Autonomy In the Choice of Childbirth in The Primiparous: Understanding Reality

Every pregnant woman has the right to care during childbirth and postpartum, and that this is performed in a humane and safe way. To ensure autonomy, it is necessary to put the woman in control of labor and birth, providing the necessary knowledge that allows her to make decisions about her own body. The study aimed to know the autonomy and knowledge of primiparous women in choosing the type of delivery. This is a qual-itative field research. The participants were primiparous women, who agreed the st udy showed the need for actions aimed at women’s health in the pregnancy -puerperal period, which enable conditions for female empowerment in decision-making about the body itself.


INTRODUCTION
Cesarean delivery (CD) and normal delivery (ND) are the alternatives available for live births and, thus, it is expected that the pregnant woman has the right to analyze the risks and benefits to freely choose the route of delivery. But there are aspects related to childbirth care that still need to be discussed. The model of delivery care in Brazil is characterized by excessive intervention [1] .
According to the World Health Organization (WHO), 140 million live births occur worldwide each year; most without identification of risk factors. When performed for medical reasons, CD may reduce maternal and perinatal mortality and morbidity. However, there is no evidence that CDs are minimally beneficial when women or babies do not face major problems [2] .
In Brazil, however, the natural order is reversed. In 2020, the Unified Health System (UHS) performed 2,727,923 deliveries, of which 1,562,282 were CD [3] . According to the WHO, Brazil has the second highest rate of cesarean sections (55%), second only to the Dominican Republic (56%). It is important to highlight that the international medical community considers that the ideal rate of CD is between 10% and 15%. César Fernandes, president of the Brazilian Federation of Gynecology and Obstetrics, understands that it is really necessary to change the current pattern.
ND is considered a physiological and natural process. When there are complications for the binomial in the face of complications or situations that can compromise life, the CD becomes a necessary intervention.
However, in any situation, the pregnant woman should receive the necessary knowledge about the events that happen to her body, and effectively participate in decision-making [2,4] .
Studies on ND and CD have addressed the various problems associated with this organization of care, demonstrating a certain concern that involves the quality of care from prenatal care to birth [5,6] . However, positive factors of CD were identified in women who experienced this delivery and chose to have it again electively. The reasons for their choice were the fear of the pain of the ND, the tranquility that the anticipation of childbirth brings and the feeling of security for the greater control of childbirth, thus, the feeling of security for greater control of childbirth [7] .
Regarding negative perceptions of CD, postpartum pain, difficulties in recovery, risks of surgery, previous concerns and experiences with anesthesia, higher levels of fear when compared to ND and difficulties in returning to sexual activities. Women who had CD, elective or emergency, were more displeased to remember the birth of their children [5] .
Satisfaction, preference or advantages associated with ND, regardless of the previous experiences of women with the type of delivery, were found in descriptions such as: little suffering, faster recovery, need for less care, feeling less pain after childbirth, possibility of returning to daily activities and being discharged ions about the team that attended, in a careful and affectionate manner, and the presence of a companion [5] .
Women, since the beginning of their lives, should be very well oriented in relation to their autonomy, choices and rights, especially during pregnancy, which is a period of great sensitivity and vulnerability caused by bodily transformations that will consequently result in a procedure, childbirth. Knowing whether to impose ourselves through theoretical foundations is fundamental for female empowerment, and instruments such as the delivery plan become an important tool for obstetric violence practices to be increasingly distant from reality [4,8] .
To ensure autonomy, it is necessary to put the woman in control of labor and birth, empowering her to actively decide on her own care, providing her feeling of security during this process. These actions are essential for women to identify and decide which care practices can favor or limit their autonomy [4] . According to the Ministry of Health, every pregnant woman has the right to care during childbirth and puerperium, and that it be performed in a humanized and safe manner, according to the general principles and conditions established in medical practice [9,10] .
The study was developed based on the following questions: Is the choice of delivery in accordance with the needs of each woman? Is your decision respected without the influence of the multidisciplinary team, or professional decision? Thus, the research aimed to understand if there is autonomy in choosing the type of delivery by primiparous women who experienced this process.

METHODOLOGY
The study is qualitative, exploratory and descriptive, based on the testimonies of primiparous women.
The selection criterion was > a participant in 18 years of age, primiparous, who underwent a ND or cesarean section, from January to December 2019, belonging to a women's health care unit in a municipality in the interior of São Paulo state. The interviews were conducted from November 2020 to January 2021 at the place chosen by the participant (domicile or health unit). Content analysis was used, inserted according to the thematic analysis modality, enabling the interpretation of the participants' statements, as argued by Cardoso et al. [11] , performing a thematic analysis consists of discovering the meaning nuclei that make up communication and whose frequency of appearance may mean something for the intended analytical objective. According to Silva et al. [12] , thematic analysis is the possibility of using a flexible and useful search tool, which can provide much more accurate and detailed but complex data analysis.

RESULTS AND DISCUSSION
The participants were 18 primiparous women from a city in the countryside of São Paulo, who gave birth in the maternity hospital of the same city. The age range ranged from 18 to 33 years. Regarding education, two have incomplete elementary school, six complete elementary school, six complete high school, four higher education, 8 married and 10 single. Regarding family income, there was a variation from one to four minimum wages in relation to the type of delivery, ten normal deliveries and eight cesarean sections were identified, all of which had prenatal care, but only four reported that pregnancy was planned (Table 1).

Embracement and Neglected Bond between Health Units and Pregnant Women
Most of the interviewees demonstrated a lack of confidence in the team, creating a gap between the care provided and the real needs of women. The bond formed by the interaction between people, paying attention to individuals, clarifying doubts and supporting their decisions, can favor the approximation between health services and women during the pregnancy-puerperal period, minimizing anxieties, fears and increasing the safety and support needed for women [13] .
[ In the reports, it is noticed that the parturient women were not properly guided by the teams that accompanied them during pregnancy and delivery, because they showed fear and insecurity. Communication is an essential instrument, so it is necessary to establish communication accessible at all social levels so that the guidelines on medicines, conducts and care can be followed and thus to continue care for a pregnancy free of complications and injuries [14] .

Autonomy In the Choice of Childbirth in The Primiparous: Understanding Reality
International Journal for Innovation Education and Research, Vol.10 No.9 (2022), pg. 100 The lack of information on pregnancy, childbirth and puerperium was evident in the reports cited. The preparation of women for delivery should occur during prenatal care by primary care professionals, either in individual consultations or in groups of pregnant women. The delivery plan has been shown to be efficient in the construction of knowledge about the pregnancy-puerperal process among women, allowing female empowerment in decision-making and favoring better preparation during childbirth [8,15] .

Factors that Prevent the Autonomy of Choosing Delivery in Pregnant Women
When a woman discovers that she is pregnant, everything she has heard about pregnancy before even imagining a mother, and what she hears during pregnancy is from her culture, from the environment in which she is inserted, from her family, or even from the multidisciplinary team that will assist her during pregnancy, will contribute to the choice of the type of delivery she should choose [1,13]   In this context, according to Ferrari [16,17] , autonomy presupposes the right of choice based on information transmitted transparently by responsible and committed professionals, attentive to the ethical duty of making the pregnant woman competent to make a choice.
In the question of the autonomy of the woman who desires the ND, the conflict between autonomy and beneficence does not apply, especially in the supplementary sector, because beneficence would only be justified in the face of a cesarean section for real medical reasons, and most women are submitted to unnecessary cesarean section [18] .

Negative Experiences and Frustrated Expectations Regarding the Time of Delivery
The reports show that women lack support, help and clarification, it is a moment of greater vulnerability, and uncertainties are constantly on the outcome of birth. Therefore, we emphasize the need for support and bonding between professionals who work during the pregnancy-puerperal process, with a view to female empowerment for decision-making, thus allowing conscious choices and autonomy in the choice of delivery.
[...] I missed them explaining things to me, you know how to breastfeed and change diapers P03. Childbirth is a unique, special and long-awaited moment, natural childbirth in a humanized way is idealized by many women, but reality is opposite. The indifference and mechanization of the procedures, felt by the women in the face of the reports, ends up transforming childbirth into a traumatic event.
ND is perceived as a painful process, with greater than expected pain intensity, even for a short period, in addition to painful and unexpected procedures that contributed to increased pain levels, such as amniotomy or oxytocin administration to accelerate labor. Discomforts associated with epidural analgesia, episiotomy and type of delivery, with the exception of elective cesarean section, and the transformation of the female body into a work object. The role of women is not favored or respected, produced by the model of medicalization of care, which also contributes to the negative perception of childbirth [5] .
[ The interventionist and mechanistic model of childbirth neglects women's rights in the process of parturition and dominates their bodies, perpetuating gender violence, which in this context has been called obstetric violence [6] . The vast majority of hospitals do not have specific techniques for pain reduction, at most they encourage the presence of the companion during labor and do not restrict to the bed [19] .
According to the Ministry of Health, in a CD performed by the UHS, the woman has the right to the anesthesiologist's duty, exclusive operating room for surgery and bedside follow-up by a team prepared for complications; in the case of ND delivery, the Ministry of Health recommends that, before offering labor analgesia, the hospital should offer non-pharmacological methods of pain relief, that offer fewer risks and can solve the problem of painful sensitivity without the risks of analgesia. These methods include continuous support, freedom of movement, access to water (such as shower and bathtub), access to ling's ladder, horse and stool that are physiotherapy instruments for the adoption of other positions for the ND, in addition to the support of the doula, the ambience of motherhood and privacy, methods present only in maternity hospitals, rare in the country [20][21][22] .

Autonomy In the Choice of Childbirth in The Primiparous: Understanding Reality
International Journal for Innovation Education and Research, Vol.10 No.9 (2022), pg. 102

CONCLUSION
ND was the most observed in most cases, and preferable in view of the good recovery of both mother and baby. However, the present study made it possible to identify a multiplicity of meanings and perceptions for motherhood of women who experienced the first pregnancy, from receiving the confirmation of pregnancy to the meaning attributed to the child, evidencing the lack of autonomy of women throughout the process.
During pregnancy, women often do not receive correct guidance on the benefits and harms of each delivery, so it is assumed that the choice of the type of delivery is not always the woman's, and that the ND is not encouraged, making the CD to deliver the culturally accepted and professionally induced "choice". It is emphasized that cesarean section is necessary and extremely important, provided that the intervention is performed when there is the correct indication of the responsible doctor. It is important to highlight the determinants of the choice of the type of delivery by pregnant women, one of the most relevant points for the knowledge of the risks and benefits of each type of delivery, thus allowing autonomy and conscious choice.
In addition, it is up to the professionals responsible from prenatal care to the moment of delivery to provide all the information to the woman during the pregnancy-puerperal cycle.
For a humanized embracement and intervention, it is suggested the training of professionals who work prenatal care to the postpartum women, as it is fundamental for maternal and neonatal health, building a new look from primary outpatient care to the hospital environment.