Performance of nurse-midwives from the perspective of Epistemologies of the South

ABSTRACT

Objective

to reflect on the role of certified nurse-midwives in caring for women during parturition from the theoretical perspective of Epistemologies of the South.

Method

this is a reflective study based on literature narrative review.

Results

after reading and critically analyzing the selected documents, and based on Epistemologies of the South theoretical framework, two thematic axes for reflection emerged, namely: Decolonization of knowledge: performance of nurse-midwives in rearranging a model of care for women during parturition; and Post-abyssal thinking and knowledge ecology vs humanized practices in childbirth and birth care.

Conclusion and Implications for practice

nurse-midwives contribute to the valorization of the knowledge of few expressive social groups (minorities), oppressed before the hegemony of a care model. Their professional attitude seeks integration of different knowledge. Reflection on nursing-midwifery care from the perspective of Epistemologies of the South may prompt discussion about current nursing-midwife practices in order to encourage adoption of qualified and humanized care for women during childbirth.

Keywords:
Obstetric Nursing; Humanizing Childbirth; Knowledge; Professional Practica; Womens’s Rights

RESUMO

Objetivo

refletir acerca da atuação do enfermeiro obstétrico na atenção à mulher durante o processo parturitivo, sob a perspectiva teórica das Epistemologias do Sul.

Método

trata-se de estudo do tipo reflexivo, com base em uma revisão narrativa da literatura.

Resultados

após leitura e análise crítica dos documentos selecionados, e com base no referencial teórico das Epistemologias do Sul, emergiram dois eixos temáticos para reflexão, sendo eles: Descolonização do saber: atuação do enfermeiro obstétrico na reorientação do modelo de atenção à mulher durante o processo parturitivo; e O pensamento pós-abissal e a ecologia dos saberes versus práticas humanizadas de atenção ao parto e nascimento.

Conclusão e implicações para a prática

o enfermeiro obstétrico contribui para a valorização do conhecimento de grupos sociais poucos expressivos (minoritários), oprimidos ante à hegemonia de um modelo assistencial. Sua postura profissional busca a integração de distintos conhecimentos. A reflexão sobre a assistência da enfermagem obstétrica na perspectiva das Epistemologias do Sul poderá suscitar a discussão sobre as práticas obstétricas vigentes de modo a propulsionar a adoção de cuidados qualificados e humanizados na atenção à mulher durante o parto.

Palavras-chave:
Enfermagem Obstétrica; Parto Humanizado; Conhecimento; Prática profissional; Direitos da Mulher

RESUMEN

Objetivo

reflexionar sobre el papel de la enfermera obstétrica en el cuidado de las mujeres durante el proceso de parto, bajo la perspectiva teórica de las Epistemologías del Sur.

Método

este es un estudio reflexivo, basado en una revisión literatura narrativa.

Resultados

después de leer y analizar críticamente los documentos seleccionados, y basándose en el marco teórico de las Epistemologías del Sur, surgieron dos ejes temáticos para la reflexión, a saber: Descolonización del conocimiento: el papel de la enfermera obstétrica en la reorientación de la modelo de atención a la mujer durante el proceso de parto; y El pensamiento post abisal y la ecología del conocimiento versus prácticas humanizadas en el parto y el cuidado del parto.

Conclusión e implicaciones para la práctica

la enfermera obstétrica contribuye a la valorización del conocimiento de pocos grupos sociales expresivos (minorías), oprimidos antes de la hegemonía de un modelo de atención. Su postura profesional busca la integración de diferentes conocimientos. La reflexión sobre la atención obstétrica de enfermería desde la perspectiva de las Epistemologías del Sur puede impulsar la discusión sobre las prácticas obstétricas actuales para alentar la adopción de atención calificada y humanizada en el cuidado de las mujeres durante el parto.

Palabras clave:
Enfermería Obstétrica; Parto Humanizado; Conocimiento; Práctica Profesional; Derechos de la Mujer

INTRODUCTION

Insertion of certified nurse-midwives (CNM) in Brazil is easily identifiable in childbirth and birth care public policies introduced around the 90s, in a context of criticism and reflection on the current biomedical model of nursing-midwifery, which is characterized by interventionist practices, vertical relations and loss of women’s autonomy in their parturition process.¹ Since the decade of 1985, the World Health Organization (WHO) had already published the document “Appropriate Technology for Birth”. Such document would be the transformation milestone of the model of childbirth care in the world with in view of humanized childbirth and birth care.²

Among the measures adopted a few years ago by the Ministry of Health (MoH) of Brazil to rearrange the care model, there are Minister’s Office/MoH Ordinances 2,815/98 and 169/98. Such Ordinances regulate obstetric care performed by nurses, including normal childbirth performed by professionals in the list of procedures of the Brazilian Health System (Sistema Único de Saúde, abbreviated SUS) and in the issue of Hospitalization Authorization (HA) signed by them. Law 7,498 of 1986 and Decree 94,406 of 1987 regulates the professional practice of nursing, with guidelines and standards for the performance of CNMs in assisting normal childbirth. CNMs are responsible for assisting the parturient, identifying dystocia, performing epsiotomy, epsiorraphy, and local anesthesia, if necessary.

Subsequently, in 2000, the Program for Humanization of Prenatal and Birth (Programa de Humanização do Pré-natal e Nascimento, abbreviated PHPN) consolidated the participation of professional nurses as co-participants in the Brazilian National Childbirth Care Policy (Política Nacional de Atenção ao Parto, abbreviated PNAP), aiming at encouraging normal childbirth and reducing maternal and neonatal morbidity and mortality indicators, cesarean section rates and unnecessary interventions during labor and childbirth.³

From the perspective of a humanized care model, the work CNMs focuses on the physiology of childbirth, respecting the needs and the role of women, to the detriment of objectifying the woman’s body to biomedical interventions. Furthermore, in a so-called humanized childbirth, non-pharmacological measures for pain relief are widely used, as well as scientific evidence without giving up other popular and/or cultural knowledge that provide satisfaction, quality and participation of women and their families during parturition.

Such precautions, which under the theoretical point of view of Epistemologies of the South⁴, oppose the hegemony of biomedical knowledge, already established and recognized as Epistemologies of the North. This new perspective is intended to rescue the autonomy of women, to allow the presence of other people (family members and doulas) at childbirth, in addition to valuing a dialogue between knowledge and experiences hitherto little valued.

Considering the above, this article aims to reflect on the role of nurse-midwives in caring for women during parturition under the theoretical perspective of Epistemologies of the South. Therefore, this reflective theoretical study aims to answer the following guiding question: how does the theoretical perspective of Epistemologies of the South permeates and improves the performance of nurse-midwives in caring for woman who experiences at parturition?

For this purpose, a narrative review of nursing literature was carried out by searching books, articles and documents that deal with the studied theme, in order to discuss it from a theoretical/contextual point of view.⁵ To this end, the book “Epistemology of the South” and scientific articles^1,3,6 that intermediated articulation between nursing-midwifery and Epistemologies of the South have been read. Also, documents and manuscripts referring to the performance of CNMs in childbirth and birth care in a political and humanized perspective have been referenced.

Search for scientific articles in electronic journals was carried out at Scientific Electronic Library Online (SciELO Brazil) and at Nursing Database (Banco de Dados de Enfermagem, abbreviated BDENF) in June 2019, using the following descriptors: nursing-midwifery and humanized childbirth, with Boolean operator “AND” between them. It was possible to identify 268 scientific documents, of which 16 were scientific articles that addressed the work of CNMs and humanization of childbirth and birth care, thus composing material for this reflective study.

Therefore, two axes of reflection emerged: Decolonization of knowledge: performance of nurse-midwives in rearranging the model of care for women during parturition; and Post-abyssal thinking and knowledge ecology versus humanized practices in childbirth and birth care.

THEORETICAL FRAMEWORK

Boaventura de Sousa Santos⁴ is considered one of the most influential sociologists in contemporary society. His works have important theoretical relevance for the different Brazilian social and human sciences courses such as law, education, social work, political science, and sociology. Also, they contribute to health sciences and, especially to nursing.

Among his published works, “Epistemologies of the South” stands out as a theoretical conception, which seeks to understand the world socio-historical context and make a counterpoint with the hegemonic model of production and social reproduction of knowledge dictated by capitalism.

Etymologically, “epistemology” means discourse or study about sciences. It comprises the critical study of the principles, hypotheses and results of the different sciences, i.e., it is the theory of knowledge.⁷ According to Boaventura and Meneses⁴, epistemology is any notion or idea, reflected or not, on the conditions of what counts as valid knowledge.

Therefore, Epistemologies of the South represent the world’s epistemological diversity, which comprises diversity of knowledge, where the South is metaphorically conceived as a field of challenges that seeks to overcome the damage caused by the colony relationship of European capitalism under southern countries and regions.⁴

Among the conceptual elements that constitute the framework “Epistemologies of the South”, it is mentioned colonization of knowledge and the abyssal line, which, in the light of Boaventura’s thought, unfold in the constructs of decolonization of knowledge, post-abyssal thinking and knowledge ecology.

In an attempt to understand decolonization of knowledge, it is understood that it consists of knowledge recovery of social groups that, as a result of capitalism’s colonialist model, were historically and socially placed as objects of the dominant knowledge of the north, concretized in modern science and considered for centuries as only valid and legitimate ones.^4,6

In line with this understanding, post-abyssal thinking is understood as part of the assumption that the world’s epistemological diversity remains to be built since the diversity of knowledge is inexhaustible. Therefore, knowledge ecology is the inter-knowledge resulting from recognition of heterogeneous knowledge plurality. Modern science is only one of them, in a sustainable and dynamic interaction between all, so as not to compromise the autonomy of each one of them.⁴

Within this conceptual theoretical framework on Epistemologies of the South, the purpose is to make a theoretical reflection regarding the performance of CNMs in humanized care for women during childbirth, whose understanding is based on the approach of Boaventura and Meneses⁴. Therefore, it will be possible to subsidize reflection on the field of knowledge and practices of nursing-midwifery, based on recognition of knowledge plurality, its interactions and autonomy.

Thus, the following topics are intended to make a dialogue between the concepts previously defined and the role of CNMs as precursors to humanization in childbirth and birth care.

RESULTS AND DISCUSSION

Decolonization of knowledge: performance of nurse-midwives in rearranging the model of care for women during parturition

Understanding the meaning of “decolonization of knowledge” requires any professionals’ prior understanding of what their “colonization” is. When thinking or reflecting on knowledge, there is a colonial zone corresponding to the universe of beliefs, behaviors and know-hows that are disregarded as “knowledge”, as they are not circumscribed in the western judgment of true and false. Such thinking is based on modern European science, which divides the world into human and subhuman, through the force of abyssal line, determining constant segregation between scientifically valid and non-valid knowledge. Therefore, colonization of knowledge means, in a denotative way, a model of radical exclusion and exploitation, just as it used to happen in the colonial explorer model.⁴

Nursing-midwifery practice has been exercised for centuries by women called midwives or trimmers, who, during the twentieth century, during the technological development of medical care, were called professionals with little scientific knowledge and assigned to the suburb of childbirth care. Empirical knowledge, inherited from generation to generation and which constituted a body of intuitive knowledge of the work of midwives was placed beyond the abyssal line, i.e., they were colonized due to western knowledge of modern medicine. Thus, the historical and social construction of this profession was guided by power relations, under the mantle of true science, including gender.

As a result, medicalized practices were routinely introduced in parturition, making birth a hospital event centered on the figure of the physician and not on the woman. From this perspective, the latter has withdrawn its autonomy and is submitted to unnecessary procedures such as diet restriction, enema, trichotomy, early amniotomy, lithotomic position, epsiotomy, Kristeller maneuver, surgical childbirth (forceps or cesarean section) without criteria for indication, among others.⁸

Although technological innovations have undeniable contributions, such as reduction of maternal and neonatal mortality, indication of cesarean childbirth in the face of obstetric and fetal emergencies, inappropriate use of technologies and unnecessary interventions without scientific evidence during childbirth, they are substantiated as iatrogenic behaviors that can harm the health of mothers and children.⁹ Therefore, it is questioned the routine use of such procedures and, mainly, exploration/colonization of the female body as an object of intervention, without being allowed to experience childbirth according to their needs or enabling conditions of access to other forms of knowledge that provide qualification and humanization of care.

Considering this context and from the perspective of Epistemologies of the South, the humanized childbirth model care transformation goes through decolonization of knowledge. It consists of a set of networks, initiatives, organizations, and movements whose principles are equality and recognition of differences in the fight against exclusion, be it economic, social, political, cultural or in the relationships established during care.⁴ Decolonization, by arguing that understanding the world exceeds the western scientific knowledge, represented in nursing-midwifery by medical hegemony in the birth scenario, advocates in favor of hybridization of this knowledge, such as the role of CNMs in childbirth care.

Results of studies indicate that in countries where childbirth care follows the model centered on the precepts of the physiology and dignity of women, associated with valorization of CNMs, they present a reduction in maternal and neonatal morbidity and mortality indicators, in unnecessary intervention rates, and in cesarean section rates.¹⁰ This is due to the performance of CNMs, whose responsibility includes principles of humanization such as respect, empathy, intersubjectivity, and bonding to women and newborns, in addition to a care free from possible iatrogenies.⁸

A care based on scientific evidence that supports the science of nursing, but which, above all, is based on individuality and feminine uniqueness, values the role of women and allows assistance interlocution before the beliefs and cultural values of the parturient.⁸

Furthermore, professionals are able to monitor the physiological process of birth and recognize distortions that require interventions. This conduct allows, in addition to direct benefits to pregnant women, newborns and family members, incentive to work in teams, elaboration of protocols that contemplate the complementarity of professions and adoption of recommended practices such as non-pharmacological measures for pain relief.¹⁰

This professional, qualified to work in childbirth care, has been trained by lato sensu graduate courses such as specializations and multidisciplinary residency programs in mother and child health and/or women’s health and nursing-midwifery. Unlike what happened in the 19^th century, with regard to the training of midwives and obstetric nurses, linked to medical schools, nowadays specialization courses in nursing-midwifery follow a teaching model emphasized on understanding the reproductive phenomenon as natural, healthy, and woman-centered. There is also an appreciation of knowledge and popular knowledge, articulated with scientific knowledge and other dimensions of professional competence such as technical skill, decision-making, autonomy, and appreciation of interdisciplinary teamwork.¹¹

Thus, the performance of CNMs in childbirth scenario constitutes a possibility of paradigmatic change, i.e., a way of expressing the knowledge of “Epistemologies of the South” in rearranging the model of care for women during parturition. Professional practice contributes to the valorization of the knowledge of social groups previously excluded by the biomedical model and to the recovery of the leading role and autonomy of women during labor and birth.

Post-abissal thinking and knowledge ecology versus humanized practices of child care and birth

Post-abyssal thinking and knowledge ecology are concepts that complement each other, both in relation to their definition and the theoretical-philosophical framework. Both are products derived from the deconstruction of abyssal thinking, understood as the embodiment of modern western thought, which does not allow co-presence of two sides of the abyssal line. In other words, it consists in granting modern science a monopoly on the division between what is scientific and non-scientific, between what is true and what is false, according to its demarcation patterns.⁴

Thinking about the presence of an abyssal line inserted in humanized care practices for childbirth and birth refers to discrimination between the conducts considered “legitimately” scientific or of a biological nature. Such conducts are generally performed by obstetric medicine, with those estimated as “humanized”, commonly performed by other professionals, including CNMs. Moreover, thinking is divided among the professions that limits exchange of knowledge and assigns judgments of relevance between the different knowledge.

Furthermore, it is necessary to reflect, since to deduce that physicians cannot provide childbirth assistance in a humanized way or that they perform childbirth applying non-pharmacological measures to relieve pain, is to prevent counter-hegemonic knowledge from being achieved in a democratic way. From this perspective, the following questions emerged: do CNMs have technical and scientific knowledge and skills compatible to carry out a clinical evaluation and outcome of labor as much as physicians? Can one judge which practice is more important than the other in childbirth and birth care? And, finally, wouldn’t these knowledges actually be complementary?

To remain linked to the nature of this dichotomous thinking means to contribute to the self-reproduction of abyssal thinking and encourage the dispute between obstetricians and CNMs for the right to practice nursing-midwifery.⁴

Seen in these terms, it is necessary to face the issue that arises, so that the hegemonic discriminatory cycle does not continue. Post-abyssal thinking is a possible way to transform this reality as it promotes global congenital justice. It is an alternative thought with alternatives, whose basic premise is based on the condition that co-presence of practices and agents on both sides of the line is essential for the construction of an egalitarian contemporary society.⁴ It corresponds to an affirmation and positive recognition of the plurality of knowledge existing in the world, not limiting it to those judged as scientific.⁶

This implies adoption of a professional behavior that seeks to integrate knowledge, whether biomedical, scientific, social, economic, cultural, popular and from different professions, in order to converge them in favor of humanization and qualification of assistance to women during parturition. Reflecting from this perspective also brings us to knowledge ecology.

Knowledge ecology is premised on the idea of the epistemological diversity of the world, i.e., it renounces any general epistemology, and it is, therefore, a counter-epistemology. It follows the utopia that it is possible to learn other knowledge without losing sight of its own, materializing itself as a technology of prudence.⁴ It is a definition of interest for nursing science. Plurality of knowledge is directly linked to the clarification of his body of knowledge and practices, concretized in the set of elements that make up his metaparadigm: person, environment, health, and nursing.¹²

Understanding heterogeneous knowledge gives us a greater range of forms of collaboration with subjects. Considering the needs of women during childbirth and birth is one of the constant concerns of CNMs, which requires from this professional the ecological thinking of seeking different knowledge to cover these needs in different contexts and realities. This behavior is consistent with humanized birth and childbirth care.

Therefore, it is necessary to recognize that humanization concerns a global project, reproduced by several social actors. However, this project needs to have the opinion of women as guiding principle, placing them as protagonists. It also implies professional conduct with respect to the physiology of childbirth, without unnecessarily intervening, and absorbing social and cultural aspects; offering the necessary emotional support to the woman and her family; ensuring a companion and respect for women’s rights.¹⁰

Above all, women must be informed of the procedures to which they will be submitted, and professionals, in turn, must act with competence and effectiveness as collaborators, making themselves available with their knowledge to maintain the woman’s physical and psychological balance.¹⁰

At this point, we highlight the role of CNMs in empowering women during childbirth, and implementation of integrative practices such as non-pharmacological measures for pain relief, free ambulation and position choices, aromatherapy, chromotherapy, music therapy, presence of companion or doula, breathing techniques, warm shower bath, massage, and use of noninvasive technological resources (Swiss ball, sling ladder, and rebozo).

Technologies used based on scientific evidence and that their benefits for the physiology of labor and, mainly, for women satisfaction are proven in systematic reviews of nursing literature¹³. They are recommended by the WHO as one of the priority strategies for promoting adequate care for childbirth and birth.¹⁴

For this reason, it is considered that CNMs have the profile and competence to monitor the physiological process of birth, contributing to its natural evolution. Their performance is based on the principles of respect for human beings, empathy, intersubjectivity and bonding, offering women qualified and humanized care.¹⁰

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

When reflecting on the performance of CNMs based on the perspective of Epistemologies of the South of Boaventura Sousa Santos, it was possible to identify points of convergence between this framework and practices performed by professionals in childbirth and birth.

In his performance, he contributes to decolonization of knowledge by valuing the knowledge of social groups previously excluded by the biomedical model, rescuing the role of women in the experience of labor and childbirth. Post-abyssal thinking and knowledge ecology are present in integrating knowledge, whether biomedical, scientific, social, economic, cultural, popular and from different professions, in order to converge them in favor of humanized and qualified care for women during childbirth and birth.

Therefore, nursing-midwifery emerges as one of the different forms of expression of Epistemologies of the South, given its emergence as a science contrary to the limited view of biologicism, in order to reverberate positively under those who must be the center of care during parturition process: the woman and her son.

As implications for care, reflecting on nursing-midwifery care from the perspective of Epistemologies of the South may prompt discussion about current nursing-midwifery practices and, from there, propel the adoption of qualified and humanized care for women during childbirth.

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• ¹
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Edited by

ASSOCIATE EDITOR

Ana Luiza de Oliveira Carvalho

Publication Dates

• Publication in this collection
  17 July 2020
• Date of issue
  2021

History

• Received
  11 Mar 2020
• Accepted
  25 May 2020