community interests. Thus, in our institution we always adopted innovative practices, such as the presence of a companion in the maternity ward, participant in the process of childbirth; rooming-in for mother and baby both in the Maternity and the Pediatric wards; and the encouragement of breastfeeding. These practices were further supported by health laws and policies, like the Brazilian Statute for Children and Adolescents (E.C.A)3, the Baby Friendly Hospital Initiative4, the Policy for Prenatal and Childbirth Humanization5 and the law which allows the mother to have a companion of her choice during labor and delivery6 . It is worth noting that democratic management was adopted since the hospital’s foundation. By mid 2003, when the discussions about healthcare management, and on humanized and comprehensive care, were at their peak, the management model of Line of Care7,8,9 was already formalized in our hospital. According to this new model, comprehensive care is achieved when the user is the focus of attention. From this point of view, the “healthcare system” works as a network of services that are provided according to the needs of each person. The “line of care” includes several health services and the hospital is considered as a “station” of this circuit10. In this new management structure, six divisions were created: Perinatal Care, Institutional Policies, Research and Teaching, Support to workers, Administrative Support and Technical Support11. The Perinatal Care division aims at maintaining the comprehensive care to women and newborns, following the same racionality of Belo Horizonte’s Municipal Health Secretariat (SMSA/BH), which, among other activities, had already created the Maternal and Child Line of Care12. The Perinatal Care Division is the foremost division and has intersections with all others. When recalling the history of Hospital Sofia Feldman, it is worth noticing that the community was involved since its foundation, both for the hospital construction and in the search of strategies to ensure its sustainability. In 1994, this involvement was officialized by the establishment of the Community Association of Friends and Users of Hospital Sofia Feldman (ACAU/HSF) and in 2006, by the Local Health Council. This participative practice is still active nowadays, both in management and in healthcare, either by users, by members of the management council, or by volunteers in projects undertaken as a partnership of the Hospital with ACAU/HSF and the Local Health Council. Over the years, the Institution seeks to maintain valid the principles and values that sustain practices addressed specially to the users of SUS. Thus, elements such as the significant community involvement and the choice for democratic management have contributed to improve the humanization of women’s and newborn’s care, with an important impact on the quality of assistance. Women, newborn and family health care practices The use of planning as a managerial tool has driven the Institutional decisions. In 1998, in its third planning edition, the Hospital defined its institutional mission as: “To develop Integral Communitary Health Care activities, especially for women and children, both as outpatient and hospitalized, with quality, resolubility and effectiveness, friendly and bonding, in an universal way, aiming to change health indicators for this group13”. The constant search for comprehensive care for women and newborns has motivated the Hospital to adopt inovative healthcare practices, that reflect on the quality of care provided to the community. In this effort it incorporates different care strategies based on the World Health Organization (WHO) guidelines, such as the use of appropriate technology for birth and emphasis in primary healthcare activities. Role of the Obstetric Nurse The fact that obstetric nurses were working in the team from the beginning deserves highlighting, since it is a practice that has been encouraged since the hospitals’ foundation: the first delivery of the hospital was assisted by an obstetric nurse, a teacher of the undergraduate course of the School of Nursing of the Federal University of Minas Gerais. The role of this professional in the care for low risk or normal pregnancies is associated with changes in institutional practices and routines, according to the recommendations of the Policy for Humanized Childbirth Care14. The fact that the training of the obstetric nurse is focused on care provides this professional with a different approach in conducting labor and delivery care. This training emphasizes the physiological, emotional and sociocultural aspects of the reproductive process, favoring a performance based on the understanding of Rev Tempus Actas Saúde Col // 203 the reproductive phenomenon as a singular, ongoing and healthy one, focused on the woman, and is developed according to a specific historical context15. In Hospital Sofia Feldman, the obstetric nurse works also in Casa da Gestante (House for High Risk Pregnant Women), in the Birth Center, in Complementary and Integrative Therapies and also supervises prenatal care and family planning. When assisting low risk labors, the nurse uses non pharmacological methods for pain relief, such as massages, birth or Bobath balls, shower or bathtubs, and encourages the woman to walk, move, have the support of a companion or relatives, adopt vertical or squatting positions during labor and other methods16,17. Care in extra-hospital Units The hospital has organized extra-hospital Units responsible for assisting women and newborns: the House for High Risk Pregnant Women - Casa da Gestante, House of Sofias- Casa de Sofias (lodging for mothers of hospitalized preterm babies), and the Predischarge Unit. These Units are located near the Hospital and reflect the comprehensive understanding of health care of the Institution. From this perspective, the model of care adopts the users as reference and seeks to fulfill their needs and provide them a greater independence and inclusion in the care process. The House for High Risk Pregnant Women, created in 2007, monitors women who need an appropriate follow up due to complications during pregnancy. In general, it is hard for these women, who are mostly from the countryside, to have access to more complex health care services. During her stay in the Unit, the pregnant woman is monitored everyday by a team composed by an obstetric nurse, an Obstetrician and a nurse technician. Professionals of areas such as Psychology, Social Service, Occupational Therapy, Physical Education and Nutrition are also part of the 204 // Rev Tempus Actas Saúde Col team. The assistance offered to women at the House for High Risk Pregnant Women is based on the guiding principles of Humanization of Care established by the Ministry of Health and approved by the Minas Gerais State Health Secretariat (SES/MG). A study conducted with 820 pregnant women admitted to this House from March 2008 to December 2009 showed that this Unit provides an efficient assistance, with clinical improvement of the baseline condition, hence reducing the causes which contribute for the high levels of fetal and maternal morbidity and mortality18. The House of Sofias - Casa de Sofias is a strategy of care for high risk newborns and their families. At the beginning it was a ward of the Hospital, started in 2001 with the institution of the Maternal Dorm, that aimed to offer, to the mothers of those babies hospitalized in the Neonatal Intensive Care Unit, conditions to stay in the hospital during the entire period, thus enhancing and strengthening the maternalchild bonding, encouraging and maintaining breastfeeding and empowering the mothers as caregivers19. In 2006, a house was bought in the surroundings of the Hospital and named House of Sofias. Equipped with laundry, kitchen, TV room, outdoor area and a beauty parlor for mothers and health professionals, this facility provides better conditions for the mothers to stay with their children. While staying in the House, women are assisted by a multi-professional team. The creation and maintainance of House of Sofias fulfill the mission of the Hospital to provide its users a comprehensive and humanized care and ensure compliance with the Brazilian Children and Adolescent Statute3. It is worth noting that this initiative promotes an expansion of the care offered to babies and contributes to the establishment of a network for their suppory. The Predischarge Unit derived from the Neonatal Home Care Program (Programa de Internação Domiciliar Neonatal - PID-Neo), which started in 2004 as a strategy to reduce children’s hospital stays, as well as continuity of care at home. It assists children from the Neonatal Intermediate Care Unit (UCIN) of the Hospital. During their stay at this Unit, the children are assisted by a doctor and a nurse. The presence of the mother is assured full time, enabling her to have a direct involvement in her child care. When necessary, the child or the mother is assisted by other members of the multi-professional team. This Unit has proven to be a good strategy to reduce the risks of long hospital stays and also to free earlier the UCIN and UTIN beds, besides encouraging breastfeeding, and integrating and enabling the family to care for their newborn after discharge. It is in those formal and informal conversation spaces, in these meetings between professionals and users, that the possibility of questioning and reinventing care is aroused, in order to achieve the goal of producing health. Therefore, the Meeting of Companions stimulates users and professionals to expose their interests, in order to negotiate and envision collective alternatives. Community involvement The Community Association of Friends and Users of Hospital Sofia Feldman (ACAU/HSF) and the Local Health Council are formal spaces for communitary involvement at Hospital Sofia Feldman; besides, they develop projects that ensure a full time social control of the Institution. Among the projects developed by the ACAU, we can underline the Communitary Doula and the Ombudsman. Conversation points In order to allow and legitimate the dialogue and listening between professionals and users, fora were created at the Hospital. One significant example of this practice is the Companions Meeting, held daily in the Institution with the companions of the Maternity ward, and representatives from the Social Service, Ombudsman and the Local Health Council. The meeting provides an exchange of experiences of the companions and of their perceptions in regard to childbirth and the care received; it is also an opportunity to disseminate information about the rules and routines of the Hospital and familiarize the parents about Civil Registry and Social Rights. This practice originated from what is called conversation squares, understood as spaces where the different actors involved in care may expose their projects, aspirations and needs in regard to a particular matter that interests the group20. Doulas are women from the community who have already experienced motherhood and assist women in labor and delivery, offering emotional and physical support. The Communitary Doula Project was implemented in HSF on July 1997, as a partnership with ACAU/HSF. From 2003 on, this practice was disseminated to other health institutions of Minas Gerais and other states, with the financial support of the Ministry of Health 21. In Belo Horizonte, capital city of Minas Gerais, from 2006 on, this project was potentialized when it was incorporated by the municipal Health Secretariat, and implemented in all public maternity hospitals. The goal of the Ombudsman Project is to listen to the claims, complaints, suggestions and compliments of the users of the Institution. In addition to that, users are requested to answer a quality survey to evaluate their level of satisfaction in regard to the care received. The community presence in the Institution, both in its management and in producing care, enables the managers to be Rev Tempus Actas Saúde Col // 205 constantly listening to the demands both of users and of workers, and hence guiding the elaboration of concrete proposals for improving care practices and working conditions. For this reason, it is right to say that the community involvement ensures effective spaces for the exercise of democracy and social control, with a positive and non resignant approach. Ongoing Feldman education in Hospital Sofia As an Institution that seeks to improve the proposal and implementation of care and management practices for women and newborn health, the Hospital maintains its commitment to training healthcare professionals. Such commitment was expressed in the Statute of the Institution since its first edition in 1988, when the Hospital became a philanthropic organization, and is sustained up to these days22. The decision to invest in Research and Teaching activities provides an updated comprehensive care, focused on the user, founded on the principles of integral care and humanization, and based on scientific evidences. In this perspective, the Institution is continuously investing in training its staff, offering ongoing training activities, participation in scientific events, and opportunities/incentives to apply for graduate programs, and so on. It is also the practice scenario for students of different health professions, both for undergraduate and graduate studies. In the last few years, the Hospital has become a reference in training health professionals, directors and professors of other Brazilian and International institutions interested in pondering and advancing their knowledge on women and newborn care practices. To achieve the training goals, the Hospital develops important partnerships with teaching 206 // Rev Tempus Actas Saúde Col and research institutions, such as the Center for Nursing Studies and Practices of UFMG - Núcleo de Estudos de Ensino e Prática e Enfermagem da Escola de Enfermagem (NUPEPE) and Laboratory of Research on Health Comprehensive Practices - Laboratório de Pesquisas sobre Práticas de Integralidade em Saúde (LAPPIS) of the State University of Rio de Janeiro - UERJ. In 2008, we created the Program “Comprehensive Health Incubator”Incubadora da Integralidade - aimed to support, encourage, help and conduct research that could provide visibility and sustainability to the activities developped by the Institution. From these several activities derived the possibility of advancing in the creation, expansion and improvement of different technologies of care, that in consequence impact positively on the care provided to the population23. Humanization activities addressed to the hospital staff The Worker’s Support Division of Hospital Sofia Feldman is responsible for proposing strategies to promote worker’s health, seeking to ensure their rights and assist their needs. Among theses activities, we can underline the projects Sofia in Good Shape and the Daycare Center “José de Souza Sobrinho”. The project Sofia in Good Shape started in 2003 with the purpose of improving the quality of life of the hospital workers. At its start, they went for walks in the avenues near the hospital, always with the presence of an instructor of the Institution. In 2005, with the increasing popularity of the project, a gym was built in the premises of the Hospital and a Physical Education Professional was invited to join the team. The Project offers the workers the opportunity to engage in physical activities during their working hours, as well as ensures them a follow up by a nutritionist and an occupational physician. The Daycare Center José de Souza Sobrinho assists children from 0 to 4 years old, whose parents work or volunteer at the institution. Besides ensuring their labor’s right, this initiative enables: strengthening the bond between the children and their family; continuity of breastfeeding; feelings of safety and peace of mind for parents during their workday. Final considerations The history of Hospital Sofia Feldman is intertwined with the history of its workers and the community. To describe and ponder about its current situation involves recalling the historical facts that led to the collective construction of a health institution concerned with Women and Newborn Health Care which, at the same time that advocates a user centered care, values the role of each of its employees and the community contribution by social control. In this journey of more than 30 years, we can stress the incorporation of principles and values when conducting health care programs, the management model, and the decision making regarding the education of its employees and other professionals working with Women and Newborn Care. Its activities are backed by principles and guidelines from the Brazilian Public Health Care System (SUS), guided by the Brazilian Humanization Policy (PNH) and addressed primarily to SUS users. Such activities and practices have contributed to give projection to the Institution in the national and international scenery of humanized care to women and newborns. This projection demonstrates the efforts of all those involved in the Hospital’s history and reinforces its commitment and responsibility in the defense of life. References 1. Fundação Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico: Brasil 2000. Rio de Janeiro: IBGE; 2000. 2. Feldman C. Carta a uma avó desconhecida. Notícias do Sofia. 2006;3(11):02. 3. Ministério da Saúde (Brasil). Estatuto da criança e do adolescente. 2. ed. Brasília: Ministério da Saúde; 2003. 4. Organização Mundial da Saúde; United Nations Children’s Fund (UNICEF). Innocenti declaration on the protection, promotion and support of breastfeeding. In: Meeting Breast-Feeding in the 1990s: a global initiative. Florence; 1990. 5. Ministério da Saúde (Brasil), Secretaria de Políticas de Saúde. Programa de humanização do pré-natal e nascimento. Brasília: Ministério da Saúde; 2000. 6. Lei n. 11.108, de 8 de abril de 2005. Altera Lei n. 8.080, de 19 de setembro de 1990, para garantir às parturientes o direito à presença de acompanhante durante o trabalho de parto, parto, pós-parto imediato no âmbito do Sistema Único de Saúde – SUS. Diário Oficial da União, 2005; 8 abr. 7. Franco TB, Magalhães Junior HM. Integralidade na assistência à saúde: a organização das linhas do cuidado. In: Merhy EE, Miranda Junior H, Rimoli R, Franco TB, Bueno WS. O trabalho em saúde: olhando e experienciando o SUS no cotidiano. São Paulo: Hucitec; 2004. p. 125-34. 8. Madeira LM, Duarte ED. A gestão hospitalar e a integralidade da assistência: o caso do Hospital Sofia Feldman. In: Pinheiro R, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio de Janeiro: EdUCS, IMS/ UERJ, Cepesq; 2006. p. 65-80. 9. Magalhães Junior HM, Oliveira RC. Concretizando a integralidade nos serviços de saúde: a aposta do SUS em Belo Horizonte. In: Pinheiro R, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio de Janeiro: EdUCS, IMS/ UERJ, CEPESQ; 2006. p. 51-66. 10. Cecílio LCO, Merhy EE. A integralidade do cuidado como eixo da gestão hospitalar. In: Pinheiro R, Mattos RA, organizadores. Construção da integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: UERJ, IMS, ABRASCO; 2003. 11. Fundação de Assistência Integral à Saúde (FAIS); Hospital Sofia Feldman. Planejamento estratégico do Hospital Sofia Feldman. Belo Horizonte: FAIS; 2003. 12. Belo Horizonte. Secretaria Municipal de Saúde. BH-VIDA: saúde integral. Belo Horizonte; [site da internet] 2003. [citado 2008 Out 30]. Disponível em: http://www.pbh.gov.br/smsa/biblioteca/mostraarquivo. php?documento=169. 13. Fundação de Assistência Integral à Saúde (FAIS); Hospital Sofia Feldman. Planejamento estratégico situacional do Hospital Sofia Feldman/FAIS 97/98. Belo Horizonte: FAIS; 1998. 14. Dias MAB, Domingues RNSM. Desafios na implantação de uma política de humanização da assistência hospitalar ao parto. Ciênc Saúde Coletiva. 2005;10(3):699-705. 15. Riesco MLC, Tsunechiro MA. Formação profissional de obstetrizes e enfermeiras obstétricas: velhos problemas ou novas possibilidades. Rev Estud Fem. 2002;10(2):449-59. 16. Pratezi DCB. Métodos não farmacológicos de alívio à Rev Tempus Actas Saúde Col // 207 dor do parto utilizados na maternidade do Hospital Sofia Feldman [monografia]. Belo Horizonte: Universidade Federal de Minas Gerais, Escola de Enfermagem; 2002. 17. Lopes TC, Madeira LM, Coelho S. O uso da bola do nascimento na promoção da posição vertical em primíparas durante o trabalho de parto. REME Rev Min Enferm. 2003;7(2):134-9. 18. Nazareth JV. Programa Casa das Gestantes de uma maternidade filantrópica de Belo Horizonte: repercussões na saúde maternofetal [monografia]. Belo Horizonte: Universidade Federal de Minas Gerais, Escola de Enfermagem; 2010. 19. Dittz ES, Madeira LM, Duarte ED. Alojamento materno: construindo uma estratégia de humanização da assistência. REME Rev Min Enferm. 2004;8(4):490-4. 20. Merhy EE. Público e privado: entre aparelhos, rodas e praças. In: Aciole GG, organizador. A saúde no Brasil: cartografias do público e do privado. São Paulo: Hucitec; 2006. 21. Rattner D. Humanização na atenção a nascimentos e partos: ponderações sobre políticas públicas. Interface Comun Saúde Educ. 2009;13 (Suppl 1):759-68. 22. Fundação de Assistência Integral à Saúde (FAIS). Estatuto da Fundação de Assistência Integral à Saúde. Belo Horizonte: FAIS; 1988. 23. Brito MJM, Madeira LM, Mendes LC, Lopes TC, Dittz ES. Experiência de integralidade no curso de graduação da Escola de Enfermagem da Universidade Federal de Minas Gerais. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensino-trabalho-cidadania: novas marcas ao ensinar integralidade no SUS. Rio de Janeiro: IMS/UERJ, CEPESQ, ABRASCO; 2006. Artigo apresentado em 20/07/2010 Aprovado em 30/08/2010 208 // Rev Tempus Actas Saúde Col