Brazilian women's use of evidence-based practices in childbirth after participating in the Senses of Birth intervention: A mixed-methods study.

Brazil has a cesarean rate of 56% and low use of Intrapartum Evidence-based Practices (IEBP) of 3.4%, reflecting a medically centered and highly interventionist maternal health care model. The Senses of Birth (SoB) is a health education intervention created to promote normal birth, use of EBP, and reduce unnecessary c-sections. This study aimed to understand the use of intrapartum EBP by Brazilian women who participated in the SoB intervention. 555 women answered the questionnaire between 2015 and 2016. Bivariate analysis and ANOVA test were used to identify if social-demographic factors, childbirth information, and perceived knowledge were associated with the use of EBP. A qualitative analysis was performed to explore women's experiences. Research participants used the following EBP: birth plan (55.2%), companionship during childbirth (81.6%), midwife care (54.2%), freedom of mobility during labor (57.7%), choice of position during delivery (57.2%), and non-pharmacological pain relief methods (74.2%). Doula support was low (26.9%). Being a black woman was associated with not using a birth plan or having doula support. Women who gave birth in private hospitals were more likely not to use the EBP. Barriers to the use of EBP identified by women were an absence of individualized care, non-respect for their choices or provision of EBP by health care providers, inadequate structure and ambiance in hospitals to use EBP, and rigid protocols not centered on women's needs. The SoB intervention was identified as a potential facilitator. Women who used EBP described a sense of control over their bodies and perceived self-efficacy to advocate for their chosen practices. Women saw the strategies to overcome barriers as a path to become their childbirth protagonist. Health education is essential to increase the use of EBP; however, it should be implemented combined with changes in the maternal care system, promoting woman-centered and evidence-based models.

Developing operational standards for Midwifery Centers.

BACKGROUND: Midwifery centres have been identified in over 56 countries. Consensus was reached on a global definition for midwifery centres, yet there is a lack of standards to assure consistent quality of care is provided. METHODS: Evidence-based standards and guidelines developed from American Association of Birth Centres (USA), Midwifery Unity Network (UK/EU), World Health Organization, International Childbirth Initiative, and White Ribbon Alliance, were gathered, duplicate standards were removed, and language was adapted for global use with sensitivity to low and middle countries (LMIC). An initial list of 52 midwifery centre standards were identified. Through an informal modified Delphi process these were reviewed by global midwifery centres experts, researchers, and midwifery centre staff at focus groups in Haiti, Mexico and Bangladesh for significance, language, and usability. The standards were then piloted at midwifery centres in eight countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda and Trinidad). All feedback was incorporated into the final standards. RESULTS: A final list of 43 standards, organized into 3 domains including quality standards for care providers, dignity standards for women, and community standards for administration, were agreed on. CONCLUSION: Midwifery centres are prevalent around the globe. Identifying standards for quality of care provides a foundation for the midwifery centre model to be replicated and ensure consistent quality of care. Evidence based standards for midwifery centres in LMIC, allows systems to embrace and encourage the implementation and growth of midwifery centres to address accessible, acceptable, respectful, woman-centred, community-engaged maternal health care that participates fully in the health care system.

Gestação e parto em uma comunidade rural amazônica: reflexões sobre o papel da parteira tradicional / Pregnancy and childbirth in a rural community in the Amazon: reflections on the role of traditional midwives / Gestación y parto en una comunidad rural amazónica: reflexiones sobre el papel de la comadrona tradicional

O artigo tem como objetivo a reflexão sobre o papel social das parteiras e sua relação com os serviços de saúde na comunidade rural de Lindoia, município de Itacoatiara, Amazonas. Nessa comunidade, há uma sala de parto onde atua uma auxiliar de enfermagem que se identifica como parteira, sendo que também atua como articuladora entre outras parteiras da localidade. Realizamos 13 entrevistas abertas e dez semiestruturadas para discutir a inserção das parteiras tradicionais na Unidade Básica de Saúde (UBS), buscando analisar as aproximações e os estranhamentos entre parteiras e equipe. Conclui-se que as parteiras da comunidade conquistaram um espaço importante na UBS, mas suas ações são limitadas e reguladas pela gestão e pela equipe de saúde. Entende-se que há necessidade de ampliarmos o diálogo intercultural entre os saberes biomédicos e tradicionais no cotidiano do cuidado em saúde.

This article reflects on the social role of traditional midwives and their relation with health services in the rural community of Lindóia in the State of Amazonas, Brazil. This community has a delivery room and nursing assistant who is acts as a midwife and articulator of other traditional midwives in the area. We conducted 13 open-ended interviews and ten semi-structured interviews to investigate the involvement of traditional midwives in a primary care center, comparing their responses with those of the health team. It was concluded that community midwives play an important role in the care center, although their activities are limited and regulated by the health facility manager and health team. There is a need to broaden intercultural dialogue between biomedical and traditional knowledge in everyday health care practice.

El objetivo de este artículo es la reflexión sobre el papel social de las comadronas y su relación con los servicios de salud en la comunidad rural de Lindóia, municipio de Itacoatiara, Amazonas. En esa comunidad, hay una sala de parto en donde actúa una auxiliar de enfermería que se identifica como comadrona, siendo que ella también actúa como articuladora entre otras comadronas de la localidad. Realizamos 13 entrevistas abiertas y diez semiestructuradas para discutir la inserción de las comadronas tradicionales en la Unidad Básica de Salud (UBS), buscando analizar las aproximaciones y los extrañamientos entre comadronas y equipo. Se concluye que las comadronas de la comunidad conquistaron un espacio importante en la UBS, pero sus acciones están limitadas y reguladas por la gestión y equipo de salud. Se entiende que hay necesidad de que ampliemos el diálogo intercultural entre los saberes biomédicos y tradicionales en el cotidiano del cuidado en salud.

Combining task shifting and community-based care to improve maternal health: Practical approaches and patient perceptions.

Globally, community-based care and task shifting strategies are used to address maternal healthcare shortages in low-income countries. Limited research exists on models that combine these strategies. Using a qualitative approach, we explored Haitian women's perceptions of the Midwives for Haiti model, which unites task shifting and community-based care by training nurses as skilled birth attendants and offering healthcare via rotating, mobile clinics. Eight focus groups (N = 52) were conducted in rural Haiti in March 2017. Thematic analysis of data indicated that perceptions of care were universally positive. Participants cited accessible patient-centred care, affordable services, and health education as primary motivators to attend. Results illustrated the importance of women's perceptions on the future use of mobile clinic sites or other formal care. Future efforts to address maternal healthcare shortages should consider the Midwives for Haiti model, combining task shifting and community-based care to address common social, topographical, or financial barriers to maternal healthcare.

The global advisory panel on the future of nursing & midwifery report: 2014-2017

Future of Nursing & Midwifery (GAPFON®) is to establish a voice and vision for the future of nursing and midwifery that will advance global health while simultaneously strengthening professional roles. GAPFON provides a platform for nursing and midwifery to have an inclusive voice worldwide, to be a catalyst for global health partnerships and collaborations, and to help develop and influence policy and practice. In addition, GAPFON provides strategies on how nursing and midwifery can improve global health outcomes and contribute to strengthening healthcare systems. (AU)

À margem da humanização? Experiências de parto de usuárias de uma maternidade pública de Porto Alegre-RS / Apart from humanization? Birth experiences of users of a public maternity hospital in Porto Alegre-RS, Brazil

Resumo O artigo reflete sobre as experiências de mulheres em relação à assistência ao parto numa maternidade pública de Porto Alegre-RS. Adota-se uma perspectiva dos direitos humanos, entendendo a humanização como uma garantia ampla de direitos das mulheres a uma parturição segura, socialmente amparada e prazerosa. Trata-se de um estudo qualitativo exploratório, que utilizou as técnicas de observação participante, entrevista semiestruturada e pesquisa documental. Aceitaram fazer parte da pesquisa 25 mulheres puérperas, com idades entre 18 e 38 anos. Os relatos das participantes e os registros de campo foram examinados por meio da análise de discurso. Como resultados, constatamos uma fragmentação das práticas tidas como "humanizadoras", atreladas a protocolos de procedimentos no manejo do parto e, muitas vezes, à inflexibilidade perante eles. A supervalorização de tecnologias/práticas intervencionistas no corpo da mulher, assim como as hierarquias entre profissionais e usuárias apareceram nos relatos e nas observações. Sentimentos e sensações das mulheres em relação ao parto pareciam não ser contemplados e ficavam à margem do cuidado. Identificaram-se práticas de violência obstétrica, que muitas vezes eram banalizadas pelas próprias mulheres em consonância ao que elas esperavam de um atendimento público. Essas situações parecem reforçar hierarquias reprodutivas, deixando essas gestantes "à margem da humanização".

Abstract This paper reflects on the experiences of women regarding childbirth care in a public maternity hospital in Porto Alegre-RS. It adopts a human rights perspective, understanding humanization as a broad guarantee of women's rights to a safe, socially supported and pleasurable parturition. This is an exploratory qualitative study, using participant observation techniques, semi-structured interviews and documentary research. Twenty-five postpartum women, aged between 18 and 38, took part in the study. Participant reports and field records were examined through Discourse Analysis. As a result, it was identified a fragmented nature of the practices considered as "humanizing", linked to protocols of procedures in the management of childbirth and often linked to inflexibility regarding these protocols. The overrating of interventionist technologies/ practices in women's body, as well as the hierarchies between professionals and users appeared in the reports and the observations. Subjective experiences of motherhood seemed not to be considered and were left on the margins of care. It was identified specific modes of obstetric violence experienced by grassroots women, which are trivialized by the women themselves in accordance with what they expected from a public service. These situations reinforce reproductive hierarchies and end up leaving these pregnant women "on the fringes of humanization".

O cuidado à mulher no contexto da maternidade: caminhos e desafios para a humanização / El cuidado de las mujeres en el contexto de la maternidad: caminos y desafíos de humanizar / The care of women in the context of maternity: challenges and ways to humanize

Objective: to know the perception of mothers about the care received during hospitalization in a public hospital. Methods: Descriptive study, performed at a secondary public hospital in Fortaleza/Ceará. Data were collected through semi-structured interview with 20 mothers, and analyzed using the technique of content analysis. Results: The most part of women realized the attention received as quality, accessible and humane, and emphasizing the reception and good relationship with the health care team. However, difficulties were also observed, as the lack of monitoring of the health team during labor, lack of information and insensitive and rude behavior of some professionals. Conclusion: The study encourages reflection and debate among professionals and managers, points out weaknesses and potentialities and indicates paths to follow in order to improve health care for women in maternity wards.

Objetivo: conhecer a percepção de puérperas acerca da atenção recebida durante a internação em uma maternidade pública. Método: Estudo descritivo, realizado em um hospital público de nível secundário de Fortaleza/Ceará. Os dados foram coletados mediante entrevista semiestruturada a 20 puérperas, e analisados a partir da técnica de análise de conteúdo. Resultados: As mulheres, em sua maioria, perceberam a atenção recebida como de qualidade, fácil acesso e humanizada, além de enfatizarem o acolhimento e o bom relacionamento com a equipe de saúde. Porém, dificuldades também foram evidenciadas, como a falta de acompanhamento da equipe de saúde durante o trabalho de parto, a ausência de informações e o comportamento indelicado e insensível de alguns profissionais. Conclusão: O estudo estimula reflexão e debate entre profissionais e gestores, aponta fragilidades e potencialidades e indica desafios a serem seguidos com vistas a melhorar a assistência à mulher nas maternidades.

Objetivo: conocer la percepción de mujeres en postparto sobre la atención que recibió durante su hospitalización en una maternidad pública. Métodos: Estudio descriptivo, realizado en un hospital públicosecundario en Fortaleza/Ceará. Los datos fueron recolectados a través de entrevistas semiestructuradas a 20 mujeres en postparto y se analizaron mediante la técnica de análisis de contenido. Resultados: Las mujeres, en su mayoría, se dieron cuenta de la atención recibida como la calidad, accesible y humana, y haciendo hincapié en la recepción y la buena relación con el equipo de atención médica. Sin embargo, también se observaron dificultades, como la falta de monitoreo del equipo de salud durante el parto, la falta de información y el comportamiento insensible y grosero de algunos profesionales. Conclusión: El estudio promueve la reflexión y el debate entre profesionales y directivos, señala debilidades y potenciales, indican caminos a seguir con el fin de mejorar la atención de salud para las mujeres en las salas de maternidad.

Nursing and midwifery in the history of the World Health Organization 1948-2017

Every country needs a competent, motivated, well-distributed and supported health workforce. Health workers are the cornerstone of the strong, resilient health systems needed to achieve universal health coverage. These are the people who keep the world safe, improve health, and protect the vulnerable. These are the people who detect, prevent and manage health emergencies, and who promote the well-being of women, children and adolescents. Nurses and midwives are the unsung heroes of the health workforce and the backbone of primary health care systems. Making up over half of the health workforce in many countries, nurses and midwives can transform the ways health actions are organized and how health care is delivered. Over the years, nurses and midwives have contributed to major global health landmarks, like the eradication of small pox and the dramatic reductions in maternal and child mortality that have occurred in many countries. But nurses and midwives need support and they need recognition. (AU)

Seguridad y destreza autoreportadas en la formación de competencias clínicas obstétricas en estudiantes de obstetricia / Self-reported confidence and skills in training for clinical-obstetric competences on Obstetrics students

Introducción: la educación en ciencias de la salud ha requerido adaptaciones de acuerdo a necesidades de la población, y así muchos programas de estudios han adoptado el modelo de competencias. Se hace necesario demostrar la adquisición del conocimiento práctico desarrollándose actividades con seguridad y destreza que permita la atención clínica efectiva. Objetivo: analizar niveles de destreza y seguridad autoreportados y rendimiento obtenido por estudiantes de la carrera de Obstetricia y Puericultura de la Universidad de Concepción, Chile, que entrenan competencias obstétricas, además con simulación clínica. Métodos: se realizó estudio no experimental, analítico y relacional, en 127 estudiantes de la carrera de Obstetricia y Puericultura de la Universidad de Concepción, en el año 2014. Se aplicó encuesta para medir destreza con escala tipo Likert posterior al entrenamiento de competencias obstétricas en modalidad preclínica, y la seguridad en modalidad clínica y se relacionó con el rendimiento obtenido. Se realizó análisis descriptivo y relacional. Resultados: 119 estudiantes respondieron las encuestas para destreza y 115 para seguridad. Las competencias obstétricas fueron 30, de complejidad variable, con resultados diversos. Las destrezas altas se relacionan con seguridad alta, sin embargo no todas las competencias siguen este curso. La destreza no se relaciona con rendimiento. Conclusiones: las competencias obstétricas son diversas en complejidad, con diferentes niveles de destreza y seguridad, algunas muy altas y otras más bajas, sin embargo algunas importantes presentan niveles más bajos que los esperados. Es necesario ordenar los niveles de complejidades. La evaluación de los estudiantes no se relaciona con el logro de competencias, se hace necesario establecer instrumentos adecuados(AU)

Introduction: The education of health sciences has required adjustments according to the needs of the general population and therefore most programs have adopted models based on competencies. It is necessary to demonstrate the acquisition of practical knowledge developed with regards to safety and skill that allows for more effective clinical care. Objective: To analyze the self-reported levels of skill and safety and the assessments obtained by students of midwifery at University of Concepcion, Chile. They train in obstetric skills mainly via clinical simulation. Method: Analytical and relational, non-experimental study with non-probabilistic by 119 volunteer midwifery students at the university at the University of Concepcion in 2014. A Likert type scale survey was administered post practical trainings in preclinical and clinical settings which was correlated with the student's performances. A descriptive and relational analysis was executed. Results: 119 students completed the surveys for skill level and 115 for security of procedures. There were 30 obstetric skills practical trainings, all of varying degrees of complexity with mixed results. High levels of skill are related to high levels of security but not all of their competencies follow this pattern. The level of skill does not relate to performance. Conclusions: Obstetric skills are diverse in terms of complexity, with diferent levels of skill and safety, mostly high for both, but some are not important. It is necessary to sort the levels of complexity. The evaluation of students is not related to the achievement of competencies. It is necessary to establish appropriate measuring instruments(AU)

A profile of midwifery in Paraguay.

OBJECTIVE: The goal of this study was to provide a descriptive profile of midwifery in Paraguay. DESIGN: The study involved three components: background research from official documents and key informant interviews to complete questionnaires, qualitative interviews with Paraguayan midwives and obstetricians, and participant observation. Data from official documents and questionnaires were tabulated using descriptive statistics. Individual interviews and small-group interviews of midwives, student midwives, and obstetricians were conducted in five health departments of Paraguay. SETTING: The research took place in the capital of Paraguay, Asunción, and four additional health departments: Central, Cordillera, Guira, and Misiones. PARTICIPANTS: Twenty-two midwives, nine student midwives, nine obstetricians, and five leaders of professional health organisations in Paraguay participated in this study. FINDINGS: Three salient themes were identified throughout the interviews. First was the understanding of the changing role of the midwife in the health system, particularly in and around the capital city of Asunción. Second, midwives and obstetricians both reported that women were not sufficiently prepared for labour and birth during the antenatal period. Limited antenatal education and childbirth classes existed and midwives felt that this was a major barrier to vaginal birth. Finally, access to midwife-provided antenatal care is perceived to be limited. A major barrier to accessing midwifery care for women in the capital is related to the midwives' changing role in practice. Obstetricians are now providing antenatal care more often than they used to, and in some public hospitals they also attend vaginal deliveries. KEY CONCLUSIONS AND IMPLICATIONS: Limiting the utilisation of midwives may well be a major contributor to the rising rates of caesarean sections. Women are not prepared for labour and birth in the antenatal period, or are scheduled for elective caesarean sections antenatal ly. Midwives are not fulfilling their potential to prepare women for labour and birth, despite their high-level professional training. Midwives have the potential to improve antenatal preparation for low-intervention birth. This transition in care provision would be a more effective use of human resources for both obstetricians and midwives.

Assistência ao parto: do domicílio ao hospital 1830-1960 / Childbirth care: the household to hospital 1830-1960

Este artigo tem por objetivo contribuir para o debate atual sobre a assistência ao parto no Brasil. Faz um retrospecto dos principais modelos de atendimento ao parto no país, com destaque para os estados do Rio de Janeiro, Bahia e São Paulo...

Cultural adaptation of birthing services in rural Ayacucho, Peru.

PROBLEM: Maternal mortality is particularly high among poor, indigenous women in rural Peru, and the use of facility care is low, partly due to cultural insensitivities of the health care system. APPROACH: A culturally appropriate delivery care model was developed in poor and isolated rural communities, and implemented between 1999 and 2001 in cooperation with the Quechua indigenous communities and health professionals. Data on birth location and attendance in one health centre have been collected up to 2007. LOCAL SETTING: The international nongovernmental organization, Health Unlimited, and its Peruvian partner organization, Salud Sín Límites Perú, conducted the project in Santillana district in Ayacucho. RELEVANT CHANGES: The model involves features such as a rope and bench for vertical delivery position, inclusion of family and traditional birth attendants in the delivery process and use of the Quechua language. The proportion of births delivered in the health facility increased from 6% in 1999 to 83% in 2007 with high satisfaction levels. LESSONS LEARNED: Implementing a model of skilled delivery attendance that integrates modern medical and traditional Andean elements is feasible and sustainable. Indigenous women with little formal education do use delivery services if their needs are met. This contradicts common victim-blaming attitudes that ascribe high levels of home births to 'cultural preferences' or 'ignorance'.

Daughter of time: the postmodern midwife (part 2).

Any effort to make sense of the complexities of contemporary midwifery must deal not only with biomedical and governmental power structures but also with the definitions such structures impose upon midwives and the ramifications of these definitions within and across national and cultural borders. The international definition of a midwife requires graduations from a government-recognized educational program. Those who have not are not considered midwives but are labeled traditional birth attendants. Since there are myriad local names for midwives in myriad languages, the impact of this naming at local levels can be hard to assess. But on the global scale, the ramifications of the distinction between midwives who meet the international definition and those who do not have been profound. Those who do are incorporated into the health care system. Those who do not remain outside of it, and suffer multiple forms of discrimination as a result.

Daughter of time: the postmodern midwife (Part 2)

Any effort to make sense of the complexities of contemporary midwifery must deal not only with biomedical and governmental power structures but also with the definitions such structures impose upon midwives and the ramifications of these definitions within and across national and cultural borders. The international definition of a midwife requires graduations from a government-recognized educational program. Those who have not are not considered midwives but are labeled traditional birth attendants. Since there are myriad local names for midwives in myriad languages, the impact of this naming at local levels can be hard to assess. But on the global scale, the ramifications of the distinction between midwives who meet the international definition and those who do not have been profound. Those who do are incorporated into the health care system. Those who do not remain outside of it, and suffer multiple forms of discrimination as a result.

Qualquer esforço para dar sentido à complexidade do processo reprodutivo na vida contemporânea se depara não só com o modelo biomédico e as estruturas governamentais de poder, mas também com as definições que tais estruturas impõem às parteiras e obstetrizes e à sua denominação, considerando-se os limites nacionais e culturais. A definição internacional de parteira demanda a formação em instituições de ensino reconhecidas pelo governo. As parteiras tradicionais não podem ser consideradas parteiras, mas são denominadas parteiras tradicionais. Há uma gama enorme de denominações para as parteiras em diversos locais, nas diversas línguas e ao longo do tempo, que torna difícil nomear este profissional. Entretanto, em escala global, pode-se reconhecer que há duas ramificações de parteira: a que está incorporada ao sistema de saúde e a que está fora dele.

Cualquier esfuerzo para dar sentido a la complejidad del proceso reproductivo en la vida contemporánea se depara no solamente con el modelo biomédico y las estructuras gubernamentales de poder, sino con las definiciones que estas estructuras imponen a las parteras y matronas y su denominación considerándose los límites nacionales y culturales. La definición internacional de partera demanda formación en instituciones de enseñanza reconocidas por el gobierno. Las parteras tradicionales no pueden ser consideradas parteras, pero son denominadas parteras tradicionales. Hay una gama enorme de denominaciones para las parteras, en diversos locales, en las diversas lenguas y a lo largo del tiempo, y por eso es difícil nombrar a este profesional. No obstante, en escala global se puede reconocer que hay dos ramificaciones de partera: la que está incorporada al sistema de salud y la que está fuera de él.

Daughter of time: the postmodern midwife (Part 1)

This article presents the notion of the postmodern midwife, defining her as one who takes a relativistic stance toward bio-medicine and other knowledge systems, alternative and indigenous, moving fluidly between them to serve the women she attends. She is locally and globally aware, culturally competent, and politically engaged, working with the resources at hand to preserve midwifery in the interests of women. Her informed relativism is most accessible to professional midwives but is also beginning to characterize some savvy traditional midwives in various countries. Thus the concept of the postmodern midwife can serve as a bridge across the ethnic, racial, and status gaps that divide the professional from the traditional midwife, and as an analytical focal point for understanding how the members of each group negotiate their identities and their roles in a changing world.

Este artigo busca conceituar a parteira pós-moderna, definindo-a como aquela que tem uma postura realista em relação à bio-medicina e a outros sistemas de conhecimento, movendo-se fluidicamente entre eles para ajudar as mulheres que assiste. É consciente, culturalmente competente e politicamente engajada. Trabalha com recursos do seu conhecimento específico, aliados aos interesses da mulher. Seu relativismo informado é mais acessível para as parteiras profissionais, mas o que se observa, ao redor do mundo, é que esta atitude está atingindo as parteiras tradicionais, em diversos países. Assim, o conceito de parteira pós-moderna representa uma ponte para as brechas étnicas, raciais e de status, que separam as parteiras profissionais das tradicionais, e um ponto focal e analítico para a compreensão da forma de negociação de identidades e papéis de cada um dos membros no grupo, no mundo em transformação.

Este artículo busca conceptuar la partera pos-moderna, definiéndola como aquella que tiene una postura en relación a la biomedicina y a otros sistemas de conocimiento, moviéndose fluidificado entre ellos para ayudar a las mujeres que asiste. Es consciente, culturalmente competente y políticamente enganchada. Trabaja con recursos de su conocimiento específico, aliados a los intereses de la mujer. Su relativismo informado es más accesible para las parteras profesionales, pero lo que se observa, alrededor del mundo, es que esta actitud está atingiendo las parteras tradicionales, en diversos países. Así, el concepto de partera pos-moderna representa una puente para las brechas étnicas, raciales y de status, que separan las parteras profesionales de las tradicionales, y un punto focal y analítico para la comprensión de la forma de negociación de identidades y papeles de cada uno de los miembros en el grupo, en el mundo en transformación.

Rekindling of nurse-midwifery in Brazil: public policy and childbirth trends.

In the last decade, nurse-midwifery in Brazil has experienced many changes both professionally and politically. In the 1990s, Brazil's Ministry of Health generated policies to improve childbirth services. Included in these policy initiatives was legislation for the reimbursement of nurse-midwifery services and a substantial increase in financing of nurse-midwifery schools throughout the country. It was during this period that the Brazilian National Nurse-Midwifery Organization was formed to provide professional leadership and an alternative model of childbirth care. The future is hopeful, but the nurse-midwifery profession will need collective determination to succeed in changing practices and improving services to women and families.