The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and bring together existing research to answer a specific research quesiton. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national licence to the Cochrane Libray, including the U.K. and Ireland, can access the Cochrane Library online, free of charge through www.thecochranelibrary.com.

Midwife-led continuity models versus other models of care for childbearing women.

Background
In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

Objectives
To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

Search methods
Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

Selection criteria
We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

Data collection and analysis
One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

Main results
We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.

Our synthesis pointed to a number of factors affecting SBAs’ provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.

Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.

Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral.

We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

Authors' conclusions
Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low‐ and middle‐income countries: a qualitative evidence synthesis

Esta e uma revisao integrativa de literatura cujo objetivo foi identificar e analisar publicacoes cientificas sobre o uso das metodologias ativas no ensino e assistencia de enfermagem no Brasil. O levantamento bibliografico incluiu publicacoes nacionais, no periodo de 1999 a 2009. Foram verificadas as bases de dados LILACS, BDENF, MEDLINE e a biblioteca eletronica SciELO. Foram selecionados 28 artigos. Os resultados e a analise mostraram a problematizacao como a principal metodologia ativa utilizada, a falta de referenciais teoricos para planejar a acao pedagogica e o uso excessivo de tecnicas de ensino que nem sempre caracterizam a inovacao do metodo. Conclui-se que a implementacao das metodologias inovadoras ainda carece de mais estudos e necessita de maior investimento em pesquisa e divulgacao sobre o assunto.

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Utilização de metodologia ativa no ensino e assistência de enfermagem na produção nacional: revisão integrativa

El objetivo fue describir indicadores de calidad de la atencion prenatal en Brasil en el ambito del Programa de Mejoria del Acceso y de la Calidad (PMAQ-AB). Se analizaron el numero de consultas, situacion de vacunacion, prescripcion de sulfato ferroso, examen fisico, orientaciones y examenes complementarios, en base a lo que se construyo como un indicador sintetico de calidad. Los datos fueron recogidos en 2012/2013, mediante entrevistas realizadas por evaluadores externos del PMAQ-AB, entre 6.125 usuarias que realizaron su ultimo examen prenatal en las unidades de Salud de la Familia. Durante el periodo prenatal, un 89% realizaron seis o mas consultas, mas de un 95% actualizaron la vacuna antitetanica y obtuvieron recetas de sulfato ferroso, un 24% informaron haber recibido todos los procedimientos de examen fisico, un 60% recibieron todas las orientaciones y un 69% realizaron todos los examenes complementarios. Solamente un 15% de las entrevistadas recibieron atencion prenatal adecuada, considerandose todas las acciones preconizadas, siendo significativamente mayor la proporcion "de en su totalidad" en la atencion en gestantes con mas edad, de mayor renta, en la Region Sudeste, en los municipios con mas de 300 mil habitantes y con IDH en el cuartil superior. Persisten desigualdades sociales e individuales que pueden ser objeto de acciones de cualificacion de los procesos de trabajo de equipos de salud.

/pdf/calidad-de-la-atencion-prenatal-en-la-red-basica-de-salud-de-3j0eyq9pmd.pdf

Calidad de la atención prenatal en la red básica de salud de Brasil: indicadores y desigualdades sociales

The educational dimension is a fundamental and innovative part in prenatal assistance. The objective of the study was to know the perception of pregnant women users of the Basic Health Unit of Maringa/PR regarding health education and how it takes place. It was a qualitative study carried out with 25 pregnant women from five Basic Health Units of Maringa/PR. Data were collected in November 2009 through semi-structured interviews submitted to content analysis. Results indicated that great part of the women knows and identifies the health educative actions accomplished by the professionals. They attribute great importance to these actions, mainly for prevention of diseases and aggravating circumstances during pregnancy, and also to learn how to care for the baby after childbirth. It was concluded that there is still a gap in what concerns to the educational actions addressed to prenatal attendance in primary health services. Descriptors: Health Education; Nursing; Pregnant Women; Primary Health Care.

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Ações educativas durante a assistência pré-natal: percepção de gestantes atendidas na rede básica de Maringá-PR

Educational practices are widely used in the health field, both in continuing education for health professionals and health education for the general population. These two fields intersect through the development of educational knowledge oriented by a set of target representations of man and society. Such representations are demonstrated by teaching/learning processes in the four main pedagogical trends in Brazil: traditional, renewed, conditioning-based, and liberating (or the Paulo Freire approach). Based on their respective principles, methods, and individual and social consequences, we contend that liberating pedagogy can produce better results than the others by allowing the student's active participation in the learning process, thus fostering continuous development of human skills in both the health services clientele and health workers.

/pdf/pedagogical-approaches-and-educational-practices-in-health-29d2w0kww9.pdf

Pedagogical approaches and educational practices in health sciences

RESUMO : Pesquisa descritiva, de abordagem quantitativa, que objetivou descrever a avaliacao da formacao e insercao profissional das egressas do Curso de Residencia em Enfermagem Obstetrica da Universidade do Estado do Rio de Janeiro. Foram 19 enfermeiras egressas, do periodo de 2004 a 2011, que responderam o questionario estruturado. As expectativas previas das enfermeiras foram totalmente atendidas pelo curso (84,2%), mas a formacao requer aprimoramentos nos conteudos teoricos e na supervisao direta da preceptoria. A maioria das egressas possui dois vinculos empregaticios (78,9%) e atua na area obstetrica (73,7%), com predominância na assistencia ao parto normal (36,8%), ao pre-natal (26,3%) e as emergencias obstetricas (26,3%). Em relacao a pratica profissional, 42,2% consideraram exercer a profissao com autonomia. No entanto, ainda persistem barreiras profissionais no sistema de saude, como o mercado de trabalho restrito, resistencia dos medicos, pouco reconhecimento profissional e precarias condicoes de trabalho. ABSTRACT : This quantitative descriptive study aimed to describe the training and vocational placement of graduates from the obstetrical nursing residency program at Rio de Janeiro State University. Nineteen graduate nurses answered a structured questionnaire. The nurses’ prior expectations were fully met by the course (84.2%), although requiring improvements in theoretical content and direct tutorial supervision. Most of the nurses had two jobs (78.9%) and worked in obstetrics (73.7%), predominantly in normal child birth care (36.8%), antenatal care (26.3%) and obstetric emergencies (26.3%). As regards exercising their profession, 42.2% have considered working independently. However, barriers to the profession persist in the health system, such as there stricted employment market, resistance from physicians, lack of professional status, and poor working conditions. RESUMEN : Investigacion descriptiva, de abordaje cuantitativo, que objetivo describir la evaluacion de la formacion y insercion profesional de las egresadas del Curso de Residencia en Enfermeria Obstetrica de la Universidad del Estado de Rio de Janeiro-Brasil. Fueron 19 enfermeras egresadas, del periodo de 2004 a 2011, que respondieron el cuestionario estructurado. Las expectativas previas de las enfermeras fueron totalmente cumplidas por el curso (84,2%), pero la formacion requiere mejoras en los contenidos teoricos y en la supervision directa de las preceptoras. La mayoria de las enfermeras tiene dos contratos de trabajo (78,9%) y actua en el area de obstetricia (73,7%), sobre todo en la asistencia al parto normal (36,8%), al prenatal (26,3%) y a las emergencias obstetricas (26,3%). En relacion a la practica profesional, 42,2% consideraron que ejercen la profesion con autonomia. Sin embargo, aun existen barreras profesionales en el sistema de salud, como el mercado de trabajo restricto, resistencia de los medicos, poco reconocimiento profesional y precarias condiciones de trabajo.

Formação e inserção profissional das egressas do curso de residência em enfermagem obstétrica

O ambiente de relaxamento para humanização do cuidado ao parto hospitalar

Expectativas, motivaciones y percepciones de las enfermeras sobre la especialización en enfermería obstétrica en la modalidad de residencia

Objetivo: Identificar motivaciones y expectativas de enfermeras que optaron por el curso de especializacion en enfermeria obstetrica en la modalidad de residencia y describir las percepciones de ellas sobre el postgrado lato sensu. Metodos: Estudio descriptivo de enfoque cualitativo. Fueron entrevistadas enfermeras residentes de dos programas de residencia en enfermeria obstetrica en la ciudad de Rio de Janeiro. Se utilizo la tecnica de Analisis de Contenido Tematico. Resultados: La opcion por la residencia es motivada por su enfasis en la experiencia practica; identificacion con el area de la salud de la mujer; obtencion de auxilio financiero durante el curso y credenciales profesionales para el mercado de trabajo. El aprendizaje practico es satisfactorio, pero hay limitaciones en las areas de hospitalizacion y en la integracion de la teoria con la practica. Conclusion: La universidad y el servicio deben trabajar de manera mas integrada para mejorar el proceso educativo en la residencia.

Adriana Lenho de Figueiredo Pereira

Papers

Pedagogical approaches and educational practices in health sciences

Formação e inserção profissional das egressas do curso de residência em enfermagem obstétrica

O ambiente de relaxamento para humanização do cuidado ao parto hospitalar

Expectativas, motivaciones y percepciones de las enfermeras sobre la especialización en enfermería obstétrica en la modalidad de residencia

Expectativas, motivações e percepções das enfermeiras sobre a especialização em enfermagem obstétrica na modalidade residência