Assessment of the implementation of the model of integrated and humanised midwifery health services in Chile

Abstract

Objective: in 2010, a pilot study was conducted among women who were attended by midwives in the public sector in Santiago, Chile. The purpose of that study was to evaluate the implementation of the 'Model of Integrated and Humanized Health Services', and the Clinical Guide for Humanized Attention during Labour and Childbirth. Results of that study indicated 92.7% of women had medically augmented labours (artificial rupture of the membranes, oxytocin and epidural analgesia). One third of the women reported discontent with the care they received. This study replicated the pilot study (2010) and was conducted in seven regional hospitals across Chile. The objectives were to : (i) describe selected obstetric and neonatal outcomes of women who received care according to this new guide, (ii) identify the level of maternal-neonatal well-being after experiencing this modality of attention, and (iii) explore professionals' perceptions (obstetricians and midwives), as well as consumers' perceptions of this humanised assistance during labour and childbirth.

Design: this is a cross sectional and descriptive, mixed methods study, conducted in two phases. The first phase was quantitative, measuring midwifery processes of care and maternal perceptions of well-being in labour and childbirth. The second phase was qualitative, exploring the perceptions of women, midwives and obstetricians regarding the discrepancy between the national guidelines and actual practice. Setting: maternity units from seven regional hospitals from the northern, central and southern regions and two metropolitan hospitals across Chile.

Participants: 1882 parturient women in the quantitative phase (including the two Metropolitan hospitals published previously). Twenty-six focus groups discussions (FGD) participated from the regional and metropolitan hospitals for the qualitative phase.

Measurements/Findings: all women started labour spontaneously; 74% of women had spontaneous vaginal childbirth. Caesarean section was the outcome for 20%, and 6% had childbirth assisted with forceps. A high number of medical interventions continued to be performed in all regions, deviating widely from adherence to the national clinical guidelines. Most of the women did not receive any oral hydration, almost all received intravenous hydration; most were under continuous foetal monitoring and medically augmented labour. The majority of women received artificial rupture of membranes, epidural anaesthesia and episiotomy. Most delivered in the lithotomy position. Two thirds of women surveyed perceived adequate well-being in labour and childbirth. Findings from focus group discussions of women (FGD=9; n=27 women), midwives (FGD=9; n=40) and doctors (FGD=8; n=29) indicated lack of infrastructure for family participation in birth, inadequate training and orientation to the national guidelines for practice, and lack of childbirth preparation among women. Some women reported mistreatment by personnel. Some midwives reported lack of autonomy to manage birth physiologically.

Key conclusions: birth is managed by midwives across the public sector in Chile. Despite evidence-based guidelines published in 2007 by the Ministry of Health, birth is not managed according to the guidelines in most cases. Women feel that care is adequate, although some women report mistreatment. Implications for practice: efforts to provide midwife-led care and include women in participatory models of antenatal care are recommended to promote women-centred care in accordance with the Chilean national guidelines.