Incorporation, adaptation and rejection of obstetric practices during the implementation of the "Adequate Childbirth Program" in Brazilian private hospitals: a qualitative study.

BACKGROUND: The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation. METHOD: This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software. RESULTS: The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals. CONCLUSIONS: After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful.

Brazil has high Cesarean Section (CS) rates, with rates far from the ideal recommended by the World Health Organization and a model of care that does not favor women's autonomy and empowerment. In 2015, a quality improvement project, called "Projeto Parto Adequado" (PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean section, in addition to encouraging the process of natural and safe childbirth. One of the components of this project was to reorganize the model of care in hospitals to prepare professionals for humanized and safe care. The data were collected in 8 hospitals with interviews with 49 professionals, approximately two years after the beginning of the project in the hospitals. There were changes in the hospital routine and in the care of women after the project. The professionals incorporated practices such as skin-to-skin contact and breastfeeding; diet during labor; non-invasive care technologies, especially to relieve pain during labor; birth plan; pregnancy courses with guided tours in hospitals (for pregnant women and family); and analgesia for vaginal labor. There was adaptation of existing practices in hospitals to reduce CS that had no clinical indication; better monitoring of labor, favoring vaginal delivery. And finally, the professionals rejected the practice that presses the uterine fundus, for not having shown efficacy in recent studies. We can conclude that the hospitals that participated in this study have made an effort to change their obstetric model. However, specific aspects of each hospital, the organization of the health system in Brazil, and the incentive of the local administration influenced the implementation of these changes by professionals in practice.

Care at the first postnatal hour in two hospitals of the Adequate Birth Project: qualitative analysis of experiences in two stages of the Healthy Birth research.

BACKGROUND:  The Adequate Childbirth Project (PPA) is a quality improvement project that aims to enhance normal delivery and reduce cesarean sections with no clinical indication in the Brazilian supplementary health care system. This study aims to analyze the care model of the first postpartum hour in hospitals that participated in the PPA. METHODS: Qualitative analysis based on the narrative of 102 women attended at two hospitals participating in the evaluative "Healthy Birth" research that analyzed the degree of implementation and the effects of the PPA. We assessed three practices within the first hour after delivery: skin-to-skin contact, breastfeeding and appropriate clamping of the umbilical cord. Data was collected through semi-structured interviews by telephone and submitted to thematic content analysis. RESULTS: The categories that emerged from the analysis of the results were "Dimension of time and care expressed in the lived experience" and "Interferences in care in the first hour of life". In the first category, women reported that in the first hour after delivery the newborn was placed on the mother's chest, but the length of time of the newborn's stay in skin-to-skin contact was less than one hour. This experience, even in a shorter period of time, was said to be positive by the women interviewed. Two barriers were observed: interruption of skin-to-skin contact for neonatal care and the transfer to the recovery room, both separating baby from mother without observing the duration of the "golden hour". It was identified that a process of improvement of the quality of care for childbirth is underway, with a gradual incorporation of recommended practices for care in newborn's first hour of life. CONCLUSIONS: Women reported access to the three care practices at two hospitals participating in the PPA quality improvement project. All practices were valued by women as a positive experience and should be promoted. Information during antenatal care to increase women´s autonomy, review of hospital practices to reduce barriers, and support from health care providers during the first hour after birth are needed to improve the implementation of these practices and access to their health benefits.

This study aims to analyze the care model of the first postpartum hour offered by two hospitals participating in the Adequate Childbirth Project (PPA), a quality improvement project to enhance normal delivery and reduce unnecessary cesarean sections in Brazilian private hospital. It is a qualitative analysis, based on the narrative of 102 women attended at two hospitals participating in the PPA. Categories that emerged from the analysis: "First hour; dimension of time and care expressed in the lived experience" and "Interferences in care in the first hour of life". Most women expressed a chronological time of skin-to-skin contact far from the ideal recommended in the first postpartum hour; however, they valued the experience and its meaning. Two barriers were observed in this care process: the interruption of skin-to-skin contact for neonatal care and the transfer to the recovery room, without observing the duration of the "golden hour". We can conclude that women evaluated the service positively, with indications that point to the sustainability of the PPA. Information during antenatal care to increase women´s autonomy are needed to improve the implementation of these practices and access to their health benefits.

Evaluation of labor and childbirth care by nurse-midwives in Brazilian private hospitals: results of a quality improvement project.

BACKGROUND: In 2015, a quality improvement project-the "Adequate Childbirth Project" (Projeto Parto Adequado, or PPA)-was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals. METHODS: Cross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test. RESULTS: 4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including "oral fluid and food", "maternal mobility and position", "monitoring of labor", "use of non-pharmacological methods for pain relief" and "epidural analgesia for pain relief" in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors. CONCLUSIONS: There was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges.

Brazil has a high rate of cesarean sections with low participation of nurse-midwives in childbirth care. Nurse-midwife care is associated with less use of interventions, lower proportions of cesarean sections and greater women's satisfaction. In 2015, a quality improvement project, called the "Adequate Childbirth Project" (Projeto Parto Adequado, PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean sections. One of its components is the expansion of nurse-midwives in labor and childbirth care. In this study, we evaluated the results of PPA on childbirth care by nurse-midwives. Data were collected in 12 hospitals with interviews with 4798 women. Women assisted in the PPA model of care had a higher proportion of labor and vaginal birth, but there was no increase in the proportion of women assisted by nurse-midwives, neither during labor nor vaginal birth. The use of recommended practices was adequate, except for the use of epidural analgesia, with greater use of some recommended practices in women assisted by nurse-midwives compared to those seen only by doctors. However, we observed excessive use of non-recommended practices during labor, both by doctors and nurses. We can conclude that there was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and a greater use of recommended practices in women assisted by nurse-midwives, but without an increase in the proportion of women assisted by nurses. The expansion of nurse-midwives' participation in childbirth care and the reduction of non-recommended practices therefore continue to be challenges.

Process of adhesion of the Adequate Childbirth Program to improve obstetric care in private hospitals in Brazil.

BACKGROUND: In 2015, a quality improvement project called "Projeto Parto Adequado-PPA" was implemented in Brazilian private hospitals to reduce unnecessary high rates of cesarean sections. This study aimed to analyze the decision-making process of managers and care leaders to adhere to the PPA. METHODS: The Healthy Birth study is evaluative research that used mixed methods to evaluate the implementation and effects of the Adequate Childbirth Program in 12 hospitals that participated in the program. Eight out of 12 hospitals were selected for a qualitative approach. We interviewed ten managers and 24 care leaders from July to October 2017. The interviews were transcripted, and data was systematized using the MaxQda software, with Thematic Content Analysis, to identify the facilitators and barriers for adherence to the Adequate Childbirth Program. We used the conceptions of the Diffusion of Innovation as an analytical reference. RESULTS: The main reasons to adhere to the Adequate Childbirth Program were the absence of other quality improvements programs in Brazilian private services using multifaceted interventions, social and market status for participating; commitment to quality of care; and the possibility of structural reforms related to the Adequate Childbirth Program implementation. In addition, inviting hospital influencers to learn about the objectives and intentions of the project before joining was considered an important strategy to motivate hospitals. CONCLUSION: Social, cultural, and economic constructs motivated adherence. The invitation strategy used by the Adequate Childbirth Program coordination, through socially respected members in Brazil, such as doctors, was highly valued by the leaders of the hospital team and encouraged adherence to the Program.

In 2015, a quality improvement program, called the "Adequate Childbirth Program" (PPA), was recommended by the National Supplementary Health Agency so that Brazilian private hospitals could, through a change in the care model, reduce unnecessary cesarean sections and stimulate the natural and safe process in childbirth. The process of adhering to the PPA was studied in this article. Ten managers and 24 assistant leaders were interviewed in 08 private hospitals in Brazil. The main reasons for joining the PPA were the absence of other quality improvement programs; for being a program considered necessary in the country's midwifery, which could increase the prestige of hospitals in the view of women and families; for proposing an improvement in the quality of care; and for stimulating of structural and ambiance reforms. Social, cultural, and economic values motivated hospital adherence. The invitation strategy used by the PPA coordination, through socially respected members in Brazil, such as medical professionals, was highly valued by the hospital's leaders and encouraged adherence to the Program.

Women's voice on changes in childbirth care practices: a qualitative approach to women's experiences in Brazilian private hospitals participating in the Adequate Childbirth Project.

BACKGROUND: In Brazil, childbirth practices are strongly marked by surgical events and particularly in the private sector cesarean sections reach rates above 80%. The National Supplementary Health Agency proposed the Adequate Childbirth Project (PPA), a quality improvement project developed at Brazilian hospitals with the aim of changing the current model of childbirth care and reducing unnecessary cesarean sections. The objective of this study is to assess how the participation of women in the process of improving quality childbirth care occurred in two hospitals participating in the PPA. METHOD: Qualitative study, based on interviews with 102 women attended at two hospitals that took part in the first and second stages of the "Healthy Birth", an evaluative hospital-based research, conducted in 2017-2018, that assessed the degree of implementation and the effects of PPA. After thematic content analysis, supported by MaxQda software, three categories emerged: (1) how women gathered knowledge about the PPA, (2) how women perceived it, and (3) which are their suggestions for the PPA improvement. RESULTS: The PPA was unknown to most women before delivery. A polysemy of terms, including adequate childbirth, promotes recognition of the "new" model of care. Visits to the maternity hospital and antenatal care groups for pregnant women are opportunities for contacts that change the perception of what childbirth can be. Women have expectations of a relationship with maternity that is not limited to the moment of delivery. The listening channels established between hospitals and women are fragile and not systematized. By increasing the supply of listening spaces, one can also increase the request to leave their suggestions and contributions, and thus gain more allies in improving the project. Women are not yet included as PPA agents and their voices are silenced. CONCLUSIONS: Women's participation to improve childbirth care is relevant and necessary. The women's voice in the PPA is still incipient, and maternity hospitals and health plan operators should create strategies to insert and engage them. Women's voices should be listened to not only during but also before and after childbirth.

In Brazil, childbirth practices are strongly marked by surgical events and particularly in the private sector cesarean sections reach rates above 80%. The Adequate Childbirth Project (PPA) is a quality improvement project developed at Brazilian hospitals with the aim of changing the current model of childbirth care and reducing unnecessary cesarean sections. A qualitative study was developed in order to understand how hospitals have included the participation of women in the PPA. Based on interviews with 102 women, the present study shows that the PPA was unknown to most women before delivery. A polysemy of terms, including adequate childbirth, promotes recognition of the "new" model of care. Visits to the hospital and antenatal care groups for pregnant women are opportunities for contacts that change the perception of what childbirth can be. Women's participation to improve childbirth care is relevant and necessary. The women's voice in the PPA is still incipient and women are not yet included as agents of change, and their voices are silenced. Hospitals and health plan operators should create strategies to engage them. Women's voices may be listened to not only during but also before and after childbirth.

Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol.

BACKGROUND: In Brazilian private hospitals, caesarean section (CS) is almost universal (88%) and is integrated into the model of birth care. A quality improvement intervention, "Adequate Birth" (PPA), based on four driving components (governance, participation of women and families, reorganisation of care, and monitoring), has been implemented to help 23 hospitals reduce their CS rate. This is a protocol designed to evaluate the implementation of PPA and its effectiveness at reducing CS as a primary outcome of birth care. METHODS: Case study of PPA intervention conducted in 2017/2018. We integrated quantitative and qualitative methods into data collection and analysis. For the quantitative stage, we selected a convenient sample of twelve hospitals. In each of these hospitals, we included 400 women. This resulted in a total sample of 4800 women. We used this sample to detect a 2.5% reduction in CS rate. We interviewed managers and puerperal women, and extracted data from hospital records. In the qualitative stage, we evaluated a subsample of eight hospitals by means of systematic observation and semi-structured interviews with managers, health professionals and women. We used specific forms for each of the four PPA driving components. Forms for managers and professionals addressed the decision-making process, implemented strategies, participatory process in strategy design, and healthcare practice. Forms for women and neonatal care addressed socio-economic, demographic and health condition; prenatal and birth care; tour of the hospital before delivery; labour expectation vs. real experience; and satisfaction with care received. We will estimate the degree of implementation of PPA strategies related to two of the four driving components: "participation of women and families" and "reorganisation of care". We will then assess its effect on CS rate and secondary outcomes for each of the twelve selected hospitals, and for the total sample. To allow for clinical, socio-demographic and obstetric characteristics in women, we will conduct multivariate analysis. Additionally, we will evaluate the influence of internal context variables (the PPA driving components "governance" and "monitoring") on the degree of implementation of the components "participation of women and families" and "reorganisation of care", by means of thematic content analysis. This analysis will include both quantitative and qualitative data. DISCUSSION: The effectiveness of quality improvement interventions that reduce CS rates requires examination. This study will identify strategies that could promote healthier births.

Obstetrical practice by nurses in instiutional childbirth: a possibility for emancipatory knowledge / A prática obstétrica da enfermeira no parto institucionalizado: uma possibilidade de conhecimento emancipatório / La práctica obstétrica de la enfermera en el parto institucionalizado: una posibilidad de conocimiento emancipatorio

Pesquisa qualitativa, que objetivou analisar os sentidos atribuídos pelas enfermeiras às mudanças de sua prática obstétrica, utilizando o método produção de sentidos no cotidiano - práticas discursivas, proposto por Mary Spink. Dados coletados por entrevista individual, semiestruturada, com 16 enfermeiras obstétricas, em maternidades públicas - Rio de Janeiro, Brasil. Foram analisadas com os conceitos de travessia de fronteiras e constelações de poder de Boaventura Santos. Os sentidos atribuídos pelas enfermeiras às práticas obstétricas evidenciaram uma transformação em processo no âmbito do conhecimento obstétrico e das práticas na perspectiva da desmedicalização. Fronteira, lugar de transição paradigmática de novas práticas surge em relações emancipatórias com as mulheres. Concluímos que experimentar novas práticas envolve superação dos limites conhecidos para encontrar autonomia, configurando-se um conhecimento e prática com possibilidades emancipatórias. Travessias, nessa direção, se dão pela ousadia de buscar e experimentar o novo, transgredir o limite e aproveitar os espaços abertos na constelação de poderes.

This was a qualitative research project with the objective to analyze the meanings attributed by nurses to changes in their obstetrical practice, using the method "production of meanings in the everyday - discursive practices," as proposed by Mary Spink. Data was collected through semi-structured, individual interviews with 16 obstetrical nurses in public maternity wards in Rio de Janeiro, Brazil. The interviews were analyzed with the concepts "crossing boundaries" and "constellations of power," by Boaventura Santos. The meanings attributed by the nurses to the obstetrical practices verified a transformation process in the field of obstetrical knowledge, and practices in the perspective of demedicalization. The frontier, as a place of paradigmatic transition to new practices, emerges in emancipatory relationships with the women users of the service. We conclude that experimentation with new practices involves overcoming known limits to find autonomy, configuring a knowledge and practice with emancipatory possibilities. In this direction, crossings come from the boldness to seek and experiment the new, transgress the limit, and make use of open spaces in the constellation of powers.

Investigación cualitativa tuvo como objetivo analizar los sentidos atribuidos por las enfermeras en los cambios de su práctica obstétrica utilizando el método de producción de sentidos diariamente, propuesto por Mary Spink. Los datos fueron recolectados por medio de entrevista individual, semi-estructurada, a 16 enfermeras obstétricas en maternidades públicas - Rio de Janeiro, Brasil. Se analizaron los conceptos de trayecto de fronteras y constelaciones de poder de Boaventura Santos. Los sentidos atribuidos a las prácticas obstétricas evidenciaron una transformación en proceso del conocimiento obstétrico y sus prácticas en la perspectiva de la desmedicalización. La frontera, lugar de transición paradigmática de nuevas prácticas, donde surgen las relaciones emancipadoras con las mujeres. Concluimos que las nuevas prácticas involucran la superación de límites conocidos para encontrar autonomía. Las trayectorias ocurren por la audacia de buscar y experimentar lo nuevo, de transgredir el límite, y aprovechar los espacios abiertos en la constelación de poder.

Modelo humanizado de atenção ao parto no Brasil: evidências na produção científica / Humanized childbirth care model in Brazil: evidence in scientific production / Modelo humanizado de atención al parto en Brasil: evidencias en la producción científica

Pesquisa qualitativa e descritiva, utilizando método o de revisão sistemática de literatura. O objetivo foi analisar as tendências na produção científica sobre atenção ao parto, no Brasil, na perspectiva da humanização, no período de 2001-2010. Realizamos busca nas Bases de Dados Scielo Brasil e Base de Dados de Enfermagem. Foram identificados 87 artigos e 34 selecionados e analisados. Os dados foram registrados em formulário aberto e organizados em dois campos: o perfil das produções e os dados das produções científicas analisadas de forma narrativa. Os eixos temáticos sintetizados expressam as tendências encontradas: impacto para as usuárias e os profissionais; impacto nas práticas assistenciais; análise das concepções e conceituações ético-políticas; e o impacto no ensino profissional. As produções apontam mudanças insuficientes para produzir impacto satisfatório nos resultados perinatais. Essas mudanças são compreendidas como processo com avanços e retrocessos, envolvendo as instituições no campo do ensino e serviço em saúde e da sociedade civil.

A qualitative-descriptive piece of research, on the basis the Systematic Review of Literature method. It aims at analyzing trends in Brazilian scientific publications from 2001 to 2010 related to childbirth care in Brazil from the perspective of humanization. We carried out an active search on the Scielo-Brasil and on the Nursing Journals database. A total of 87 (eighty-seven) abstracts on the subject were identified and 34 (thirty-four) were selected and analyzed. Data were filled into an open form and organized under two captions: production profile and data analysis in narrative form. The synthesized themes point to the trends identified: impact for users and professionals; impact on care practices; concepts and analysis of ethical and political concepts and the impact on professional education. Productions indicate the changes identified fall short of causing satisfactory impact on perinatal outcomes. Such changes are regarded as back and forth moves, involving educational institutions, health care services and the civil society.

Investigación cualitativa y descriptiva, utilizando el método de revisión sistemática de literatura. El objetivo fue analizar las tendencias en la producción científica sobre la atención al parto, en Brasil, desde la perspectiva de la humanización, en el período de 2001 a 2010. Llevamos a cabo una búsqueda en la Base de Datos Scielo-Brasil y Base de Datos de Enfermería. Fueron identificados 87 artículos y 34 seleccionados y analizados. Los datos fueron registrados en formulario abierto y organizados en dos campos: el perfil de la producción científica y los datos analizados en forma narrativa. Los temas sintetizados expresan las tendencias encontradas: impacto para las usuarias y los profesionales, impacto en las prácticas de cuidado; análisis de las concepciones y conceptos éticos-políticos; y el impacto en la formación profesional. Las publicaciones perfilan cambios insuficientes para producir impacto satisfactorio en los resultados perinatales. Esos cambios son entendidos como un proceso de avances y retrocesos, involucrando las instituciones educativas, los servicios de salud y la sociedad civil.

Assistência pré-natal da casa de parto do Rio de Janeiro: a visão de suas usuárias / Prenatal care of the Birth Center of Rio de Janeiro: the vision of its users / Atención prenatal de la Casa del Parto de Río de Janeiro: la visión de sus usuarios

Trata-se de uma pesquisa quantitativa que teve como objetivo analisar a assistência pré-natal oferecida pela Casa de Parto David Capistrano Filho (RJ) sob a ótica de suas usuárias e baseou-se no conceito de Humanização do Parto e Nascimento. Para tanto,foram convidadas a responder o questionário todas as puérperas que tiveram seus partos entre os meses de maio e setembro de 2005. Os resultados obtidos nos informam que esta maneira diferenciada de assistência vem sendo bem aceita pela populaçãoassistida, além de oferecer os serviços e cuidados preconizados pelo Ministério da Saúde, seguindo as normas da Organização Mundial de Saúde de atenção segura e efetiva à gestação e parto de baixo risco.

The present study discusses the results of a quantitative research with the objective to analyze the prenatal care offered by the Casa de Parto David Capistrano Filho (RJ) (Birth Center) focusing on its users, based on the concept of Humanization of theChildbirth and Birth. For this purpouse , the women that gave birth between May and September of 2005 were invited toanswer a questionnaire. The results obtained indicate a good acceptance by the population of this differentiated way of assistance.. This model offers services and cares praised by th of Health Administration , in compliance with the regulations of The World Health Organization for safe and effective attention to insure a low risk pregnancy and childbirth.

Se trata de una investigación cuantitativa que tiene como objetivo analizar la asistencia prenatal ofrecida por la casa del parto David Capistrano Filho (RJ) bajo óptica de sus usuariosy basado en el concepto de la humanización del parto y del nacimiento. Para esto, fueron invitadas para contestar un cuestionario las mujeres que tuvieron sus partos entre losmeses de mayo y septiembre de 2005. Los resultados obtenidos reflejan que que esta forma especializada deasistencia cuenta con cada vez mayor aceptación por la población atendida. Por otro lado, , además del ofrecimientoa los servicios y a los cuidados, elogiados por el Ministerio de de la salud bajo las normas de la Organización Mundial de la Salud de el rubro de atención segura para garantir la gestación y parto del riesgo bajo.

Perfil da mulher atendida pela consulta de enfermagem gincológica em Unidade Básica de Saúde / The profile of women assisted by gynaecological nursing consultation at a basic health unit

O trabalho descreve o perfil da clientela de mulheres atendidas no Programa de Assistência à Saúde da Mulher, do Centro Municipal de Saúde Milton Fontes Magaräo - XIII RA, pelos professores e alunos das disciplinas de Enfermagem Ginecológica do Departamento de Enfermagem Materno-Infantil da Faculdade de Enfermagem da UERJ (DEMI/UERJ). Através de Projeto de Extensäo foi analisada uma amostra de 180 prontuários, selecionados aleatoriamente dentre os 4.128 atendimentos realizados pelos autores no período de maio/1995 a maio/1998. A análise mostrou uma clientela de perfil diversificado quanto às características pessoais, porém de muita semelhança no que tange aos agravos à saúde e motivos de comparecimento ao serviço.

Quando säo mulheres (clientes e enfermeira) na consulta de enfermagem / When women (client and nurse) in nursing consultation

O presente trabalho pretende levantar questöes para reflexäo, a partir da observaçäo do campo e desenvolvimento da prática de consulta de enfermagem à mulher em unidade básica de saúde. Discute a abordagem da educaçäo em saúde de forma individual ou coletiva, tendo como base o Programa de Assistência Integral à Saúde da Mulher.