Brain Research Laboratory,
Discipline of Physiology, and Bosch
Institute,
University of Sydney,
Australia
Abstract
The biomedical hypothesis proposed here is
that the immediate trigger for a yawn is a
restricted collapse of a few alveoli in the
lungs. The extent of this alveolar collapse may
be too small for it to be detected by current
X-ray technology, but this technology is
continually improving and may soon be good
enough to test the hypothesis.
In support of the hypothesis, it is shown
that yawning can be inhibited by deep breaths of
air, nitrogen or carbogen, thus showing that
yawning is not triggered by lack of oxygen or by
excess carbon dioxide, leaving alveolar collapse
as the most likely possibility.
A more extensive form of alveolar collapse
is termed atelectasis and this involves a
serious state of hypoxia which, if deepened or
prolonged, can be fatal. Therefore, if the
hypothesis is correct, yawning may prevent the
development of atelectasis and save lives.
This paper is not concerned with other
indirect ways in which yawning may be induced,
nor with the mechanism and neural circuitry of
the yawn, nor with social aspects of yawning,
only with the immediate trigger. The author's
aim is to get better evidence for the hypothesis
put forward here and also to study the behavior
of the pulmonary alveoli in normal
respiration.
Résumé
L'hypothèse biomédicale
proposée ici est que le
déclenchement d'un bâillement est
un collapsus partiel de quelques alvéoles
pulmonaires. L'étendue de ce collapsus
alvéolaire peut être trop peu
important pour pouvoir être
détectée par la radiographie mais
cette technologie s'améliore
continuellement et pourrait bientôt
être suffisamment performante pour tester
l'hypothèse.
À l'appui de cette hypothèse,
il est démontré que le
bâillement peut être inhibé
par des inhalations profondes d'air, d'azote ou
de CO2, démontrant ainsi que le
bâillement n'est pas
déclenché par un manque
d'oxygène ou d'excès de dioxyde de
carbone.
La forme plus importante de collapsus
alvéolaire s'appelle
l'atélectasie. La conséquence de
l'atélectasie peut être une hypoxie
qui, s'elle s'aggrave ou se prolonge, peut
être mortelle. Par conséquent, si
l'hypothèse est exacte, le
bâillement pourrait empêcher
l'installation de l'atélectasie et ainsi
sauver des vies.
Cet article ne s'intéresse pas
à d'autres façons indirectes de
provoquer un bâillement, ni au
mécanisme et aux circuits neuronaux du
bâillement, ni aux aspects sociaux du
bâillement, mais seulement au
déclenchement immédiat. Le but de
l'auteur est d'obtenir de meilleures preuves de
l'hypothèse présentée ici
et aussi d'étudier le comportement des
alvéoles pulmonaires dans la respiration
normale.
1. INTRODUCTION
"There weren't enough beds, awful
environmental conditions, use of contaminated
material, and inevitable contagion", this
picture may look so common and up to date, but
it has to do with the first registries of the
conditions of several hospitals visited by Tenon
and Howard in France and England between 1775
and 1780 [1]. The concern was to shift
the hospitals into places which were less
"sickness bringers", and which for some time
were used as shelters for those who put the
hygiene of the city at risk.
This historical issue reveals that the
concerns around the quality of the assistance
are not a novelty, it's recurrent and, nowadays,
in the Brazilian reality it is a part of a
Brazilian public policy of humanization of the
health system. There's also at the same time, a
big discussion which is weaved around the
humanization of medicine which had an inverted
movement. The doctor has always been associated
to care, consolation, much more than a
therapeutical one, yet this care was destined to
the rich and wealthy. Primum no nocere (not
damaging before anything else), Hippocrates'
expression, considered the father of medicine
since Ancient Greece, shows that the doctor's
role was on top of all, the one minimizing the
suffering in the clinic performance of hearing
the complaints, listening to the reports of
pain, and performing physical checkups in order
to establish an approach for the treatment.
The 21st century witnessed the great advance
caused by the development of high technology
after the surge and the development of the
computers and, today, the technology allows us
not only to see the human body from inside in
details, but also to see it in its working
process.
All that has allowed an increasingly growth
of life expectancy, the so called longevity, the
discovery and the cure of many sicknesses, and
the softening of the damages caused by
pathologies which don't have a definitive cure
yet, such as AIDS. The provided benefits to
mankind by the technologic advent are
undeniable. However, to what extent has all this
advance helped in the improvement of the quality
assistance, especially the assistance to the
woman health concerning the childbirth and the
delivery?
Especially taking humanization of health,
medicine and its effects on the assistance to
woman health in the childbirth and the delivery
as the object for this article, it fits
perfectly here an analysis of the reached
advances and the blockers to its evolution:
after more than ten years of the promulgation of
the National Program of Humanization and
Hospital Assistance, (NPHHA) [2], which
evolves to NPH in 2003, was an important step
even to the elaboration in 2001 of the document
"Childbirth, abortion and child killing:
humanized assistance to woman" [3] and,
in 2002, "Program of Humanization of Delivery,
Humanization in the Prenative and the
Childbirth" [4]. All of them were
elaborated, developed and made possible by the
Health Ministry.
This is so because we realize that with
similar objects and objectives, the policies and
the programs seem to go independently in the
theoretical, clinic and epistemological
fields.
If those facets of the humanization seem to
have obvious connections, based on our
theoretical findings in this study, we can
affirm that being put into practice they are
dissociated and even follow their ways
independently. We humanize by inserting
professionals of different areas into the
hospitals, improving the ambience, developing
more cordial and cozier postures. But neuralgic
issues keep untouched. At the maternities,
mothers breastfeed their babies together with
those mothers who have a dead child. Because of
this and other day-by-day situations in the
Brazilian public maternities, we propose to
discuss the necessity to reflect over the
humanization of medicine for the effectiveness
of the national policies of humanization of
health, mainly those ones referring directly to
woman care with the assistance to childbirth and
delivery.
Therefore, going from this great area of our
interest, this study aims to analyze the
possible articulations of the health field and
of the medicine and its ideals of humanization,
especially, its interface with the Field of
obstetrics in which the care for the pregnant
woman is concentrated, and which is necessary in
the formation of the doctor and the discourse of
the importance of humanization into the
doctor-patient relationship.
For that objective, a bibliographic review
was performed articulating the analysis of the
context in the changes which have been proposed
to the medical courses, keeping ourselves to the
humanization of the delivery and the childbirth,
important topic into the Obstetrics subject. In
a general way, those changes emerge from the
current criticism to the overuse of technology
and the almost exclusive development of the
technical competence provided by the curricular
structure of the courses. The most direct and
visible consequence of this process is the
distancing of the doctor, reduced to the level
of a technician, who aims to take care of a sick
organ and refuses the relationship/meeting with
the sickened person. In the context of the woman
health, this picture brings about a difficult
consequence to deal with. Once the care with the
woman requires necessarily the consideration of
psychosocial and gender aspects, issues which
are not inscribed into the technological
universe but on the other hand into the ethic,
aesthetic, social, cultural, psychological and
anthropologic universe.
To reach our goals, we shall use the
hermeneutic-dialectic method proposed by Minayo
[5] to highlight the complementarities
and oppositions between the two facets of
humanization, for this methodology constituted
as an important way of thinking to fundamentally
qualitative studies which take into account the
subjectivity and may create parameters for
analysis. Such ways are of extensive spectrum in
the interaction between hermeneutics and
dialectics: both go from the previous knowledge
that there's no neutrality in studies and that
the comprehension and the criticism go over the
technique; both go beyond the tasks and are more
than simple tools for the thinking and,
ultimately, are referred to the instituted
practice to the power and the common sense
[5].
2. HUMANIZATION OF HEALTH: CONCEPT AND
PROBLEMATIZING
By the year 2000, the 9th National Health
Conference was held in Brazil. The title is:
"Brazil saying how it wants to be treated
effectuating SUS: access, quality and
humanization in the attention to health with
social control" [6]. Out of it the
National Program of Humanization and Hospital
Assistance (NPHHA) was derived in 2000
[2], whose objectives were directed to
the perfecting of relationships between the
users and the health system represented by the
professionals and the services provided by them,
aiming to improve the quality and effectiveness
of the services in the environment of SUS.
In 2001, already inscribed into those change
processes of the health scenarios and
humanitarian principles, the Health Ministry
announced the official document inscribed in the
environment of the health policies, the title
is: "Childbirth, abortion and child killing:
humanized assistance to woman" [3].
Following this one there was in 2002, "Program
of Humanization of delivery. Humanization in the
pre-native and the childbirth" [4], with
the same contents and of operational character,
whereas the first one offers principles and
proper lightings to the implementation and
effectiveness of policies.
In 2003, National Policy of Humanization
[7] (NPH) was consolidated, under the
title "Humanizing SUS: the humanization as the
guiding axis of the practices of attention and
management in all the instances of SUS" which,
having similar objectives to NPHHA, goes further
in important issues as better delimitating the
category actions, defining general strategies,
guiding principles and delimitating
priorities.
Initially the NPH problematizes the concept
of humanization: "And why to talk about
humanization when the established relationships
in the process of health care happen among
humans? We would be willing to "make the
relationship with the user more human" with such
concept, just giving the services very small
detailings, but leaving the conditions of the
production of work in health untouched?"
[7].
According to this statement, the reflexion
about humanization implies fundamentally into
the need of undoing the misunderstanding around
the concept of humanization which puts as
essentially human practices, w Either good or
bad, all the human actions belong to the human,
for they are the product and producer of social
relationships, way from which they can opt to
give out or not to give out the best of
themselves. The human is the dialectic
assembling of social relationships and without
the dichotomy between the good (human) and the
bad (inhuman) [9]. It is not therefore,
an abstraction, but on the other way around it
is an action that, aimed at people, necessarily
brings about a check point of ethics, involving
finality, the potential and direction of this
movement.
In the Brazilian scenario the discussions
about humanization aim to overcome the current
dichotomies, searching to articulate
technological inseams with relationship
Technologies, better saying, ways of care which
value the listening, the dialog, the welcoming,
without overlooking the benefits of technology,
knowledge and techniques.
The development of the policies around
humanization implies necessarily in the
recognition of health as a right and also the
quality of assistance and, yet it evokes
humanistic values (respect, cordiality,
solidarity and generosity) it is not limited to
them, which are implicit to the notion of
humanism. The guiding principles of humanization
aim to rescue, from a critic reflexion, such
values as actions in the day-by-day practices of
health in the institutional level, by the health
professionals.
The humanization may be understood,
according to its status quo, in five different
ways: as a principle of humanistic and ethic
basis, rescuing respect, the human valuing and
dignity, with special emphasis upon the human
values; as a movement opposed to the
institutional violence that is operated by the
imposing of tough rules and inflexible
structures, both to the users and professionals;
as a public policy of attention into the
management of SUS and, in this context,
constituted as an important tool to guarantee
the protagonism of different actors and subjects
of co participative management; as a
methodology, once humanization does not come
true only in the field of ideas and reflections,
but can only come true in the field of
practices; and as for technology of care into
the assistance which poses as extremely
necessary its association to the techniques by
involving the ethic and relationship dimensions
related and, many times, determining of this
process [10].
The proposal of humanization first appeared,
among other determiners, as a response to one
opposing to institutional violence [11]
(understood as cancelling out of subjects in
collective contexts) which is developed in
several levels in the ambiance of health,
practically speaking as a technical demand,
either it is physical, psychological or symbolic
[12,13].
There are explicit ways of violence in the
contexts of health: physical (by invasive
attitudes to which the patients have to go
through), symbolic (by affecting them either
morally or ethically), or behavioral
(insensitivity, brutality, carelessness, words
which cause constraint). But there are also
kinds of violence which operate by other
disguises, more difficult to be perceived and
have been named as silent violence by Leite
[14]. For the author, the silent
expression of violence is shown in subtle
actions which violate the human dignity and get
associated to symbolic actions, going over all
the other ways and ends up being accepted as a
normal aspect, naturalized by many people who
live it, who practice it and watch it.
Invisible, this kind of violence goes by
unnoticed by most of us and, in the health
services, it gets present yet it is not
perceived, by the delay on the feedback of a
clinic analysis which retards the patient's
expelling and agonizes the patient, in the
procrastination of a diagnosis and the response
about the feeling bad or even the total lack of
information about the clinical picture for the
interned patient about the reason for them
staying there, many times feeling pain and
suffering with the isolation of their social
terms. The humanization tends to remind us that
we need solidarity and social support. "It is an
everlasting remembrance about our vulnerability
and others' as well&emdash;A wake up call
against violence" [15]. The denial or
non recognition of the statute of the subject or
person is a nocive effect of the symbolic
violence, as a concrete possibility of no
relationship [16].hat is agreeable and
what is the opposite of it (anger,
aggressiveness, violence) as something inhuman.
If we agree with Nietzsche that we are human
beings who are excessively human and thus we'll
never be totally good, such conception will not
be supported [8].
Following these same principles, the
humanized assistance to the child delivery is
characterized by stimuli to breast feeding and
the precocis linking, incentive to natural and
vertical delivery, presence of companion chosen
by the woman for the delivery process. This
model opposes to the reductionism of
comprehending the delivery as a pathologic
phenomenon from the biomedical point of view
[17], which has provoked the shifting of
the caesareans in an epidemic, instead of
keeping it as an important alternative for
therapeutically indicated cases.
If we consider the violence issue as
something against which the humanization
struggle a big and important battle, an
important issue to be considered is the right of
the woman in delivery process to one companion
as recommended by the WHO [18]: "A
delivering woman must be accompanied by people
she trusts and with whom she feels comfortable,
her partner, her friend, a nurse or obstetrics
nurse".
Another relevant aspect is the issue of
pain. Reflections around the cutting down of
pain during the delivery are not new. In the
19th century there are registries of use of
opium and, in the 20th century, painkillers and
also the resource of caesarean delivery. Around
the far fetched 1950's we conceived the delivery
with no pain through a prophylactic method.
In 1990, the eastern techniques, mystic and
psychological to prepare the women and the baby
came to the scene. The background of those
reflections, the delivery with no violence,
became a reference for the humanization of the
assistance which aims to make the delivery more
and more natural and less invasive. "The
presence of companion, the emotional support,
the relief techniques, the team support, are not
enough to eliminate the pain experience factor
though, experience which not only gets related
with the subjectivity of each woman, but, even
more, with the self way how this pain is built
by the culture" [17].
In the sense, it is perceived that some
women try to control the emotions to be into
certain cultural considered to be more
proper&emdash;gestures and acts of despair,
obeying to medical rules and accepting the
advice of the team. Those ones who get out the
Standards are considered to be decompensated and
are blamed for the promotion of stress in the
ambiance and in the professionals: to their
state of imbalance and, in some cases, loss of
consciousness is addressed to difficulties faced
at the delivery.
Nevertheless, when it is possible that the
idea that the pain is legitimate is shared among
delivering patients and the team the
establishment of benefits are really
established: "The legitimating of the pain in a
context that in principle is adverse,
establishes a two way communication, reverse of
which happens when a professional reduces the
pain to the universal organic dimension; there
is no possible negotiation, but otherwise,
imposition and violence (...). The important to
retain here is that the situations of
decompensation are exactly those in which the
respect to the physiological process of the
woman and her decisions is replaced by the
conventional: with no explanations, without
negotiation margins, with disqualification and
jeopardizing of the delivering woman. They are
always neuralgic situations which bring about
disrespect to the rights and symbolic violence"
[17].
And why not to say silent violence? Many
aspects belonging to the humanization of the
delivery and the childbirth have been that
target of effective governmental actions: right
to appointments and prenatal exams, permanence
of the companion in the delivery and post
delivery, that the baby is immediately taken to
their mother right after receiving the first
podiatric cares, except in the cases when either
the mother or the baby require special care,
among other cases.
But there are other untouched issues yet and
which are still part of the day-by-day of
Brazilian public maternities: beds in the
infirmaries which don't allow privacy for the
household contact, not even for the mother and
baby to be breastfed; women who are placed in
the infirmaries indistinctly, better saying,
women remain at the same infirmary: women with
their babies breastfeeding them and living
situations which are all predictable in the
context whereas others immediately beside them
cry out for either their baby who died at the
birth or who have gone to intensive therapy
because needed special care. Typical
manifestations of silent violence, once they are
institutionalized and naturalized practices by
the professionals in the everyday work
shift.
As for other sectors of assistance, at the
hospital maternity it is also possible to check
out the autonomy and the higher margins of power
of the doctor if compared to other
professionals. However, they don't always show
to be flexible and sensitive to the proposed
changes aiming to humanize the assistance as
these last ones.
We start to question then, about the
relationship of the medical formation with the
humanization of the assistance to the health of
the woman. That is what we start to approach
from this point.
3. HUMANIZATION OF MEDICINE AND THE
HUMANIZED ASSISTANCE TO THE WOMAN: PROPOSALS AND
PERSPECTIVES
In the ambiance of medical formation,
several elements have been appointed by the
studies of medical sociology, psychology and
anthropology as important to be thought over the
humanization of medicine. Some of them are:
subjective dimension and the importance of
affections in situations of suffering, pain and
death; discussion on welcoming, importance of
dialog and communication; care over the mental
health of the health professional.
Other pertaining themes to the discussions
around the humanization of medicine are the
projects which concern the medical formation,
having as its central target, giving back to
medicine what it has lost as time went by. We
will take as previously supposed that the
doctor's formation is a neuralgic for the
discussion on the humanization of health and
assistance to the woman, neither the only nor
the most important one. However, to a great
extent, the identity and the profile of the
professional gets defined during their formation
and this is the fundamental issue of our object
of reflection.
The passage of the 18th century to the 19th
century was a very important epoch for the
transition for the modern medicine which started
to base itself on the anatomyclinic model, due
to the discoveries performed by the pathologic.
In the 19th century there was an explosion of
knowledge and techniques and little by little
the act of caring, comforting, consolation,
welcoming which were part of the day-by-day of
the doctor were being suppressed. The picture of
sick patient assumes new representations:
besides the aim of care, they become object of
learning, studies and researches
[1].
Until then, the doctor associated the
scientific advances, arts, philosophy and
history to the elaboration of diagnosis and
conduction of treatment, in the fields of
anatomy, pharmacology, pathology and clinic.
That doctor didn't reduce their art of curing to
one technique, their role was the one of
alleviating the suffering and the pain of both
patients' and their families', preparing them to
the facing of death and acting preventively,
through orientation to prevent getting sick and
contagions.
The discovery of microbiology revolutionized
the field of study of pathology, making it
possible to develop laboratory analysis and
other clinic methods. Little by little
medications were being discovered and developed,
rising the spectrum of actions and possibilities
of treatment. Also the evolution of pathologic
anatomy guided the medical interest to lesions
as an explaining basis of sicknesses, making it
possible to create classifying
generalizations.
"New objects are given to the medical
knowledge, at the same time and at the point
that the cognitive subject gets organized,
modified and gets to work out in a different
way. It was not, therefore, the conception of
sickness that has changed at first, and right
after it the way to recognize it; not even the
system of signals that has been changed and
right after that the theory; but all the
collection and, more properly, the relationship
of the sickness with this point of view to which
it gets offered and that at the same time
constitutes it" [1].
Flexner's model provoked a revolution into
the medical education in the early 20th century,
producing an adaptation in the medical schools
to the scientific and economic parameters of
that epoch, with emphasis on the technical
dimension, work specialization and fragmentation
of knowledge [19]. These paradigmatic
changes were enough to guide medicine in the
parameters of the biomedical model.
In the international extension Flexner's
Report cooperated into the reorganization and
regulation of the working of medical schools,
and moreover, provided the search of excellence
in them. On the other hand, it eliminated
completely all the proposals of attention to
health and, based on scientific reasoning, it
increased the dichotomy between learning of
medicine and professional practice, as well as
their applications and consequences in the
health services [20].
Disturbances and insatisfactions about the
model of teaching adopted since then provoked a
wide debate in the end of the 1990's and the
beginning of the year of 2000 in Brazil. The
National Inter-institutional Commission of
Medical Teaching (NICMT) had as its objective to
construct proposals of changes to medical
schools, reviewing theoretical landmarks and
pedagogic practices, in order to develop, in its
core, a new point of view to this formation.
Using an innovative way to evaluate
collectively, the focus of the commission was to
shift the medical school to the formation of a
committed Professional to the social demands
into the treating of the patient [19].
We shall consider positive the transformations
of the contemporary medicine concerning the
auxiliary instruments to diagnosis and
treatment. However, they were accompanied of a
distancing of the sick patient, the excessive
contact with exams, machines and procedures,
exaggerated and invasive interventions and the
inconsideration of psychosocial aspects.
The great proposal of humanization of the
curricula of the colleges of medicine is
repositioning the ethic dimensions and the
related ones during the formation. This happens
into the trans-disciplinary universe as a
collective of subjects, which is generally
called Humanities. It deals with reincluding the
subjects (concepts and contents) of human
sciences in order to make it possible to have a
reflection about medical practice through other
paths which are not only biologic, contemplating
the social, cultural, psychological, philosophic
aspects present in the pictures of pain,
suffering, sickening and death.
In a final analysis, "the medical humanities
allow the developing of a new comprehension of
the living dimension and the person's suffering,
incorporating the social reality and the
individual experience into the meeting between
the doctor and the patient. It is an integrated
conception that aims to improve the doctors'
communicative abilities and going deeply into
the narrative about the ailment, searching news
ways of promoting patients' [...]
rethink not only the medical practice but also
the formation in medicine, through the
development of new ways into the continuing
education and in the clinic activity"
[21].
All these premises are also valid to the
proposals of medical formation so that to
contemplate, among other issues, the
humanization of the assistance to the woman in
the delivery and the childbirth. In this sense
it is worth considering that the delivery has
undergone modifications historically speaking:
from a natural event, to the natural delivery to
the medicalization and the institutionalization
of the delivery, there is a historical path
since the first practices of the midwives,
beliefs and prayers up to our days when the
technological advances and the development of
the medicine have cooperated to the fall over of
the rates of deliverer mortality and, mainly
newborn death. Paradoxically, at the same time,
the nowadays deliverer became a sick person, a
patient without rights over their own bodies and
that, not rarely, unluckily, are disrespected as
a human being and citizen, subject of rights and
duties [22].
Among other consequences, these
transformations introduced the masculine Picture
and the medical dispositive as dominants, giving
the woman's body scientific denomination, while
symbolic elements of domination. The one which
in the past was performed in the household
ambiance, by midwives or godmothers, people of
the pregnant women's trust or of recognized
experience in the community, starts to be an
event controlled by the biomedicine.
Since then, the assistance to the deliverer
started to be of responsibility of a doctor
specialized in obstetrics, Field of the medical
sciences which cares for the human reproduction
in the woman, as well as their health in the
prenatal, delivery and child death. It's
interesting to observe that this term comes from
the Latin word, obstetrix, as a derivation of
the verb obstare, which indicates the action of
"staying by the side". In this sense, the
obstetrician has the important role of being
together the woman at this particular and
special moment when a new life is being
generated.
These changes have as their landmark the
centuries 18th and 19th, coinciding with the
technological development of medicine as a whole
and, which in the field of obstetrics, was also
impulsed by the exaltation of motherhood
[23].
There came so, the intervention by forceps
and the horizontal delivery which are symbols of
the art of medical obstetrics, favoring its
acceptance as a technical and scientific
subject. This factor contributed significantly
so that the natural event of the delivery
started to be considered a harmful, private,
intimae and feminine event, not being lived in a
public way anymore.
The 19th century witnessed the development
of new techniques of surgery, anesthetics and
the use of cleanliness during the delivery
process and, although even today there is a
broad debate whether the delivery must be done
simply by a midwife or an obstetric nurse, the
event of birth was appropriated by medicine,
became institutionalized and medicalized and it
was fundamental for the development of such
techniques. With the decreasing of the rates of
mother/newborn death, the acceptance of the
hospitalization and the improvement of the
medical knowledge were made easier by the ideals
of security credited to the figure of the
doctor.
In Brazil, the development of the obstetrics
hasn't happened in a distinct way of the one in
Europe. In the colonial period, the midwives
were the holders of the art of delivering,
possessors of the empiric knowledge and
practitioners of the mystic arts as a way to
minimize the deliverers' suffering.
In Brazil the development and the evolution
of the obstetrics science happened in a slow and
gradual way, because of depending directly on
either the immigration of foreign professionals
or the comeback of some professional who had the
chance to study in Europe. Soon the first
colleges started to be inaugurated and the
figure of the midwife was eliminated by the
medical science.
The church and medicine made an alliance for
the domination and medicalization of the female
body&emdash;the first one dealing with the care
of the soul and the second one of the body, by
the means of the ideals around the female figure
as an object at service of reproduction with the
determined role of dedicating exclusively to the
household life, being the suffering of the
delivery seen as an opportunity to get purified
and redeeming from sins [22]. The
ownership of the female body on medicine's
behalf resulted in a culture which transformed
the delivery into a surgical action, the
pregnancy and menopause into a sort of sickness,
the menstruation into a chronic event, all of
them subjected to be medicalized.
This conception was taken along until the
post war period when the lifestyles were
radically altered in all the levels. The psycho
social problems increased, the demographic
control started to be a need to the
restructuring of life in the cities. If the end
of the 19th century was remarked by the
competition between laymen and scientists as for
the care around the delivery, the 20th century
witnessed the emancipation of the woman impulsed
by the feminist movements and, because of so,
the consolidation of the medicalization and
hospitalization process of delivery happens in
the middle of the 20th century.
Nowadays the delivery has been considered an
event which is far away from the woman an epoch
when there are strong and wide bioethics debates
around genetic engineering, in vitro
fertilization and fetal medicine. We have
watched the indiscriminated use of technology
which has transformed the delivery in an event
far from the woman, about which she has no more
privacy or autonomy.
We have also watched the tiredness of the
obstetrics doctor to deal with the complex
bio-psychosocial realities which surround the
event of reproduction, pregnancy, delivery and
child death contemporarily. Women who have a
problem in their pregnancy, be it because of
economic or household issues which impeach them
to keep track of their prenatal program or
sometimes because it was not a planned event
itself.
The absence of a partner or companion, not
rarely generates insecurity into the pregnant
woman who starts to require from the doctor a
relationship of trust which is not found all the
time, once that, as we have already seen, the
biomedical formation is much more focused into
the technique and the biological plan, than into
the ethic and relationship dimensions.
Therefore the search for specialization in
obstetrics has been falling down in number of
cases, for similar reasons, for example, the
search for specialization in podiatric
[24]: there is one transition moment in
the structuring of the family which affects
directly the professions that in one way or
another are related to it.
It is in this sense that the courses of
medicine in Brazil have proposed more and more
the re-inclusion of the contents of the human
sciences into the medical curricula, with the
objective of giving back to the doctor what has
been lost along time: the art of care which in,
the specialization of obstetrics, is fundamental
to deal with the feminine universe into
everything it comprises currently, especially,
the essence of the obstetrics science, the
staying side by side, as we have described
above.
There are initiatives which show that the
humanization of medicine has provoked positive
effects into the formation of new doctors,
especially in what deals with the humanization
of the delivery, as reported by Rebello e Neto
[25]: the perception of the medical
students has been altered, which is fundamental
for the effectiveness of the current policies of
humanization.
4. CONCLUSION
We must consider as positive the changes of
contemporary medicine in the situations dealing
with the auxiliary instruments to the diagnosis
and treatment. However, they have come together
from the distance of the person of the sick one,
the excessive contact with checkups, machines
and procedures, exaggerated and invasive
interventions, and inconsideration of
psychosocial aspects.
The great proposal of humanization the
curricula of medical schools is repositioning
the ethic dimensions and the like during the
formation. We consider it to be possible in the
future if it is associated with another also
fundamental change, the paradigmatic change of
the biomedical model to the bio-psychosocial
model.
The scientific reasoning called bio-medic is
shown as a systematically organized collection
around five theoretical basic elements:
morphology (anatomy), physiology, diagnosis
(sickness), intervention (medicine oriented or
surgical) and the medical doctrine (treating the
lesions) [26]. This biomedical reasoning
may be summarized from the structured ideals
into a scientific logic, which are: check up
universal validity to the knowledge; naturalize
the models of the machines applying them to the
human body; and isolate parts which pre conceive
the overall work.
Even though the medical reasoning has
favored the inclusion into the medicine in the
overall study and the models of natural
sciences, resulting the objectivities of the
sickening processes and the naturalization of
its object of study, this becomes a classic way
of silent violence, for it makes possible the
exclusion of subjectivity of the sick one and
favors the generalization of sicknesses and
subjects [14]. With these situations
dichotomies are installed: objective/subjective;
sickness/sick person; theory/practice;
individual/social; technology/human factor. The
subjective factors, therefore, start to be seen
as anomalies [27], as obstacles which
impeach the doctor for exercising their
competence and professional ethics.
As said by Leite [28], "the doctor
still exercises some power which is visible in
one omnipotence over the destiny of the human
life, sectioning the patient's body in such a
way that both&emdash;doctor and sick
person&emdash;end up losing the domain over the
'organic overall'."
This way we get face to face with a great
stalemate: the current model (bio-medical) which
guides the medical formation, develops health
practices which don't follow important
principles of SUS: "they [the bio-medical
professionals] are 'charged' by the sick
ones and for their ethic mission of healers, and
now by SUS and by PSF, for them to have whole
attention to health, but their recent knowledge
and tradition are centered in something which is
alike the contrary of the wholeness"
[29].
On the other hand, the psychosocial model,
contemplates the plurality, presupposing the
overcoming of the biological specification of
the body which, in the sickening, brings about
"social production condition, and the space for
inter subjective exchanges" which are weaved
"over, into and beyond the biological bodies"
[30].
We have advanced in the epistemological
aspect according to a biomedical model and it is
fundamental to go on its overcoming. Replacing
it by another paradigm in health would
contemplate non objectivable aspects, especially
concerning the relationship doctor-patient.
The bio-psychosocial model, because of being
based on the health concept of the
WHO&emdash;bio-psychosocial welfare&emdash;is
presented as an alternative to biomedicine and
as more appropriate to the facing of complex
demands which emerge in the Field of health as
we have stated in previous work
[31].
It is a model that "besides of
comprehending, physical psychological and social
dimensions, providing a whole view of the human
being and, when incorporated to the formation of
the doctor, points out to the need that the
professional keeps in a constant process of
formation to beyond the technical learning,
perfecting of the instrumental abilities. The
related capacities also evolve and allow the
doctor to establish proper and effective
connection and communication" [32].
These indispensable presupposed factors, to
think of the re-humanization of the medicine
[33], are also absolutely necessary to
the humanization of health and, to our point of
view, eventually, for the humanization of the
assistance to the woman in the delivery and the
childbirth. They are interlaced and any
impossibility of effectivation of one of those
will compromise the other one.
Denise Ribeiro Barreto Mello, Ligia Costa
Leite Thus we understand that the biggest
current challenge is promoting the discussion
linked to the themes approached here, thinking
about possible solutions which come at last to
promote the coming around of the obstetrics
doctor and the pregnant woman, seeing her above
it all, as a person who feels, thinks, gets
agonized, desires and can cooperate in the
process of generating, delivering, welcoming and
caring.
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