História Essencial da Filosofia Vl 5 (Portuguese Edition)

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On receiving ethical permission for the study at a central Lisbon hospital, the principal researcher lead author interviewed one midwife and made observations at childbirth education classes, but after several months of failed attempts at interviewing obstetricians was forced to secure an alternative fieldwork base. She identified a hospital situated within commuting distance of Lisbon whose maternity unit had promulgated normal birth since a rare approach , and was more open to the study.

However, despite the authorization and full support of unit management, recruiting doctors for interview was again problematic. All midwives approached agreed to be interviewed. Observations were conducted over the same period as the interviews.

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Given the dearth of doctor respondents, however, ethical permission was also secured for supplementary interviews with three female doctors responsible for ante-natal care at a government Health Centre in central Lisbon; while one of these was also a qualified obstetrician and had experience of providing support during childbirth, two of these interviewees were solely responsible for ante-natal care within the public health system.

In a separate element to the study, eight Portuguese women were interviewed throughout pregnancy and seven of these following birth, whereby they detailed their personal experiences, resulting in a total of eight detailed birth narratives. These individuals were recruited through advertisements in a magazine aimed at mothers and at local health centres, and through snowball sampling.

All interviewees provided informed consent. Interviews were conducted in Portuguese and recorded, transcribed and translated into English, with the support of the co-researcher second author and analysed using a content analysis approach. Observation notes were transcribed and integrated within the analysis. In the words of one respondent: As one interviewee detailed:. However, the reference to the WHO in the first citation, rather than to the policies of the hospital employing the midwife, may reflect the ambiguous status of physiological birth within the Portuguese institutional context.

At the same time, as noted, the hospital under study was unusual in its official promotion of this locally-defined normal birth approach. All midwife interviewees expressed their support of this relatively recent development, highlighting how observable progress had been made:. We midwives, we know perfectly well what we are doing. As described by one professional who had been working for more than 22 years in the unit:.

Sometimes there is a cataclysmic haemorrhage… women who have already given birth. No distinction is made between the potential individual needs or wishes of women, or parturients of known high risk or low risk. Moreover, doctors described an apparently coherent, complementary model, whereby midwives cared for women throughout labour, freeing obstetricians to carry out urgent and emergency work, up until the point when intervention, in certain cases, became necessary. Midwives were more likely to present labour pain as a unique physiological phenomenon which certain women can be supported to bear without medical intervention.

Certain doctors equated the rejection of epidural anaesthesia to refusing pain relief during a tooth extraction, an analogy evoking an earlier historical period of more primitive medicine — anaesthetic thereby being associated with progress see De Luca, this volume.

Such an analogy is also often employed in popular discourse in Portugal 14 to pose a logical argument for accepting epidural during birth, exemplifying perhaps how authoritative knowledge functions in sustaining beliefs and associated behaviour in relation to birth. Obstetricians, further, described institutional pressures which precipitate other forms of intervention, such as induction of labour to hasten deliveries late at night in order to ensure colleagues arriving for the morning shift would not find all unit beds occupied.

This phenomenon adds considerable complexity to the patient-midwife-doctor triad of care provision. Do you know why? In other words, they come… see a patient, operate… do whatever, then go away… This is one thing I tried to change… even getting doctors to meet together was difficult, let alone arranging meetings between doctors and nurses. The different perspectives identified concerning the nature of modern and progressive care reveal how different forms of authoritative knowledge may co-exist, reflecting contested and sometime shifting power relations and cultural values Jordan ; Sargent and Davis-Floyd ; and while some doctors may be accepting change, some may be actively resisting it.

This individualism was also observable in the way doctors described how they worked.

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Midwives, contrastingly, often referred to working within a team of peers, a distinction which mirrors findings from previous hospital research in Portugal Monteiro No joint meetings of obstetricians and midwives ever took place. Workplace tensions between the two groups were, moreover, openly described in interviews.

One obstetrician exemplified the tensions in his description of a recent interaction:. With a line we can also give blood. In each case, the women described not being given information to explain the reasons for the intervention. Sometimes people find it hard to assert their expertise… due to their fear of biomedicine, basically. This is the kind of thing we [midwives] discuss. For us and for women: Doctor is used in social interactions to mark the professional status of those who have a medical qualification or a PhD , and is a term of formal and polite respect denoting superior status.

It can be applied very formally, obsequiously and also even ironically. The reference to women as the ostensible focus of interest in the final citation raises a critical question: The eight birth narratives ranged from four cases of C-section following induction of labour , 20 two in a private and two in a public hospital, and four vaginal births, three of which included epidural anaesthetic and one also an episiotomy , two of which took place in a public hospital, one in a private hospital and one at home.

The hospital births occurred in different settings in and around Lisbon — it was not methodologically possible to triangulate by only recruiting women from the hospital where interviews and observations were conducted. During interviews through the course of her pregnancy, the question of ensuring that her personal obstetrician was present for the birth regularly emerged, until the prospect of induction was introduced by this doctor:.

She wants to be here and work carefully with time to deal with everything. But I want an epidural [laughs]. Do you want anaesthetic or not? Nowadays we have the option of not suffering. Surprised and taken aback by this proposition, she detailed her resistance to this approach:. Of course you can go into labour and come to the hospital and deliver… then it could be with any doctor.

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The description of her friends, reproducing the discourse presented to them by doctors, represents the active, seemingly uncritical reinforcement and legitimisation of an interventionist practice. The concept of risk transmitted to women can be considered an important element of the vocabulary of authoritative knowledge.

It resulted in the extreme opposite where we have… a glut of appointments and of measures and medication etc. Yet the outcome of the perceived successes of medicalized hospital birth — untrammelled intervention — is criticised. Similarly, a pregnant woman participant in the study, who had a vaginal birth, described her perception of other service users:. There is an implied criticism here, an associated onus on women to be better informed, to fit within the understanding of birth promulgated by midwives.

Yet it was also suggested that medical staff do not provide all the required information for women to make an independent choice.


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Similar, ethically dubious, behaviour has also been observed in other settings Torres and De Vries One interviewee for example, reported extremely negative interactions with a doctor whom she had never met before, soon after her arrival in a public hospital, whereby her membranes were ruptured without prior discussion and she was given an epidural:. If you have difficulties in expressing yourself in Portuguese for lack of vocabulary as well as with conjugating your verbs, this book is for you!

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