Methodological reflection about the fieldwork of an international multisite research Brazil-Canada

Abstract

Aim

To present the results of a structured reflection on the methodological phases of an international research in Brazil regarding the implementation of the Program of Humanization of Prenatal and Childbirth, as well as, reflection on the project's social actors.

Method

A reflective research method that modifies the perception of a given situation, leading to new ideas, revealing themes of analysis, and engendering proposals for possible solutions with the creation of an action plan. The object of the reflection was the participation of co-investigators in an international, multidisciplinary, and multisite ethnographic study, implemented in June/2019-March/2020.

Results

The reflections indicate emotional sensitivity to the theme and silence about obstetric violence. There are multiple manifestations of institutionalized violence including resistance to confronting obstetric violence in hospital settings, negligence and distorted questioning in the political spaces of organizational authorization. The delay caused by a research ethics committee put the timetable for completion of research development at risk by requiring funding from a foreign agency.

Conclusion and implication for practice

Structured reflection allowed a unique learning process for co-investigators navigating different university and social research cultures.

Keywords:
Global Health; Nursing Methodology Research; Qualitative Research; Violence Against Women; Women’s Rights

Resumo

Objetivo

Apresentar o resultado de uma reflexão metodologicamente estruturada sobre o caminho trilhado em todas as fases de uma pesquisa internacional no Brasil sobre a implementação do Programa de Humanização do Pré-natal e do Nascimento e seus atores sociais.

Método

Método reflexivo de pesquisa que conduz à percepção modificada de uma dada situação levando a novas ideias, com o potencial de revelar temas de análise e engendrar propostas de possíveis soluções com desenho de um plano de ação. O objeto das reflexões concentrou-se nas participações dos copesquisadores de um estudo etnográfico internacional, multidisciplinar e multicêntrico implantado em Junho/2019-Março/2020.

Resultados

As reflexões indicam sensibilidade sobre o tema e silêncio imposto em relação à violência obstétrica. Sob múltiplas manifestações da violência institucionalizada, constatou-se ações como resistência ao assunto na rede hospitalar, negligência e questionamentos distorcidos nos espaços políticos de autorização para a anuência institucional. A demora por comitê de ética colocando em risco o calendário de conclusão da condução da pesquisa, exigido por agência estrangeira de fomento.

Conclusão e implicação para a prática

A reflexão estruturada possibilitou um processo ímpar de aprendizagem para os copesquisadores navegando em distintas culturas universitárias e sociais de pesquisa.

Palavras-chave:
Direitos da Mulher; Pesquisa Metodológica em Enfermagem; Pesquisa Qualitativa; Saúde Global; Violência contra a Mulher

Resumen

Objetivo

Presentar resultados de una reflexión estructurada metodológicamente sobre el camino metodológico seguido en todas las fases de una investigación internacional en Brasil sobre la implementación del Programa de Humanización del Cuidado Prenatal y el Nacimiento y sus actores sociales.

Método

Método de investigación reflexiva que conduce a una percepción modificada de una situación dada, dando lugar a nuevas ideas, con el potencial de revelar temas de análisis y generar propuestas de posibles soluciones con el diseño de un plan de acción. El objeto de las reflexiones se centró en la participación de los co-investigadores en una investigación etnográfica internacional, multidisciplinar y multi sitio implementada en Junio / 2019-Marzo / 2020.

Resultados

Las reflexiones indican sensibilidad sobre el tema y silencio impuesto en relación a la violencia obstétrica. Bajo múltiples manifestaciones de violencia institucionalizada, hubo acciones como resistencia al tema en el ámbito hospitalario, negligencia y cuestionamientos distorsionados en los espacios políticos de autorización para el consentimiento institucional y demora por parte del comité de ética, poniendo en riesgo el calendario para completar la realización de la investigación requerida para una agencia de desarrollo extranjera.

Conclusión e implicación para la práctica

La reflexión estructurada permitió un proceso de aprendizaje único para los co-investigadores que navegaron en diferentes culturas universitarias y de investigación social.

Palabras clave:
Derechos de la Mujer; Investigación Metodológica en Enfermería; Investigación Cualitativa; Salud Global; Violencia contra la Mujer

INTRODUCTION

Global health research investigates themes considered to be sensitive either from the perspective of individuals, communities, institutions, or governments. Research about social sensitive issues requires greater methodological and conceptual clarification due to the complexity of studying stigmatized, socially disadvantaged, or socially neglected groups.¹ The research fieldwork requires skills to harmonize distinctive research cultures, manage differences in understanding about ethics in research, and mitigate institutional power and interference by political authority, which can cumulatively threaten the researcher’s freedom and autonomy.²

A particularly challenging research area is the violation of human rights investigated by international organizations – whose decisions have economic, political, and social impacts on countries that commit to respect such rights. The researcher is expected to manage strategies which mitigate the impacts of political and structural resistance so that she/he can advance the work with determination and firm purpose. Commitment and engagement in the research fieldwork on such a sensitive topic does not exempt the researcher from being exposed to threats and political risks. The list of difficulties for the researcher includes feelings of guilt and vulnerability in the relationship with participants, discomfort in ending the brief relationship established with the participant, which leads her/him to psychological exhaustion and, sometimes, the need to declare her/himself as a person.

International research collaboration has advanced considerably by following trends implemented by multi and interdisciplinary teams and by reproducing the composition of care teams in health organizations.³ Such teams provide opportunities to strengthen and manage cultural diversity between international partners, especially for first-time researchers, and they are thus able to offer support to fit into research contexts. Because the researcher conducts social research under restrictive conditions of freedom of expression (in which a sensitive topic may be involved) and implicit prohibitions,⁴ a series of facilitators guide the researcher’s actions when he or she commences. The facilitators are:⁴ (a) knowledgeable of local culture, control practices, and risks to freedom of expression; (b) aware of the once-limited methodological reflections of research with social minorities; (c) knowledgeable of ways to access information and the research field; (d) review the researcher's personal and professional identity, as well as the researcher’s position at the foreign university or in the country where the research is implemented; and (e) are informed on the type and status of international inter-university relationship and agendas.

LITERATURE REVIEW

To achieve globalization, the economy, the science-technology-innovation triad, as well as the social and human development are mixed. These factors include women's rights, which is a controversial political issue requiring global monitoring because several countries neglect to respect women.⁵ Prioritizing women’s rights is relevant to the Sustainable Development Goals, specifically Goal 5: Achieving equality of gender and empower all women and girls.⁶ One way to guarantee gender equality in society is to eliminate all forms of violence against women and girls in the public and private sectors. To this end, recommendations include strengthening policies and adopting specific legislation to promote gender equality and empower this population.⁶ Because of these recommendations, the violation and degradation of the women’s and girls’ human rights, which are themes in the international diplomatic agendas, is monitored. These policy and legislation recommendations are present in the international diplomatic agenda,⁷ specific to the protection of women during pregnancy and childbirth.^8,9 In this area, it is emphasized that the Canadian feminist conceptual framework represents a pillar for international aid to be provided by the government, focusing on the review of its decisions about offering international cooperation, including in the area of research.¹⁰

In societies where social inequities in health are recognized, the advancement of scientific research on life experiences, health, and death of female populations is essential to guide political decision-making and policy development. Research conducted by nurses and midwives in Caribbean and Latin American countries represents only 15.9% of that region’s scientific production on themes of motherhood, birth, breastfeeding and neonatal results.¹¹ Most research originates in Brazil and is for the purpose of obtaining graduate degrees; there is emphasis on neither clinical research nor discrete implementation of individual research programs by doctors in nursing after obtaining such degrees.¹¹

In Brazil, obstetric violence¹² is an issue of undeniable humanistic, social, and political relevance, and it is related to multiple vulnerabilities experienced by women in obstetric care. In the Brazilian context, childbirth and birth (which are holistic and complex events) are gaining increasing global visibility.¹³ There has been an appeal to society's commitment and interest in the reduction of maternal mortality and unnecessary cesarean sections, as well as in the qualification of obstetric care and professional education in health in this specific field.^14-16 Awareness by professionals about these natural events in life can change and improve their praxis.

Launched in 2000, the Program for the Humanization of Prenatal and Childbirth (PHPN),¹⁷ concomitant with social movements for consumer rights and human rights, became a milestone for encouraging the qualification of prenatal care, organization, regulation, and investments in obstetric and neonatal care. Thus, the concept of humanization in labour and childbirth assistance was adopted from the perspective of equity, citizenship, autonomy, and knowledge production. Despite the efforts made by the Ministry of Health, major challenges persist including the interventionist care model, high rates of maternal and child morbidity and mortality (especially in neonates), fragmentation and low resolution of the healthcare network, as well as obstetric violence, which is an underestimated problem that reflects persistent and recurrent inequities in assistance of childbirth and birth in the country.¹⁴ Despite plural initiatives to curb obstetric violence, victims remained “speechless” and invisible to public authorities. The inefficacy of initiatives culminated in 2019 with “inadequate connotation”¹⁸ to the term of obstetric violence and no “recommendation”¹⁹ of its use in the Brazilian context. This occurred three months before the beginning of the fieldwork of the research reported in this article.

The conceptual framework of reflective professional practice²⁰ guided this research. Reflection is a cyclical process that allows the professional to relearn from a given situation, whether it be unique or intriguing, and from the newly obtained information, resulting in the amalgamation of data and leading the professional to improve actions in future situations. Through reflection, the professional can tacitly criticize the understanding that has emerged after repeated experiences, often within the perspective of specialized practice. This conceptual framework influenced the methodological choice of the reflective research method. This method was applied by our team of co-investigators who exercise their professions in several dimensions in the practice of women’s health care and well-being. Thus, the objective of this article is to present the results of a methodologically structured reflection on the work process in all phases of an international ethnographic research in Brazil on the implementation of the Program for the Humanization of Prenatal and Childbirth as well as the study’s social actors.

METHOD

The design of this qualitative research was the reflective research method,²¹ which is conceptually based on reflective professional practice.²⁰ The structured reflection was used as a tool in this method and induces a modified perception of a given situation, leading to new ideas and the potential to reveal themes for analysis and generate proposals for possible solutions. This method purposefully promoted the appraisal of professional experiences through post-facto weighing, resulting in a systematic description of facts and feelings, a review of negative and positive aspects, an analysis of lessons learned, the restructuring of potential solutions, as well as the design of an action plan.

The authors’ reflections focused on their participation as co-investigators in a multi-site, multidisciplinary ethnographic research carried out in international cooperation under the academic leadership of both Ryerson University and Federal University of Minas Gerais, which is located in the Southeast region of Brazil, along with the partnership of seven other Brazilian universities. The implementation took place in the North (states of Amazonas and Rondônia), Northeast (state of Paraíba), Central-West (Federal District), and Southeast (States of Rio de Janeiro and Minas Gerais), from July 2019 to March 2020. In this reflective research, the procedures applied the following components of the chosen research method:²¹ (a) definition of the topic; (b) utilization of multidisciplinary perspectives; (c) choice of an integrative perspective covering ways of understanding the experience; and, (d) recognition of the legitimacy of individuals’ unique experiences with their contribution to the process of reflection and proposed recommendation. In this article, we present a qualitative, methodological research in nursing with a reflective research method.²¹

Participants: Five nurses, nine Canadian research interns (including seven undergraduate nursing students and two undergraduate social work students), two community health agents (CHAs), a communication professional, and a representative of an international organization.

Organization and analysis of data: Individual reflections are primary data and were reported in short narrative texts, on average 200 words, and organized in Displays (see Display 1 to 4). Inspired by the qualitative methods of thematic analysis, these reflections were submitted to analysis, generating the themes Academic diplomacy and Encounter with obstetric violence: meaning, impact, and consequence. The final interpretation of these compiled reflections substantiated the design of an ideal action plan, addressing the responsibilities of social actors in the multi-site research and international collaboration, as illustrated in Display 5.

Display 1
Reflective narrative of the research coordination. Research Data, 2020.

Reflections
This perspective (of the humanization of labour and childbirth) has been strengthening based on experiences of training generalist nurses and specialists in this field. For that reason producing knowledge through it and by the experiences we have lived as representatives of a professional nursing association, but fundamentally for the fact of being in this field for over 30 years, and hopefully – hope…here placed as historical concreteness, as becoming of bodies immersed in a scientific, ethical-political practice -social and humanist, as is Nursing. To join in a solidarity and collective action as it is established in the production of this research. Hence, the whole sense of forming this collective of researchers and Brazilian public organizations, in an international partnership, in which collective health and humanization in health, in the specific field of obstetric and neonatal care, can be enhanced. This was the path we took to understand that together, in / for carrying out this research, it will be possible to apprehend an object of study that constrains us all - Obstetric Violence - seeking to unfold it in its challenges: violence / institutional racism, childbirth violence, gender violence, health inequalities, among others, but which does not immobilize / will immobilize us. It is, therefore, an object that we must understand as a starting point. (Brazilian co-principal investigator in Brazil, 33 years of experience as an obstetric nurse, Belo Horizonte-Brazil)
In a Brazilian context of restricted funding for nursing research and the widespread interest in implementing internationalization projects, the status of 17 university nursing faculty with recognized clinical knowledge did not guarantee the expected respect when negotiating the processes of organizational authorization. Despite the extremely serious and formal process that I implemented following Canadian guidelines for international scientific cooperation, I was surprised to see the numerous attempts to interfere in the content of the research project, questioning the methodological rigor and the total disregard for the timeline for implementation/conclusion. Such non-compliance can make foreign-funded research unfeasible due to strict schedules. (Brazilian-Canadian researcher, principal investigator, 40 years of experience, Toronto-Canada)

Display 2
Reflective narrative about entering the field and collaborative activities. Research Data, 2020.

Reflections
From the experience with the participants, I was able to perceive the subtleness of their actions; for example, when the pregnant woman perceives herself to be vulnerable, this state corroborates the permissiveness of some acts, and, after that, they may have a different understanding for the same situation. So, it is not restricted to procedures without consent, since in many cases, women agreed with oxytocin; to be quiet in bed; in long wait times, instead of scheduling; to agree with the structure of the place where they were served, even though they perceived aspects to improve, seen by themselves as too demanding and, thus, to be content to be served, only. This issue is not limited to the dissemination of health information. Therefore, the challenge of implementing the prenatal and childbirth humanization program includes effectiveness in the care process, in the collective sense, and overcoming the only transfer of information about rights to women, as well as of the child and family, but informing that people deserve better quality care. To this end, the awareness of health, education, work, science, technology and communications constitute a basis for government action so that it can equip people in general, because if women do not claim, no matter how well educated in health they feel, others do. And, when talking to women about obstetric violence, I also had the opportunity to self-reflect on my professional condition. (Brazilian co-investigator, 20 years of experience in Public Health, Brasília-Brazil)
The involvement in [social media] was very different, it was very profitable, since all the work had to be done together with the international responsible, our media staff, so that the content was suitable for the target audience. And we were able to see this on social networks, we were able to reach this focus, which had a lot of participation from women, we were successful on the response with [social media]. The CHAs felt important, they also suffered ... because there was [x number] that ended up participating, as long as their reports. They saw the importance of their participation in this project, they saw themselves there, it was a moment when they could show the greatness of their work, they could understand the greatness of they work. (CHA, collaborator in announcement and recruitment, 18 years of experience, São Gonçalo-Brazil)
I was very happy to know that these interns are developing methodologies, they are thinking about broader health for everyone, because they are interns everywhere. It was very important, as an observer and participant in the meetings, to observe that the health area is increasingly reinventing itself, increasingly wanting to improve…, trying to see the rights of all women, pregnant women and why not their future babies who can come to have this knowledge, so that obstetric violence does not perpetuate, that other professionals are educated..., with that they retain the knowledge and this issue of obstetric violence ends once and for all. This is the crucial point of knowledge, this is the most sensible point of health education so that future mothers will no longer experience any problem of obstetric violence. This is the point that I was most pleased to be part of this whole project, to know that there are people, there are professionals who want to change this concept, they want to change this health failure, which is obstetric violence. (CHA, recruitment collaborator, 18 years of experience, São Gonçalo-Brazil)

Display 3
Reflective narrative about data collection. Research Data, 2020.

Reflections
Often, during data collection, the question arose as to whether women are aware or not of having suffered violence. This raises the question of what defines violence and what defines a victim. Many women who experience obstetric violence do not see themselves as being abused. The story of what happened to them can be portrayed in different ways, and we can be the first to attribute the word “victim” to them. Even so, all of these women are survivors of this violation of their fundamental human rights. Violations of these rights, promulgated through physical, emotional, spiritual and economic forms of violence, trying to keep women “in their place”. They do not make room for the woman who speaks, who is loud and not afraid to show pain, or the woman ... who may be having a child without the conventional family structure. Instead, they want only submissive and obedient women. However, even many of the women who are afraid to keep quiet, who act “perfectly”, are unable to escape the threat of violence during the vulnerable moments of childbirth. (Social work undergraduate student, Niterói-Brazil)
My experience collecting data in qualitative research on violence against women has made me aware of my limited ability to help women who have shared their moral, psychological and spiritual pains. In a focus group with women who are CHAs (rural area, Rio de Janeiro) in this research, two of them did not report experiences of their clients; in an explosion of catharsis they revealed personal experiences with obstetric violence. The first reported, as a parturient, the physical violence suffered, in tears, under the astonished gaze and the respectful posture of the other community health agents (and my silent prayers that God would help us to act with solidarity in careful silence). The second, as the mother of an adolescent parturient, reported while crying, a shocking interaction with the nursing team composed of indifferent women who promoted institutional violence. This mother's requests for her to remain with her daughter, terrified by the risky delivery situation, were ignored. Except for one of the non-professional women who pledged to “look more” for the teenager in labor. It is revolting to see how women in nursing also perpetuate this monstrosity in organizational settings. (Brazilian-Canadian researcher, principal investigator, 40 years of experience, Toronto-Canada).
I had the opportunity to hear a report from a 45-year-old immigrant postpartum woman. A year after her birth she was still in pain because her rights had been violated. According to her, she had no comorbidities during pregnancy, had a doula and followed prenatal care expecting a normal delivery. Because she is an immigrant, in her culture she doesn't even think about opting for a cesarean delivery, however, the day she went into labor she went to the hospital, called the doctor who accompanied her, her parents who were in Brazil and her husband, all ready for the baby's arrival and here's the surprise, her doctor informed her that due to her age, a cesarean delivery would be better. She reported that the environment was claustrophobic, that she was not given any comfort, with the opinions all contrary to the birth plan she had made, she was also afraid of what would happen to her son if she did not accept the advice that led her to cesarean delivery. One year after childbirth she is still processing the invisibility of the violence she suffered, something she was unable to do on the day of childbirth due to the invisible pressures she suffered. (Brazilian co-investigator, 24 years of experience in Obstetric Nursing, Brasília-Brazil)

Display 4
Reflective narrative about the analysis and dissemination of the finding. Research Data, 2020.

Reflections
As a researcher involved in the design of the project and in the transcription of 26 hours of audios related to the interviews and focus groups, the women's narratives about the suffered obstetric violence called my attention, revealing the inappropriate professional conduct in the care of the women and the newborn. It seemed intriguing to me that many women do not have information about their rights, as well as feel frightened by the professional confrontation and its consequences. However, others exposed extremely positive experiences when reporting the welcoming, safe and quality care received from the multidisciplinary team. I think that information is the key to expanding quality service, both for women and health professionals. (Brazilian co-investigator, 13 years of professional experience, Toronto-Canada)
I conducted about 20 interviews to produce a documentary about the research. In the statements of the coordinators/researchers, the importance of the exchange of knowledge between Brazilians and Canadian researchers was perceived in order to inform women about obstetric violence and make them aware of their rights. In the speeches of community health agents and nurses, the relevance is in the way the project was carried out, mainly in the practical part. With students discussing the subjects with professionals and patients within Primary Health Units, communities and/or hospitals, they said that the impact of the research was positive and that, in a way, they managed to “translate” what is obstetric violence for many women, community members and even professionals. It was exciting to record with the students. For most nursing students, the project allowed for the first time to watch a childbirth. Some mentioned that it was the most beautiful thing they have ever witnessed and were sure of the real importance of the profession, regardless of the country or culture. The social work students confessed that it was in Brazil, during the internship, that they realized the vast field of work that health makes possible for them. One said that she already decided to pursue hospital care because she wants to guarantee people’s rights and access to public policies. (Brazilian co-investigator, 15 years of professional experience, Brasília-Brazil)
I observed with the meetings with academics and teachers ... how much interest there is in addressing this issue, how broad this subject is, how much there is to address, how many answers must still have been hanging in the heads of these mothers. The idea that came up there to make educational videos with obstetric nurses training community health workers for this approach is very interesting. As a professional who does not have all this expertise, I am satisfied to participate in this project and bring knowledge to these mothers who need more knowledge, more instructions, more about their rights, not to suffer obstetric violence, not to pass because of this constraint and not knowing how to defend themselves in such a way, because they have no knowledge, they do not know that the health professional who is attending is wrong. Knowledge for them is essential and, in these videos that will be covered, they will be short, they will be in simple language, didactic, they will have the most professional part of the specialized nurse, but they will also have the community agent speaking on a daily basis, in a simpler language. (CHA, collaborator in planning the dissemination of results, 18 years of experience, São Gonçalo-Brazil).
It was excellence in our work. The CHAs felt not only important, but some who participated as a target audience saw the importance of the work that was done, it was exciting, they comment on this work, their involvement there, they wait for the return, the response of this project, to see what was done, what was the result of this work, they are waiting for it, as I am also waiting for. (CHA, recruiting collaborator, 18 years of experience, São Gonçalo-Brazil)

Display 5
Recommendations for a multi-site international research action plan. Research Data, 2020.

Areas of possible actions
In the administrative scope of the universities:
- Articulate dialogue between local, national and international ethics committees on their modus operandi with a priority focus on protecting participants.
- Mobilize the international affairs office to ensure the formal presentation of international co-investigators to local collaborating organizations.
- Increase the engagement of the vice-provost of research from the universities hosting the projects to make ethics committee procedures complete in a timely manner, respecting the work schedule by international funding agencies.
At the State / District / Municipal administrative level regarding data collection sites:
- Present the research project using an audiovisual approach to the clinical staff and organization administration to expand their understanding about the research.
- Promote organizational dialogue on the social value of the proposed research.
Within the scope of civil society:
- Establish formal recruitment partnerships with professional and community associations.
- Expand advertising about research in all site of data collection using all social media.
Within the research team:
- Add undergraduate students as co-investigators in training with similar duties, rights and responsibilities with other team members.
- Develop promotional material about the research, considering different target audiences and prioritizing audiovisual material.
- Harmonize pre-existing working methods and communication strategies in research sub-teams from different countries.
- Mobilize the potential of local and foreign undergraduate and graduate students by connecting them to the research programs of their mentor-researchers.
- Train students as research assistants with the use of realistic simulation, to enter the field of local research paying attention to differences related to the context of life and academic origin.
Within the scope of data collection
- Ensure that data collection under a sensitive theme is conducted by researchers able to respond to the participants' destabilizing emotional situations.

Ethical considerations: The original research, in which this synchronous research was inserted, was approved by Ryerson University Research Ethics Board (REB 2019-063) and Brazil National Research Council (2019-3.461.935). The research that is about critical reflections based on personal thoughts and experiences of authors, as teachers, co-investigators, and care providers to women, is an activity of creative practice.

RESULTS

The reflections presented in this section complement the evidence produced in the implementation of a qualitative research facing numerous barriers. Naming, describing, and narrating obstetric violence was already a challenging task in Brazil,²² which was addressed by the aforementioned document.¹⁸ Because this process strengthens actions, as well as indicates ways to guarantee human rights and to overcome gender, race and class inequalities in obstetric care, obstetric violence has emerged in recent years as a global theme of scientific research.⁷

The fieldwork was implemented in 27 public health organizations. Some of the organizations completed the authorization process promptly, while others had a delay of a maximum of six months, which impacted the ethical approval process. Two of these organizations took a year to respond to the request, without providing formal justifications, but with demands for clarification related to field logistics and financial resources described in the project (although they only referred to the cost of assistance for Canadian interns in Brazil). In addition, these same demands were presented at different times and without the necessary formality for registration and institutional dialogues. These delays faced by the coordinators postponed the start of data collection considerably and threatened the research interns' permanence in Brazil, affecting the project's viability.

The reflections, as a methodological contribution to obtain the results, indicate that the critical awareness about the political-social invisibility of obstetric violence and the PHPN emerged through fieldwork. This critical awareness enriches co-investigators’ human and professional experience with growth, solidarity and personal empowerment. Displays 1-4 show the co-investigators’ and collaborators’ reflections at different stages of the research. Cultural immersion during data collection offered to the Canadian team (co-investigator and interns) a different perception about obstetric care. The interpretation was done according to their professional references of social justice, social inclusion and social equity, protection of women's human rights, and respect for clientele's autonomy, which cumulatively added to their professional responsibility and citizen commitment. These co-investigators came from the Ryerson University’s Faculty of Community Services, whose teaching programs are guided by an educational philosophy aimed at social change in individuals and communities to drive positive and solid changes with passion, rigor, and curiosity. This educational philosophy provides tools to address complex social and environmental challenges and build a more just society to enable collaboration with communities through social change.²³

Thanks to the research awards granted by the Canadian program, Mitacs Globalink Research Award to the nine research interns, these interns were able to stay for 12 weeks in Brazil for the research fieldwork. This work included cultural and social immersion, experiences of gender relations, social, artistic and leisure exchanges, as well as learning about the legal and operational structure of the Unified Health System (SUS). During their experiences in different social and cultural environments, interns made visits to community organizations, read policies, learned health norms, reviewed popular media material on the theme of obstetric violence, and kept a structured and reflective field diary.

These Canadian research interns were sensitized to recognize and deal (at least initially) with issues of racism, discrimination, and social inequities in clinical settings and in research context. By integrating into Brazilian undergraduate nursing programs, they learned about nursing education and practice in prenatal care, childbirth, and the puerperium. In health organizations, they also identified the imbalance of power between professionals and the women as clientele. They learned about multidimensional obstetric violence and promptly identified it when they faced it. The specific reflections of these Canadian interns from their experiences in different regions of Brazil indicate the multiplicity of perceptions based on local realities of prenatal care and childbirth. Such reflections are interconnected with the reality observed in the humanization of obstetric care and human rights, as well as with the internalization of reflections on the perception of student experience compared to the Toronto context to develop expectations for their future professional practices in Canada or in another international context.

In the North, major issues of human rights violation have emerged:

This project helped me to understand that violence ...starts with the attempt to control women’s bodies…. Experience clarified the dangers of making value judgements about the client’s behaviour as a health professional and taught me the importance of questioning my own internal prejudices. (Nursing undergraduate student, Porto Velho).

Obstetric violence is evident (according to shared comments) but the vast majority lack this knowledge. One professional stated that “as soon as the mother is hospitalized, she is at risk of obstetric violence”, however, more than 90% of the women interviewed stated that obstetric violence was a new concept for them and believed that these actions were “normal”. As a result, the relationship between the lack of health education/health rights and the implications of obstetric violence became evident. (Nursing undergraduate student, Manaus).

In the Central-West, the team’s only Nursing-Social Work duo brought complementary perspectives on social cultures of care and practice in their reflections:

In the hospital, I noticed some human rights violations, especially the lack of women’s lack of privacy during childbirth. (Social Work undergraduate student, Brasilia).

I observed many unnecessary interventions that compromised the mother’s safety to promote a quick delivery... felt that the priority of a quick delivery gave patients the impression of receiving care with compassion. The focus on unnecessary interventions intrinsically removes the mother’s autonomy to decide for herself what is safe, best and convenient for her. (Nursing undergraduate student, Brasilia)

In the Northeast, reflection noted uncritical and passive acceptance of the female clientele:

...women have no choice in childbirth and accept whatever care they receive. I also found that women are happy to receive disrespectful maternity care, as long as the baby is delivered safely - “the ends justify the means”. Not having options in their care increases the susceptibility to violence... (Extract from the structured reflection document, Nursing undergraduate student, João Pessoa).

The experience of Nursing and Social Work interns in the Southeast revealed the interconnections between institutionalized practices that extended to the community context:

Cycles of violence are subtle. This helped me to internalize the importance of our work here in Brazil and to understand why systems and policies need to be evaluated. Policies need to be defined and oriented towards public empowerment. (Extract from the structured reflection document, Nursing undergraduate student, Rio de Janeiro).

The first home visit… accompanied by the community health worker. The interview was short; however, it was an open and honest exchange, which revealed reports of obstetric violence by the woman and her mother. I attribute a lot of shared information to the presence of the community health worker, who had built a relationship with the service user, which allowed confidential information to flow easily. As a future social worker, I was inspired to see this type of professional-client relationship built on mutual trust. (Social Work undergraduate student, Niterói).

During a focus group with the community health agents… It was impressive to see the number of agents willing to provide their ideas on the humanization of labour and childbirth. (Nursing undergraduate student, Juiz de Fora).

This experience and everything else I found during my time in the field allowed me to grow and learn as a person and professional in many ways that would only be possible through integration in the community, physical presence in the ethnographic field and experiencing the culture and the scenery as it is. (Nursing undergraduate student, Belo Horizonte)

Thus, we can emphasize that the findings and results uncovered the potential for influence in the formulation of programs and public policies. Overcoming authoritarian professional behaviors and updating obsolete and harmful technical procedures in childbirth care is a major challenge for everyone.

Initiatives for the development and formulation of programs and public policies require the empowerment of women, the recognition of obstetric violence, the mobilization of society, as well as representatives of public authorities and the private health system. (Co-investigator, 30 years of experience in the development and implementation of gender and family policies in an international organization, Brasilia)

The reflections indicate the theme sensitivity and the existing and imposed silence on the PHPN's final objective, that is, to curb obstetric violence. Multiple manifestations of institutionalized violence exist including: resistance within the hospital network as well as neglect and distorted questions, which were reported in the political spaces of authorization for organizational consent, causing delay by the ethics committee and putting at risk the timetable for completing the research required by the agency foreign funding. The thematic analysis revealed two themes: Academic diplomacy and Encounter with obstetric violence, meaning impact and consequence. From the perspective of academic diplomacy, when placing the results in a larger context of organizational policy, it became evident that difficulties in decreasing obstetric violence were faced. These difficulties related to the issues of diplomacy in international research and preparation for the reception of research in international collaboration. This interpretation implies critical geopolitics of knowledge,²⁴ which proposes to advance the spectrum of international collaborative actions in the development of scientific research, with the mobilization of strategic resources and recognition of the real and symbolic power of science and technology. The cultural significance of the power and scientific influence that Brazil exercises places it in a strong position for collaboration. Such understanding of international knowledge diplomacy requires dialogue between peers and respect for previously agreed and approved work agendas.

The encounter with obstetric violence allowed for the creation of its meaning, the recognition of its social impact, and the possible consequences for professionals and clients. Reflections indicated that obstetric violence is rooted in obstetric practice as a form of control over women’s bodies, and its manifestation occurs in subtle actions – actions that, when normalized, lead women to be grateful for receiving any form of obstetric care. The normalization of various violations of women's rights, pressure, and coercive tactics is due to fear and sometimes plays the role of creating expectations for parturient women, which ultimately leads them to obedience and silence.

Through reflections, Canadian research interns questioned their premises, judgments, feelings, actions, and reactions. Qualitative research on sensitive topics with individuals vulnerable to harm, abuse, and disrespect uses self-reflection to connect research experiences with ethical, political, and social issues,²⁵ focusing on the ethics of practice, everyday issues, and specific unexpected expectations. Upon reflection, co-investigators articulate and manage their emotions related to social justice according to their positionality, reciprocity, and emotionality towards the research participants. Research was performed through direct contact with the participants during data collection, and this was a fundamental approach. Emotional exhaustion was caused by the subject studied, but was overcome with emotional empathy, distance from the subject of research, and various forms of support that the field supervisor can offer.²⁶

The reflections allowed Brazilian co-investigators to “build” and “analyze” their own research results and ponder the possibility of improving their own practices, while the Canadian co-investigators were confused by the range of rights violations from women's rights to obstetric rights. The reflections allow for a clearer illustration of the subtle manifestations of obstetric violence and the challenges women and professionals are faced with during the implementation of PHPN. Writing about experiences and reflecting on them showcases the cognitive, emotional, and psychological investment you make as a researcher²⁷ when collecting data, decoding meanings, and building new understandings. Such evidence reiterates that reflections contribute to guaranteeing the results contain a certain level of emotional security and provide a type of emancipatory awareness.²⁸ The personal and professional struggles experienced awaken this awareness, particularly when a reflection diary is kept, as was done by research interns.

It was understood that the systematic violation of rights, in fact, represents the suffering which the most deprived citizens of services and rights are generally subjected, namely the poor, women, children, and the elderly. The reflections led to the conclusion that there are three challenges in implementing a socially inclusive, transformative research agenda that is capable of producing scientific evidence to support the formulation of public policies with support and feasibility: (1) Making obstetric violence an eye-catching topic for academia and political stakeholders, policy makers, managers, and professionals; (2) Transforming obstetric violence into a theme of complaints and denunciations to bring it to the world of academia, allowing individuals to occupy all social spaces; and, (3) Challenging the society’s mobilization to share with women the leadership roles in this humanization movement. In the results, the thinking about critical reflection is reiterated^{21: 64}, transferring it to the context of professional research practice:

I am convinced that it is crucial to develop the academic and intellectual credibility of the critical reflection process for understanding professional practice experience. Its ability to illuminate the way we engage with our work in complex, integrated and fluid ways may yield new and invaluable insights about professional practice and about ourselves as human beings within it.

The action plan (see Table 5) resulting from collective reflection and its interpretations contains 13 recommendations related to planning and data collection work for future international research with Brazilian universities, as well as future partners in multi-site research. We emphasize that most of the recommendations seek the harmonization and effectiveness of administrative and technical actions for the high quality and effectiveness of research fieldwork.

DISCUSSION

Canadian and Brazilian co-investigators with different profiles of professional experience, some of whom held organizational power, added a spectrum of internal and external views and voices, outlining their personal, social, and cultural perspectives to this research. Despite the different levels of knowledge in research, ideas from professionals were explored that were directly and remotely validated by the participants and corroborated by the variety of evidence collected. This set of elements was crucial to the epistemological validity of this reflective research.

The reflections also indicated that, in the ten sites of the research implementation, obstetric violence is a topic that can silence many professionals, despite becoming the object of questioning in interactions between peers in the clinical context (e.g., perinatal asphyxia and low-quality childbirth care). In the context of prenatal and puerperium, obstetric violence is associated with global interests and equity in global health, notwithstanding the Sustainable Development Goals related to gender and equity.⁶ This is a central theme for collective health due to its relationship with maternal and child mortality, violence against women, and preterm birth.^8,9 When researching the PHPN, a voice was given to the oppressed within the professional community, students, and users (men and women) of the Integrated Health System (SUS). Humanizing healthcare and assisting women during childbirth constitutes a milestone; it is the route and the target for us to face the challenge of doing research collaboratively. Therefore, we can follow methodological paths for interference in health care, management, and training practices and also knowledge production. Humanization as a concept-experience provides the basis for expanding its ethical-aesthetic-political use in the field of obstetric care through a (new) analytical-evaluative look, in order to (trans)form the realities of work and care.¹⁵

This proposal is aligned with the gap identified in Brazilian health research²⁹ regarding the distance in know-how, that is, a gap between the production of knowledge and its application in professional health practice. The research, when translating the social realities of SUS clientele, highlights benefits of the knowledge generated for them. Still, the results may indicate areas in which changes to innovate practices in the context of SUS are necessary to reduce social inequalities in health.²⁸ To face and overcome the barriers of the wide implementation of PHPN, the movement with this expanded research collective, under the ethical imperative of producing inclusion, brings co-investigators and organizations on the path of humanization as a policy of the global commitment to make the science of care advance with otherness.

Therefore, in the general call for the idea of collectivity, as co-investigators, teachers, health professionals, and students, there is an invitation for women and men to politicize the path of knowledge production, renewing values, interests and producing new collective spaces of amplified voices. In this collaborative project between members of the academy and the community for the production of knowledge with the potential for social changes, challenges imposed by gender identity and sexuality are foreseen, even requiring the negotiation of social roles. As warned by Lenette et al,²⁹ participatory research is associated with social movements - as reported here - which are generally conducted by female scientists who experience the impact of their gender on fieldwork. Being female scientists in participatory research brings investigators closer to the feminist perspective, of which the ultimate goals focus on caring for the other, empowerment, and social justice.²⁹

CONCLUSION AND IMPLICATION FOR PRACTICE

Structured reflection as a research method enabled an innovative learning process for an international research team navigating different university and social research cultures. In the research fields, the presence of professors and students and their unique, difficult, and successful experiences stimulated the renewal of practices and strategies for the achievement of research objectives. The learning provided by this experience has become a unique inspiring source, not only for future research projects, but also subsidizes current teaching practice on global health research. This learning emphasizes that the leadership exercised by nurse investigators in an international research team is a necessary and revolutionary change.

A possible limitation of the research is that the reflections of the authors themselves has limited depth in translating a whole range of emotions, feelings, and learning, especially when carried out with interactions of local and foreign knowledge. What is seen as an action in the context of research for global nursing is due to the result of multiple moments of reflection on the research fieldwork (which is not captured here in its entirety and complexity) as performed by the research field supervisors, led by Brazilian nursing faculty in conjunction with Canadian research interns and supported by Brazilian nursing undergraduate students. Additionally, this resulted in using the structured reflection method in the research in a joint way, encouraging the team to aim at raising the level of sophistication of the research practice in an international context, exposing itself to peer criticism and improving the quality of the research fieldwork.

ACKNOWLEDGEMENTS

Paloma Terra (Independent Practice Midwife/Network for the Humanization of Childbirth and Birth). Dr. Gilmária Salviano Ramos (Federal University of Viçosa) for the technical review of this manuscript, contributing to raising the quality of this manuscript. Bridget Miller for the English language review.

• FINANCIAL SUPPORT

  Mitacs Globalink Research Award 2018 earned by Vanessa Fofie (#IT 12953), Dakota Carrie (#IT 12407), Francesca Aviv (#IT 12406), Milena Oliva (#IT 12475), Dorin d’Souza (#IT 12470), Hannah Stahl (#IT 12476), Hannah Argumedo-Stenner (#IT 12401), Hilary Hwu (# IT 12473) and John Tadeo (#IT 12952). Ryerson University President Office and Faculty of Community Services, Seed Grant 2019.

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Edited by

ASSOCIATE EDITOR

Antonio José de Almeida Filho

Publication Dates

• Publication in this collection
  15 Jan 2021
• Date of issue
  2021

History

• Received
  16 Sept 2020
• Accepted
  16 Oct 2020