Intentionality of women’s actions in labor: a study in social phenomenology

Objective: to understand the intentionality of women’s autonomous actions in labor. Methods: a study in Alfred Schütz’s social phenomenology, developed with 15 puerperal women admitted to a university hospital in southern Brazil. Data were collected through phenomenological interviews and analyzed according to the adopted framework and the comparison with scientific productions. Results: the actions intended to receive physical and emotional support from their companions, from pregnancy, for a peaceful delivery with less pain, fast and without interventions. The intention was to do the right things for the child’s well-being and, after delivery, to be painless and active to take care of their children. Final considerations: women’s actions have intentionality arising from their knowledge, which is guided by the social relationships established in the world of life. das mulheres trabalho de Métodos: referencial científicas. Resultados: as intencionaram receber físico intervenções. foi coisas certas


INTRODUCTION
The development of nursing as a science permeates the role of nurses inserted in women and family care from reproductive planning, pregnancy, parturition, and puerperium. In this field of knowledge, the profession leads changes when developing care and the possibilities of reducing unnecessary interventions in obstetric care, considering women in the foreground (1) .
Such interventions come from the institutionalization of childbirth at the beginning of the 20 th century, when it started to be conceived as an object of medical knowledge and practice to the detriment of meanings and senses of childbirth for women (2) . From then on, their decisions were anchored in medical knowledge and technologies, leaving the idea of childbirth as a physiological event in the background and carried out by women (2)(3)(4) .
These interventionist practices have often made this setting a cause of suffering for women, in addition to increasing the risks of maternal morbidity and mortality in childbirth and birth by disregarding scientific indication (1)(2)(3)(4) . Morbidity and mortality rates show that quality of obstetric care does not converge with the institutionalization of childbirth (98% of births in hospitals) or with high prenatal coverage (5) . It is worth remembering that the maternal mortality ratio in 2015 was 60 deaths per 100 thousand live births in Brazil, which is well above the 35 deaths per 100 thousand live births recommended by the World Health Organization (WHO) (6)(7) .
To improve this setting, governmental actions were implemented at an international level based on indication of practices based on best scientific evidence. Among the actions, the WHO publication in 1996, which was reaffirmed in 2018, makes recommendations regarding using obstetric practices (8) . The publication even asserts that women's decision-making anchored in the physiology of parturition and the expansion of social actors in this setting is restored. This should cover nursing, since the insertion of nurse-midwives contributed to the qualification of this care, including the reduction of interventions (9) . Such actions contribute to the goal of reducing maternal mortality to 20 deaths per 100 thousand live births, established by the UN in the Sustainable Development Goals (10) .
In Brazil, since the beginning of the 20 th century, the Ministry of Health has proposed policies and legislation based on WHO guidelines, with a view to qualifying obstetric care. The propositions are based on evidence-based practice (11) . However, there are difficulties for the effective implementation of programs and adequacy of health services, which include administrative, social, economic and cultural issues, in addition to consolidated practices, often based on the convenience of health professionals and institutions (11)(12) .
Among the aspects to be overcome, there is a need to consider the demands of the social actors involved, and especially the role of women and their families (13)(14) . Such leadership in labor and childbirth spaces permeates recognizing the Brazilian sociocultural issue that may be expressed in the birth plan meanings, its constituent elements and in positive birth experiences (13) . Thus, understanding the intentionality of women's actions allows us to glimpse what aspects are present in their actions and how they can be incorporated during labor.
To achieve this goal, Alfred Schütz's social phenomenology theoretical framework is listed as a guiding thread for understanding the human actions inscribed in a social world or world of life, which are influenced by it (15) . This framework focuses on the premise of the existence of an intentional meaning in all actions. This intentionality is based on future projects and expectations (reasons for) and come from present and past experiences (reasons why). This motivation results in typical characteristics of a given social group (15) .

OBJECTIVE
To understand the intentionality of women's autonomous actions in labor.

Ethical aspects
This research was approved by the Research Ethics Committee of the study institution and met all the rules foreseen for research carried out on human beings, with the ethical precepts being formalized by signing the Informed Consent Form and maintaining participant anonymity (alpha identification numeric), in compliance with Resolution 466/12 of the Brazilian National Health Council (Conselho Nacional de Saúde).

Theoretical-methodological framework
Alfred Schutz's social phenomenology theoretical-methodological framework supported the study, since its main theoretical assumption is the understanding of motivations of actions of a social group (15) . The motivations of individuals in a particular group are based on present and past experiences (reasons why and/or reasons) and future projects (reasons for). The first is related to their experiences in the world of life or the experiences shared with their contemporaries, and is based on their knowledge that biographically situates individuals. The second evokes the possibility of analyzing actions' intentions, which are the perspectives of the future (reasons for).
The focus of this study was to seek the understanding of women's autonomous actions, anchored in intentionality to meet their expectations (what they had in mind) considering puerperal women as a social group.

Type of study
This is a qualitative study of a phenomenological nature. The COnsolidated criteria for REporting Qualitative research (COREQ) was used, as it offers consolidated criteria for writing qualitative research, promoting complete and transparent reports.

Methodological procedures, study setting and data sources
The study was conducted at a rooming-in of a university hospital, where a multidisciplinary team works to meet pregnant women's and high-risk women's demands (tertiary health care level) from the central region of Rio Grande do Sul State. For this reason, this hospital is considered a reference in the integration with the Unified Health System (SUS -Sistema Único de Saúde).
In this setting, the researcher made the approach and setting in order to know the rooming-in's routine, medical record organization, listing a room to carry out the interviews aiming at privacy and anonymity. Information was sought from puerperal women's medical record to identify those who met the inclusion criteria (women within a week after delivery, with assisted labor at the study's setting institution). Thus, the enrollment of study participants took place intentionally, at which time the exclusion criteria were considered (puerperal women with indication for cesarean section, severe maternal pathologies or fetal death). A list of possible participants who were hospitalized in the institution, setting of this study, and who met the inclusion criteria, with the potential to provide information relevant to the object of study, was composed.

Data collection and organization
The interview technique occurred with an individual approach between September and December 2017 through phenomenological interview (16) . Participants were invited to move to a reserved room in the rooming-in and. After clarifying about the research, their consent was requested to start the interview from an informal conversation. So it was necessary to talk with women about where and with whom their newborn would be so that they would feel more comfortable. Some were accompanied by their children and others left them with their companions in the rooming-in. It is noteworthy that four women refused to participate, as they said that remembering the moment of childbirth was not something of interest to the negative aspects that it would bring to remember the suffering experienced.
The environment aspects were favorable to develop the interview that was mediated by empathy, intersubjectivity and phenomenological attitude, in which the researcher needed to decentralize herself to focus on the understandings of the research participants in a one-to-one relationship, without any object between researcher and participant. This enabled each woman to express her motivations. For the interviews, a script was prepared with open-ended questions that focused on the research problem and contemplated the adopted theoretical framework. Due to the accumulated experience of research in phenomenology, we believe it is necessary that the questions be tested in the first interviews and applied only after adjustments. After this procedure, the interview started with the question: "Tell me about the birth and delivery process", "What did you do during this process?" and "Did you feel participatory?" Then, the guiding phenomenological question was: "What did you have in mind when you performed such an action?" The content conduct in this type of interview is carried out by the individuals interviewed, in which the researcher identifies actions in the reports and deepens the understanding of the meaning of those actions and their intentionality. For this reason, in the interviews (16) , keynotes were taken from those reported, seeking to reveal the motivations of women's autonomous actions childbirth and birth. By autonomous actions or autonomy, we mean the freedom to act for itself in a participatory way. With the authorization of the interviewees, the statements were audio recorded, which allowed the researcher to be freer to listen to them and allowed the expression of their expressions. The interviews took between 15 and 30 minutes.
The statements were transcribed in full and carefully read to begin analysis of these results, which occurred concurrently with data production. Data collection ended when there was convergence and sufficiency of meanings, in the 15 th interview, when the objective for understanding the studied object was reached (17) .

Data analysis
Analysis was developed from reading the interviews to identify the intentionality (reasons for) of actions of women in labor. "Reasons for" were grouped by similarity of meaning, and a synthesis was elaborated in concrete categories of experience (14) . Thus, the concrete categories of experience of reasons for were three (03): They expect to receive physical and emotional support from their companion; They want a peaceful delivery, with less pain, fast and without interventions; They intend to do the right things so that, after birth, they are pain-free and active to care for their children.
Data were analyzed and the results were interpreted according to the foundations of Alfred Schütz's sociological phenomenology. Then, the results were compared with national and international literature on the topic to clarify and understand the phenomenon of female autonomy in labor.

RESULTS
Participants were between 18 and 36 years old, and worked as housewives, baker's assistants, secretaries, psychologists, maids. More than half had already had children, and of these, all had a normal delivery.
As for category 1, to receive physical and emotional support, women choose someone they trust to accompany labor. This choice is made during pregnancy or only when they arrive at the hospital, as the institution requires them. In fact, one of the reasons is to strengthen family ties. Despite these motivations, women have ambiguous actions, sometimes they intend support and sometimes ask their companions to leave the delivery room.
With motivation to have a peaceful delivery, with less pain, fast and without interventions, which concerns category 2, women seek information about the parturition process with close people (mother, sisters, friends) and with health professionals. With this intentionality, they also develop oriented physical activities during pregnancy (Pilates) and/or after arriving at the hospital during labor (walking, squatting, hot bath, use of birthing stool, Swiss ball, and music).
As for category 3, the intentionality of doing the right things is aimed at the postpartum period, whether for the child's wellbeing or for them to be pain-free and active to care for them. Women try to achieve ideal behavior, which they understand must be convergent with the conduct and performance that professionals expect from them during labor. They even identify that excessive expression of their emotions (anxiety, nervousness and pain) goes against the ideal behavior.
It appears that women's actions during labor are based on the intention to feel support so that childbirth is a moment shared with their families and that they are supported to perform their autonomy, which is related to the information accessed until the moment of delivery. On the other hand, when entering the hospital, actions are shared with professionals who are there. To perform autonomy, they need to transpose what is seen as the ideal behavior expected from professionals.

Intentionality of women's actions in labor: a study in social phenomenology
Honnef F, Padoin SMM, Paula CC, Langendorf TF.
Chart 1 shows clippings of the illustrative statements and the code of other participants who also reported such intentionality, grouping by similarity of meanings composes concrete categories of experience.

DISCUSSION
The intentionality of women's actions during labor was related to their biographical situation. In social phenomenology, this situation is constructed throughout life, based on experiences in the world of life, which constitute their knowledge and their system of interest (15) . Thus, the women in this study had experiences related to the parturitive process in their biographical situation, both from their previous births and from what they heard about in their social relationships.
Their knowledge comprises the information that the women in this study sought during pregnancy to meet their desires and, with this, gave meaning and (re) signified aspects of childbirth and birth. Therefore, it is understood that women's actions during labor were based on a project that they created during their lives. For phenomenology, the project is foreseeing a future conduct (action) (15) . Women imagine a future action, even during pregnancy and, thus, establish projects for the delivery process to occur as imagined. These projects motivate their actions and make their role possible.
It is noteworthy that, between the project or foreseeing and human action, there is a link, a path that leads to this fulfillment (15) . It was in this way that women accessed their social relationships in the study on screen. These relationships took place with health professionals and their families, someone they trust, with a view to helping to achieve the idealized/projected, which was to receive support at delivery time.

They expect to receive physical and emotional support from their companion
With the intention of receiving physical and emotional support from their companion, this was chosen during pregnancy, being expected by pregnant women to have a person they trust on their side. To this end, in this choice, aspects such as affective bond and knowledge of people and their relationships were taken into consideration for the companion's choice action.
In this study, a partner was chosen by most of interviewees, for their presence during prenatal care and for having participated in previous births. Studies indicate that the presence of a partner in prenatal consultations has an impact on satisfaction with the support received during labor (18) and also on the security to perform support in actions planned by women (19) . However, there are other participants in this study who chose women from their social relationship, such as their mothers and sisters, as they already had knowledge about the process of childbirth and birth.
Companions' actions were significant for assistance, support to provide affection, attention and anxiety control, in addition to promoting the reduction of practices not guided by best evidence, such as food restriction and movement. During delivery, the presence provided conditions for non-lithotomic position, skin-to-skin contact and reduced Kristeller's maneuver (20) .
The place's characteristics where this study was carried out ensured for all of them the presence of a companion of their choice, in line with the indication supported by legislation since 2005 (21) . According to indications that deal with good practices in care for childbirth and birth, such as those of WHO and MoH (8,22) , such practice should be encouraged. However, it should be noted that this reality is not evident in other places. Cross-sectional research data showed that 89% of the studied population had their birth in the public sector and that the presence of a companion was guaranteed for 51.7% of women, reduced delivery time to 39% (20) . Another study that described the results of childbirth care after the implementation of Rede Cegonha and Nascer Saudável programs showed that the presence of a companion increased in public sectors, but in the private sector it is still small (12.5%) (23) . MoH and WHO indications are based on the benefits that companions, through their actions, will promote, among which, childbirth with less interventions and more peaceful, due to the emotional and physical support received (8,22) . However, these indications did not include the preparation of this actor, as evidenced in women's statements regarding the unpreparedness of their companions, pointing out that their preparation would be necessary for this actor to meet the expectations of women in the delivery setting. Parents showed great expectations and curiosity related to their role during labor and showed an increasing interest and commitment to participate and get involved in training sessions for preparation for childbirth (18) .

They expect to receive physical and emotional support from their companion
A study points out that knowledge about the right to the presence of a companion should permeate prenatal consultations, as the said study showed that women received information about the companion's right in inpatient units and less than 20% reported that this information was given during prenatal (24) .
Culturally, companions still receive little information to compose their knowledge and understand how to act during the delivery process to perform actions that promote the exercise of female autonomy and their role. Otherwise, when this actor is prepared, he or she can assist in the exercise of female autonomy, promoting self-confidence and questioning professional practices (25) .

They want a peaceful delivery, with less pain, fast and without interventions
For a smooth delivery, with less pain, fast and without interventions, women prepare themselves during pregnancy, from the search for information, to support their choices and familiarization with the delivery process. In this action, according to assumptions of social phenomenology, women have a project in mind and stop acting in their natural attitude to have a reflective attitude. They highlight in their knowledge learned experiences, which are accessed for planning actions with a view to attending to their project (26) .
In the study, this attitude was evidenced in the search for information through research in newspapers, the internet and in the relationship with social actors in women's daily lives such as professionals, friends and family. This exchange of information between social actors is mediated by a one-to-one relationship established in a direct experience between people permeated by intersubjectivity (15) .
The construction of women's desires about ways of giving birth begins when imagining the pregnancy comes to fruition. At that moment, all of their internalized knowledge about ways of giving birth becomes the background against which intentions are projected (27) . In this context, a sum of both empirical and scientific learning is built, which can contribute to women and their family to fully experience the pregnancy-puerperal period (28)(29) .
Thus, the support found in information about childbirth physiology in different relationships established is essential for women to believe in their ability to give birth, and also, when experienced during pregnancy, to promote and strengthen their autonomy (30) . In a randomized clinical trial, the intervention during pregnancy about the evolution of stages of labor, interventions and their indications helped to experience this moment with less fear (31) . Thus, it is essential that surrounding information in the world of life prepare women to perform their autonomy by making conscious choices so that they can develop the knowledge, attitudes, skills and necessary self-knowledge and effectively take the responsibility for all decisions made during childbirth (31) .
Choosing vaginal birth converged with the intention of a smooth delivery and without interventions. This understanding was evidenced in a qualitative study in which women associated normal birth with a natural process and with the benefits provided to women and babies (32) .
Another aspect that permeated the actions of the women in the study on screen was the intention of pain relief. A study carried out to understand women's experiences with the pain of labor showed that actions depend on the meaning attributed to pain by them. When they signify pain as productive and with a purpose, it is associated with positive cognitions and emotions, on the other hand, when conceiving pain as threatening, they tend to feel that they need help from external pain control methods (33) .
In this study, women performed pain relief actions to promote dilation, which converge with WHO and MoH recommendations. Liquid supply, the adoption of vertical positions and freedom of movement, seeking to increase maternal comfort and facilitate the progression of labor, and the use of non-pharmacological methods of pain relief, should be encouraged for labor management (8,12,22) .
The presence of qualified professionals to encourage good practices was observed to be beneficial for qualification of obstetric care. A cross-sectional observational study identified an increase in good practices in assisting the parturition process in institutions where nurse-midwives were present (30) .
They intend to do the right things so that, after birth, they are pain-free and active to care for their children With the perspective of doing the right things so that after birth they are pain-free and active to care for their children, through ideal behavior, their actions are aimed at not causing inconvenience to the hospital and professionals. In this sense, they refer that the excessive expression of their emotions, such as anxiety, pain and nervousness may not be beneficial, and that their actions must converge with what, in their conception, professionals consider ideal. This process was referred to in women's statements about how to do the right things.
In their natural attitude, women act according to their ideal behavior, which in their conception is expected of them by professionals. This conception is the result of institutionalization of childbirth, with which professionals took control of childbirth and birth and hierarchies are established in this process. For Alfred Schütz, hierarchies of superiority and subordination are naturally accepted in all contexts, being social inheritances that guide individuals. These aspects determine the conduct of 8 of Intentionality of women's actions in labor: a study in social phenomenology Honnef F, Padoin SMM, Paula CC, Langendorf TF.
individuals in the world of life and add traces of common sense to their actions (15) . In the context of obstetric care, such social inheritances are related to the institutionalization of childbirth, in which abusive and unnecessary interventionist practices are widely used, without privacy and respect for the will of women subjected to strict routines (12) . In this investigation, it was possible to infer that women tried to control their physiology during labor to follow the rhythm of labor recommended by professionals.
In this sense, time control and the dynamics imposition of labor explain the excessive rate of interventions, including cesarean sections, making obstetric care in Brazil focused on the decision of health professionals and not on the physiology of women's bodies (34)(35) . Despite efforts to modify this setting, which emphasizes the idea of women's passivity before interventions that shorten birth time, the cultural essence in which such behaviors are submerged, in fact, are practices of power over women's body, implicitly, they determine how it should act, position itself and even express itself during its delivery experience. These experiences are passed intergenerationally over time and are accepted naturally, making it difficult to change behavior (34,36) .

Study limitations
Setting's and participants' characteristics stand out among the limitations of this study. As for the first, we understand that data generation having been developed in a single setting may reflect the intentionality of women's actions in labor determined, including the context of the population and the characteristics of that service and the professionals who work there. As for the population of women up to one week after delivery, which indicates a period that favors the memory of recently experienced labor, we understand that they are under the influence of physiological changes and adaptation to care for themselves, newborns and family, which can influence data generation.

Contributions to nursing, health and public policies
Understanding the intentionality of women's actions in labor contributes to qualify obstetric care by presenting the motivations since the choice of a companion who will offer support, the type of delivery and the activities of their choice during labor. This evidence contributes to the role of nurses who develop care for women and their families from reproductive planning, pregnancy, parturition, and puerperium.
Understanding women's perspectives contributes to humanization of childbirth and birth by promoting that they are the main focus of care. Recognizing that women's intention is to do the right things, both for the child's well-being and for their recovery after childbirth, can contribute to their role, decentralizing convenience practices of professionals and health institutions. The results of this study provide evidence for teams to discuss obstetric settings that involve respect and support for their actions and expectations of having a peaceful delivery, with less pain and faster. These practices can even reduce unnecessary interventions and, perhaps, contribute to the reduction of maternal mortality, contributing to the response to the Sustainable Development Goals.

FINAL CONSIDERATIONS
The study's findings demonstrate that the intentionality of women's autonomous actions emerges from their knowledge that composes a projection of how they would like childbirth to occur. Therefore, it will be important for health professionals to provide subsidies for women to achieve a plan that is still idealized, culminating in the development of a birth plan, anchored in the reciprocity of user and professional interests.
Positive experiences make up women's knowledge and when they are added to the evidence and good practices for normal childbirth, they reflect on a reflexive attitude that will make it possible to rescue the protagonism and autonomy of women in labor and thus modify the context of obstetric care.