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Research Article
Clinical Medicine
Gynecology & Obstetrics

First experiences and current feelings as care providers in a birthing center: an ethnographic study

Michelly Christiny Marcondes Nunes1, Luiza Akiko Komura Hoga1, Luciana M. Reberte2, Jéssica Gallante Reis1


Alternative birth care settings provoke suspicion in cultural contexts where the medicalized approach of childbirth is deeply rooted. The aim of this study was to explore the first experiences and the current feelings of the professionals as care providers in an alongside midwifery unit (AMU). Data were collected through 51 participant observation sessions of an AMU located in a general hospital of the metropolitan area of Sao Paulo, Brazil. Ethnographic interviews were done with seven key and fifteen general informants, including obstetric and neonatal physicians and nurse midwives. The two cultural themes “unpreparedness and distrusts” and “satisfaction with childbirth care model and work in a team” express the professionals´ first experiences and current feelings as care providers in the AMU. Adequate prepare about the midwifery model of care and the role of each member of the care team should be done previously to the insertion of a professional in contexts where the AMU is an innovative birth care setting. The current professionals´ feelings of satisfaction related to the midwifery model of care and as a member of the care team indicated the potentialities of the AMU as a care setting to be widespread.
KeywordsHealth Personnel, Birthing centers, Cultural Anthropology.

Author and Article information

Author Info 1 School of Nursing, University of São Paulo.
2 Arts and Humanities, School of Sciences, University of São Paulo.
RecievedAug 30 2013  AcceptedOct 1 2013  PublishedJan 29 2014

CitationNunes MCM, Hoga LAK, Reberte LM, Reis JG (2014) First experiences and current feelings as care providers in a birthing center: an ethnographic study. Science Postprint 1(1): e00013. doi:10.14340/spp.2014.01A0002

Copyright©2014 The Authors. Science Postprint published by General Healthcare Inc. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.1 Japan (CC BY-NC-ND 2.1 JP) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

FundingI have not received funds for the research.

Competing interestWe do not have any conflict of interest.

Ethics StatementAll the research meets the ethical guidelines, including adherence to the legal requirements of the study country.

Corresponding authorLuiza Akiko Komura Hoga
Address University of São Paulo, School of Nursing.
419 Avenida Dr. Enéas Carvalho de Aguiar ave, Cerqueira Cesar, 05403-000, São Paulo, SP. Brazil.
E-mailIf you want to contact author,Please register as a member.


The creation of innovative birth care settings and the introduction of midwifery model of care (MMC) were recommended by the World Health Organization 1. Considering the need to transform the culturally rooted birth care model in Brazil, the first public freestanding midwifery unit (FMU) 2 was introduced in this country, two years after the WHO´s recommendation. This event was special in the history of childbirth care in Brazil, and motivated strong debates involving obstetricians (Obs), neonatologists (Neos), nurse midwives (NMs), the correspondent professional councils, and the media. The main concerns of the doctors were the unsafely nature of a FMU and the care team composed only by NMs 3.
In cultural contexts where the medicalized approach permeates the birth care, alternative childbirth care settings are usually seen with suspicion, mainly in relation to the safety of labor and birth 4. One year after the introduction of the first Brazilian FMU, positive obstetric and neonatal outcomes, similar to the WHO´s recommendations, were found. In that FMU, the prerogatives of the midwifery model of care (MMC) 5 including the strict use of the technology and medical interventions, the watchful wait for the physiological evolution of laboring women are rigorously followed
An intermediary model, between obstetric unit (OU) and FMU named as “alongside midwifery unit” (AMU) 6 was recommended as a public policy in Brazil 7. In such birth care settings, the primary responsibility is taken by midwives or NM and the medical care needed should be available in the same building 6. Although the AMUs have increased the presence of NMs in birthing sceneries 8, the childbirth care through cooperation among NMs and Obs is still strong in cultural contexts where the doctors are predominantly educated in biomedical perspective 9. Such conflicts among professional team´s members persist because the Obs have long assumed the main role in birthing sceneries. Changes in this solidified structure require agreements in power relations and the identification of team member´s needs 10.
Some researchers have explored the visions of Obs regarding NMs. An increased openness of physicians to midwives was found among the doctors with higher client-centered values 11. The confidence of Ob´s on NMs depended on how these childbirth care providers knew each other 12, and this confidence was higher when the NMs comproved their skills to provide a safety childbirth care 13,14.
A deep exploration of professional´s experiences as childbirth care providers assumes importance, especially in cultural context where the AMU is seen as an innovative care setting. A detailed description of the experiences lived by each member of care team permits to identify strategies to promote a successful collaboration among Obs and NMs working in AMUs 15. Qualitative empirical studies focusing specifically the care teams´ experiences as care providers in FMUs or AMUs were not identified. The justification of this research study was to provide knowledge to fill this gap in the scientific literature.
The aims of this study were to explore the first experiences and the current feelings as care providers in an alongside midwifery unit.



The studied AMU is located within a general public hospital of the metropolitan area of Sao Paulo, in Brazilian Southwest. The AMU was inaugurated in November F07 with the aim to offer birth care according to WHO´s recommendations 1. The antenatal and postnatal care is provided in the outpatient setting of the hospital or in primary care facilities. The physical structure of AMU, located in a floor of the hospital, is composed by five delivery rooms and a restroom with shower, a resource shared among the pregnant women. Swiss balls are available and the continuous presence of a companion is permitted, and only pregnant women with physiological conditions are admitted. An average of 600 pregnant women is attended per month in that AMU.
Before the inauguration of this AMU, the childbirth care was been provided in the OU of the hospital. Routine practices such as episiotomy, pharmacological resources to relieve pain, adoption of lithotomic position, prohibition of companion were the main characteristics of the childbirth care provided in OU, and the normal birth care was provided by both Obs and NMs.
The care team of the AMU is composed of 35 NMs, 42 OBs, and 18 Neos. Each work shift averaged four NMs, two Obs and two Neos, but usually was incomplete. The team was working for a period of twelve hours in fixed days of the week. Each day of the week had the same professional team. The NMs were occupied exclusively with birth care but the Obs and Neos had responsibilities in other settings of the same hospital.

Research Approach

According to the aim of this study, it seems appropriate to use a qualitative approach to answer specific research questions: How were the initial experiences as care providers in an AMU, considering its innovative nature in Brazil? How the professionals are feeling currently as childbirth care providers in an AMU, some years after it´s inauguration?
The ethnography appeared to be the appropriate qualitative methodology to study a distinct culture such as an AMU. As Kirkham (2003) considered, the experiential domains of care providers in a distinct birth environment should be approached qualitatively and the care team can be seen as members of a cultural group 16. In this sense, the perspective of the members of a culture and their daily practices were explored through ethnography 17.
The participant observation (PO) process began with emphasis on observation, and gradually were incorporated the participative activities 18. It was undertaken in average frequency of twice a week, between January 2011 and July 2012, totalizing 51 sessions, each of them variate in length from six to twelve hours. The PO was perfomed by one of the authors of this manuscript, a midwife who has a colleague working in the AMU. The observer was not a care provider of AMU but the previous knowledge of a professional of the studied setting become easier the insertion in the culture. All work shifts and days of the week were observed and these data were registered using word processor immediately after de OP process.
The care providers engaged in the transition from OU to AMU and have demonstrated special interest to be collaborators of the study were elected as key informants (KI). According to Angrosino (2007), KIs are the members of culture with deeper knowledge about cultural daily practices and general informants (GI) are the ones with generic knowledge 18. None professional refused to participate as study informant. Twenty licenced practical nursing also worked there but they were not included as informants because their responsibilities were not directly related to birth care.
The members of the professional team were approached individually, requested to be a study informant, and to tape-record an interview. The confidentiality of data and security of tapes were guaranteed. Individual in-depth interview was performed in a private room of the hospital before or after the work time, according to individual´s preference. Two ethnographic questions were used to begin the interviews: Tell me about your first experiences as care providers including aspects related to professional team and birth care in this AMU; Tell me about the current experiences as childbirth care provider in this care setting. The interviews lasted from 30 to 65 minutes and averaged 50 minutes. They were also performed by the observer, a researcher with previous experience in qualitative research and ethnographic interviews.

Data Analysis

Initially, the interviewer transcribed verbatim all the interviews. The observer and the other researchers participated in data analysis. The steps proposed by Angrosino (2007) were followed to analyse data 18. Initial reading of interviews and other data obtained during OPs permitted the identification of the main cultural symbols permeating the culture. Similarities in the narratives permitted to elaborate preliminary codes. These codes became increasingly more conceptual as the phases of interpretation progressed. A continuous process of reading and discussion of narratives produced the final cultural themes (CT). It´s title and main contents were presented to all the KIs who confirmed credibility and trustworthiness of the analysis.
The CTs main meanings were exemplified by small quotes extracted from the interviews. The informants were identified through correspondent profession´s initials, and sequential numbers, guaranteeing their anonymity.
Ethical approval was granted after submission to the Research Ethics Committee of the hospital. Informed written consent was obtained from all the study´s participants.


The sociodemographic characteristics of KIs and GIs are presented in Table 1.

Table 1 Sociodemographic characteristics of KIs and GIs.

Informants Age
Higher  academic degree Professional
experience (years)
Time in institution
NM1 46 specialist 22 14
NM2 46 specialist 14 07
NM3 45 master 26 07
OB1 37 specialist 11 06
OB2 28 specialist 04 03
Neo1 36 specialist 10 08
Neo2 43 specialist 11 06
NM4 46 specialist 37 14
NM5 46 specialist 21 02
NM6 45 master 10 05
NM7 51 specialist 06 01
NM8 42 specialist 16 07
NM9 47 specialist 25 03
NM10 60 specialist 34 04
OB3 57 specialist 19 01
OB4 29 specialist 05 02
OB5 30 specialist 04 01
OB6 30 specialist 03 02
Neo3 46 specialist 20 06
Neo4 51 specialist 28 06
Neo5 44 specialist 21 04
Neo6 31 specialist 06 01

Ten NMs, six Obs, and six Neos, for a total of 22 informants, participated as key or general informants. The time each worked in the institution varied from one to fourteen years.
In the Table 2 were summarized data related to the childbirth protocol as implemented in AMU, the professionals responsible for the care, if the items of protocol is practiced (yes/no), and the ways in which the childbirth care is being provided currently.

Table 2 Items of childbirth care protocol, professional responsible, following of protocol and ways to provide birth care.

Items  Professional Protocol followed
Ways to provide
childbirth care
Admission in the maternity OB    
Pregnancy >37 and < 41 weeks   Yes  
Uterine height ≤ 36 cm   Yes  
Single fetus in vertex presentation   Yes  
Clear amniotic fluid to amnioscopy   Yes  
Normal cardiotocography   Yes  
Full amniotic sac or route < 4 hs   Yes  
Cervix dilation ≥ 3 cm   No Cervix dilation
< 3 cm
Regular uterine activity   Yes  
Reception in birth centre NM    
Self presentation as care provider   No Lack or incomplete
Presentation of clinical setting and accommodations   No Lack or incomplete
General guidance*   No Incomplete
Obstetric care NM    
Clinical and obstetrical monitoring NM Yes  
Oxytocin used after ineffectiveness of other resources OB/NM No Use without
other resources
Guidance, stimulation and practice of non-pharmacological resources to relieve the pain NM No No presentation
of all resources
Suggestion to adopt semi-sitting or lateralized position during birth and women to choose the position NM No Suggestions were given
but the furniture
was innapropriate
Episiotomy under rigorous indication NM No Lack of rigorous indication
Kristeller maneuver strictlly prohibited OB No Performed few times
Allow companion to cut the umbilical cord NM No Variation in practice
Neonatal care NM/Neo    
Mother/newborn skin-to-skin contact for 15 minutes NM/Neo No Variation in practice/time
Avoiding aspiration of the upper airways Neo No Procedure done routinely
Support and stimulus of early breastfeeding NM/Neo No Variation in practice

* The general guidance includes the following items: feed, roam, bath, exercises in birth ball, rest in the left lateral decubitus when desired,

Two CTs were elaborated. The CT1 reflects the experiences lived during the initial phase of AMU, and the CT2 reflects the feelings related to the childbirth care as provided currently. In the Figure 1, the main contents of the two CTs are summarized.

Figure 1 Cultural themes and summary of contents

CT1- Unpreparedness and distrusts: initial experiences as care provider in an AMU

- Lack of training and previous experiences with AMU childbirth care model
- Resistance against the health care model
- Implementation of childbirth care model without previous preparation of the care team
- Distrusts regarding the competence of NM to provide adequate childbirth care
- Fear of negative obstetric and neonatal outcomes
- Lack of clarity about the attributions of each professional
- Insecurity related to the presence of companion

CT2- Satisfaction with childbirth care model and work in a team: current feelings as care providers

Work in team
- Competence to work in team and establishment of good mesh
- Deeper knowledge to take care according to the birth care protocol
- Confidence in the NM´s competence and valorization of their role
Childbirth care model
- Possibility to follow the international recommendations related to birth care
- Affection and sense of security offered at the admission in clinical setting
- Establishment of bonding with pregnant women and companion
- Offering of a family environment
- Adequate and constructive interpersonal relationship
- Valorization and support to companion
- Main role of birthing attributed to pregnant women
- Provision of care according to individual needs
- Avoid unnecessary interventions
- Freedom to feed
- Respect and promotion of the physiology of birth
- Use of non-pharmacological resources to relieve the pain
- Provision of guidance, psychological support, and continuous presence in care setting
- Supportive care to promote early mother/newborn/father bonding
- Adequate time to clamp the umbilical cord
- Supportive care to encourage breastfeeding
- Existence and following of birth care protocol
- Positive obstetrical and neonatal outcomes and decrease of perinatal mortality

CT1- Unpreparedness and distrusts: initial experiences as care provider in an AMU

Lack of experience and prepare to provide childbirth care according to the protocol implemented in the AMU were reported. Only a written protocol was available in the clinical setting. Continuous or permanent education about childbirth care was not provided for them. Consequently, the initial experience of care in the new birthing scenery was strong, especially for the Obs:
Physicians learn about birth care in a different culture, where topics related to AMU or humanization of childbirth is not approached. (Ob2) No physician is trained to perform childbirth care in AMU. (Ob1) The implementation of AMU without any preparation was strong for us, were not prepared previously. (Ob1); I have not received any training, any preparation before or after the implementation of AMU. (NM8)
The Obs also reported resistances against the childbirth protocol adopted in AMU. One Ob said that the model of care adopted in that setting was seen by many Obs as “the birth of an animal” because the interventions are avoided:
There are reluctances among Obs regarding birth in AMU. Some Obs see the humanized childbirth as a 'birth of an animal' because nothing is done. (Ob2)
Some Obs never have shared birth care responsibilities with NMs. These professionals had several distrusts related to NM´s competency to provide childbirth care. They used to supervise NM´s activities to prevent eventual problems related to adverse events in care and took careful care to admit patients. Only pregnant women with high possibilities of normal birth were admitted by them and this caution was taken to assure positive obstetric and neonatal outcomes:
I never worked with NMs taking responsibilities for childbirth care. (Ob2). During the initial phases of this AMU, we closely supervised the care provided by NMs. This caution was taken to ensure positive outcomes. (Obs 1, 2, 3, 4, 5). We took care to admit patients through careful evaluation of the possibilities for normal birth. (Obs 2,6)
The lack of clarity about the responsibilities of each member of professional team provoked feelings of uncertainty in the first phases of AMU:
At the beginning, I felt uncertainty because I did not know about my professional attributions in AMU. (Ob3, 5)
Two NMs reported distrusts about the presence and inclusion of companion in birth care during the beginning of AMU:
I was not sure about the competence of companion to offer support. In the beginning, I distrusted them. (NM 3, 7)

CT2- Satisfaction with childbirth care model and work in a team: current feelings as care providers

The professionals expressed satisfaction as care providers in AMU. The reasons for this feeling were the ability to work as a team and the humanized birth care model.
The competence to work as a team and the preservation of a good relationship among the members were reported by the three professional categories involved:
Our team is good, cohesive, and communicative. We have a good relationship and we can offer a good childbirth care. (NM 1). We felt safe with the whole team: well structured and smooth. (NM 2, 4, 6; Ob4, Neo 3)
The need to deepen the knowledge about birth care has satisfied the NMs:
I had to study a lot about the new birth care model. It was very positive for my professional career. (NM 4, 6, 9)
The competence of NMs to provide adequate birth care and the consciousness about their limits as birth care providers were motives of satisfaction for Obs. They acquired confidence and contributed more value to NMs, mainly in the roles played by them, specifically their autonomy and scientific background:
NMs provide birth care in the best way. They are excellent, committed, well- prepared. They know their limits and ask for help when they need. (Obs 1, 3, 4, 5, 6)
Several characteristics of birth care were mentioned as motives of satisfaction. Although these motives were reported by Obs in their narratives, it was noted that some items had not been implemented systematically.
The possibilities to follow the recommendations given regarding childbirth care were highlighted as motive of satisfaction:
I am pleased to follow the birth care protocol as recommended. (Obs 1, 3)
For clarity purposes, the motives of satisfaction related to birth care model expressed by care providers are presented in items.

- Affection and sense of security offered to the pregnant women and companions during the admission in clinical setting. It was considered essential to establish bonding among the care team, pregnant women, and their companions:
The women are received warmly. Safety is emphasized and it is important for bonding. I am satisfied. (NM 9, 10)
- Offering a family environment, through inclusion and adequate support to companions:
The presence of the companion is very positive. The woman feels safer, in a family environment. (NM1). The most important in humanized childbirth is the presence of companion, who contributes to the bond among the family members. (NM 1, 2, 3, 10).
- The main role of birth attributed to pregnant women:
Pregnant woman is considered the central element of childbirth. This is very good. (NM 6; Ob 1,3).
- Provision of care according to personal needs:
The birth care was improved through the respect of individualities. (NM 6; Ob 1)
- Avoidance of unnecessary interventions:
Unnecessary interventions were avoided. (NM 5, 9, 10; Ob 1, 4, 6).
- Freedom to feed:
The pregnant women are free to feed and this too is positive. (NM 4, 9; Ob 5, 6)
- Respect and promotion of the physiology of birth. This was seen as the main aspect of philosophy of birth, innovative and different if compared with other care procedures adopted in traditional maternities. These aspects were seen as a great contribution for the dissemination the idea related to humanized birth care and normal birth:
The humanization of the birth is a philosophy, a way to innovate care. (NM 1, 10; Ob 2, 3, Neo 3, 6). The birth care changed. Currently, the culture of normal birth predominates. The pregnant women know that their birth will be normal. Our service is a way to disseminate the culture of normal birth. (NM 1, 4, 10; Ob 1, 4)
- Use of non-pharmacological resources to relieve pain. This aspect was reported by Obs although such resources were not applied systematically:
We use shower, birth ball, body positions, and movements. All resources favored childbirth and it is reason for satisfaction. (NM 6, 7, 10). Through hydrotherapy, pregnant women forget pain. (NM 9).
- Provision of guidance, psychological support and continuous presence in care setting:
I explain what the woman and her companion can do during the birth. (NM 4, 5). The midwives are in the care setting the whole time. This is positive; the patients feel safe and we feel satisfied. (Ob 3, 6; Neo 5)
- Supportive care to promote early mother/newborn/father bonding:
I promote interactions between mother and child. (NM 6).
- Adequate time to clamp umbilical cord:
We take necessary time to clamp the umbilical cord. (NM 3, 4, 6)
- Supportive care to encourage breastfeeding:
I encourage and advise the importance of early breastfeeding, placing the newborn to breastfeed. (Neo 3, 5, NM 1, 4, 8)
- Positive obstetric and neonatal outcomes and decrease in perinatal mortality:
Good birth care is the success in obstetric and neonatal outcomes. (NM 5, 8; Ob 6); The prenatal mortality rates dropped substantially. (Neo 3)


The study findings are indicating the complexity involved in the effective transformation in the ways to provide childbirth care. These ways are deeply incorporated into the culture. Consequently, the professionals, especially the Obs, have demonstrated the strong resistances towards the implementation of AMU in a setting where the OU childbirth care model was a tradition.
The lack of previous knowledge and experience related to humanized birth care provided in AMU were the main reasons for the resistance of Obs to provide childbirth care in the innovative setting. Consequently, these professionals had distrusts regarding the proposed childbirth care model.
The main distrusts of Obs were related to the MMC. The responsibilities of provision of childbirth care taken by NMs, the possible negative obstetric and neonatal outcomes, and the inclusion of companions in the birthing scenery were the main reasons of Ob´s distrusts. Researchers who have focused another Brazilian AMU 10 also reported the existence of distrusts among Obs regarding the NM´s competency to provide adequate childbirth care. This trouble provoked tensions and misconceptions among the members of care team 10. The own Obs of this study have reconsidered their conceptions regarding the NM´s competency to provide adequate and responsible childbirth care after the positive obstetric and neonatal outcomes found in AMU.
Everly (2012) also observed that the doctors assume authority in the provision of birth care 5. Especially in medical-centred settings, the NMs must focus their practices on medical tasks because there is the expectative for the provision of care according to the medical model. These findings have demonstrated the influence of the nature of care setting on the provision of birth care.
The incorporation of natural childbirth and humanized childbirth care provided in AMUs into educational medical programs was recommended considering that this measure can promote changes in medical care 19. The American College of Nurse Midwives (2012) has also recommended the implementation of the shared learning programs strategy in undergraduate obstetrics and midwifery courses 20. A systematic training of the members of interdisciplinary team before the implementation of AMU was also recommended. The adoption of these measures might promote changes in the medical approach to childbirth, with positive reflections such as leadership, mutual support, effective communication, respect, adaptability, and avoidance of hierarchies within the team.
The professionals reported the feeling of satisfaction regarding the implementation of international recommendations 1 in AMU. This feeling was also motivated by the possibility to strength normal birth, to have constructive relationship within care team and establish bonding with women and family. The benefits of the companion participation, provision of support, and focus on the physiology of childbirth were also reported as important aspects of the care model adopted in AMU. Several researchers considering its benefits for mothers and newborns recommended the adoption of childbirth care model in such settings. The main positive aspect was the low rates of unnecessary interventions 14,21,22. The care centred on women´s needs and the high levels of satisfaction with childbirth care model were also reported 14,21-25. As found in this study, the professionals were also satisfied with the childbirth care provided in AMU.
There is the need to consider the findings of a qualitative study reporting the power of Obs on decision-making about augmentation of labour. When the ward was led by midwives and had Obs working on a consultancy basis, the midwives did not experience this stress as influencing the course of events 12. This way to work in team sounds to be a better alternative for NMs. As found in this study, the harmony between Obs and NMs in AMU requires more. The dissemination of natural childbirth and humanized birth care provided in AMUs, especially its incorporation into medical and nursing educational programs, can be a way to promote the required harmony among the members of birth care team.
Study findings have showed a deeply incorporated and traditional birth care practices requiring time, efforts and the evidence-based practice (EBP). Great effort need to be taken in this scope. Jennings & Loan (2001) reported the incongruity among nurses in the interpretation of the basic tenets of the evidence-based paradigm and the underestimation of the EBP implications 26. The existence of such problems impedes the participation of these professionals as full partners in the advancement of that movement. A more standardized framework for advancing EBP in nursing was recommended.
This question assumes deeper complexities in developing countries, with limited EBP resources 27. Decisive and quick acts to bring a dramatic change in ideas and practices in this scope are needed. Expectatives in this initiative include the creation of appropriate evidence base for developing world and identification and use of appropriate technology for evidence transfer.
From this research study, what becomes evident is the need to prepare the care team before the implementation of AMU. The philosophy supporting AMU childbirth care, the previous integration and mutual knowledge of care team, the attributions of each member as well as, the principles supporting the EBP are some items of the professional´s previous prepare. These measures represent the initial steps for the stronger challenge, represented by the concretization of midwifery care in AMUs.


Strong experiences were lived by the care team at the beginning of AMU, especially the Obs who were not trained in similar childbirth care philosophy during university educational programs. But these first strong experiences were overcome by the feeling of satisfaction regarding the midwifery model of care adopted in AMU and the ability to work in a team.
The findings indicated that the troubles emerged during the initial phases of AMU were gradually overcome. Currently, the professionals are satisfied with the childbirth care provided in this childbirth care setting. It is demonstrating that the occurrence of changes in solid cultures should be promoted but all members of the culture need to agree in some principles and act accordingly. Such efforts are of particular importance in birth care, where the facility culture and enough resources are particularly factors that help the NM´s efforts to provide adequate support to pregnant women during labour and birth.
Greater knowledge of NM and midwives´ work and scope of practice, gained through collaboration in workplace can promote a better understanding by physicians about the meaningful contribution these care providers can make to birth care.
The findings of this study are limited to the focused AMU because other similar clinical settings may be different. Therefore, this study does not aim to be applicable to all of them. However, it might stimulate a debate in regards to similar places of birth.


Acknowledgments as Grant Beneficiary of Productivity Research Fellow of Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Author Contributions

The names of all the co-authors have been included in the manuscript and these co-authors all had an active part in the final manuscript.


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