INTRODUCTION

Humanization in providing health services, understood as human-centered care, is a challenge, given the conditions and commitments that must be fulfilled by institutions and health staff ¹. The aim of humanization is to concentrate care on the individual’s, rights, needs and expectations of the women as the protagonist, seeking for their optimal health and wellbeing². Within this context, it is expected that delivery care becomes a loving, pleasant, and positive experience ². However, some mothers manifest having gone through obstetric violence. This is cause for concern, especially when globally 830 women die due to preventable causes related with gestation and childbirth; 16.7% of them due to complications during delivery ³ because of outcomes related with abuse ⁴.

In search for the highest level of humanized care during childbirth, programs have been promoted to improve the quality of care ⁵. Thus, the International Conference on the Humanization of Childbirth, in Fortaleza, Brazil, established the search for wellbeing as a factor of progress and human development for the players in the process: mother, child, and family ⁶. This makes necessary to have strategies and validated tools that permit communicating and educating on practices that contribute to turning childbirth into a humanized experience for pregnant women and their families. Educommunicative strategies generate knowledge and attitudes in the construction of environments and spaces for dialogue and respect ⁷, with the advantage of encompassing different areas of knowledge and achieving citizen participation ⁸.

In this sense, the educommunicative booklets are strategies proven through investigation-action, as useful to reach changes in relation to the perceptions and behaviors of the individuals ⁹, with positive impact on education and generation of participation settings ¹⁰. This requires an adequate validation process, to guarantee levels of understanding and comprehension of the different factors intervening, in this case, on humanized childbirth care ¹¹. The aim of this study was to elaborate and validate a booklet on humanized childbirth to disseminate knowledge on the theme among pregnant women and the general population in Colombia.

METHODS

Elaboration and validation was conducted on an information, education, and communication booklet on humanized childbirth. This included a process of production, evaluation, and improvement of the booklet in Bucaramanga, Colombia, during December 2019 ¹¹. Table 1 displays the stages and steps followed.

Table 1.  Stages and validation steps of a booklet on humanized childbirth. Colombia, 2019. 

The goal group was established as being that to which the booklet is directed, a population that could be interested in the care of humanized childbirth, especially women in reproductive age, pregnant women, and their relatives. The exclusion criterion considered those individuals who had cognitive disability that hindered comprehension of the booklet.

Thereafter, the bibliography search was conducted in the LILACS, SCIELO, and PUBMED databases, using the keywords: humanized childbirth, obstetric violence, and educational-communicative strategies, resulting in 56 scientific articles. The study also reviewed national ¹² and international ^13,14 norms and guidelines on humanized childbirth.

The contents for the booklet were selected by bearing in mind relevant information, obtained from the previous search. The booklet was organized via the following themes: a. rights of women during childbirth and postpartum; b. duties of the women; c. unnecessary practices during low-risk childbirth; c. when to attend the health service due to the start of the delivery?; d. stages of childbirth; e. complications of delivery and childbirth; and f. role of the companion during delivery and childbirth.

The illustrations were designed in digital format based on the reflexive reading of the contents. The booklet sought to transmit the message of humanization in the contents through attractive and harmonious illustrations according to situations alluding to humanized childbirth. The initial version of the booklet had 12 pages in color, with dimensions of 14 cm by 22 cm.

The second stage elaborated two validation formats. One aimed at specialists, another to mothers and relatives. The questions for the formats were adapted from those used in prior studies by Piaui ¹⁰ and Ceara ¹⁵ in Brazil, respectively. The specialists were asked to assess objective, content, language, structure, presentation, illustrations, and relevance of the booklet, using Likert-type scoring options, like inadequate, partially adequate, and adequate. The content validity index (CVI) was calculated, which suggests considering acceptable an index > 0.60 and discarding or reevaluating those below said value ¹⁶. Pregnant women and relatives evaluated: a. general perception of the booklet; b. writing style; c. presentation; and d. motives. In this case, the scoring system was adopted with dichotomy yes/no responses. For the total adequacy rating, the sum of scores obtained was divided by the maximum score and multiplied by 100, to transform it into percentage (%). It was established that scores between 70% and 100% correspond to approved material; between 40% and 69% material subject to changes; and 0% to 39% to inappropriate material.

The tools were applied by two physicians, young researchers, experienced in approaching human beings and trained in the application of research instruments.

Prior to opening the call for the group of experts, specialists in the field of interest were defined as professionals with specific knowledge in gynecology and Obstetrics, public health, and humanization of care. Sixteen specialists were chosen, selected intentionally due to their suitability, according to that expressed in their curriculum vitae, using a scale from 1 to 6 in which each potential participant should obtain at least four points ¹⁷, as shown in Table 2. Contact was made in their places of work, along with the invitation to participate, the procedure and signing the informed consent. The place and date to apply the tool was agreed upon, according to the specialist’s availability.

Table 2.  Selection criteria of specialists in the area of interest 

Adapted from Sheyla C. et. al.¹⁰ and Holanda de Moura I. et. al.¹⁵

The population of interest was comprised of 100 individuals, between mothers and relatives who were contacted in the outpatient or hospitalization services in a private institution caring for people from all social security regimes. The participants were explained the objectives of the validation process, informed consent, delivery of the booklet, and evaluation of such according to the format.

The findings were transcribed in separate databases in Excel in double tabulation and verification of digitization quality. Upon correcting the databases, these were exported to analyze the information in the Stata14 statistical progrAm

RESULTS

A booklet on humanized childbirth was designed, aimed at the general public, especially pregnant women and their relatives. In 12 brief and attractive pages with color illustrations, the booklet introduces theoretical content on humanized childbirth, based on findings from the literature, national legislation, and international agreements. To guarantee interactivity, an alphabet soup was used with keywords from the humanization process in childbirth care.

Sixteen experts validated the booklet, among these: nurses, general physicians, gynecologists, and health professionals. Table 3 shows the format questions, number of specialists who scored them in each of the scale options and the respective CVI.

Table 3.  Results of the evaluation conducted by specialists in humanized childbirth. 

^*CVI: content validity index

As seen in Table 3, the calculated CVI was > 0.60 in all items, which indicates that the booklet’s content is valid. Items 6, 8, 16, and 22 were scored as adequate by all the experts, which show that the message is concise, explains what humanized childbirth is, the title size is adequate and the front cover attracts the reader’s attention. The item with the lowest score was # 23: the front cover expresses the purpose of the material. Eleven items obtained scores < 1.0, principally those assessing the illustrations, but the score was always > 0.60, which is why it was deemed not to compromise the booklet’s validity. The CVI median was 0.94; Cronbach’s alpha reliability was 0.81.

For the validation performed by the target population, the positive response level ranged between 87% and 100%, with a median of 97.9%, sufficient to validate the booklet’s content. The sections of general perception and presentation had the highest results. Table 4 shows the results obtained by each question.

Table 4.  Results of the evaluation conducted by target population 

N: Number of people. %: Percentage

The booklet’s final version underwent minor changes in form, according to the recommendations by both groups of evaluators.

DISCUSSION

This study found that, by following the steps proposed, conducting the literature review, and minding details in writing, form and depth, a booklet can be achieved with high validity index to provide education to pregnant women and their relatives. In health, communication is an aspect of importance to inform, influence, and motivate the public, principally on themes of health promotion and disease prevention, in favor of improving the quality of life of communities ¹⁸. This educational-communicative strategy permits offering didactic information of easy comprehension to improve the population’s knowledge and satisfaction. Besides propitiating comprehensive and humanized care ¹⁸, it contributes to health education ¹⁹, its promotion, and recognition of the needs of pregnant women ¹⁰.

Validation of educommunicative materials is a process that permits understanding the theme introduced, analyzing different opinions, recognizing the importance of the socio-cultural component of the population, as well as correcting and improving the material to fulfill the objectives proposed. All this is done to identify the message that permits generating positive changes in the population’s behavior ²¹. Other studies have sought to provide spaces to improve the physician-patient relationship, along with empowering the population with the themes ²². Using communication has also been proposed as a means to promote physical, cognitive-emotional, and social-relational wellbeing from the information and communication technologies (ICT), given that it has been found that by adopting the strategies, there is improved quality of life ²³, acceptance, level of understanding, memory of the information and of the medical instructions ^{24 25}.

Regarding humanized childbirth, research whose aim was to promote humanized childbirth care, from an educational intervention of formation and sensitization of health professionals and pregnant women, showed a reduction in the rate of cesarean sections and their complications, besides improving maternal satisfaction and mother-fetus wellbeing ²⁶.

Among the strengths of this study is the support from the scientific literature, follow up of a structured and organized process, besides the sample size of specialists, as well as the target population, compared with other studies. The study’s weaknesses focus on the collection of information, in relation to filling out the survey, given that in the target population it was conducted in the hospital environment, which could limit or mask the responses obtained, as well as the collection by the specialists, which was carried out in a work site with limited time to answer the survey.

CONCLUSIONS

The booklet elaborated based on the literature review on humanized childbirth is valid to guarantee understanding, by mothers and relatives, of humanized childbirth. During the validation process by experts, a CVI score above 0.60 was achieved in the 30 items, with a median of 0.94 and Cronbach’s alpha of 0.81, while the target population scored it with positive response between 87% and 100% with an average of 97.9%; which is why the booklet was deemed appropriate to educate, inform, and communicate on humanized childbirth.

The design and illustrations were carried out and organized by a graphic design professional, which is why after its validation it may be considered as relevant material to educate on humanized childbirth, as an impact event in the life of the mother-child binomial and their relatives where an adequate physician-patient relationship must exist, which leads to comprehensive care centered on the expectations and needs of the pregnant woman for which the health staff, the pregnant woman and her family must be trained.