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OBSTETRIC NURSING IN MINAS GERAIS: ANALYSIS OF EMERGENCE AND PROVENANCE

LA ENFERMERÍA OBSTÉTRICA EN MINAS GERAIS: ANÁLISIS DE EMERGENCIAS Y ORÍGENES

ABSTRACT

Objective:

to analyze the historical constitution of obstetric nursing in Minas Gerais.

Method:

this is a qualitative, interpretative study, anchored in Michael Foucault’s Genealogy, based on socio-historical research, with an oral thematic history approach and mastery of the history of obstetric nursing. The study was carried out in the state of Minas Gerais. The study covered data referring to professional training and the practical insertion of obstetric nurses from 1957 to 2005. Data collection was carried out from August 2021 to July 2022 with the identification of seven documents and twelve interviews. Data were submitted for analysis.

Results:

three genealogical configurations were created that represent the discourses, practices and events that characterized obstetric nursing of Minas Gerais. The first deals with initiatives for training obstetric nurses in Minas Gerais and ruptures related to space restriction for practical performance. The second addresses the articulation of a nursing school with a philanthropic hospital as an important event for obstetric nursing in Minas Gerais. The third addresses the period of insertion of first obstetric nurses in professional space. Analysis made it possible to identify the historical moment and the forces acting for the emergence of obstetric nursing as well as the conditions of possibility (provenance) involved and events that followed this conformation.

Conclusion:

obstetric nursing from Minas Gerais emerges with the equation of teaching and practice forces from the proliferation and combination of conditions involved in this process.

DESCRIPTORS:
Address; Obstetric Nursing; Obstetric Nurses; Teaching; History of Nursing

RESUMEN

Objetivo:

analizar la constitución histórica de la enfermería obstétrica en Minas Gerais.

Método:

estudio cualitativo, interpretativo, anclado en la Genealogía de Michael Foucault, basado en la investigación sociohistórica, con abordaje de la historia oral temática y dominio de la historia de la enfermería obstétrica. El escenario fue el estado de Minas Gerais. El estudio abarcó datos referentes a la formación profesional y la inserción práctica de las matronas en el período de 1957 a 2005. La recolección de datos se realizó de agosto de 2021 a julio de 2022 con la identificación de siete documentos y doce entrevistas. Los datos fueron sometidos al análisis del discurso.

Resultados:

se formaron tres configuraciones genealógicas que representan los discursos, prácticas y acontecimientos que caracterizaron a la enfermería obstétrica en Minas Gerais. El primero trata de iniciativas para la formación de comadronas en Minas Gerais y rupturas relacionadas con la restricción del espacio para la actuación práctica. El segundo aborda la articulación de una escuela de enfermería con un hospital filantrópico como un evento importante para la enfermería obstétrica en Minas Gerais. El tercero aborda el período de inserción de las primeras enfermeras parteras en el espacio profesional. El análisis permitió identificar el momento histórico y las fuerzas actuantes para el surgimiento de la enfermería obstétrica, así como las condiciones de posibilidad (procedencias) involucradas y los acontecimientos que siguieron a esa conformación.

Conclusión:

la enfermería obstétrica en Minas Gerais surge con la ecuación de la enseñanza y la práctica se fuerza a partir de la proliferación y combinación de condiciones involucradas en ese proceso.

DESCRIPTORES:
Discurso; Enfermería obstétrica; Enfermeras obstétricas; Enseñando; historia de la enfermería

RESUMO

Objetivo:

analisar a constituição histórica do campo profissional da enfermagem obstétrica em Minas Gerais.

Método:

estudo qualitativo, interpretativo, ancorado na Genealogia de Michael Foucault, fundamentado na pesquisa sócio histórica, com abordagem da história oral temática e domínio da história da enfermagem obstétrica. O cenário foi o estado de Minas Gerais. O estudo abrangeu dados referentes à formação profissional e à inserção prática de enfermeiras obstétricas no período de 1957 a 2005. A coleta de dados foi realizada de agosto de 2021 a julho de 2022 com a identificação de sete documentos e doze entrevistas. Os dados foram submetidos à Análise de Discurso.

Resultados:

foram conformadas três configurações genealógicas que representam os discursos, práticas e acontecimentos que caracterizaram a enfermagem obstétrica mineira. A primeira trata das iniciativas para a formação de enfermeiras obstétricas mineiras e rupturas relacionadas à restrição do espaço de atuação prática. A segunda aborda a articulação de uma Escola de Enfermagem com um Hospital Filantrópico como acontecimento importante para a enfermagem obstétrica mineira. A terceira aborda o período da inserção das primeiras enfermeiras obstétricas no espaço profissional. A análise possibilitou a identificação do momento histórico e das forças atuantes para emergência do campo profissional da enfermagem obstétrica, bem como condições de possibilidade (proveniências) envolvidas e acontecimentos que sucederam à essa conformação.

Conclusão:

o campo profissional da enfermagem obstétrica mineira emerge com a equação das forças de ensino e prática a partir da proliferação e conjunção de condições envolvidas nesse processo.

DESCRITORES:
Discurso; Enfermagem obstétrica; Enfermeiras obstétricas; Ensino; História da Enfermagem

INTRODUCTION

In Brazil, since the 1960s, birth care has been characterized by the hospital institutionalization movement, with a progressive increase in the number of surgical deliveries and, consequently, medicalization of the female body. Currently, Brazil is among the countries with the highest number of surgical deliveries in the world and vaginal deliveries are marked by the excessive use of interventions.11. Backes MTS, Carvalho KM, Ribeiro LN, Amorim TS, Santos EKA, Backes DS. The prevalence of the technocratic model in obstetric care from the perspective of health professionals. Rev Bras Enferm [Internet]. 2021 [cited 2022 Oct 10];74:e20200689. Available from: https://doi.org/10.1590/0034-7167-2020-0689
https://doi.org/10.1590/0034-7167-2020-0...
-22. Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Progress in childbirth care in Brazil: preliminary results of two evaluation studies. Cad Saúde Pública [Internet]. 2019 [cited 2022 Oct 10];35(7):e00223018. Available from: https://doi.org/10.1590/0102-311X00223018
https://doi.org/10.1590/0102-311X0022301...

In recent years, the need to restructure health professional training, both in quantitative and qualitative perspective, has been spreading to change paradigms in childbirth and birth care and achieve better care outcomes.33. Bourguignon AM, Grisotti M. Conceptions on childbirth humanization in Brazilian theses and dissertations. Saúde Soc [Internet]. 2018 [cited 2022 Oct 10];27:1230-45. Available from: https://doi.org/10.1590/S0104-12902018170489
https://doi.org/10.1590/S0104-1290201817...

In this regard, the recommendations of international bodies, such as the World Health Organization (WHO), encourage the training and improvement of obstetric nursing professionals to act actively in changing the obstetric model. Obstetric nurses are considered strategic agents for changing the obstetric scenario, since they are trained to assist in normal childbirth and defend a safe and free birth from unnecessary surgical and medication interventions.44. Leal MS, Moreira RD, Barros KC, Servo ML, Bispo TC. Humanization practices in the parturitive course from the perspective of puerperae and nurse-midwives. Rev Bras Enferm [Internet]. 2021 [cited 2022 Oct 10];74(Suppl 4):e20190743. Available from: https://doi.org/10.1590/0034-7167-2019-0743
https://doi.org/10.1590/0034-7167-2019-0...

In Minas Gerais, since the enactment of law 775/1949, which allowed the creation of specialization courses in obstetric nursing, the training process of obstetric nurses has been gaining notoriety, with tradition in professional training and expansion of insertion and practical performance in health services. The Universidade Federal de Minas Gerais (EEUFMG) Nursing School plays an important role in the history of obstetric nursing in the state, with a wide trajectory in practical and theoretical teaching of midwifery.

Studies on the trajectory of obstetric nursing in Brazil are dedicated to a linear construction of traditional history. in Minas Gerais, there are few records about the historical process of training these professionals.55. Schreck RSC, Frugoli AG, Santos BM, Carregal FAS, Silva KL, Santos FBO. History of obstetric nursing at the Nursing School Carlos Chagas: an analysis based on the Freidsonian approach. Rev Esc Enferm USP [Internet]. 2021 [cited 2022 Oct 10];55:e03762. Available from: https://doi.org/10.1590/S1980-220X2020014703762
https://doi.org/10.1590/S1980-220X202001...
-66. Carregal FAS, Schreck RSC, Santos FBO, Peres MAA. Historical rescue of advances in Brazilian Obstetric Nursing. Hist Enferm Rev Eletron [Internet]. 2020 [cited 2022 Oct 10];11(2):123-32. Available from: https://publicacoes.abennacional.org.br/ojs/index.php/here/article/view/86
https://publicacoes.abennacional.org.br/...
In this context, the present research was outlined based on the following guiding question: how was obstetric nursing professional training in Minas Gerais? The work arises from the need to know and disseminate the history of training and practical insertion of obstetric nurses from Minas Gerais, to understand the events’ singularity and the points of insurgency of relationships that sustain the daily life of this professional category.

The theoretical framework used to elucidate the research question was Michael Foucault’s Genealogy, a strategic formulation to look, study, write and act in relation to historical events, determining a critical and political way of writing history.77. Prado-Filho K. Genealogy as a historical method of analysis of practices and power relations. Rev Ciênc Hum [Internet]. 2017 [cited 2022 Oct 10];51(2):311-27. Available from: https://doi.org/10.5007/2178-4582.2017v51n2p311
https://doi.org/10.5007/2178-4582.2017v5...
-88. Foucault M. Microfísica do poder. Rio de Janeiro, RJ(BR): Paz e Terra; 2019. Genealogy is dedicated to the analysis of power, in its various forms: “(...) in its multiplicity, in its differences, in its specificity and in its reversibility; study them, therefore, as relations of force that intersect, that refer to each other, converge or, on the contrary, oppose each other (...).”99. Foucault M. Resumo dos cursos do Collège de France (1970-1982). Rio de Janeiro, RJ(BR): Jorge Zahar Editor; 1997.:71

“Effective history”, a term translated from Nietzsche’s concept, Wirkliche Historie, which inspired Foucault’s genealogy, intends to make appear, under a conscious interest, the mutable, the ephemeral, the countermemory and the particular. Rather than finding the roots of identity, genealogy is concerned with dispelling them. Thus, Foucault describes genealogy as a thorough research activity, which focuses on the facts that have been disregarded by traditional history.1010. Faé R. The genealogy on Foucault. Psicol Estud [Internet]. 2004 [cited 2022 Oct 10];9(3):409-16. Available from: http://doi.org/10.1590/S1413-73722004000300009
http://doi.org/10.1590/S1413-73722004000...

The constitution of “effective genealogical history” postulates the analyzes of methodological operators of provenance and emergence. Provenance refers to the conditions of possibility through which discourses and practices were formed. Emergence marks the singular point of emergence or appearance of an event, encompassing the historical location in which the correlation of forces of the conditions of possibility converged to the appearance of a discourse or practice.77. Prado-Filho K. Genealogy as a historical method of analysis of practices and power relations. Rev Ciênc Hum [Internet]. 2017 [cited 2022 Oct 10];51(2):311-27. Available from: https://doi.org/10.5007/2178-4582.2017v51n2p311
https://doi.org/10.5007/2178-4582.2017v5...
-88. Foucault M. Microfísica do poder. Rio de Janeiro, RJ(BR): Paz e Terra; 2019. Regarding the object of this study, the analysis of emergence is concerned with the states of forces that mark the historical point of emergence of obstetric nursing in Minas Gerais. Provenance, in turn, analyzes the proliferation of events, socio-historical landmarks, encounters and deviations that enabled the emergence of this professional field.

Given the above, the present study aimed to analyze the historical constitution of obstetric nursing in Minas Gerais. Based on the theoretical-philosophical principles of Michael Foucault’s Genealogy, we sought to give visibility to the effective history of training and practical insertion of obstetric nurses from Minas Gerais. Thus, the research aimed, by moving away from traditional progressive and teleological history, to unveil the events, the historical moment in which there was the introduction of obstetric nursing professional field (emergence) in Minas Gerais and juxtaposed conditions of possibility (provenance).

METHOD

This is a qualitative, interpretative study, anchored in the theoretical-philosophical aspects of Michael Foucault’s Genealogy, based on socio-historical research, with an approach to thematic oral history and mastery of the history of obstetric nursing.1111. Barros JD. O campo da história: especialidades e abordagens. 9th ed. Petrópolis, RJ(BR): Vozes; 2013. It is noteworthy that the study was developed according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) precepts.

To meet the proposed objective, we used documentary research and thematic oral history due to the existence of oral sources in public collections and the presence of important subjects who experienced the beginning of training and practical insertion of obstetric nursing in Minas Gerais. The criterion for selecting documents was the mention of training and performance of obstetric nurses from Minas Gerais. Regarding oral sources, the inclusion criterion was the identification, based on the survey of written documents, of key names of subjects who were directly or indirectly involved with the first specialization courses and the beginning of professional insertion of obstetric nurses in maternity hospitals in Minas Gerais.

The study was carried out in the state of Minas Gerais. Considering the historical approach, the temporal outline was delimited from 1957, period in which the first events for professional training of obstetric nurses in Minas Gerais, ending in 2005, when the practical insertion of these professionals in maternity hospitals in the state was expanded.

Data were obtained from primary sources of collections of the UFMG Nursing School Memory Center (Cemenf) and the UFMG Faculty of Medicine Memory Center (Cememor), as shown in Chart 1. We also consulted secondary sources of publications on the history of obstetric nursing in Brazil. The interviews were carried out face-to-face with five professors and former professors at the EEUFMG and seven obstetric nurses.

Chart 1 -
Documents from the physical and digital collection of Cemenf and Cememor. Belo Horizonte, MG, Brazil, 2022.

Data collection in the collections was carried out from August to December 2021 and interviews from January to July 2022. For each document, a reading form was created containing a summary, bibliographic reference and transcription of important excerpts for analysis. The reading sheets were organized into folders separated by collection and subject. The interviews were conducted using a semi-structured script with five guiding questions for producing participants’ oral history about the beginning of professional training and practical performance of obstetric nursing in Minas Gerais. The interviews were audio recorded and later transcribed with an average duration of 1 hour and 48 minutes, totaling 9 hours, 22 minutes and 55 seconds.

The documents and interviews used as research sources were submitted to Michael Foucault’s discourse analysis (DA). The choice for this mode of analysis was due to the relationship with the theoretical-philosophical framework adopted and its ontology of critical and emancipatory positioning, which seeks to go beyond the understanding of discourse as a set of signs.

Given these DA principles and having Foucault’s Genealogy framework as a guiding principle, two steps were used in the study analysis process: selection of sources and data knowledge and analysis of genealogical discourse. Genealogical DA was divided into: themes and objects of discourses (events and contexts/social, formative, political and legislative landmarks) and strategies and techniques of discourses (discursive elements: narrative construction and choices for certain lexical terms that allowed identifying resistance, disputes, strategic games, flows and movements of power relations).

The documents used in the research are in the public domain. For the interviews phase, the research followed the ethical and bioethical principles that guide the development of research with human beings, with approval by the Research Ethics Committee. Given the importance of context and identity in historical research, participants consented to sharing information and identifying names.

RESULTS

The results indicate the conformation of three genealogical configurations that represent the discourses, practices and events that characterized the historical trajectory of obstetric nursing in Minas Gerais.

First genealogical configuration: restriction for training and practical action

The first initiatives of Obstetric Nursing Specialization Courses in Minas Gerais took place in 1957 and 1966 by the EECC, currently EEUFMG. The first course, entitled “Graduate Course in Obstetric Nursing”, was offered in 1957 and lasted one year. According to the document in the institution’s enrollment book, a total of twelve students graduated in this course, coming from different parts of the country, including the states of Ceará, Bahia and São Paulo.

At the EECC, for the creation and implementation of this course, there was dialogue between nursing professors, specialists in midwifery from Escola Paulista de Enfermagem and medicine professors at UFMG Faculty of Medicine. The curriculum content included disciplines that indicated the construction of nursing knowledge in the care of women during the pregnancy-puerperal cycle, such as prenatal hygiene, prenatal care, neonatal child care, deontology, gynecological nursing and hospital nursing.

However, despite the conditions described above, Minute of the 6th Faculty of Medicine Congregation Session, 1958, regarding taking Obstetric Nursing Specialization Course, reveals “extensive discussions” and strategies undertaken by medicine professors to limit the role of nurses in prenatal and postnatal care and guarantee “entirely childbirths for the learning of future physicians.”

[...] on implementing specialization course for obstetric nurses at the EECC, the opinion was issued: asks the clinical director to try to help the course, bearing in mind that the essential objective of teaching is pre and postnatal care, leaving entirely childbirths for future physicians’ learning. After being widely debated, the matter was forwarded for further study.

Subsequently, in 1958, the closing of an internship space at the Hospital das Clínicas, where the course’s practical part took place, was decisive for the interruption of obstetric nurses’ training in Minas Gerais during this period.

The resumption of instruction for nurses with the title of specialist in midwifery occurs again, at the EECC, in 1966, with the offer of a new Obstetric Nursing Specialization Course class. According to the EECC professor congregation minute, course vacancies were limited, being intended only for graduates from the institution. The Note Map document for this course indicates that subjects were offered in conjunction with the Faculty of Medicine professors, together with hiring nursing professors for the specific subjects in the area. However, a second group was not created, marking another interruption in the process of training obstetric nurses in Minas Gerais.

In 1968, EECC reached the status of autonomous unit integrated with UFMG, being renamed EEUFMG. Subsequently, in 1972, under Opinion 163/1972 of the Federal Council of Education, the nursing course curricular structure is reformulated, starting to consist of three phases: pre-professional, common professional core and qualifications.

Despite the preparation of a preliminary draft for qualification in midwifery, aiming at “preparing obstetric nurses with solid knowledge, skills and attitudes for safe care for the mother and child, during the pregnancy-puerperal cycle,” and this modality of training was not offered at the EEUFMG.

The interviewees’ reports present a regularity in speeches about limiting factors for training obstetric nurses, at that moment, with lack of teaching resources, unavailability of places for students’ practical performance and increase in the number of surgical childbirths associated with disputes and medical practice hegemony.

[...] but you also didn’t have the scenario to continue with the training, right? of available professors... so, there was no potential to open a class. In addition, we had to have a field where it was possible for you to have nurses’ work, right? Autonomy for childbirth assistance, and it did not exist! (Laíse Caetano).

[...] when childbirth was institutionalized, the physician took over and nursing professionals: nurses, midwives lost their space [...] but, here at school, there was never a qualification in obstetric nursing (Torcata Amorim).

[…] we were at the peak of cesareans... at the peak of interventions! Physicians didn’t care about nurses! (Lélia Madeira).

Second genealogical configuration: teaching-practice articulation

The process of searching for events that marked the construction of obstetric nursing in Minas Gerais reveals the articulation, in the 1980s, between the EEUFMG and the newly created Hospital Sofia Feldman (HSF), built within the logic of care offered mainly by nursing.

The speeches of the interviewees who participated in the movement to create this hospital reveal the principles and values of defending social equality involved in running the institution and influences of Alma-Ata Declaration policital framework for an innovation in the way of thinking about assistance to women for a more egalitarian health.

[...] we were already discussing public health, so the care model bothered us and we had a lot of discussions... with the feeling that things couldn’t be that way. Then, in 1978, Alma-Ata Declaration emerged, a very important milestone both for our public health and for changing our model (Lélia Madeira).

[…] I think it’s typical of the moment they lived...in that Alma-Ata movement, where health is for everyone, right? From then on, Dr. Ivo became very involved with nursing issues, so he was part of a student movement group that were driven by a life goal! (Vera Bonazzi).

Assistance at the HSF, from the opening of maternity beds in 1982, was conducted jointly by professors from the EEUFMG and nurses. At this time, professors were specialists in midwifery, trained in institutions in São Paulo and Rio de Janeiro, who worked with and supervised undergraduate nursing students, and nurses who exercised the practice they acquired in this hospital, as evidenced in the speech excerpts below:

[…] the UFMG Nursing School relationship with Sofia was being built [...] nurses did everything! It was a way of Dr. Ivo to guarantee professionals who would help with care, because it was a needy hospital (Laíse Caetano).

[…] Sofia was raised in this culture! To meet the community’s needs! With the best possible quality. Dr. Ivo was always very studious and tuned into the future [...] so he started to invest in nurses (Lélia Madeira).

[...] Professor Maria Nazareth Figueiras was invited to perform and was the first obstetric nurse to assist a childbirth at Hospital Sofia Feldman (Laíse Caetano).

[…] we instituted the internship at Hospital Sofia Feldman, the childbirth room in the undergraduate course... do you see? Students loved it, they adored it, because it was an act! Dr. Ivo always insisted that the hospital belong to nurses! (Márcia Pitanga).

[…] so, we had this performance yes! Professor Márcia Pitanga also helped a lot, because she kept her internship field there (Karla Caldeira).

[…] the nursing school was always present, right? [...] including, the first childbirth was with professor Maria Nazareth Figueiras (Eliane Rabelo).

This articulation between HSF health professionals and EEUFMG professors became fundamental for resumption of training for obstetric nurses in Minas Gerais. These professionals and professors, aligned in the same proposal to meet women’s health needs, organize the offer, in 1999, of Obstetric Nursing Specialization Course, with the training of five specialist nurses, which is an important event in the category’s genealogical trajectory in Minas Gerais.

The proposal for this specialization arises from the need to meet legal workforce regulations and qualification for nurses’ practice in childbirth care. For this, there was an agreement between teaching and practice with the EEUFMG faculty, PhD professors, masters and specialists in midwifery and the HSF practice space, which allowed students to work and made professionals available for clinical teaching and preceptorship.

In the negotiation between the HSF and the training institution, the EEUFMG, the “law’s” argument stands out as an impediment to the performance of nurses without specialization and the need for professional training to guarantee the space of nursing without mastering medical practice.

[…] Dr. Ivo also did the negotiation, right? He inserted the field of obstetric action to nurses and the school did part of theoretical teaching (Laíse Caetano).

[…] It was a need in the field, because Sofia needed qualified labor. The UFMG Nursing School had professors for that, right? Sofia had a need and the school had the potential to graduate and awarded the title! The other important link, which I believe was, was Lélia Madeira, because she was a professor at the school and she was from Sofia. So, she was a facilitator for this to happen (Torcata Amorim).

[…] there, Dr. Ivo went to the school, sat down with me, with the coordination of my department and said, “Look, either you promote a training course for obstetric nurses, for us, for a specialist, or I’m going to have to put a physician in the hospital, I don’t know where we’re going to stop! By law, I can’t put a graduate nurse there (Lélia Madeira).

From this articulation, there is an expansion of professional training of obstetric nursing professionals. At the EEUFMG, between 1999 and 2012, 14 courses were offered to train 230 specialist nurses in midwifery. In 2013, training began to be offered in the residency modality with funding from the Ministry of Health in a strategic action to qualify professionals to improve woman care indicators. Later, throughout the state of Minas Gerais, other centers for professional training of these specialists emerged.

[…] the school made this agreement there and it was very good! Sofia had space, so it was an exchange, a very happy marriage that we had, and the thing took shape! (Márcia Pitanga).

[…] now, here it started with the great support of Sofia Feldman’s team. I believe in my vision, Sofia Feldman played a very important role in leveraging, funding and maintaining midwifery (Torcata Amorim).

Third genealogical configuration: clashes for professional insertion

The genealogical composition of the insertion of the first obstetric nurses in other maternity hospitals, in addition to the HSF, in the 2000s, exposes the clashes between physicians and obstetric nurses for defense of knowledge and childbirth care practices of each of these professional categories.

Participants’ speeches in this research demarcate the difficulties encountered by obstetric nurses, who graduated from the specialization courses at the EEUFMG, for professional performance. In contrast to the HSF, the interviewees enunciated a scenario marked by institutional barriers and confrontations with the medical category for professional autonomy.

[…] but here the assistance was the following: we saw the childbirth from afar, right? And there in Sofia, not [...] in Sofia there was an opening [...]. The difficulty was the clash between medicine and nursing, there was always this clash because medicine considered it a priority [...] and we were an appendix! [...] So, medical power has always been very incisive in practice! (Laíse Caetano).

[…] there were contractors like me, who was an obstetrician, but took over the role of assistant, because I had to cover the various sectors of maternity (Lúcia Barreto).

The discursive formations were characterized by the regularity in the description of the “jokes” made by physicians in an attempt to depreciate the assistance provided by obstetric nurses. Nurses’ resistance tactics are expressed in the confrontation with scientific evidence and defense of the knowledge of practices used in childbirth care, as expressed in participant Mônica Azevedo’ speech.

[...] It was me entering the room that they changed and, like, the jokes, teasing, right? Then, the woman lacerated a lot and they said, “Childbirth ‘a la Sofia’! Isn’t that how it is there?” (Mônica Azevedo).

[…] I heard things, jokes [...] I can’t forget an obstetrician who said to me, “Will the child be born in the bathroom? Like a duck? Will the boy fall and swim in the toilet?” And when we bought the birth stools, each twisted to go wrong (Lúcia Barreto).

[...] It was chaos! Because the baby was being born and the physician shouted, “Trim quickly here, do it!” Then I said, “Doctor, the boy is being born! Hair will not stop the baby from being born!”, then they say that the baby was born without trichotomy [...] (Mônica Azevedo).

The title of specialist and the insertion of obstetric nurses, although regulated and restricted at that time, in addition to the HSF, acted as devices to define the space that was now disputed by these professionals for childbirth care, as expressed in interviewee Tânia Cotta’ speech.

[…] when I came back as an obstetric nurse, the team coordinator saw that there was no going back, “Now the coordinator is an obstetric nurse, I won’t be able to hold back much”. He has already started to impose a little more on residents, “Their space has to be occupied, you respect it”, you know? (Tânia Cotta).

DISCUSSION

Emergence and provenance of obstetric nursing in Minas Gerais: equation of teaching and practice strengths

Michel Foucault’s work on genealogy has focused on analyzing the historical and political conditions of discourses for understanding a social phenomenon. The author announces genealogy as a laborious investigation that, in order to confirm its hypotheses, looks for clues in the disregarded and devalued facts of traditional history. Genealogical activity necessarily requires the search for the singularity of events.77. Prado-Filho K. Genealogy as a historical method of analysis of practices and power relations. Rev Ciênc Hum [Internet]. 2017 [cited 2022 Oct 10];51(2):311-27. Available from: https://doi.org/10.5007/2178-4582.2017v51n2p311
https://doi.org/10.5007/2178-4582.2017v5...
,1010. Faé R. The genealogy on Foucault. Psicol Estud [Internet]. 2004 [cited 2022 Oct 10];9(3):409-16. Available from: http://doi.org/10.1590/S1413-73722004000300009
http://doi.org/10.1590/S1413-73722004000...
,1212. Foucault M. Em defesa da sociedade. 4th ed. São Paulo, SP(BR): Martins Fontes; 2005.

From the collected data, under the Foucauldian perspective, important elements were revealed about the “effective history” of introduction and professional insertion of obstetric nursing in Minas Gerais. “Effective history” seeks the singularity of events and the understanding of power relations in which power games are constituted. Thus, it determines a strategic perspective to look at, study and write historical events.77. Prado-Filho K. Genealogy as a historical method of analysis of practices and power relations. Rev Ciênc Hum [Internet]. 2017 [cited 2022 Oct 10];51(2):311-27. Available from: https://doi.org/10.5007/2178-4582.2017v51n2p311
https://doi.org/10.5007/2178-4582.2017v5...
,1313. Resende H. Michel Foucault's genealogy and history as a diagnosis of the present: elements for the history of education. Cad Hist Educ [Internet]. 2020 [cited 2022 Oct 10];19(2):335-44. Available from: https://doi.org/10.14393/che-v19n2-2020-4
https://doi.org/10.14393/che-v19n2-2020-...

In this regard, the first initiatives for training obstetric nurses by the EECC, described earlier, in 1957 and 1966, and discussions on qualification in midwifery are characterized as unique events in the construction of effective history of obstetric nursing in Minas Gerais.

The offer of these first specialization courses, although linked to the Faculty of Medicine, initiates a movement towards the construction of a body of knowledge and human resources for obstetric nursing in Minas Gerais, with the development of practical and theoretical knowledge and an expanded assistance initiative for women’s health. However, the deprivation of space for practical action was established as a strategy for limiting professional training.

In the national context, since the mid-twentieth century, there has been an increase in the number of maternities and medical clinics, with the domain of medical exercise and, consequently, an increase in the number of cesarean sections.11. Backes MTS, Carvalho KM, Ribeiro LN, Amorim TS, Santos EKA, Backes DS. The prevalence of the technocratic model in obstetric care from the perspective of health professionals. Rev Bras Enferm [Internet]. 2021 [cited 2022 Oct 10];74:e20200689. Available from: https://doi.org/10.1590/0034-7167-2020-0689
https://doi.org/10.1590/0034-7167-2020-0...
,22. Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Progress in childbirth care in Brazil: preliminary results of two evaluation studies. Cad Saúde Pública [Internet]. 2019 [cited 2022 Oct 10];35(7):e00223018. Available from: https://doi.org/10.1590/0102-311X00223018
https://doi.org/10.1590/0102-311X0022301...
,1414. Silva F, Nucci M, Nakano AR, Teixeira L. “Ideal childbirth”: medicalization and construction of a hospital delivery assistance script in Brazil in mid-20 th century. Saúde Soc [Internet]. 2019 [cited 2022 Oct 10];28(3):171-84. Available from: https://doi.org/10.1590/S0104-12902019180819
https://doi.org/10.1590/S0104-1290201918...
The lack of space for practice, demand for courses and professors were the main reasons for nterruption of specialization courses in Minas Gerais and elsewhere in the country.1515. Bonadio IC, Andreoni S, Riesco MLG, Ortiz ACLV. Survey of the number of obstetric nurses trained in the last 20 years by the Nursing Schools in Brazil. Nursing. 1999;2(8):25-9.

It is noteworthy that, at the end of the 1980s, nursing practice was regulated by Law 7.498/86 of June 25, 1986,1616. Conselho Federal de Enfermagem, Brasil. Lei nº 7.498/86, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da Enfermagem e dá outras providências [Internet]. 1986 [cited 2022 May 22]. Available from: http://www.cofen.gov.br/lei-n-749886-de-25-de-junho-de-1986_4161.html
http://www.cofen.gov.br/lei-n-749886-de-...
which established aspects of nurses’ performance in obstetric care. They are responsible for nursing care for pregnant women, parturients and postpartum women, for monitoring the evolution of labor and for carrying out the childbirth without dystocia.

However, when tracing the genealogical configurations of the object of this research, avoiding the construction of a progressive history, data revealed, still in the early 1980s, the equation of two important forces that determined the emergence of obstetric nursing in Minas Gerais. Emergence is taken here in Foucault’s sense of the singular point of happening and emergence that is always produced in a certain state of forces that pass from the backstage to the stage.88. Foucault M. Microfísica do poder. Rio de Janeiro, RJ(BR): Paz e Terra; 2019. Emergence does not mark the appearance of an event prepared in advance, but deals with the “scene in which forces take risks and confront each other, being able to triumph or be confiscated.”88. Foucault M. Microfísica do poder. Rio de Janeiro, RJ(BR): Paz e Terra; 2019.:79

Therefore, Minas Gerais obstetric nursing emerges in the successful articulation of teaching and practice forces by approaching the EEUFMG and the HSF. Speeches reveal, as a singular event of this emergence, the assistance of the first birth at the HSF by Maria Nazareth Figueiras, an obstetric nurse and professor at the EEUFMG. This event gives visibility to the equation of these forces (teaching and practice), meeting the interests of professor obstetric nurses and HSF management that, by providing a space for nursing and the EEUFMG to work, guaranteed human resources for hospital care to the community.

The HSF, named in interviews on the subject of the institution’s clinical director, Dr. Ivo Lopes, by offering the space for nurses’ performance and training, becomes a locus of counter-conduct and a prominent role in the historical trajectory of obstetric nursing in Minas Gerais. In Foucault’s genealogy, counter-conduct can be understood as a different attitude in relation to instituted and normalized modes. It is a concept related to a new way of conducting oneself, “ways of escaping others’ conduct, seeking to define for each one the way of conducting oneself.”1717. Foucault M. Segurança, território e população. São Paulo, SP(BR): Martins Fontes; 2008.:287

This locus of counterconduct is also revealed by the HSF organization and management model, guided by an expanded conception of health care, going against the biologicist and reductionist view of care for women. The Alma-Ata Declaration’s influence on the proposal to create the HSF stands out in the discourses, a document formulated from the first international conference on Primary Health Care in 1978.1818. Perry HB, Rohde J. The Jamkhed comprehensive rural health project and the Alma-Ata vision of primary health care. Am J Public Health [Internet]. 2019 [cited 2022 Oct 10];109(5):699-704. Available from: https://doi.org/10.2105/ajph.2019.304968
https://doi.org/10.2105/ajph.2019.304968...

In genealogical analytics, provenance concerns the multiplicity of forces of a historical process and the proliferation of events, fragmenting what seemed united and static. Provenance, therefore, makes it possible to find the conditions of possibility by which events, discourses and practices emerge. Unveiling provenance is, unlike an evolutionary process, a critical demarcation of encounters or deviations that supported existing events.88. Foucault M. Microfísica do poder. Rio de Janeiro, RJ(BR): Paz e Terra; 2019.,1919. Mattioni FC, Rocha CMF, Faria MA. Analysis of emergencies and proveniences of health promotion practices performed in a PHC service. Rev Psicol Saúde [Internet]. 2022 [cited 2022 Oct 10];14(2):3-19. Avaliable from: https://doi.org/10.20435/pssa.v14i2.1854
https://doi.org/10.20435/pssa.v14i2.1854...

Thus, genealogical analysis announced the conditions of possibility (provenance) that converged to the emergence of obstetric nursing in Minas Gerais: existence of teaching nurses at the EEUFMG, specialists in midwifery, willing to act and train students to practice in women’s health care; locus of counter-conduct, assumed by the HSF to open the space for practical action by nurses, mainly in childbirth care; and influence of social and political values that guided the model of obstetric care in HSF management.

It is noteworthy that, at that time, in the national context, since 1939, the Escola Paulista de Enfermagem, and in 1947, the Escola de Enfermagem Anna Nery, offered courses for training obsteric nurses. These courses graduated teaching nurses who started to work in specialization in Minas Gerais, being, therefore, an important condition for obstetric nursing training in Minas Gerais.55. Schreck RSC, Frugoli AG, Santos BM, Carregal FAS, Silva KL, Santos FBO. History of obstetric nursing at the Nursing School Carlos Chagas: an analysis based on the Freidsonian approach. Rev Esc Enferm USP [Internet]. 2021 [cited 2022 Oct 10];55:e03762. Available from: https://doi.org/10.1590/S1980-220X2020014703762
https://doi.org/10.1590/S1980-220X202001...
,2020. Pimentel MRAR, Xavier ML. Faculdade de enfermagem da universidade do estado do Rio de Janeiro: 70 anos de sua trajetória. Hist Enferm [Internet]. 2018 [cited 2022 Nov 10];9(2):86-8. Available from: http://here.abennacional.org.br/here/v9/n2/_EDITORIAL-1_portugues.pdf
http://here.abennacional.org.br/here/v9/...

Such conformation marks the beginning of visibility in a space dominated by the medical hegemony of mastered and subjected knowledge of nursing practice in normal childbirth care. The concept of dominated and subjected knowledge is considered here as the specific knowledge of resistance, inherent to every exercise of power, considered naive and hierarchically inferior when compared to discursive practices that present themselves as truth and that circulate freely in social body.88. Foucault M. Microfísica do poder. Rio de Janeiro, RJ(BR): Paz e Terra; 2019.

It is recognized, under a genealogical analysis, that the emergence of obstetric nursing did not demarcate the end of a flow, but resulted in other emergences. The data show that this articulation between teaching at the EEUFMG and practice at the HSF contributed to resuming, in the context of Minas Gerais, the possibility of training and nursing activities.

At this juncture, in Minas Gerais, after periods of rupture in professional training of obstetric nurses in 1957 and 1966, it was organized, at the end of the 1990s, a new Obstetric Nursing Specialization Course. Speeches revealed negotiations, interests and relationships involved in offering this course as a result of the consolidation of articulation between teaching and practice at the EEUFMG and the HSF. The proposal for this specialization arises from the need to meet legal workforce regulations and qualification for nurses’ practice in childbirth care.

Under this circumstance, among the conditions of possibility (provenance) involved in offering this new specialization course, the influences of legal frameworks and scientific knowledge traced in the national and regional scenario of childbirth assistance are identified. As a milestone of scientific knowledge, there was the development of humanization of labor and birth with actions by the Ministry of Health which, anchored in scientific evidence and suggestions from international health bodies, began to indicate nurses specializing in midwifery as the most appropriate care providers in normal childbirth care.2121. Ministério da Saúde (BR). Programa de Humanização no Pré-natal e Nascimento [Internet]. Brasília, DF(BR): Ministério da Saúde; 2001 [cited 2022 Nov 15]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/parto.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

Regarding the legal frameworks, in 1998, important ordinances were also published by the Ministry of Health to regulate obstetric nurses’ practice in the country. Ordinance 2815 of May 29, 1998 proposed that care for low-risk normal births be performed by an obstetric nursing professional. On the other hand, Ordinance163 of September 22, 1998 granted obstetric nurses the possibility of issuing a Hospital Admission Authorization and the inclusion of this professional in the Unified Health System (SUS - Sistema Único de Saúde) payment table.

The third genealogical configuration of this study deals with the process of inserting obstetric nurses from Minas Gerais in areas of activity other than the HSF. The speeches state that this process was characterized by institutional barriers, clashes and disputes, mainly with the medical category. The search for visibility and recognition of professional practice was mediated by confrontations, resistance and defense of one’s own knowledge. Other studies also point out that institutional, organizational and medical hegemony barriers still remain as challenges to obstetric nurses’ professional autonomy. The lack of recognition of obstetric nurses’ technical competence for childbirth care, the difficulties in interpersonal relationships and historical power relations, such as disputes, interests and repressions in care practices, are discussed.2222. Oliveira OS, Couto TM, Oliveira GM, Pires JA, Lima KTRS, Almeida LTS. Obstetric nurse and the factors that influence care in the delivery process. Rev Gaúcha Enferm [Internet]. 2021 [cited 2022 Oct 10];42:e20200200. Available from: https://doi.org/10.1590/1983-1447.2021.2020-0200
https://doi.org/10.1590/1983-1447.2021.2...
-2424. Progianti JM, Moreira NJMP, Prata JA, Vieira MLC, Almeida TA, Vargens OMC. Job insecurity among obstetric nurses. Rev Enferm UERJ [Internet]. 2018 [cited 2022 Oct 10];26:e33846. Available from: https://doi.org/10.12957/reuerj.2018.33846
https://doi.org/10.12957/reuerj.2018.338...

Limitations of this study are the subjectivity associated with the method of analysis employed, sample size and intention, although the sampling strategy used was instituted to reach key subjects capable of contributing to accomplishing the study’s objective.

CONCLUSION

The genealogical perspective, in seeking to build the effective history of obstetric nursing, revealed the moment of emergence and the provenance involved in this process, identifying articulations, relationships involved, games of interest, disputes and confrontations.

The genealogical configurations of nursing obstetric in Minas Gerais revealed a unique historical trajectory with initiatives for professional training in the 1950s and 1960s, followed by ruptures in the training process due to restriction of space for practical action. The emergence of obstetric nursing in Minas Gerais, from the 1980s onwards, occurs with the equation of teaching and practice forces in the important event of articulation of EEUFMG and HSF. For this emergence, there was a proliferation of conditions of possibility (provenance) of existence of trained nursing professors for training and the practice space for nurses to perform in childbirth care, with the influence of political milestones.

Subjects that make up this field announce in their daily practice the confrontations and resistance to medical hegemony in the defense of professional autonomy and the expression of their own knowledge, socially dominated and subjected.

We believe in the relevance of this study for conceptualization and characterization of obstetric nursing in Minas Gerais, contributing to understanding the relationships that sustain the professional routine of this class. Finally, the importance of continuing discussions and research on the subject is highlighted, especially considering the genealogical framework, to enhance the dissemination and understanding of historical construction of obstetric nursing.

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    » https://doi.org/10.12957/reuerj.2018.33846

NOTES

  • FUNDING INFORMATION

    Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) - Financing Code 001.
  • APPROVAL OF ETHICS COMMITTEE IN RESEARCH

    This research was approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais, under Opinion 4,743,979 and CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 45061821.0.0000.5149.

Edited by

EDITORS

Associated Editors: Laura Cavalcanti de Farias Brehmer, Ana Izabel Jatobá de Souza. Editor-in-chief: Elisiane Lorenzini.

Publication Dates

  • Publication in this collection
    09 Jan 2023
  • Date of issue
    2022

History

  • Received
    10 Oct 2022
  • Accepted
    16 Nov 2022
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