BRAZILIAN SCIENTIFIC PUBLICATIONS OF OBSTETRICAL NURSES ON HOME DELIVERY: SYSTEMATIC LITERATURE REVIEW

This review study of national journals aimed at characterizing the scientific production of Brazilian nurses regarding home delivery and identifying the results achieved. A total of 27 studies were found, of which ten studies complied with the inclusion criteria, with eight constituting the analytical corpus in accordance with the Critical Appraisal Skills Program. Data were synthesized using the meta-ethnographic approach, following the interpretation of the reciprocal translation. Three categories emerged: The care provided by traditional midwives; Experiences of women cared for by health professionals in a home delivery; and Comparative experiences of women who experienced deliveries both at home and in a hospital. The metacategory 'respectful delivery in the embracing home environment' points to the need to assess the reality of the Brazilian home delivery. Results reveal the practice of traditional midwives and the satisfaction of women who delivered their child at home, and reveal an important gap regarding the production of knowledge of the obstetrical nurse regarding home delivery. DESCRIPTORS: Home childbirth. Obstetrical nursing. Review literature as topic.


INTRODUCTION
For a long time, childbirth was considered an integrating and expected event in the woman's life cycle, experienced in a private setting, and, generally, shared within a feminine view of the living process. There was permeability of knowledge and practices among parturient women, midwives and other women who were invited to the event. 1 In the Brazilian context, for a long time, particularly after the 60's, "traditional" midwives were concentrated mainly in locations where access to hospitals was difficult. 1-2 However, after recent (last 20 years) social movements, the World Health Organization and organized professional groups took a fresh look at midwifery. This culminated in the establishment of public policies involving home deliveries, and a new space was gained for the activity of physicians and obstetrical nurses who began to work as "professional midwives" in home environments and in large urban centers, responding to the demand of women who choose the experience of delivering their baby at home, even when access to a hospital institution was guaranteed.
This activity is supported not only by professional legislation, but also by ministerial health policies. 2 Regarding the activity of obstetrical nurses, particularly, care is relegated to lowrisk deliveries, 3 and their professional activity is regulated by law no. 7.498/1986. 4 Despite this law being in force for 25 years, home delivery by obstetrical nurses is relatively new. 5 In the world of scientific production, on the other hand, there has been a profusion of publications, especially in terms of investigative results regarding obstetric safety. [6][7][8] In Brazil, however, studies and publications involving the subject of "home delivery" have been infrequent. A closer look at the means of communication of this production, mainly in indexed journals, reveals the gap in knowledge on this theme. There are no known literature reviews that systematically approach the subject either -especially in terms of nursing production. Hence, a question emerges: what have obstetrical nurses published, in Brazilian journals, regarding home delivery care, and what results have they obtained? It is believed that the identification and analysis of such publications will assist the comprehension of the already-produced knowledge corpus, in addition to detecting the strengths and weaknesses that this knowledge presents. Therefore, these facts justify the present literature review of national journals with the purpose to characterize the scientific production of Brazilian nurses on home delivery and identify the results achieved.

METHODOLOGY
A meta-ethnographic systematic review was developed, 9 comprised of three stages: systematic literature review; critical evaluation of the studies found; and metasynthesis. 10 Inclusion criteria were: studies published in Brazil, by obstetrical nurses, between 1986 (the year when the law of professional exercise was regulated) and 2010, and discussing the theme "home delivery". Exclusion criteria applied to reflective studies, narratives, case studies, dissertations and theses, in addition to studies developed by nurses in Brazil, but published abroad. A retrospective electronic search was performed between September and December of 2010 in the databases BDENF, LILACS, MEDLINE, ADOLEC, PAHO and WHOLIS. Besides these search tools, the SciELO electronic library was consulted, and the search finished with the journals available at Capes, which was used only with the purpose to determine whether the studies were repeated.
As a search strategy in the online databases, the keyword "home delivery" was used in association with the term "obstetrical nursing". A search was also made using the words "delivery at home" and "midwives", separately, associated with the terms above. The volumes that were not available electronically were accessed directly through the files of a public library, in order to supplement the sample composition.
The criteria used for quality evaluation was the standardized Critical Appraisal Skills Program (CASP), 11 which proposes a checklist to assist in the critical analysis of studies for rigor, reliability and relevance, through the use of 10 items: clear and justified purpose; appropriate methodological design for study purposes; methodological procedures presented and discussed; intentional sample selection; described data collection, explicit instruments and saturation process; relationship between researcher and researched subject; ethical principles disclosed; dense and grounded analysis; results presented and discussed, reliability aspect discussed; and description of the study contributions, implications and limitations. After each study was filtered through the checklist, it was classified into one of two categories (A or B). Category A comprised studies with a bias of lower risk, since they met at least nine out of the 10 necessary items, and category B comprised studies with moderate risk bias; that is, at least five out of 10 items were met, only partially fulfilling the adopted criteria. [10][11] The studies selected were then evaluated via the meta-ethnographic method, 9 which demands a careful reading focusing on the metaphors, themes and concepts used by the authors, allowing the presentation of results in a synthesized way. 9 Through induction and interpretation, the authors obtained the resignification (translation) of the results of the studies, thus allowing the comprehension and transference of ideas, concepts and metaphors. 10 Once similarity was perceived between studies-that is, once concepts were related by similarity-it was possible to construct the translation by reciprocity (reciprocal translation), which also occurred when there was disagreement between concepts. [9][10] The analysis stage was developed in seven steps: 9 identification of the area of interest and definition of the question for bibliographical research, using search strategies for the selection of studies; learning what was relevant to the study and the decision on which criteria were used to achieve the metasynthesis purpose; knowledge of the selected studies, through reading and rereading them; establishment of the relationship among studies and the elaboration of an initial presupposition; treatment of the narratives as analogies, aimed at the identification of similarities or differences; synthesis of the results, developing transferences or resignifications; and explanation of the synthesis result.
The electronic and library searches resulted in the identification of 27 studies. Among these, 13 were included, since they met the eligibility criteria, being original studies, elaborated by obstetrical nurses and regarding home delivery. After a new reading, one study was excluded because, despite being a study developed by Brazilian nurses and involving planned home deliveries, and being translated in Portuguese, it was verified that it had been published abroad (Portugal). 12 Thus a total of twelve studies were identified which complied with the pre-established criteria. This set of studies was read in its totality, aimed at being submitted to quality evaluation. Nevertheless, according to the criteria applied for this evaluation, two studies did not meet the CASP checklist, and only three were classified as B and seven as A. In the end, the analytical corpus of this review totaled ten studies.

Characteristics of the productions
The selected and analyzed studies are listed in table 1, characterized as to author/year, purpose, study type/data collection technique, subjects and study quality level, according to CASP. 10 Investigating and understanding the experience of the home delivery process assisted by midwives.

Exploratorydescriptive/Semistructured interview
Six women between 70 and 90 years of age who delivered their children at home with midwives in attendance during the last century.
A Brazilian scientific publications of obstetrical nurses on home...

Author/Year Purpose(s) Study type/Data collection techniques Study subjects CASP
Crizóstomo et al 17 (2007) Understanding, through the narratives of women, the home and hospital delivery experience, as well as discussing the experiences of women during both types of delivery. These studies were published in nursing journals between 1999 and 2009. As for the study purposes, most of them were related to understanding the work of midwives, with four aimed at "traditional" midwives who were still active during the study, and two focused on the activity of these women in the past. The other studies aimed at analyzing the feelings of women related to the choice of home delivery, and only one investigated the factors that influenced the choice of home delivery assisted specifically by nurses. In summary, half of these studies involved the participation of midwives (former and current), and the other half were developed with women who experienced a home delivery. Regarding methodology, most authors developed exploratory-descriptive studies, using the semi-structured interview as the main instrument of data collection (Table 1).

Results obtained with the productions
The results obtained from the published studies were divided into three categories: 1) The care provided by traditional midwives; 2) Experiences of women cared for by health professionals during home delivery; and 3) Comparative experiences of women who experienced deliveries both at home and in a hospital. The approach of these categories led to the establishment of the metacategory "Respectful delivery in the embracing home environment".

The care provided by traditional midwives
The results of the studies involving obstetrical nurses revealed that the care provided by traditional midwives involves: A -Motivations for delivering a baby; B -Required virtues for delivering a baby; C -The midwifery art; and D -The care of midwives from the perspective of women who experienced a home delivery.

A -Motivations for delivering a baby
Five of the analyzed studies identified motivations that led these women to start working as a midwife, [14][15][16][22][23] revealing that the initiation and learning rituals occurred through diversified stimuli: Need -some midwives acquired an aptitude for delivering babies "on their own". Learning took place in the daily midwifery routine: " [ 15:320 Feelings of solidarity -many were driven by the desire to serve; a social need of altruistic connotation: "[...] I've thought of helping since I was a child [...] when I grow up I will be a midwife, bring babies into the world. At 17 years old I started achieving my dream". 13:649 Family tradition -some of the midwives were motivated by women who were also midwives in their family, and who were willing to share the secrets of this work. "My grandmother was a midwife. She was far [...], when one of my cousins started labor. As I was skillful and followed my grandmother, they called me to help and I did it". 21:322

B -Required virtues for delivering a baby
Studies developed in different states in Brazil 13-15,20-21 revealed that midwives have developed their work based on qualities they consider essential for the proper execution of this activity: Patience -this virtue was associated with the quality of waiting, mainly in terms of allowing "nature" to act, so that the delivery would take place "in its time": "at that moment [...] it is necessary to have patience to wait for nature to act". 18:483 Courage -this was another fundamental attribute, mainly during the occurrence of complicated deliveries: "[...] only God". 21:322 "I became a midwife through acting [...] I had to go there and do it". 21:322 Respect -this is an imperative quality, since the work is always done in service to another human being: "taking care of what is human means respecting the other, respecting that woman in front of me, respecting this moment of fragility for her [...]". 15:321 Generous spirit and perseverance -these were generally attached to the attitude adopted by the traditional midwife, when she noticed potential socioaffective "risks": "[...] if it is night, I make a charity soup, there is nothing better. When the morning comes, I kill a chicken, put it in a pan, get the dirty laundry and wash it [...] at night I stay with the baby, because she would get cold; there were few clothes". 14:252 "[...] some say thank you, others do not even do that, but you have to keep going". 21:322

C -The midwifery art
Four studies explored the art of midwifery, 13,15,18,21 revealing the knowledge and actions of "traditional" midwives, as well as the difficulties they face or faced in maintaining the profession: Knowledge and practices -these are generally supported by the knowledge regarding the healing properties of plants: "I used to make tea with the leaf and root of parsley, it removes everything from the uterus, reduces inflammation". 15:320 "When the baby has colic, I make pennyroyal tea, and put some water in the little navel and let it stay in there". 15:320 In order to promote the health of mother and child and prevent complications, midwives sought strategies focused on a specific context and circumscribed in the local knowledge. This involved ritual practices and maneuvers which were practiced during each stage of the pregnancy, delivery and postpartum period. This knowledge guaranteed a place of acknowledgement in the community, 21 who saw them as "physicians, nurses and pharmacists, capable of relieving the pains and illnesses of the population with balms, baths, herb teas and prayers [...]". 15:320 Difficulties faced-studies reveal that the working conditions were/are precarious, despite concluding that the midwife occupation was/is a necessary social practice, particularly in regions that are located far from professional resources. 14,21 The most critical difficulty, despite the charitable aspect of the activity, was related to the low profitability, both for midwives who worked in the past and for those who are still active in the profession. Former midwives mentioned that, on the occasions when they obtained some sort of reward for the provided care, it would almost always come in the form of donations, such as domestic animals and food. Current midwives, however, struggle to be paid fairly for deliveries through the Single Health System. 21 D -The care provided by midwives from the perspective of women who experienced a home delivery Two studies reveal the nuances of the care provided by midwives, from the point of view of women who were assisted by them in the past. [16][17] The respect they had for these women becomes evident, mainly because of the confidence with which they acted during the pregnancy: "when I was pregnant she always told me to drink marcela herb tea [...]"; 16

Experiences of women assisted by health professionals in a home delivery
Only two studies investigated the home delivery experience from the point of view of women who were assisted by health professionals. [19][20] The obtained results included the following subcategories: A -Motivations for having a home delivery; B -Active participation in the delivery; and C -Perception regarding obstetric nursing care.

A -Motivations for having a home delivery
Studies 19-20 aimed at identifying the reasons why women decide to have their baby at home, even when they reside in a large urban center; that is, what led them to give up the touted "obstetrical safety" offered by hospitals in order to have their baby at home.
Childbirth experienced safely in the home, is an intimate act -for these women, pregnancy and delivery are "expected" stages of life. They are healthy events, inherent to the female reproductive cycle. The option of home delivery reveals this understanding and the wish to experience it in an intimate and embracing environment. Nevertheless, they do not dismiss professional help in order to ensure that obstetrical and neonatal procedures are as appropriate as possible: " [ 19:400 The main role -women state they want to "experience" the delivery in its entirety, taking responsibility to make decisions about their bodies and their children. Different from the practices of subservience common in maternity institutions, they state they wish to be "in control": "at a hospital everyone is a patient, right? [...] I do not like being an object [...] I wanted to be in control of my delivery". 19:403 The trust in the professional -women learn about safe procedures adopted in obstetric and neonatal care and seek professionals who have the qualifications to act according to those guidelines. If they already know someone with these qualifications, motivation is doubled. However, if they do not, they are persistent in the search for a professional in whom they can trust: "[...] I did not feel influenced by my physician, I felt protected by him. It was clear to me that I wanted to do this, but I needed to feel confident that he could handle it". 19:401 B -Active participation in the delivery A study showed that all women who had a home delivery voiced a need to be proactive, acting as event agents. Professionals act in the role of assistants, as delivery guides and safe "support", instead of acting as determining subjects of the women's conduct.
The care of the body and mind -the appropriate preparation is necessary for the experience to be successful: "shiatsu and walking helped a lot [...], because you start getting into the act". 19:403 Environment preparation -the organization of the birth place reveals the concern for the phenomenological experience of delivery and birth. an idea that would be inconceivable in the hospital context: "I started organizing the house, decorating with flowers, curtains, establishing my environment [...] I would light a candle, listen to music, burn incense. It was a month of rituals, preparing myself and my space, praying for light, peace and tranquility". 19

Comparative experiences of women who had deliveries both at home and in a hospital
One of the studies concerned the comparative experiences of women who had both home and hospital deliveries, with the home deliveries being assisted by midwives, their own mothers or alone. 17 Six out of the seven interviewed women stated that the home delivery was better for many reasons: among them, delivery was faster, had fewer interventions (such as no vaginal contact), and there was freedom of movement: "at home I felt better, it was faster, I could decide on my position;, when I got home from the hospital I was bruised, I even had a fever. At home that did not happen [...]. They do a lot of touching there, I got all sore". 17:102

Metacategory -Respectful delivery in the embracing home environment
Based on the careful re-reading of the studies, a metacategory emerged; that is, a theme that stood out and encompassed all of the other categories. 9 The home environment stands out in the statements of those who went through the home delivery experience as being the facilitator for a respectful experience, mainly in terms of an event that is considered to be intimate and individual. The care provided to the woman and child, based on emotional and technical authority, as well as human consideration, is found in the speeches and attitudes of the "traditional" midwives: those who do not have access to scientific knowledge, acting "intuitively", or even following the examples of their predecessors in the art of midwifery and those who do it as a profession and struggle for a suitable financial return. The reflection of a reverent care provided to the woman, at all stages of the process, is registered in the memory of the women who received the midwife's assistance with extreme acknowledgement and consideration.
Furthermore, the representation of a respectful delivery also stands out for those who were assisted at home by health professionals and, especially, by obstetrical nurses. Although technical-scientific preparation is referred to as an important characteristic of home births it is the consideration of the woman's wishes to be in control of the delivery, the joint decisions regarding the positions to be adopted and interventions to be made, as well as the confidence transmitted through the perinatal period that are evaluated as expressions of respect and human consideration towards them and their newborns.
Both for women who live in remote areas of Brazil, assisted by "traditional" midwives, and for those who live in large centers supported by "specialized" nurses, as well as the midwives who worked or still work delivering babies, respectful delivery is possible, mostly due to the birth taking place in a familiar environment, in the most well-known and safe place for the family, and not necessarily due to the person who assists the delivery. In a certain way, both the women who provide assistance during home births and those who are subjects of their own delivery wish and struggle to escape from the hospital-centered care model, considering the home to be the most embracing and respectful place to give birth and receive the new human being into the social group.

DISCUSSION
The practical experience of midwives, broadly studied by obstetrical nurses, points to an activity with a strong missionary appeal, operating under strict conditions with its knowledge supported by practice. These predicates are equivalent to the results obtained in other academic nursing studies, developed at stricto sensu degree. [23][24] The results of the studies involving midwives show that, in their self-appreciation and in order to develop this role, it is fundamental to promote altruistic and humanist values which contemplate the parturient as someone living an existential experience, and not merely supported in the concept of reproduction, or even in the promotion of the maternity ideology, something so close to the hospital-centered and biomedical model, and also far more expensive. [25][26] Regarding the midwifery activity itself, nurses stated that the knowledge of the midwives resulted from empirical data related to the "native" culture, which offered support considered to be appropriate in order to promote the health of mother and child, prevent complications, or even to establish techniques and treatments that would contribute to the resolution of complications. Despite interpreting the activity based on systems of "emic" meanings and symbols (that is, systems of native meanings and symbols), 26 this analysis may be slightly biased and rushed, mainly due to disregarding the fact that such practices integrate cosmologies, thus going way beyond "knowledge resulting from practice". It is also observed that, in the view of the midwives regarding their own work, there is no reference to the lack of "scientific" knowledge as an obstacle for being a midwife. This concern seems to be more important to the obstetrical nurses who developed the studies than to the midwives themselves. It is interesting to observe that other professionals from the social area who study midwives do not consider this condition to be a deficiency in the midwife's "doing" and "being". [25][26] This interpretation of the research nurses probably represents an agreement with the technical-professional ideology of the professional specialty, in which the "non-scientific" is considered to be less qualified than the "formally" prepared professional to act under the rigors of obstetrical science.
The most relevant difficulties mentioned by the midwives concern the question of survival. This reality is still common in some regions of Brazil (for instance in Amapá), where a large portion of the population come into the world through the hands of over 700 traditional midwives. 27 In light of the speeches of the women assisted by midwives, it is possible to identify the feeling of respect and acknowledgement they feel. The studies show that the familiarity of the women with the principles of health care and local practices facilitated the acceptance of the recommendations made by the midwives, favoring respectful care. 25 The parturients interviewed by the obstetrical nurses also do not suggest that the lack of knowledge regarding obstetrical science is a value that disqualified the work of the midwives. On the contrary, the respect and confidence with which they worked or work is what "counts" as major benefits, according to the women assisted by midwives.
The studies that approached home delivery in large urban centers, assisted by professionals, focused their results on the motivations that led women to choose to have their baby at home, as well as on their active participation in the delivery and their perceptions regarding obstetric nursing care. This choice is based on the fact that women are reflecting on the benefits of natural childbirth, experienced in a way that is respectful of the physiology of birth. The home environment seems to be the ideal place for a birth experience with freedom and autonomy. 12,27 It is interesting to highlight that the researchers gave voice to the women who had the home delivery experience, rather than to the couple. It is possible that, for this reason, the representations regarding the preparation of the body and home prior to the delivery were more explicit. The female role stood out in the results in light of the activity of the nurse who assisted in the delivery, but that was not a reason for the women not to verbalize, at any time, the satisfaction they felt with the provided care. All the results of this category were permeated by criticisms of the delivery care model of the Brazilian maternity institutions.
The study 17 that approached the experience of women who had deliveries both at home and in a hospital revealed the frustration with the hospital delivery experience, in comparison to the home birth. Women who experienced a hospital delivery following a home birth were surprised by the institutional routine and the excess of interventions. The study results reinforce the ideology of the delivery performed by specialized professionals, without unnecessary technological interventions, at a time when obstetric nursing is making new paths to a responsible, ethical and legal execution of this professional activity. On the other hand, from the point of view of the nurses who assist in deliveries at home and in the hospital, the literature is almost irrelevant due to the small number of national publications. Nevertheless, two studies, one of them being a master's degree dissertation and the other an investigative study published abroad, were developed in 2010, presenting excellent maternal and neonatal results originating from home deliveries assisted by obstetrical nurses. 12,28 Despite the national publications on the theme "home delivery" being scarce, it was noted that there is a growing interest from nurses and researchers to understand the practices of traditional midwives. [23][24][25][26][27][28][29][30][31] The knowledge of midwives, formerly questioned by the scientific community and, particularly, by the obstetric specialty, is currently part of the academic interest. [23][24][25][26][27][28] The lack of articulation between the empirical knowledge and the formal healthcare system has generated conflicts that are in the process of being redimensioned and rethought in order to find feasible solutions for the peaceful co-existence of all the agents acting in home deliveries. 24 Many of these studies expect to find and "rescue" more humanized and respectful practices in the treatment of laboring mothers, both to make these allegedly "forgotten" assistants more "visible" and to inspire new ways of delivering care. 25 The main limitations of this literature review were related to the exclusion of studies that did not consist of original papers in indexed journals, and to the exclusion of one of the studies which was developed by Brazilian nurses but published abroad. Despite being only a single study, it resulted in the exclusion of an important research involving the activity of obstetrical nurses in home delivery. Regarding the positive aspects, it is important to highlight that the use of the CASP 11 as a critical-methodological evaluation instrument allowed the necessary rigor and reliability for a systematic review of qualitative studies.
The results of this review reveal the interest of nurses to study the work of traditional midwives, eliciting the relevant contributions these women have made in the different Brazilian scenarios of extra-hospital delivery care; however, on the other hand, they reveal the lack of studies regarding the relationships between nurses and midwives in the current context of professional care practices during deliveries, a pertinent and necessary theme of general interest to the area of contemporary Brazilian obstetrics. The results also point out the need for publications regarding the activity of obstetrical nurses and other professionals involved in home deliveries, which may highlight the rewards and difficulties found in this care scenario.