Cesarean childbirth: an institutional socio-clinical study of the professional practices and discourses

Objective: to analyze how the social, historical, economic and professional elements influence the institutionalization process of cesarean childbirth in Brazil and France. Method: a qualitative study grounded on the theoretical framework of the institutional socioclinic. The data were produced through focus groups and individual interviews, supported by semi-structured scripts, with health professionals, mothers and fathers and a research diary. The study had 83 participants. The analysis was based on the theoretical framework and thematic analysis. Cross analysis was developed between the different types of data, services and groups, as well as between countries. Results: the participants were characterized in terms of schooling, employment, level of training and workplace. The countries researched have their own peculiar health and educational structure and are marked by a social-historical-economic construction outlined by patriarchy. The New Public Management influences both contexts and makes health care precarious. The technical and organizational dimensions reinforce an intellectual and social division of work and knowledge in health. Conclusion: the institutionalization process of childbirth in the countries is marked by social, economic and professional aspects. Practices and speeches of the professionals in their work process influence the occurrence, or not, of cesarean sections.


Introduction
For a long time, delivery was an intimate experience, which took place at home, vaginally and accompanied by midwives or people with traditional knowledge. In the period before the eighteenth century, childbirth was not thought of in any other way than the established one (1) .
Different dimensions, such as social, historical, cultural, political and economic, associated with the advancement of the technologies, demarcate strong influences in the context of maternal and child care, while hospital-centered interventionist practices began to expand. In this process, medical knowledge takes control of deliveries and this is reflected in the increased occurrence of cesarean interventions (1)(2)(3) . It is recognized that, when adopted under ideal and necessary conditions from a biological point of view, the cesarean intervention reflects positively on the maternal and neonatal morbidity and mortality rates (1) .
This transformation that has taken place is a dialectical process in which social structures are under the action of forces that provoke constant changes, the instituting forces. The action of instituted and instituting forces causes social dynamics and promotes constant changes, called institutionalization (4) .
Currently, in the world context, the debate about childbirth is marked by the effort to reduce the number of cesarean interventions and, at the same time, by the defense of the provision of qualified care to women (5)(6)(7) .
In Brazil, in the last 40 years, there has been a marked increase in the number of surgical deliveries associated with high rates of preterm childbirth and prematurity with iatrogenicity (3,8) .
In this production, supported by the institutional socio-clinical framework (9) , a result of the French Institutional Analysis (IA) (10) , maternal and child health is understood as an institution that operates based on the precepts validated in policies and legislation. It even integrates the professional protocol practices, also instituted. IA clarifies how the institution's transformation process, institutionalization, is cross permeated by active contradictions, which bring about contributions from the participation of subjects (4,(10)(11) . The notion of object group and subject group (10) contributes to the analytical process of the institutional interventions outlined in the framework. The object group is the one that does not question much, identifies itself with the aspects instituted in the institution and is a resource that contributes to its existence. Inversely, the subject group acts in the search for strategies that deviate from the instituted (10) .
Brazil is among the countries in the world that performs a high number of unnecessary cesarean interventions (1,3,5,7,8) . France has low rates of cesarean operations; however, social and professional groups are concerned about the increase in interventions around the world, the so-called "active cesarean sections" and the growing trend of the so-called "cesarean sections on demand by women" (12)(13) . The reflection about performing unnecessary cesarean sections includes the influence of the technocratic models in the construction of the idea of safety and protection in the social imaginary related to delivery (1,5,7,12) .
Given above, the study aims at analyzing how social, historical, economic and professional elements influence the institutionalization process of cesarean childbirth in Brazil and France. There is no intention to carry out a comparative study between the countries since, eventually, each of them has its peculiarities in its constitution, history and context. The intersection of the different realities studied can produce analyses explaining barely visible aspects and recognizing specificities and differences.
This study is the result of a multicenter research study, which deepens issues related to childbirth and parenting in Brazil, Canada and France (14) .

Method Study design
This text follows the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ), which seeks to ensure the quality of the description of the research stages. It is a qualitative study, guided by the theoretical-methodological framework of IA, in line with the French Institutional socioclinic (4,(9)(10)(11) . Among the characteristics of institutional socioclinic, there are the following: Working on the ordering and demands; participation of subjects in the approach in variable ways; working on the elements that reveals hidden issues of the institution; analysis of the changes produced as the work progresses; implementation of restitution modalities that return provisional results of the work to the research participants; working on the primary and secondary implications with the people involved in the process; prediction of knowledge production; and attention to the institutional contexts and interferences linked to the researchers and participants (15)(16)(17) .
Data production was initiated with the research diary written by the first author throughout the research.
As already mentioned, the study is articulated with a multicenter study (14) that organized focus groups to deepen the dialog on childbirth and parenthood. Based on the arguments of these groups, for this study, the information that dealt with the experience with childbirth was selected. Finally, another data production strategy To assemble the focus groups, the following criteria were adopted: two groups constituted by parents coming from different social, economic and educational contexts classified as: "Social 1" and "Social 2". In Brazil, they were represented by a public daycare center (Social 1) and a language school (Social 2). In France, the "Social 1" group consisted of mothers and fathers who used a service that served families, called "Maison des familles" and the "Social 2" group was constituted by an association of parents.
Organization of the group of professionals was based on the following criteria: two groups of public servants with different profiles, classified as "hospital" and "other institution". The "hospital" group, coming from the Brazilian context, was a hospital care service for women, and the focus group called "another institution" consisted of a reference hospital for maternal health. In France, the groups were made up of professionals from a maternity ward and a mother and child protection service, referred to as "Protection Maternelle Infantile" (PMI). Three meetings were held with each group. for this reason, women or couples were asked to indicate another mother or couple from their social group and who underwent the experience of giving birth, regardless the delivery outcome. The individual interviews with the professionals were initiated by the members of the focus groups and CMMI professionals. It is important to clarify that the first author participated in the CMMI case discussion meetings and, when appropriate, invited the members to take part in the research. As the members of that committee worked in the municipality's mother and child care network, they were part of the professional categories.
A semi-structured script was developed to support conduction of the groups and for the interviews.

Data treatment and analysis
The analysis was supported in the approach of Paillé and Mucchielli's thematic analysis (18) , which has the argumentation stage of the theme concretized in a qualitative, interpretive and hypothetical exercise.
Based on the data transcriptions, a hybrid approach to the analysis was adopted, in which continuous thematization and sequential thematization were included. Continued thematization consists in assigning, regrouping and adjusting the themes progressively until the end of the apprehensions. In turn, sequential thematization offers support for carrying out analyses with approximations and distances between groups. In summary, the moments that supported the analytical process were as follows: 1-transcription * (listening to and transcribing the groups); * Not all the individual interviews conducted in France were transcribed. For those not transcribed, synthesized texts were used.
2-transposition (constituting the units of meaning and the approximations between them and the theoretical frameworks); 3-reconstitution (rebuilding a text with the final analyses). Figure 1 illustrates the organization process of the analytical stage of this research.
The research diary notes were intertwined with the syntheses from the groups and the individual interviews.
Horizontal summaries were written from the records resulting from each data production category. Convergences, divergences and complementarities were demarcated.  The moments of participatory restitution can enable the study participants to continue and mutually analyze, in addition to prompting them to reflect on their own practices, conceptions and experiences (11,15,19) .

Ethical aspects
Data production in Brazil was initiated after authorization from the co-participating institutions and approval by the Research Ethics Committee (opinion No.

2.623.731).
Identification of the participants in the focus group

Results
It is verified that the socioeconomic profile of the members of the focus groups of mothers and fathers assembled in the countries is quite heterogeneous.
In relation to the focus groups conducted, in France, the mothers' and fathers' age varied between 35 and

Discussion
In view of what is pointed out in the results, it is possible to highlight that childbirth by cesarean section is an analyzer of the professional practices and discourses.
The contradictions of an institution are revealed by the analyzers, which can be an object, an event, an individual or a piece of information, among others. They find a way to give visibility to the camouflaged aspects of social life and often reveal themselves in more ambiguous and less vivid ways (19) . In this production, it is verified that childbirth is influenced by different places and contexts. It Women can decide to run the possible risks, resist and create strategies to claim their desires. In relation to these desires, it is necessary to clarify that the starting point is the understanding that they are also built based on the professionals' practices and discourses, specific experiences and culture, among others. Regarding the debate on autonomy and delivery, the study points out that French women seem to be closer to the appropriation of their bodies and desires.