Obstetric violence: theme approach in the training of Certified Nurse-Midwives

Abstract

Objective:

To construct the Discourse of the Collective Subject of graduate nurses in obstetric nursing on obstetric violence.

Methods:

This is a descriptive and qualitative study carried out at a University Center in Teresina, PI. Twenty nurses participated, graduate students in obstetric nursing. Data collection took place through guided interviews using a semi-structured questionnaire. The data were processed using the software IraMuTeQ and the Descending Hierarchical Classification. The data were analyzed using the Discourse of the Collective Subject technique.

Results:

Through the Descending Hierarchical Classification, six classes were obtained from which the speeches emerged. It was possible to confirm the importance of training nurses in the face of obstetric violence. The main key expressions identified in the speeches were academic training, knowledge in educational practice, quality assistance, scientific, technological and humanistic mismatches, strengthening of the care model, strategic planning in the health sector, humanist base and professional clinical view.

Conclusion:

Through the Discourse of the Collective Subject, it was possible to partially observe the importance of training nurses, since they enable the contribution of comprehensive care, corroborating a physiological process, which can reduce obstetric violence.

Keywords
Violence; Violence against woman; Pregnant women; Nurse midwives; Students, nursing; Humanizing delivery

Resumo

Objetivo:

Construir o Discurso do Sujeito Coletivo de Enfermeiros pós-graduandos em Enfermagem Obstétrica sobre a violência obstétrica.

Métodos:

Estudo descritivo, de abordagem qualitativa, realizado em um Centro Universitário em Teresina-PI. Participaram 20 Enfermeiros, pós-graduandos em Enfermagem Obstétrica. A coleta de dados ocorreu por meio de entrevistas guiadas a partir de questionário semiestruturado. Os dados foram processados no software IraMuTeQ, utilizando a Classificação Hierárquica Descendente, e analisados pela Técnica do Discurso do Sujeito Coletivo.

Resultados:

Mediante a Classificação Hierárquica Descendente, obtiveram-se seis classes das quais emergiram os discursos. Foi possível ratificar a importância da formação do Enfermeiro diante da violência obstétrica. As principais expressões-chave identificadas nos discursos foram: formação acadêmica, conhecimento na prática educativa, assistência de qualidade, descasos científicos, tecnológicos e humanísticos, fortalecimento do modelo assistencial, planejamento estratégico no setor saúde, base humanista e olhar clínico do profissional.

Conclusão:

Por meio do Discurso do Sujeito Coletivo, foi possível observar, parcialmente, a importância da formação dos Enfermeiros, visto que possibilitam a contribuição de cuidado integral, corroborando para um processo fisiológico, que pode reduzir a violência obstétrica.

Descritores
Violência; Violência contra a mulher; Mulheres grávidas; Enfermeiras obstétricas; Estudantes de enfermagem; Parto humanizado

Resumen

Objetivo:

Construir el Discurso del Sujeto Colectivo de enfermeros estudiantes de posgrado en Enfermería Obstétrica sobre la violencia obstétrica.

Métodos:

Estudio descriptivo, de enfoque cualitativo, realizado en un Centro Universitario en Teresina, estado de Piauí. Participaron 20 enfermeros estudiantes de posgrado en Enfermería Obstétrica. La recolección de datos se realizó mediante entrevistas guiadas a partir de un cuestionario semiestructurado. Los datos fueron procesados en el software IraMuTeQ, mediante la clasificación jerárquica descendente, y analizados con la técnica del Discurso del Sujeto Colectivo.

Resultados:

Mediante la clasificación jerárquica descendente, se obtuvieron seis clases de las cuales surgieron los discursos. Fue posible ratificar la importancia de la formación del enfermero con relación a la violencia obstétrica. Las principales expresiones clave identificadas en los discursos fueron: formación académica, conocimiento en la práctica educativa, atención de calidad, indiferencia científica, tecnológica y humanística, fortalecimiento del modelo asistencial, planificación estratégica en el sector de la salud, base humanista y mirada clínica del profesional.

Conclusión:

A través del Discurso del Sujeto Colectivo, fue posible observar, parcialmente, la importancia de la formación de los enfermeros, ya que permiten contribuir con el cuidado integral, corroborando un proceso fisiológico que puede reducir la violencia obstétrica.

Descriptores
Violencia; Violencia contra la mujer; Mujeres embarazadas; Enfermeras obstetrices; Estudiantes de enfermeira; Parto Humanizado

Introduction

Obstetric violence is considered a socially complex phenomenon in women's health. Its prevention requires changes in care practices during the pregnancy-puerperal cycle to reduce unnecessary medical interventions, which can be harmful to women's physical and emotional health.⁽¹⁾

Abusive treatment during labor and birth violates human rights, being able to negatively influence the outcomes of these processes and discourage women from seeking future care. Moreover, it is seen as structural violence that makes them vulnerable to suffering and death.⁽²⁾

A research highlights that obstetric violence also affects women who have a history of abortion. For assistance with this procedure, health care must be supported by receptivity, information, guidance, and emotional support. However, despite the existence of a public policy that guarantees humanized care to women during abortion and that calls for impartial care, assistance to this woman in the Brazilian Health System (Sistema Único de Saúde, abbreviated SUS) does not meet their needs, sometimes.⁽³⁾

In this sense, it is important to clarify that the relationship between health professionals and parturient must be based on care and safety, aiming at an adequate performance of humanized practices. It is necessary for the professional to put himself in the other's place, listening to the woman's needs and knowing their demands in the health service, thus reinforcing the principles recommended by SUS.⁽⁴⁾

They reinforce the above the results found in a survey that expressed that women, in some cases, end up not adapting to the environment in which they will “give birth” and, often, to get rid of suffering and withdraw from that environment, agree with unnecessary interventions, considered serious or harmful to your physical and emotional health. Therefore, changes in current care practices must be made to reduce such interventions.⁽⁵⁾

In this sense, it is considered that health education through educational actions can be important to contribute to the exchange of knowledge between professionals and women - in clarifying questions, criticisms and in promoting health -, being possible to rethink the action strategies in the context of Primary Health Care (PHC), even during prenatal care.^(6.7)

Furthermore, the debate on this theme in the training of nurses becomes of notorious relevance in the Brazilian setting, mainly because it highlights the need to address violence against women in the curriculum during academic training, either in undergraduate or graduate studies. Thus, it is expected that the present study can contribute to the strengthening of nursing in healthcare practice and to the educational training of nurses, in addition to raising a greater debate on this practice in the obstetric setting.

This study is justified by addressing a current and relevant theme, which needs to be widely disseminated and addressed in different education and health settings. It presents important aspects, such as education and health promotion, women's empowerment and issues related to individual economic advantages in obstetric care to the detriment of maternal and child well-being.

This study aimed to build the Discourse of the Collective Subject of graduate students in obstetric nursing on obstetric violence.

Methods

This is a descriptive and qualitative study developed at a private University Center, based in the city of Teresina, PI. It is a Higher Education Institution (HEI), accredited by the Ministry of Education, which currently offers undergraduate and graduate courses. The graduate course in obstetric nursing stands out, which comprises 700 hours of theoretical and practical disciplines and has as its target audience nurses with an interest in improving knowledge.

The sample was selected for convenience, including all nurses regularly enrolled in the latu sensu graduate course in obstetric nursing at the selected HEI. Those who were absent during the data collection period were excluded due to leave or sick leave.

The target population was 40 graduate students in obstetric nursing. However, obtaining new speeches ceased with the participation of 20 nurses, being sufficient to reach the theoretical saturation of the information obtained in the data collection, that is, when there was no longer a need for new elements to guide or deepen theorization.

Participants were invited to participate in the study at HEI during the break or at the end of classes, according to the course schedule provided. Data collection took place between August and September 2018. Also, we chose, for data production, to use a semi-structured interview composed of the following questions: (1) “In general, as a graduate student in obstetric nursing, what are the contributions of the approach to the theme of obstetric violence during the training of nurses?”; (2) “Talk about the aspects of your academic education and professional qualification that contributed (or may contribute) or interfered (or may interfere) in the professional performance in caring for women during the prenatal-birth-puerperium cycle.”; (3) “In your opinion, what are the strategies to overcome the aspects that interfered with your academic training and professional qualification for your professional performance in caring for women during the prenatal-birth-puerperium cycle?”.

The interviews were conducted at a time and place chosen by the participants, previously informed about anonymity and the use of a voice recorder. The average duration of the interviews was 15 minutes.

For the processing of the data, a corpus text was organized with the transcripts of all interviews. The software IRaMuTeQ (acronym for Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) was used for processing from Descending Hierarchical Classification (DHC) and dendrogram.

Key expressions (fragments of testimonies that reveal the essence of the argument), central ideas (synthesis, made by the researcher, which reveals the meaning of the testimonies) and anchors (evaluative statement, belief or theory that is explained by the participant) were identified, from which the Discourse of the Collective Subject (DCS) was built, which consists of the qualitative way of representing the thought of a collective, aggregating, in a synthesis discourse, the discursive contents of similar meaning emitted by different people.

The Research Ethics Committee (REC) approved the project for this study, under Opinion 2,694,389. All participants were informed about the anonymity and the voluntary nature of the research. Likewise, all of them read, agreed and signed the Informed Consent Term, attesting to their consent.

Results

Of the 20 graduate students in obstetric nursing participating in this study, 18 were female, with an average age of 24 years; 17 were single; and the average training time was 3 years.

IRaMuTeQ recognized the separation of corpus in 160 Elementary Context Units (ECU) and six classes, taking advantage of 80% of the total of corpus, a value considered high enough for the analysis.

The corpus obtained an axis, from which emerged class 6, with 23 ECU (17.97%), and two other subdivisions: from a subdivision emerged class 5, with 23 ECU (14.06%), and two ramifications: that of class 1, with 16 ECU (12.5%), and that of class 3, with 25 ECU (19.53%); from the other subdivision, class 4, with 30 ECU (23.44%), and class 2, with 16 ECU (12.5%) emerged.

Through the DHC, it was possible to interpret the statements obtained in corpus of the approach on obstetric violence in the training of Certified Nurse-Midwives, named in their respective senses in the six classes from the dendogram (Figure 1).

Figure 1
Thematic structure of the approach to the theme of obstetric violence in the training of nurses

The six classes in this study listed the approach of obstetric violence in the training of Certified Nurse-Midwives. According to the DCS assumptions, each graduate nurse in obstetric nursing interviewed contributed his/her share of thought to the collective discourse. Therefore, after analyzing the interview transcript, based on the key expressions (K E), the central ideas (CI) were identified, enunciated according to the DHC, and the DCS were constructed. Then, the speeches were normalized, in order to make the testimonies private, to give coherence and cohesion to the ideas and to avoid repetition. Chart 1 presents the CI, KE and speech-synthesis (DCS).

Chart 1
Discourse of the Collective Subjects elaborated by “future” Certified Nurse-Midwives about obstetric violence

Key Elements	Central Ideas	Discourses of the Collective Subject
Academic training knowledge in educational practice. Assistance in the pregnancy cycle. Importance of nurses.	Importance of the obstetric violence theme in the academic education of nurses as an educational practice in the pregnancy cycle.	Obstetric violence, characterized by the dehumanization of birth and the misappropriation of health professionals in the reproductive process of women, in the training of nurses, is of great value and importance. It is essential to assist in the pregnancy cycle as a preventive strategy to combat this phenomenon to obtain a harmonic relationship, minimizing possible errors of obstetric complications. Progress in the valorization of professionals is also crucial, as is the support of a public policy network, enabling a better working condition in SUS, better financial or structural performance, in order to awaken a new scientific view on educational practice, developing a thought critical and avoiding this “disentanglement”.
Risks from lack of care. Financial valuation. Quality assistance.	The profile of the Certified Nurse-Midwife in humanized care.	The term “qualified provider” emphasizes exclusively the individual with skill in professional birth care, able to accompany the care of the puerperal woman, from her interaction in the family environment to her mental state. When asked about the care commitment, most professionals and the entire multidisciplinary team are giving more value to the economic sector, that is, they are valuing the currency more than humanization itself. Professionals must prioritize quality service with comfort, responsibility and credibility. The profile of an Obstetric expert is that of an adjunct, and the protagonist is the pregnant woman herself. This means having professional ethics, empathy with others and human dignity.
Quality of care provided. Scientific, technological, and humanistic neglect. Rights to parturient women.	The role of the Certified Nurse-Midwife in caring for women during prenatal care.	The Certified Nurse-Midwife aims to assist the pregnant woman with quality, wishing to primarily reach the poorest parts of society. We observe a neglect and even the absence of integrality when deepening its scientific, technological and humanistic aspects in this context. It is important for pregnant women to receive guidance, knowing the procedures and their rights in this parturition, especially teenage mothers, so that they are prepared to enter this setting.
Strengthening the care model. Risks in the birth process.	The importance of nurses in humanized prenatal care to reduce postpartum complications.	Humanization implies changes in the routine, with the purpose of making the moment of delivery as “medicalized” as possible. One of the main objectives of prenatal care is to know the patient's medical history. It is necessary that the nurse plays a role of total strengthening in the care model, providing early assistance, as the risks evolve into a series of problems that can put the life of both the mother and the newborn at risk.
The importance of scientific knowledge. Maternal and neonatal well-being. Scientific improvement in academic training. Strategic planning in the health sector.	Applicability of scientific knowledge as a strategy in women's health care.	When analyzing institutional violence, we realize that, with regard to combining practice with scientific knowledge, there is a high complexity in the women's health care network, which serves as a gateway to maternal and neonatal care and well-being. Knowledge is an information tool focused on the learning process. Primary care is of great relevance in professional development, as it comprises a detailed - that is, a holistic view - in the field of women's health care, which provides conditions for health promotion and improvement in physical and emotional control. In view of the high level of demand for services, strategic planning in the health sector is necessary, aiming at the elaboration of actions such as assistance restructuring.
Humanist base. Birth interventions. Clinical look of the professional.	Obstetric violence in the view of the health team, in the current context of humanized care.	Humanization would be a strategy in the production of health, understood by a humanist base, capable of transforming the professional's vision. To make a birth satisfactory, it is necessary to reduce interventions and implement good therapeutic obstetric practices, which were previously based on the understanding that birth was associated with the disease, biologically. Today, it becomes a model of expanded care, which makes it possible to discourage unnecessary conduct in labor and delivery. Professionals must have a clinical view so that it is possible to analyze and interpret violence to reduce evils that cause so much suffering and affect the health of women and newborns.

Discussion

Despite the unfavorable context in relation to the methodological arsenal of good practices, based on scientific evidence, the partial restriction of participating nurses, the non-contemplation of collective thoughts and the insertion of graduate students in obstetric nursing from other institutions and particularly from other regions of the country. The data presented do not cancel the scientific relevance of this investigation, but point to the need for future qualification and improvement.

For the scientific community, the development of research projects with more advanced methods is suggested, given the relevance of the theme in the training of nurses and health professionals involved in obstetric health care, for the benefit of best practices within the Basic Health Units (BHU). This practice favors the implantation of educational actions and the minimization of unnecessary obstetric interventions.

The present study allowed, from the DCS, to understand the importance of obstetric violence approach in the educational training of nurses in the pregnancy cycle, due to the need for a Certified Nurse-Midwife for humanized care. It was also possible to highlight the importance of restructuring birth care in view of academic training, given that it is up to health professionals to create and use systematized scientific knowledge directed to the needs of each woman.

Another data observed from the DCS is related to educational practice and adherence to health promotion actions, a way to remedy care failures. It is necessary to have a host that encourages the exchange of experiences to fill the existing gap, generating a bond between patient and professional, to minimize anxiety, fear, insecurity, doubts, and complaints associated with pregnancy.

Therefore, strategies such as critical and self-critical reasoning and the implantation of therapeutic groups that plan the social and political issue of the category Certified Nurse-Midwife is important, thus discussing problematization in a general situation. This professional exercise proposes the practice with quality of the nursing professional's functions.⁽¹⁾

In the speech constructed based on the speeches of the professionals, it is possible to identify the risks caused by the lack of humanized care, capable of causing problems to the fetus during pregnancy. However, it is noteworthy that, sometimes, problems occur mediated by the team of professionals, who accumulate functions to add profit, in addition to facing high turnover and precarious employment relationships. It should also be emphasized that this fact can influence humanization - which causes professional negligence - and the incorporation of values, since professionals are more interested in individual socioeconomic issues than in reducing maternal and child mortality rates.⁽⁸⁾

These professionals are constantly challenged in providing care. The health system is deficient because it does not have a comprehensive care standard aimed at personal mobilization. It is extremely important to have a technological mechanism for the exchange of information between team members that, when properly used, enables continuous care.⁽⁹⁾

Based on this, it is also emphasized that, for the health professional-patient relationship, it is essential that the professional shares knowledge in order to minimize possible patient mistakes. On the other hand, it is important to mention that there are still many barriers to be faced, including the absence of wholeness and clarity in the face of the guidelines given to pregnant women, leading to their insecurity, which directly interferes with the quality of life and the trivialization of women's rights. women. Therefore, it is proposed to legitimize effective actions to suppress and prevent obstetric violence.⁽¹⁰⁾

In line with this study, a research⁽¹¹⁾ points out that dialogue makes up the right to parturient women. In this context, the nurse must seek the judicial recognition of the woman for the choice of birth, in addition to the rights not to be injured by unnecessary maneuvers, to be accompanied by a person of her choice and to have clarification about the procedures.

Judicial recognition is essential because injured women do not always know how to seek redress, so the dialogue with the nurse can allow for preventive and information measures.⁽¹¹⁾ Thus, it is important that the Certified Nurse-Midwife performs humanized care as a way of improving the qualified and humanistic service, both capable of contributing to a positive reflection.

This study also made it possible to understand the risk of the parturition process, which has a negative impact on pregnant women. It is considered that interventions can save lives when properly implemented, ensuring total care and providing maternal satisfaction.⁽¹²⁾

Strengthening the care model is relevant to the training of humanized professionals. There is a need to prepare the parturient effectively and offer harmonic assistance in this pregnancy-puerperal cycle, which is summarized in technique, procedure and theoretical foundation. It is worth noting that the lack of information creates greater risks of complications in the postpartum period for the parturient.⁽¹³⁾

It is noteworthy that, to understand the contributions of humanized care, it is necessary that experts have an essential role in caring for women during prenatal care, using clinical practices based on evidence, in the care experience based on respect and emotional support. Therefore, it becomes pertinent to identify socio-cultural, physiological and care factors to contribute to the process of renewing scientific research. In this sense, the reflection about the professionals in the prenatal service is justified, as they are the first ones who need to be sensitized in the biopsychosocial scope, guaranteeing comprehensiveness.⁽¹⁴⁾

In agreement with this study, it is also stated that maternal complications also occur due to the increase in caesarean sections without clinical indication. A research revealed that complications are frequent and affect women's quality of life. For caesarean sections to be performed, it is therefore necessary to have clear, coherent and prudent indications, the benefits of which outweigh the potential risks.⁽¹⁵⁾

It was possible to confirm in the speeches the importance of nurses in prenatal care, in order to reduce the risk of complications during birth. In this way, it is important to discern the problems that may arise early and face them correctly, in order to avoid irreparable damage. A study revealed that assistance must be based on health promotion and protection, and the pregnant woman must be a protagonist in this process, giving priority to the entire assistance and emotional context in the prevention of obstetric complications.⁽¹⁶⁾

Regarding the fifth central idea, shown in Chart 1, the applicability of scientific knowledge on the theme of obstetric violence lacks education and health practices, that is, mandatory health practice. The insertion of these practices favors the quality of care during primary consultations, which aim at embracing. It is therefore important that professionals prioritize educational activities as a way to improve interpersonal relationships in individual care, aiming at the preparation and construction of knowledge.⁽¹⁷⁾

Knowledge makes it possible to provide professionals with a space for reflection, aiming at the principle of integrality and commitment to health and extending this approach to the vulnerable population. This issue is necessary for obtaining laws, punishments and forms of denunciation that aim to avoid the aggravating factor of violence and to overcome the emotional and psychological aspects.⁽¹⁸⁾

Given the above, the existence of strategic methods capable of reversing this situation through evidence-based guidelines, changes in attitudes on the part of experts and provision of health care is highlighted. Furthermore, it is possible to minimize aggressions, avoid wasting the use of materials, encourage the development of research on new indicators and disseminate results to the scientific community.

In accordance with the above, a study⁽¹⁹⁾ pointed out that assistance has undergone transformations regarding its ethical, cultural and psychological aspects, generating the autonomy and empowerment of women, who become the protagonist in the parturition process. In order to adopt this practice, it is essential that the professional provides consistent information to propagate the reduction of instrumental births, since this culture is rooted in society. The interest in interpreting violence in the current care context proposes safety and comfort in the care of nurses, which allows benefits to the mother-child binomial.

Carrying out this study demonstrated the need to reflect on the importance of combating obstetric violence in the training of Certified Nurse-Midwives, emphasizing it, with the aim of promoting conducts aimed at reducing high mortality rates. In this way, accompanying labor and delivery with efficiency and humanization and propagating embracement.

Addressing obstetric violence in the training of nurses is a structuring role in birth care and is important for improving the quality of care for users. For future experts, the professional training environment brings reflections and has the ability to contain unnecessary systems. Care standard becomes challenging, which must be reinforced at all times, not only for nursing professionals, but for the entire health team.⁽²⁰⁾

Conclusion

The training of nurses on obstetric violence must be broader, as they are supporting these experiences, and they play an important role in offering the quality of health care that women need and deserve as citizens of law. It is worth mentioning that, when women are properly oriented, they are less likely to suffer obstetric violence. Thus, the role of nurses in training is fundamental with regard to obstetric violence, since they have the possibility to reduce the rates of this problem and change the social reality. It was possible to identify through the DCS that, through the existence of humanized care policies for labor and delivery, such as the Brazilian National Guidelines for Assistance to Normal Birth (Diretrizes Nacionais de Assistência ao Parto Normal) and the Stork Network there is an intensification of scientific improvement related to obstetric violence, reflecting on best practices in assisting women in the parturition process in the public health service network.

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Publication Dates

• Publication in this collection
  26 Oct 2020
• Date of issue
  2020

History

• Received
  17 June 2019
• Accepted
  25 Mar 2020