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385 Chapter 14 Humanizing Childbirth to Reduce Maternal and Neonatal Mortality A National Effort in Brazil Daphne Rattner, Isa Paula Hamouche Abreu, Maria José de Oliveira Araújo, and Adson Roberto França Santos scenario # 1: itabuna A town by the south shore of Bahia, Itabuna became famous in Brazil because of the books written by Jorge Amado about the life of people living in this cacao growth region with names like Gabriela, Clove, and Cinnamon. Until January 2006, women used to have babies in Itabuna’s hospital just as they did in most hospitals in the country: as soon as they arrived in labor, they were admitted (even in very early labor), their pubic hair was shaved, they were given enemas, they were made to lie down with a drip of oxytocin, and they were not allowed any food or drink—and although there were so many norms, no protocols were available for the professionals. Other common, non-evidence-based practices included routine amniotomy, routine episiotomy, no personal companion during labor and delivery, and no use of the partogram (an evidence-based tool for tracking the progress of women in labor).1 Cesarean sections were fairly common—in January 2006 the rate was 50.8%. In July 2006, about six months after participating in one of our seminars, Dr. José Leopoldo dos Santos, director of the Hospital Manoel Novaes, a proud presenter at a state seminar, described the current care offered to delivering women: no early admission, amniotomy only according to the partogram, no routine or liberal use of oxytocin, defined protocols, no restriction of fluids during labor (and soon women will also be allowed to eat), freedom of movement during labor, empathic support from doulas— now women are allowed a companion of their choice by their side—as well as other changes. Now medical interns and residents in this hospital are being taught to care for childbirth following these guidelines, a reform that has introduced to them the importance of adopting practices based on scientific evidence. In that month of July, the cesarean rate dropped to 37.4%—not yet ideal, but a significant improvement. But not all is rosy in 386 d. rattner et al. this story: the medical professionals are having a hard time—and giving their director a hard time—accepting the presence of the woman’s companion , which, though it is her prerogative by force of Law No. 10,108 of April 7, 2005, does not come easily. This successful story is one of many, and it introduces the focus of this chapter: a program created by officials of the Ministry of Health to humanize childbirth in Brazil through the adoption of a snowball strategy. It started with a few hospitals in 2004 (one in each state) and, by involving them in a process of multiplication, by the end of 2006, almost 500 hospitals and more than 2,000 health professionals had participated in the process. In this chapter, we also describe how the Ministry of Health is working to integrate traditional midwives into the public health care system. All the authors of this chapter work or worked for the Brazilian Ministry of Health. Daphne Rattner, a public health physician and epidemiologist, is responsible for government strategies to reduce unnecessary cesareans, among other assignments. Prior to her admission to the Ministry of Health, she was the national coordinator of the Brazilian Network for the Humanization of Childbirth—ReHuNa, a nongovernmental organization (NGO) that influenced this public policy. Isa Abreu, a public health physician, was responsible for training traditional midwives from 2000 to May 2007, among other assignments. Maria José Araújo, also a physician, was the coordinator of the Women’s Health Program of the Ministry of Health from 2003 to May 2007. Adson França Santos, the national coordinator of the Pact for the Reduction of Maternal and Neonatal Mortality and currently the director of the Department of Programmatic and Strategic Actions of the Ministry of Health, is an obstetrician/gynecologist and a member of the Brazilian Federation of the Societies of Obstetrics and Gynecology. All helped shape the strategy and develop the classes, and all have served as seminar instructors. MEET THE CONTEXT With a territory of 3,300,000 square miles (8.5 million square kilometers) spreading from the equatorial zone in its north down under the Tropic of Capricorn at its south,2 Brazil is the largest country of South America, composed of twenty-six...

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