History of obstetric nursing at the Nursing School Carlos Chagas: an analysis based on the Freidsonian approach

1 Universidade Federal de Minas Gerais, Escola de Enfermagem, Programa de Pós-graduação em Enfermagem, Belo Horizonte, MG, Brazil. 2 Universidade Federal de Minas Gerais, Escola de Enfermagem, Graduação em Enfermagem, Belo Horizonte, MG, Brazil. ABSTRACT Objective: to analyze the offering of the first graduate certificate program in nursing in the state of Minas Gerais, called “Graduate Certificate Course in Obstetrics” (Curso de Pós-Graduação em Obstetrícia), by the Nursing School Carlos Chagas, in 1966, and its contribution to the professionalization of obstetric nursing. Method: this is a documentary, socio-historical study, based on the Sociology of Professions by Freidson. Results: the data collected allowed the following thematic composition: academic organization of the graduate certificate program and differentials and discontinuities of the first graduate certificate program at the Nursing School Carlos Chagas, with two categories delineated: “Construction of specific knowledge for obstetric nursing” and “Enhancement of specialized knowledge for scientific notoriety”. Conclusion: The first offering of a graduate certificate program in nursing by the Nursing School Carlos Chagas at the Universidade Federal de Minas Gerais was a milestone in the history of nursing in Minas Gerais and of the institution itself for being groundbreaking and having attracted students from other states, with repercussions in Brazil. This protagonism supported the professionalization course in the state and in the country, contributing to the scientific notoriety of the institution and of the professional category.


INTRODUCTION
Brazilian nursing has undergone significant changes in the educational background throughout history. Professionalization has followed the organization path of the Anglo-American nursing model, from the periods of connection with the Medical Schools to the achievement of autonomy in the training process and institutional administration (1)(2) .
Since the 1920s, with the first nurses graduated following the Anglo-American model, the desire to consolidate nursing as a science around the construction of knowledge specific to the area was identified. For this, in this period, "about seventeen nurses graduated from the Nursing School Anna Nery took graduate courses in the United States, with a scholarship from the Rockfeller Foundation" (3) . Later, in the 1940s and 1950s, the number of Brazilian nurses in graduate courses abroad increased (2)(3) .
In 1939, among the first initiatives to create graduate courses in nursing in Brazil, the Graduate Certificate Program in Nursing and Obstetrics started being offered in São Paulo. After the enactment of Law No. 775/1949, which provided for the expansion of specialized knowledge in nursing education in the country, this course was incorporated into the Nursing School of Hospital São Paulo, currently Escola Paulista de Enfermagem. At the Nursing School Anna Nery, the first graduate certificate programs began in 1947, primarily for the training of teachers, with a view to graduate courses and, from 1948 onwards, courses referred to as graduate certificate courses for the areas of Obstetrics and Public Health (4) were offered.
In 1955, Law No. 2.604 regulated the nursing professional practice in Brazil, discussing the six categorizations present in Nursing at the time: Nurse, Nurse Assistant, Obstetrics Nurse, Midwife, Traditional Midwife, Practical Nurse. This law revoked the first legal standard regulating Nursing practice, addressing the gaps in the attributions of professionals, as well as the reference to the qualifications required for the professionalization of Brazilian nursing (5) .
Other initiatives to meet the requirements of professional qualification in the country took place in the 1950s in the nursing graduate certificate programs in the areas of Pedagogy and Didactics applied to Nursing and Administration of a Nursing Unit at the Nursing School Rachel Haddock Lobo, currently the Nursing School of the Universidade Estadual do Rio de Janeiro (UFRJ), and at the Nursing School of the Universidade de São Paulo (USP) (6) .
In the 1960s, the political context of conservative modernization defined important milestones for the development of nursing education in the country: the first Law of Directives and Basis of National Education (LDB) of 1961 and the report No. 977/1965 of the Chamber of Higher Education, which established general rules for the organization and functioning of graduate studies in Brazil. Thus, graduate certificate nursing programs for specialization and improvement arose with the technical-professional objective of training specialized professionals to assist in the healing and management areas of health services (2) .
The Universidade Federal de Minas Gerais (UFMG) has always been at the forefront of discussions directed to the progress of Brazilian education. The institution has been following the changes and rules in force of the national higher education and the Nursing School Carlos Chagas (EECC), currently called Escola de Enfermagem da UFMG (EEUFMG), the second nursing school in the country created in 1933 following the Anglo-American model, was the pioneer in offering nursing graduate courses in the state, leading the professionalization processes in Minas Gerais (1) .
The first graduate certificate course offered by EECC was called "Graduate Certificate Course in Obstetrics" in 1966 (1) . Importantly, the state of Minas Gerais has a tradition of training nurses specialized in obstetrics and the EEUFMG is currently playing an important role in the history of obstetric nursing, with a long history in teaching combined with scientific practices in assistance to women. Considering the history of EEUFMG in obstetric care, it is now important to define a specific field of knowledge to legitimize the profession in terms of scientific notoriety (7) and to unveil the roads and deviations taken throughout history to consolidate the specialization in obstetrics. The findings of this study may contribute to understand the rise of nursing in Brazil in recent years, which is linked to historical knowledge (1) . Therefore, the present study aims to analyze the offering of the first graduate certificate program in nursing in the State of Minas Gerais, called "Graduate Certificate Course in Obstetrics", by EECC, in 1966, and its contribution to the scientific notoriety of the professional category of obstetric nursing.

Design of stuDy
This is a socio-historical study with documentary analysis. The social perspective was considered, allowing us to state that, in history, all approaches are inscribed in this order and have an interface with each other (8) .

scenario
The study local was the city of Belo Horizonte, capital of the state of Minas Gerais, in the 1960s, the place and period in which the first course of the Graduate Certificate Program in Obstetrics of the EECC, currently called UFMG Nursing School, was organized and offered.

selection criteria
The criterion for selecting documents was the free mentioning or speech about this specialization course.

Data collection
Documentary collection was carried out from June to September 2019, based on six documents from the collection of the Memory Center of the UFMG's Nursing School (CEMENF), as shown in Table 1.

Data analysis anD treatment
After reading and condensation, the findings were organized considering the theoretical framework Sociology of professions by Eliot Freidson, since it is assertive for the analysis of the processes of professionalization and construction of specialized knowledge. Thus, two analytical categories were outlined: "Construction of specific knowledge for obstetric nursing" and "Enhancement of specialized knowledge for scientific notoriety".

ethical aspects
The study used documentary sources from a public collection, and was exempt from the report of a Research Ethics Committee; there are no ethical implications for mentioning historical personalities.

RESULTS
acaDemic organization of the graDuate certificate course The Graduate Course in Obstetrics was divided into two terms of 5 months: 1 st term: April 11, 1966 to September 30, 1966 and 2 nd term: October 1, 1966 to March 31, 1967. The course, of a duration of at least 180 days of "effective school work" and 6 hours of "daily school activities", comprised theoretical-practical teaching, internships in hospital services, home maternity services, outpatient clinics, and health care units. Table 2 presents the description of the curricular activities developed by the students.
The teachers of the course were four nurses: Sister Cecília Bhering, Maria Vitória da Silva, Elza Lanza and, almost at the end of the course, in 1967, Aparecida Ferreira. The four nurses did their degree in the same location, Escola Paulista de Enfermagem / Hospital São Paulo, in close years, and were responsible for the theoretical and practical content of the EECC's graduate course in obstetrics. For the creation and implementation of EECC's graduate course, an interlocution with the professors of the discipline of obstetrics at UFMG's Medical School was required, as they knew the renowned work of Sister Cecília Bhering and strongly supported the initiative. The basic segment was taught by medical professors, according to the direction of the nurse professors. The content was divided into three subdivisions, as shown in Table 3.   The students assisted the pregnant women continuously in the prenatal care, delivery and up to 30 days in the postpartum. All activities were supervised by the teachers, and the clinical cases followed should be described in reports. A total of 270 cases per student was required, divided in visits described in the documents, such as monitoring of pregnant women, prenatal anamnesis, assisted natural deliveries, assessment of normal and pathological newborns, pre-and postoperative gynecological surgeries, normal and pathological postpartum, and social cases.
The partial and final trainings took place in three stages, with assistance from the graduate students to women throughout the pregnancy-puerperal cycle and to the newborns. The students' evaluation was made through the average of the mid-term and final internship grades, called "internship average", and was considered with the other competences required for their final approval. The internships, called internatos in Portuguese, were all developed in Belo Horizonte, at Hospital São Vicente, currently named Hospital das Clínicas of UFMG, Hospital Militar and Santa Casa de Misericórdia. In general, the relationship between nurses and the internship fields was respectful, with the physicians' trust, and nurses' autonomy in the places of practice.
The physicians trusted us (...) they did nothing without asking us, nothing, they did not prescribe anything without asking us (...) (E1).
In a teaching hospital, medicine, we are (we were) responsible for prenatal care, we had 45 women in the morning and we referred three to four cases to the doctor (...) and the woman participated (E1).
The graduate certificate course in obstetrics offered at EECC followed the model of the Escola Paulista de Medicina, created by Mother Domineuc, at the end of the 1930s. This model was important to outline the course disciplines organization, because along with the disciplines related to the biological care, there was a focus on the socalled "Social Obstetrics". The teachers, together with the students, with no support or funding from the medical school, raised funds to cover the costs of renting a house, which was named "Colmeia". It is reported that they asked for money at the churches doors and at the cemetery on all souls' day. The house, located in the neighborhood Santa Efigênia, close to the EECC, has as objective receiving women in poor conditions and preparing them to maternity.
At Colmeia, in addition to students and teachers, there were single mothers and pregnant women, who paid for their stay with the care of the clothes of students and teachers. The students lived with these women and, at the same time, developed some work, which showed traces of permanent education in health, something that was very remarkable in the nursing praxis.
We had that philosophy (...)every obstetric nurse has to provide support for the mother for her not to donate the child (...) she (the mother) only donates the baby if she is pressed by the family or if she has nowhere to go (E2).
(...) This house was a need we perceived, we have mothers in the maternity hospital who do not (...) they had their husbands, who didn't undertake their responsibilities as fathers (...).This is social obstetrics, solving the problem, it's not giving birth and bye bye (...) (E1).
The house grew over the years until it was moved to a new address, where social work continued independently from EEUFMG. The presence of Sister Cecília Bhering in the direction of the course also gave it a characteristic of assistance, following a historical process of training for nursing and other health professions, with a strong influence from the population's social, cultural, and political needs. EECC's teaching high quality ensured the students a demanding and complete intellectual and professional training, especially regarding comprehensive care for women and newborns. The graduate course offered by EECC quickly became nationally known, attracting students from all over the country, as reported in all consulted interviews. The first group consisted of 12 students, coming from various locations, among them some mentioned in the interviews (Ceará, Bahia, and São Paulo), who received the title of obstetric nurses in a graduation day. The expectation was that there would be a second group of students for the course started, but it was not continued.
The end of the offering was not well explained in the consulted documentation. However, two hypotheses were raised, both related to the change of leadership at EECC and Hospital São Vicente. One of the hypotheses, defended by Sister Cecília Bhering, attributes the end of the graduate certificate course to the change of direction at the EECC, pointing out Sister Emília Clarízia, director in this period, as one of the opponents. According to Bhering, the new direction was opposed to the course for no clear reason. In her turn, Aparecida Ferreira relates the end of the course to the change in management at Hospital São Vicente. She describes the change of director as "authoritarian and impolite" (E2), sometimes preventing nurses from attending births, even with all the documentation and regulations of the course presented in response to them. Finally, a contact with an employee at Hospital Militar organized the progression of the internships of the second group of students to that hospital.
It is known that the change of direction of the EECC coincides with the displacement of power between religious and lay women. Would the opposition to the course be a divergence of interests between these two groups? Or did the exit of nuns from the board culminate in the loss of the main internship field, resulting in the end of the course? In both cases, the exact moment of course termination is not clear from the documentation, leaving the closure of the graduate certificate course without clarification.
Anyway, the EECC course resulted in the training of 12 obstetric specialist nurses and in the pioneering spirit of this institution in offering graduate education in Minas Gerais. This graduate certificate course deserves being mentioned so that it can be the object of a historical study, as it had important characteristics (formation of specific knowledge; practical and theoretical knowledge; expanded assistance for women's health) for the history of obstetrics nursing development, supporting professionalization in the state and country, when it took the path of social recognition of nursing specialized in the care of women and the binomial mother-child.

construction of specific knowleDge for obstetric nursing
From the perspective of the sociology of professions, the profession is characterized as a type of occupation that masters specialized knowledge, based on credentials obtained at universities. Thus, the designs of the professionalization of obstetric nursing point to the influences of the role of educational institutions in the construction of their own knowledge and the consequent achievement of market reserves (9) .
In Brazil, between 1922 and 1925, the title of specialist in obstetrics "for nurses was attributed to graduates of the Obstetrics Course at the Medical and Surgery School of Pará (Faculdade de Medicina e Cirurgia do Pará)" (10) . In 1931, childbirth courses were added to the obstetric clinic discipline of the Medical Schools (11) . The nursing education regulation in Brazil occurred in the middle of the 19th century, and since then the "profession has undergone numerous changes and has gained much space and respect in the field of health, especially with regard to women's health" (10) .
The evolution of the contemporary society is linked to the development of institutionalized knowledge, the way in which the occupation of professionals in the labor market is organized. In addition, there is the importance of the State in the regulation and control of professional practice (9) .
Despite the formation of only a single class, EECC's graduate certificate course in obstetric nursing had great national visibility and importance for this category professional development (12) , which can be evidenced by the presence of students from other states who came for a specialization in Minas Gerais, and due to the training model focused on the social commitment to improve the health conditions of women and newborns, which still today characterizes the premise of values in professional training supported by EEUFMG.
The graduate certificate course offered by the institution of Minas Gerais operated autonomously from the Medical School, even with the collaboration of medical professors in the curricular structure. In its turn, the Obstetric Nursing Course that was offered, in this same period, by the Midwives School of São Paulo (Escola de Parteiras de São Paulo), was strongly subordinated to medical knowledge and was operated as an annex to the Medical School until the early 1970s, when it was incorporated into the Nursing School of the USP (11) .
The nurse professors at EECC, who also carried out the supervision of internships, trained the students for a professional performance centered on theoretical and practical knowledge specific to the profession. This characteristic points to the reason for the demand for the course by students coming from São Paulo, since, despite the participation of midwives, obstetrics nurses, and nurses in teaching, the course in São Paulo had the principle of training nurses to act as assistants in medical practice, in home and hospital deliveries (1,13) .
In addition, the EECC's particularity is highlighted in the training of nurses specialized in obstetrics with theoretical knowledge and practical experiences about the social conditions of vulnerability of women's health in the region, unlike other institutions that prioritized training focused on hospital care and obstetric urgency (11,13) .
The quality of the graduate certificate course allowed the students to work at Santa Casa de Misericórdia, since, due to a violation of the rules in an obstetrics internship at the undergraduate level, the Nursing School had been prohibited from entering the institution's facilities since 1936 (12) . The registration of Santa Casa de Misericórdia as an internship field for graduate studies may mean a reopening of doors for EECC in this institution, in addition to showing, based on the Sociology of Professions (7) framework, the interest in students, as they were trained nurses, to compose the professional staff.
The characteristics of the training at EECC later ensured the graduates a space in the job market. There are records that three recent graduates from the first class stayed at Hospital das Clínicas or continued to work as nurses at the UFMG. The credibility of the course offered by EECC, along with possible other interests, including political ones, ensured the student Corina Bastos Crespo a scholarship financed by the Government, with publication in the Official Gazette of the Union, for expenses during the graduate certificate course (14) .
Also noteworthy is the professional history of the graduate Vera Moreira de Oliveira, who served as a professor at the Escola Paulista de Enfermagem in 1972, demonstrating the quality of teaching offered by EECC, with insertion in a field outside the state (15) . In this setting, the events of the first graduate class at EECC mark the beginning of a process of professional autonomy, with the construction of an obstetric nursing knowledge of its own, in Minas Gerais, and its affirmation "as work in the field of health, discipline of scientific knowledge, and as a service-oriented profession" (16) .
Based on the theoretical framework that "a profession achieves, by itself, its autonomy when it is able to exercise control over the norms and performance of its professional members" (16) , it can be said that EECC's first graduate certificate course contributed to the construction of obstetric nursing scientific knowledge, with teaching coordinated by nurse professors, a curricular structure with an important course load of disciplines based on nursing practices, and an evaluation process among peers (7,9) .
The formulation of care teaching in obstetric nursing in the EECC graduate certificate course followed the same principles as the professional nursing work, with the organization of a set of health actions and the implementation of care practices, also following the characteristics of training of other institutions in the country, such as the Nursing School Anna Nery, at the UFRJ and the Nursing School of Hospital São Paulo (11,13) .
The curricular structure of the course, strongly marked by practice, with the requirement of a greater course load of "effective school work", demonstrates the need for the training, in service, of a professional with technical skills associated with theoretical and scientific knowledge for the assistance to women and newborns. This training model is currently recommended and defended by the pedagogical guidelines of the residency programs in obstetric and multiprofessional nursing, which have as a strategy the theoretical-practical teaching in service, to allow an experienced learning of health care and education (17) . The theoretical disciplines of the course, together with internships in the fields of hospital practice, as can be seen in the professional experience of at least two specialist nurses trained in the course, allow the construction of specific knowledge for obstetric nursing, training nurses able to work with quality and safety in the care of women during pregnancy, childbirth, and puerperium.
The nurses' specialization process, within the formal environment of the university, inaugurates a journey of ruptures and continuities in the training of obstetric nurses, in Minas Gerais, that is, even today, marked by confrontations and disputes for areas of performance (17)(18) . strengthening scientific knowleDge for scientific notoriety Graduate certificate courses in obstetric nursing in Brazil begin the construction of specialized and specific knowledge for the area, centered on the care of women and family, on the humanization of childbirth and birth, with the reduction of unnecessary interventions to reduce maternal and neonatal mortality. EECC's 1966 Graduate Certificate course presented curricular elements that were essential to highlight the course on the national scene, even attracting students from other states, inaugurating the journey of this institution in the training of qualified professionals.
Through the analysis of the EECC's course curricular organization, it is possible to state that mandatory disciplines of "Psychiatric Nursing integrated to Obstetric Nursing", "Social Obstetrics", and internship in "Medical-Social Services" demonstrate a concern of the faculty with the preparation of student nurses to work in a broader panorama of women's health, addressing particularities of population groups, as well as social and economic conditions. Nowadays, childbirth care in Brazil is characterized by intense medicalization of the female body, also related to the socio-cultural and economic characteristics of the population, health policies, inequity and exclusion, resulting in a high rate of cesarean sections and maternal and perinatal mortality, overloading the social and financial systems. Brazil is among the countries with the largest number of these surgeries in the world, and for every 10 births performed in private maternity hospitals in Brazil, 8.5 are cesarean sections, exceeding the World Health Organization (WHO) recommendation of 1.5 (19)(20) .
A strategy to reduce the number of caesarean sections and, consequently, to reduce maternal mortality rates, was the investment of the Federal Government in the training of obstetric nursing professionals, since they are trained to assist in natural childbirth of usual risk. In addition, obstetric nursing, by building a specific knowledge, has conquered a differentiated space in health services, defending a safe birth, free from unnecessary surgical and medication interventions (20)(21) .
Thus, public policies began to prioritize the training of obstetric nursing professionals. An important milestone was the implementation, in 1984, of the Program of Comprehensive Assistance to Women's Health (PAISM), of the Ministry of Health, whose main objective was to ensure

RESUMEN
Objetivo: Analizar la oferta del primer curso de especialización en enfermería de la provincia de Minas Gerais, denominado "Curso de postgrado en Obstetricia", ofertado por la Escuela de Enfermería Carlos Chagas en 1966 y su contribución para la profesionalización de la enfermería obstétrica. Método: Estudio socio-histórico documental basado en la Sociología de las Profesiones de Elliot Freidson. Resultados: Los datos colectados permitieron la siguiente composición temática: Organización académica del curso de especialización y diferenciales y discontinuidades de la primera especialización de la Escuela de Enfermería Carlos Chagas en dos categorías: "Construcción de conocimiento propio para la enfermería obstétrica" y "Fortalecimiento del saber especializado para notoriedad científica". Conclusión: La primera oferta de un curso de especialización en enfermería por la Escuela de Enfermería Carlos Chagas de la Universidad Federal de Minas Gerais representó un hito de la enfermería minera y de la propia institución, por ser pionera y haber captado estudiantes de otras provincias con repercusión por el país. Este protagonismo apoyó la trayectoria de la profesionalización en la provincia y en Brasil con contribución científica y profesional. comprehensive assistance to women's health and equity of genre. The financing of graduate courses in obstetric nursing, since 1999, was a strategy of the Ministry of Health to comply with these principles, in a joint action with universities and health departments in the country (10,22) . In this perspective, the UFMG stands out, due to its historical role of teaching and training in this professional category, as a pole of coordination and execution of teaching and research projects in the area. In 2000, in the search to improve maternal and perinatal care, the Humanization Program for Prenatal Care and Birth (PHPN) was also launched to, together with the obstetric nursing training initiative, ensure higher quality of care for pregnant women, parturients, puerperal woman, and the newborn (10) . However, the insertion of obstetric nursing in the country, even today, faces some of the same difficulties from the beginning of their training, such as the confrontations with the medical category, since a large number of them disregards the importance of the work performed by the obstetric nurse for a safe and humanized assistance to natural delivery (10,23) .

DESCRIPTORES
Thus, the EEUFMG, a pioneer in teaching the profession in the State, contributed significantly to the construction of specific nursing knowledge, allowing the acquisition of specialized knowledge and the necessary credentials to support the labor market reserve.
It is considered that the process of building a specific knowledge for the obstetric nursing in Minas Gerais, based on humanized care and focused on public health, had as a landmark this graduate certificate course. However, this study cannot generalize the journey of obstetric nursing courses in the country, since it recognizes the influence of different socio-cultural, political, and historical contexts for each Brazilian region that have changed the trajectories of professionalization in each location.
This work is relevant for allowing the comprehension of the process of educational and practical training of obstetric nurses as a field of specific and specialized knowledge, seeking to understand the progress and difficulties of the profession. In addition, it allows the analysis of the formulation of guidelines and regulations that address the specificities of obstetric nursing teaching and practice.
The gaps left in the documents, such as the lack of clarification of the reason and time of closure of the course and conflicting information in the interviews, were presented as limitations of the study. However, it was possible to outline the graduate certificate offering and to suggest hypotheses for its termination, as well as to assess its importance.

CONCLUSION
The first offering of a graduate certificate program in nursing by the EEUFMG was a milestone in the history of nursing in Minas Gerais and of the institution itself for being groundbreaking and having attracted students from other states, reaching considerable repercussion in Brazil, at this moment, beyond the state of Minas Gerais. The protagonism of EEUFMG supported the professionalization course in the state and in the country, contributing to the scientific notoriety of this institution and of the professional category. Historical knowledge stands out as a tool for understanding man as a being who constructs his space and time and as an instrument for the transformation of society.