ASSISTANCE TO PLANNED HOME CHILDBIRTH: PROFESSIONAL TRAJECTORY AND SPECIFICITIES OF THE OBSTETRIC NURSE CARE

ASISTENCIA AL PARTO DOMICILIARIO PLANIFICADO: TRAYECTORIA PROFESIONAL Y ESPECIFICIDADES DE LA ATENCIÓN DE LA ENFERMERA ESPECIALIZADA EN OBSTETRICIA

ABSTRACT

Objective:

to analyze the professional trajectory of obstetric nurses, who work in planned home childbirth.

Method:

a descriptive and exploratory study with a qualitative approach, conducted with 12 obstetric nurses who work in planned home childbirth. The participants were recruited using the non-probabilistic Snowball Sampling technique. In this perspective, semi-structured interviews were used, applied during the months of August to November 2018, in private places in the city of Rio de Janeiro. The collected data were submitted to content analysis in the thematic modality.

Results:

the research pointed out the value of experience and professional training - important milestones - in the setting of planned home childbirth, and motivators for the work of the professionals, as they enable autonomy. It is also emphasized the need for the obstetric nurse to acquire different skills for home childbirth, not covered during the training process.

Conclusion:

the results consolidate that obstetric nurses, who work in planned home childbirth and have a professional trajectory focused on the constant theoretical improvement associated with an approximation with “experts” in the area, provide experience, safety and quality of obstetric care, as well as autonomous action, in this care-related setting.

DESCRIPTORS:
Women's health; Obstetrics; Obstetric nursing; Humanized childbirth; Humanization of assistance; Home childbirth

RESUMEN

Objetivo:

analizar la trayectoria profesional de las enfermeras especializadas en Obstetricia, que se desempeñan en el parto domiciliario planificado.

Método:

estudio descriptivo y exploratorio con enfoque cualitativo, realizado con 12 enfermeras especializadas en Obstetricia que se desempeñan en el parto domiciliario planificado. Las participantes fueron captadas por medio de la técnica no probabilística Snowball Sampling. Desde esta perspectiva, se emplearon entrevistas semiestructuradas, aplicadas durante los meses de agosto a noviembre de 2018, en lugares privados de la ciudad de Río de Janeiro. Los datos recolectados fueron sometidos a análisis de contenido bajo la modalidad temática.

Resultados:

la investigación señaló el valor de la experiencia y de la capacitación profesional, marcos importantes en el ámbito del parto domiciliario planificado, además de ser factores motivadores para el desempeño de las profesionales, por posibilitar su autonomía. También se destaca la necesidad de que las enfermeras especializadas en Obstetricia adquieran habilidades diferenciadas para el parto domiciliario, no contempladas durante el proceso de formación académica.

Conclusión:

los resultados consolidan que las enfermeras especializadas en Obstetricia, que se desempeñan en el parto domiciliario planificado y tienen una trayectoria profesional enfocada, en la mejora teórica constante asociada a un acercamiento a “expertos” en el área, proporcionan experiencia, seguridad y calidad de asistencia obstétrica, así como un desempeño autónoma, en este ámbito de atención.

DESCRIPTORES:
Salud de la mujer; Obstetricia; Enfermería obstétrica; Parto humanizado; Humanización de la asistencia; Parto domiciliario

RESUMO

Objetivo:

analisar a trajetória profissional das enfermeiras obstétricas, que atuam em parto domiciliar planejado.

Método:

estudo descritivo, exploratório, com abordagem qualitativa, realizado com 12 enfermeiras obstétricas que atuam no parto domiciliar planejado. O recrutamento das participantes ocorreu por meio da técnica não probabilística Snowball Sampling. Nessa perspectiva, foram utilizadas entrevistas semiestruturadas, aplicadas durante os meses de agosto a novembro de 2018, em locais privados na cidade do Rio de Janeiro. Os dados coletados foram submetidos à análise de conteúdo na modalidade temática.

Resultados:

a pesquisa apontou o valor da experiência e da capacitação profissional - marcos importantes - no cenário do parto domiciliar planejado, e motivadores para a atuação das profissionais, por possibilitarem a autonomia. Ressalta-se, também, a necessidade da enfermeira obstétrica em adquirir habilidades diferenciadas para o parto domiciliar, não contempladas durante o processo de formação.

Conclusão:

os resultados consolidam que as enfermeiras obstétricas, as quais atuam no parto domiciliar planejado têm uma trajetória profissional focada, no constante aprimoramento teórico associado a uma aproximação com “experts” na área, conferindo experiência, segurança e qualidade da assistência obstétrica, bem como uma atuação autônoma, neste cenário de cuidado.

DESCRITORES:
Saúde da mulher; Obstetrícia; Enfermagem obstétrica; Parto humanizado; Humanização da assistência; Parto domiciliar

INTRODUCTION

In Brazil there is a real ‘epidemic’ of cesarean sections that can be verified by the increase in the rates over the years, which went from 14.5% in 1970 to more than 50% in 2010. Such cesarean sections are mostly elective interventions, contrary to the 10% to 15% of all births recommended by the World Health Organization (WHO),1^-2 and can reach up to 90% when they occur in private institutions.

On the other hand, in relation to deliveries, 43.1% were assisted with interventions, as opposed to only 5%,1 showing that they are medicalized under the logic of a technocratic model, whose focus is intervention in the female body.

It is noteworthy that the inadequate use of technologies implies unfavorable indicators, both maternal and neonatal, and adds costs when performed without a real need, which cause potentially adverse effects. This care profile has resulted in negative experiences and frustration about normal hospital delivery.3 Thus, in 2018, the launched new guidelines for a safe delivery and a drastic reduction of unnecessary interventions, since recommendations were created in 2019 on how to face structural problems, among other causes: violence against women in the health services.4^-5

Given such context, and although timidly, the search for Planned Home Childbirth (PHC) in Brazil has become an alternative for women who do not want a delivery full of interventions, medicalized, with violence of different natures, in which they do not have decision-making power with regard to their own health because they do not agree with the institutional model offered, questioning the procedures and routines imposed, which associate the childbirth event with the concept of disease.

It is important to record that more and more pregnant women seek consistent information, through the Internet, in groups on social networks, where they share experiences and information. With this, it is possible to generate empowerment and better preparation for the experience of pregnancy, delivery and birth, within the principles of humanization and against the practice of obstetric violence. Cyberactivism then emerges as a method, strategy and action tool.6

Thus, women empowered by their pregnancy look for teams made up of multi-professionals, including obstetric nurses, to perform planned home childbirth. It is verified that the care is provided in a full manner, with resolution, continuity and accountability and, for this, the team must be ready and based on scientific knowledge, seeking the best evidence.7

In Brazil, the training of obstetric nurses is carried out, currently through an Undergraduate Nursing course, plus a Specialization course in the Lato sensu Post-Graduation modality or Residence in Obstetric Nursing. These courses aim at training compatible with current trends in the care for pregnancy, childbirth and the puerperium,8 based on the principles of humanization and understanding the social, cultural, emotional and biological determinants that involve reproductive health, pregnancy, childbirth and the puerperium.

In this context, the process of training and improving obstetric nurses in Brazil is broadened, with strategies such as Rede Cegonha implemented in 2011, the National Residence Program in Obstetric Nursing (ProgramaNacional de ResidênciaemEnfermagemObstétrica, PRONAENF) elaborated in 2013 and the Improvement and Development Project for Innovation in Care and Education in Obstetrics and Neonatology (Aprimoramento e Inovação no Cuidado e EnsinoemObstetrícia e Neonatologia, Apice-On), launched by the Ministry of Health in 2017, which aims to qualify the care for women in different settings and life phases.9^-10

Considering that families have increasingly opted for PHC, carried out by multi-professional teams, mostly integrated by obstetric nurses, it is clear that the training of these professionals, predominantly, is based on the hospital environment, and aims to analyze the professional trajectory of obstetric nurses who work in planned home childbirth.

METHOD

This is a descriptive and exploratory study with a qualitative approach, conducted with 12 (twelve) obstetric nurses working in planned home childbirth care in the city of Rio de Janeiro (RJ), Brazil. The recruitment referred to as Snowball Sampling was used by means of the non-probabilistic technique, which does not fix the number of subjects in the sample.

This method is used for a relatively small population, which is constantly in contact with one another, even as a productive way of constructing an exhaustive and representative sampling. Such sampling of the recruited interviewees will indicate - "seeds” - which result in new contacts from a personal relationship, facilitating the interviewer's access based on reliability.11

In addition, the interviewees are chosen by convenience, where the first participant of the sample is asked to subsequently indicate another person who meets the eligibility criteria to participate in the study and so on, successively, until the desired number of participants is reached.

In this case, the initial participant was recruited by indication of the researcher, upon knowledge of her performance in PHC. Subsequently, she indicated the second participant who, in turn, indicated the third and so on, successively, until completing 12 interviews, when theoretical saturation of the data was observed because no new elements emerged that would deepen the theorization for the study object.

After each indication, a telephone contact was made in order to make the invitation, in addition to explaining the research and the inclusion and exclusion criteria to participate in the study. Next, the date of the interview was set at each person's home for the collection of information, when the participant signed the Free and Informed Consent Form, the confidentiality and anonymity of the interview being assured by using an alphanumeric code: EO (standing for “Enfermagem Obstétrica” in Portuguese, Obstetric Nursing), followed by a numeral, according to the order of the interviews (EO1 to EO12).

It is interesting to note that the following inclusion criteria were established in the research: working in PHC and having at least one year of professional experience in this assistance modality. It is verified that obstetric nurses who were working outside the city of Rio de Janeiro were excluded.

This collection occurred through semi-structured interviews, which addressed social identification data and questions that traced the training and construction of the professional trajectory, as well as the following aspects: motivators, facilitators and specificities of this obstetric care setting. The interviews lasted a mean of 20 minutes and were conducted from August to November 2018. The data obtained were recorded in a digital device with prior authorization of the participants, fully transcribed and submitted to content analysis in the thematic modality,12 the Registration Unit (RU) based on the theme being used as a strategy for organizing its content. Colorimetry allowed for the identification and grouping of each unit, enabling an overview of the theme.

The interviews in focus originated the following RUs: ability and training; professional trajectory; professional value; quality of care; obstetric settings; trust and tranquility; welcoming and bonding; freedom and autonomy; physiology of childbirth; and humanization of obstetric care. These RUs based the construction of the following thematic categories: 1) The value of experience and professional training; 2) The setting for planned home childbirth as a motivator for the professional trajectory; 3) Obstetric Nursing Training: Are the professionals prepared for planned home childbirth?

The research involved minimal risks related to the exposure of the participants' data, which were mitigated through confidentiality and anonymity from data collection to the publication of the results. The benefits are related to the implications of this research that can lead to reflection on professional training and care settings, a subject relevant to specialization courses and residence in obstetric nursing. Thus, it aims to contribute to the scientific production by means of new research studies on the subject.

With regard to Resolution No. 466 of the National Health Council, of December 12^th, 2012, the research respected the principles of autonomy, beneficence, non-maleficence, justice and equality. The study was evaluated and approved by the Research Ethics Committee of the Fernandes Figueira Institute/Oswaldo Cruz Foundation.

RESULTS

The age group ranged from 26 to 53 years old. In their majority, 75% (n=9) obtained the title of obstetric nurses through the Lato Sensu Post-Graduate Program in the residence modality and 25% of the participants (n=3) graduated through the Lato Sensu Post-Graduate Program in the specialization modality. Still on academic qualification, 41.7% (n=5) had already completed a master's degree while 25% (n=3) had a doctorate in progress and 8.3% (n=1) had already completed it.

The training time of the nurses, when they started working in planned home childbirth care, varied from less than 1 year to 6 years; however, we must also consider the nurses who started working with less than 1 year from their training. In addition to participating in planned home childbirth groups as apprentices, during the training in obstetric nursing, after invitation from the teams, with the objective of gaining experience with home childbirth and understanding its specificities.

The value of experience and professional training

The professional trajectory of the obstetric nurses was pointed out by the participants, evidencing the need for experience with the aim of ensuring quality care for women and babies. As it is a professional experience outside the hospital environment, these nurses considered that having previous experience in that environment adds safety to home care. Below are the participants’ speeches:

[...] The practice helped a lot, you know? Even improving my perspective to know what humanization is has helped (EO4).

[...] I needed to have more of this delivery room practice to feel safe, to be able to work in home childbirth (EO9).

[...] I think this practical experience is important before you leave for a home childbirth (EO11).

Training was also mentioned as essential in the professional trajectories so that the obstetric nurses could feel that they were ready to enter the field of home childbirth assistance, with this theoretical-practical training being considered constant even after insertion:

[...] And when we take a course, we improve, we hear other experiences that end up renewing our self, being a nurse (EO3).

[...] Taking courses that will ensure that you will safely provide assistance to the mother and baby, either on [...] hemorrhages, major dystocia, about complications, resuscitation [...] Always being up to date so you can be confident to work safely at the woman's home (EO7).

[...] Always trying to keep up to date, studying even the scientific evidence, that is, through courses or through training, even looking for any protocols, articles, courses and that you can access to become more confident for assistance to this type of delivery, which differs from hospital delivery (EO9).

In view of the differences that the hospital and home settings display, the obstetric nurses mentioned some courses taken during their respective trajectories, considered important in their professional preparation. Below is what they said:

[...] hemorrhages, major dystocia, about complications, neonatal resuscitation [...](EO7).

[...] postpartum hemorrhage protocols, neonatal resuscitation [...](EO11).

Acting in home childbirth, as reported by the participants below, requires greater professional responsibility and constant communion with protocols and scientific evidence:

[...] The Obstetric Nurse who enters home childbirth studies hard because she puts herself to the test every time. The rigor of the other's gaze on me is very different and at the same time it is bad because it keeps away many people who cannot cope well with this pressure (EO2).

[...] Knowing that we are accompanying two people at their home and that the responsibility is on you. You don't have a hospital, it is just you. So, you must have a plan (EO6).

[...] Because I think you need to have a lot of responsibility, because you have a lot at stake in home childbirth. You need to have dexterity, you need to have prior knowledge, you need to know how to deal, know how to identify dystocia, know how to deal with risk situations (EO9).

The setting for planned home childbirth as a motivator for the professional trajectory

The profile of PHC assistance is totally different from hospital care, starting with the setting. The home is the place where the woman feels familiar and cozy, because she is with the people of her choice, which allows her to have greater tranquility and confidence during childbirth, including the fact that the parturient is safe, alongside a team with whom she created a bond throughout pregnancy. The following are statements on this respect:

[...] The hospital environment still causes strangeness, it causes that break in the triggering of oxytocin, tranquility (EO7).

[...] Because it is not just a delivery. When we are in a home childbirth, but we are conquering this bond since pregnancy, from the prenatal consultations until the moment she gives birth. So in that time you manage to have a bond like that, you know? Eternal (EO6).

[...] It is the ideal environment, for you to have an evolution of labor, for you to have a birth, if it is a usual risk pregnancy, if the woman feels comfortable (EO9).

Because they can exercise their profession with greater freedom and autonomy, home care performed by obstetric nurses differs from hospital care, because institutional protocols and routines make their professionals have their health actions restricted, due to compliance with those standards.

[...] There are some things that we do not do at home and that sometimes, in some hospital births, we do to become a hospital delivery space. For example, in the hospital delivery space, there is a ringing every few hours, per protocol (EO3).

[...] Here in the hospital there are more rigid protocols. So, like this, I need to carry on (EO4).

[...] At the hospital I have to keep on doing, but I have to follow a protocol. In home childbirth too, but it is a slightly more flexible protocol (EO6).

[...] The hospital actually forces you to intervene. Even if there is no one telling you to intervene, just because you are in the hospital, you end up having to intervene so you don't have to answer(judicially) (EO9).

Therefore, home care is less interventionist, and trusts and respects childbirth physiology, the each woman's times and her wishes. Monitoring starts in the prenatal period, when the woman will be able to learn more about the physiology of childbirth and, thus, start to understand the process.

[...] So, the consent is to fulfill the desires in fact, we actually have lesser invasion (EO1).

[...] I think that because I look at childbirth in a different, physiological way, respecting her times, the physiology of childbirth (EO5).

[...] That sometimes we think that “oh, you're not doing anything”, but our doing nothing is due to a lot of study, it is very scientifically based (EO9).

[...] The woman, she looks for you because she believes in physiology and that she can give birth and her baby knows how to be born and that she is capable of giving birth, so she wants someone who respects her physiology (EO11).

Here is another motivational factor to act in PHC; the interviewee's speech stands out, which points out this home care modality as another source of financial resources, and not only arising from the salary remuneration of employment bonds with hospital institutions.

[...] Firstly, for the question of autonomy, right? [...] The question of having another financial alternative is also a factor (E05).

Obstetric Nursing Training: Are the professionals prepared for planned home childbirth?

It is important to state that, when asked about the training in Obstetric Nursing, most of the interviewees answered that they did not feel ready to enter the home and monitor the delivery, after having completed only the Postgraduate course and, for that reason, there was a need for better training and more professional experiences.

[...] No, because home childbirth skips the curve of anything you learn in academic terms. I do not know today any specific training for home childbirth (EO2).

[...] I think the residence prepares her to work as an obstetric nurse, but in the space of the home she still needs [...] showing the experience of obstetric nurses who are doing the same thing because we end up getting too inserted in the hospital space and end up ignoring some other spaces (EO3).

[...] No. Not for home childbirth, but I, what I think too, so, it does not train you but the experience is valid for you to start work, because the most difficult for me was the office (EO8).

[...] Just the residence no. I think we need the experience after the residence (EO11).

According to the statements above, the obstetric nurses consider it essential to have not only theoretical training but, above all, professional experience in order to successfully perform home childbirth. In this sense, some strategies were considered that could lead them to achieve their professional goals, such as carrying out internships during and after graduation, and also seek to fit into teams as apprentices. Such insertion in the teams aims to carry out follow-ups throughout the pregnancy-puerperal cycle, in addition to working with other more experienced obstetric nurses, in order to acquire more or new knowledge, about the specificities of home care, in order to conduct it later. Below are the testimonials:

[...] Accompanying someone who has more experience, for a while, this is normal in any profession (EO2).

[...] When I really joined the team, I had two very strong bases, you know? A friend of mine invited me. She was experienced, she has experience in neonatology, and she has a great deal of experience in care. So, she passed a lot of things on to me. It was very important, you know? My first delivery was with her and so on (EO4).

[...] And then, as a resident, she asked me if I wanted to be an apprentice in the group and so on, if I wanted to work with her. And I accepted the proposal and I saw another world (EO5).

[...] Whenever you join a team there is always a midwife, a more experienced obstetric nurse. So you end up receiving a bit of training. So I am the person today who empowers many of them, many friends, many nurses who are graduating now (EO8).

It is noteworthy that, in order to meet this professional experience of childbirth, the obstetric nurses faced a different reality from the hospital experience and even the one arising from the training. Therefore, they needed to modify their care profile, adapting it to the new scientific evidence and to the WHO/MS recommendations:

[...] I have been trained within an episiotomist graduation. So when the big hands off movement started 8 years ago, it was difficult, I confess it was difficult (EO1).

[...] I think it is necessary to change the perspective, so that at every moment, in each phase we need to be improving (EO3).

[...] I think that so... a lot of knowledge, a lot of confidence, it's a lot of practice (EO6).

DISCUSSION

In fact, it is understood that, from the practical experience, the professionals can correlate the knowledge acquired in theory, improve their skills, and acquire dexterity and reflective capacity on the experiences. Experience allows the professionals to learn to deal with non-routine situations, with uncertainties, with the specificities and conflicts inherent to the work and, consequently, manage to improve their practice.13 Obstetric nurses also pointed to this reality, emphasizing that the previous hospital professional practice provides for their improvement, so that they can provide the necessary care to women in PHC.

In the analysis in focus, it was possible to identify that professional experience is attributed as a factor that adds safety to the obstetric practice. In addition, having experienced professionals in home care, which makes it possible to quickly identify the situations that require a specific intervention to be put into practice in a timely manner, for example, in situations of non-tranquilizing fetal auscultation, fetal dystocia, puerperal hemorrhage and neonatal resuscitation.

This corroborates with a study14 which evidences that the basis for the theory and practice in the professional training, with a great deal of experiences, provides knowledge and skills necessary for the safe exercise of the profession.

It is therefore inferred that professional training and constant improvement are essential for the professional to be well qualified, especially in the case of obstetric nurses, who, as they deal with the lives of the mother and baby, must be ready to work in the most varied situations. So, it is essential to maintain constant improvement based on scientific evidence, demonstrate commitment to work and to women, offering them the best assistance possible.

Therefore, being aware of the responsibility of their performance, obstetric nurses seek professional experience, training to be in communion with the needs of women in PHC and, also, the constant improvement to be qualified to act, when necessary.

In this aspect, professional satisfaction is added to the quality of care, due to the fact that obstetric nurses work with pleasure and enthusiasm. It is worth highlighting the valuable remuneration resulting from a PHC due to the characteristics of this type of individualized, humanized care and focused on female autonomy and protagonism, as a motivator for acting in this setting, as pointed out in an interview. In addition, the return from the satisfaction of the assisted women and families adds value to their work, which contributes to the recognition and aggrandizement of the professional category before the population.

The assistance of obstetric nurses, for being based on good practices, values the importance of sensitivity and welcoming, promoting humanized care and also listening attentively to the individual needs of each woman.15 Thus, conducting courses with the purpose of developing their technical skills and their own care is essential to promote quality of assistance in PHC, making these professionals recognized in the labor market by the expertise in their performance area.

It is good to remember that the experience of giving birth in a hospital represents, for some women, a traumatic event that generates feelings of pain and suffering, and the search for PHC is a choice that represents, in addition to questioning a current obstetric care model and against rules and routines imposed by the institutions, also a form of protection against obstetric and neonatal interventions.16^-17At their homes, women have greater freedom to fully exercise their autonomy, with their wishes respected by the team that assists them. It is in this environment that she has the necessary confidence to experience the experience of parturition, a unique moment that requires tranquility and privacy.

At this movement, women identify in the obstetric nurse that professional who promotes a new mode of childbirth assistance, based on the individual's autonomy and protagonism.18^-19

However, the importance that the prenatal monitoring be carried out by the team of obstetric nurses is highlighted since, at these moments, the woman and her companion will get to know the team better, creating bonds and trust.4

Some studies20^-21 evidence that PHCs have lower rates of intervention when compared to hospital births. In addition, there are higher rates of adoption of good practices, such as free movement, feeding, participation of more than one companion if the woman choses so, freedom of position in childbirth, and a high rate of normal childbirth after a cesarean section. Thus, an attentive look at the physiology of childbirth, the use of non-pharmacological techniques for pain relief, and care based on scientific evidence for childbirth, are initiatives that favor the qualified and safe process of assistance to PHCs.

Thus, it is emphasized that the vigilant posture in obstetric care aims to early detect possible complications, with the triggering, if necessary, of a multi-professional team for resolution in a hospital environment, aiming at the safety of women in the process of parturition and of newborns.

Therefore, this birth setting gives women the peace of mind of being intimate with their environment and being close to the family members they dreamed of having around at this moment. Monitoring by the obstetric nurse ensures their autonomy, listening, sharing decisions, and respecting the physiology of their body.17 In addition to being the women's wish, planned home childbirths also came to be dreamed of by obstetric nurses for allowing attention directed to women and newborns, facilitating the act of midwifery,22 associated with discontent with hospital care and lack of professional recognition. From this perspective, it is perceived that PHC enables both the satisfaction of the woman and the professional who accompanies her.

According to the aforementioned, obstetric nursing training alone does not qualify the nursing professional for PHC, but technical training is necessary to start the path for home childbirth. In addition, the role of obstetric nurses at the women's homes requires sensitivity and a different perspective that cannot be taught in courses, merely developed with practical home experience.

In fact, the obstetric nurse has technical, scientific and legal competence to assist home childbirth.23But also, the constitutive sensitivity of this professional is directly related to a holistic view being originated by tacit knowledge learned and legitimized in the life experiences. As for the training of these professionals, it must be continuous and permanent, involving the movement of practice-theory-practice, represented by the health institutions, learning spaces.7 In this study, other important learning settings must be considered, such as sharing experiences in the home setting as apprentices of renowned and more experienced obstetric nurses. However, they need to be more alert to the commitment and personal financial investment, in search for knowledge and for the daily practice to meet the safety demands necessary for quality home care.

It is a consensus that less interventionist care anchored in evidence-based practices is inherent to the training of obstetric nurses, allied to raising awareness for the rescue of the role of women in parturition.24 However, to enter the home space, already widespread in Brazil as a work tool for obstetric nursing, it is necessary to expand the curriculum in professional training, especially in Postgraduate courses, considering the experiences of obstetric nurses who work in PHC and the international protocols for the care of home childbirths, which are then better explored.

Corroborating the data from the study carried out,25 the obstetric nurses reported practices considered as not recommended for the physiology of childbirth. This reflects that, at that time, the basis of professional training was centered on the technocratic biomedical model with maneuvers and interventions as routine practices. However, the situation began to change with the humanization of childbirth movement in the late 1980s, the implementation of the WHO/MS recommendations, and the widespread of good obstetric practices and care based on scientific evidences. Care has repercussions on professional training and, consequently, on the practice of obstetric nurses, making episiotomy and repeated vaginal touches, among others, obsolete practices.

Another significant aspect in this study were the reports of obstetric nurses that reflect the need for changes, to which they submitted themselves throughout their professional trajectories, so that they were adapted to the specific needs in the care of planned home childbirth. Such needs generated the search for knowledge in training, master's and doctoral courses. These trainings were based on scientific evidence, protocols and national and international recommendations; as well as an approach with "expert" professionals in the assistance to PHC, aligning their praxis with respect to the culture of the woman, the family and the physiological process of pregnancy, childbirth and the puerperium.

Nevertheless, we understand that the study presented as a limitation the difficulty of reaching a greater number of professionals working in home childbirth in the city of Rio de Janeiro, as well as the observation of its practice in locus and so, it aims to favor the expansion of discussions on the theme. Thus, there is a need for further research studies that encourage reflection on the obstetric care promoted in the home field by obstetric nurses and the training of these professionals, in favor of acting with quality and safety permeated by autonomy and professional appreciation.

CONCLUSION

The study revealed that the obstetric nurses who work in home childbirth have a professional trajectory focused on constant theoretical and practical improvement, which permeates training courses, master's and doctorate degrees, and showing that an experienced trajectory is relevant, capable of providing greater safety during home childbirth. It is known that the relationship between professional training and practical experience is close, so as to provide quality obstetric care.

Another important aspect raised in the research is that the home environment favors obstetric care with a focus on the physiology of childbirth, and on the freedom for women to express themselves and live this experience in a respectful and safe manner. From a professional perspective, these characteristics of the setting provide job satisfaction and, thus, allow for motivation for future updates and training.

In summary, through this study it was possible to understand that the current training in Obstetric Nursing alone does not guarantee the professional the necessary practice and safety for home childbirth assistance, which was corroborated by the interviewees when reasserting that experience and training are points to be valued by everyone who wishes to work in home childbirth. Therefore, it is considered important that Postgraduate courses in Obstetric Nursing from this perspective follow this growing field of action, with regard to the relationship between professional, experience and training, adapting these significant practices, so that they can prepare better future professionals focused on home childbirth, considering the responsibility they should have in this field of action, given the characteristics of this context.

REFERENCES

• 1. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Nascer no Brasil-Inquérito Nacional sobre parto e nascimento. In: Sumário Executivo Temático da Pesquisa [Online]. 2014 [cited 2019 Jul 22]. Available from: http://www.ensp.fiocruz.br/portal-ensp/informe/site/arquivos/anexos/nascerweb.pdf
  » http://www.ensp.fiocruz.br/portal-ensp/informe/site/arquivos/anexos/nascerweb.pdf
• 2. Riscado LC, Jannotti CB, Barbosa RHS. Deciding the route of delivery in Brazil: themes and trends in public health production. Texto Contexto Enferm [Internet]. 2016 [cited 2019 Jul 22];25(1):e3570014. Available from: https://doi.org/10.1590/0104-0707201600003570014
  » https://doi.org/10.1590/0104-0707201600003570014
• 3. Souza SRRK, Oliveira MCJD, Aldrighi JD, Peripolli LO, Wall ML. A enfermeira obstétrica no cuidado ao parto domiciliar planejado: uma revisão integrativa. REFACS [Internet]. 2019 [cited 2020 Feb 26];7(3):357-65. Available from: https://www.redalyc.org/jatsRepo/4979/497960141010/html/index.html
  » https://www.redalyc.org/jatsRepo/4979/497960141010/html/index.html
• 4. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience [Internet]. 2018 [cited 2020 Mar 09]. Available from: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=314128e4bac1c525913c76a59913d88b?sequence=1
  » https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=314128e4bac1c525913c76a59913d88b?sequence=1
• 5. World Health Organization. Asamblea General. Enfoque basadoenlosderechos humanos del maltrato y laviolencia contra lamujerenlosservicios de saludreproductiva, con especial hincapiéenlaatencióndel parto y laviolencia obstétrica. [Internet]. 2019 [cited 2020 Mar 09]. Available from: https://saludmentalperinatal.es/wp-content/uploads/2019/09/a_74_137-es.pdf
  » https://saludmentalperinatal.es/wp-content/uploads/2019/09/a_74_137-es.pdf
• 6. Sena LM, Tesser CD. Violência obstétrica no Brasil e o ciberativismo de mulheres mães: relato de suas experiências. Interface ComunSaúde Educ [Internet]. 2017 [cited 2019 Jul 22];21(60):209-20. Available from: https://doi.org/10.1590/1807-57622015.0896
  » https://doi.org/10.1590/1807-57622015.0896
• 7. Pompeu KC, Scarton J, Cremonese L, Flores RG, Landerdahl MC, Ressel LB. Practice of episiotomy during childbirth: challenges for nursing. Rev Enferm Cent O Min [Internet]. 2017 [cited 2019 Jul 22];7:e2892. Available from: https://doi.org/10.19175/recom.v7i0.1142
  » https://doi.org/10.19175/recom.v7i0.1142
• 8. Giantaglia FN, Garcia ESGF, Rocha LCT, Godinho MLSC, Leite EPRC, Calheiro CAP. The care of nurses of an obstetric residence program under the scope of humanization. Rev Enferm UFPE [Internet]. 2017 [cited 2020 Feb 26];11(5):1882-90. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/23337
  » https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/23337
• 9. Lima GPV, Pereira ALF, Guida NFB, Progianti JM, Araújo CLF, Moura MAV. Expectations, motivations and perceptions of nurses on the nurse-midwifery specialization course in the residence modality. Esc Anna Nery [Internet]. 2015 [cited 2019 Jul 22];19(4):593-9. Available from: https://doi.org/10.5935/1414-8145.20150079
  » https://doi.org/10.5935/1414-8145.20150079
• 10. Wall ML. Contributions of nursing care to women. Rev Bras Enferm [Internet]. 2018 [cited 2019 Jul 22];71(Suppl 3):1274-5. Available from: https://doi.org/10.1590/0034-7167-201871sup301
  » https://doi.org/10.1590/0034-7167-201871sup301
• 11. Vinuto J. A amostragem em bola de neve na pesquisa qualitativa: um debate em aberto. Temáticas [Internet]. 2014 [cited 2020 Feb 20];22(44):203-20. Available from: https://pdfs.semanticscholar.org/cd8e/3ecb215bf9ea6468624149a343f8a1fa8456.pdf?_ga=2.48567078.1074782786.1582835590-1930580843.1582835590
  » https://pdfs.semanticscholar.org/cd8e/3ecb215bf9ea6468624149a343f8a1fa8456.pdf?_ga=2.48567078.1074782786.1582835590-1930580843.1582835590
• 12. Cavalcante RB, Calixto P, Pinheiro MMK. Análise de conteúdo: considerações gerais, relações com a pergunta da pesquisa, possibilidades e limitações do método. Inf & Soc [Internet]. 2014 [cited 2020 Feb 24];24(1):13-8. Available from: https://www.researchgate.net/profile/Ricaro_Cavalcante/publication/286677588
  » https://www.researchgate.net/profile/Ricaro_Cavalcante/publication/286677588
• 13. Netto L, Silva KL. Reflective practice and the development of competencies for health promotion in nurses’ training. Rev Esc Enferm USP [Internet]. 2018 [cited 2019 Jul 22];52:e03383. Available from: https://doi.org/10.1590/s1980-220x201703430338 3
  » https://doi.org/10.1590/s1980-220x201703430338
• 14. Pereira ALF, Guimarães JCN, Nicácio MC, Batista BDS, Mouta RJO, Prata JA. Perceptions of nurse-midwives of their residency training and professional practice. Rev Min Enferm [Internet]. 2018 [cited 2020 Feb 26];26:e-1107. Available from: http://reme.org.br/artigo/detalhes/1243
  » http://reme.org.br/artigo/detalhes/1243
• 15. Pereira SB, Diaz CMG, Backes MTS, Ferreira CLL, Backer DS. Good practices of labor and birth care from the perspective of health professionals. Rev Bras Enferm [Internet]. 2018 [cited 2019 Jul 22];71(3):1393-9.Available from: https://doi.org/10.1590/0034-7167-2016-0661
  » https://doi.org/10.1590/0034-7167-2016-0661
• 16. Castro CM. Os sentidos do parto domiciliar planejado para mulheres do município de São Paulo. Cad Saúde Colet [Internet]. 2015 [cited 2019 Jul 22];23(1):69-75. Available from: https://doi.org/10.1590/1414-462X201500010012
  » https://doi.org/10.1590/1414-462X201500010012
• 17. Sanfelice CFO, Shimo AKK. Home birth: understanding the reasons for this choice. Texto Contexto Enferm [Internet]. 2015 [cited 2020 Feb 27];24(3): 875-82. Available from: http://www.scielo.br/pdf/tce/v24n3/pt_0104-0707-tce-24-03-00875.pdf
  » http://www.scielo.br/pdf/tce/v24n3/pt_0104-0707-tce-24-03-00875.pdf
• 18. Prates LA, Timm MS, Wilhelm LA, Cremonese L, Oliveira G, Schimith MD, et al. Being born at home is natural: care rituals for home birth. Rev Bras Enferm [Internet]. 2018 [cited 2020 Feb 27]; 71(Suppl 3):1247-56. Available from: https://doi.org/10.1590/0034-7167-2017-0541
  » https://doi.org/10.1590/0034-7167-2017-0541
• 19. Duarte MR, Alves VH, Rodrigues DP, Souza KV, Pereira AV, Pimentel MM. Care technologies in obstetric nursing: contribution for the delivery and birth. Cogitare Enferm [Internet]. 2019 [cited 2019 Jul 22];24:e54164. Available from: https://doi.org/10.5380/ce.v24i0.54164
  » https://doi.org/10.5380/ce.v24i0.54164
• 20. Koettker JG, Bruggemann OM, Freitas PF, Riesco MLG. Obstetric practices in planned home births assisted in Brazil. Rev Esc Enferm USP [Internet]. 2018 [cited 2019 Jul 22];52:e03371. Available from: https://doi.org/10.1590/s1980-220x2017034003371
  » https://doi.org/10.1590/s1980-220x2017034003371
• 21. Koettker JG, Bruggemann OM, Freita PF, Riesco MLG, Costa R. Obstetric practices in planned home births assisted in Brazil. Rev Esc Enferm USP [Internet]. 2018 [cited 2020 Feb 26];52: e03371. Available from: http://www.scielo.br/pdf/reeusp/v52/pt_1980-220X-reeusp-52-e03371.pdf
  » http://www.scielo.br/pdf/reeusp/v52/pt_1980-220X-reeusp-52-e03371.pdf
• 22. Mattos DV, Vandenberghe L, Martins CA. Motivation of midwives for household childbirth plans. Rev Enferm UFPE [Internet]. 2014 [cited 2020 Feb 27];8(4):951-9. Available from: https://files.cercomp.ufg.br/weby/up/151/o/5580-54545-1-pb_artigo_cleusa.pdf
  » https://files.cercomp.ufg.br/weby/up/151/o/5580-54545-1-pb_artigo_cleusa.pdf
• 23. Conselho Federal de Enfermagem (Brasil). Nota oficial nº 001/2012/ASCOM [Internet]. 2012 [cited 2020 Feb 27]. Available from: http://www.cofen.gov.br/wp-content/uploads/2012/03/nota%20oficial.pdf
  » http://www.cofen.gov.br/wp-content/uploads/2012/03/nota%20oficial.pdf
• 24. Reis TR, Zamberlam C, Quadros JS, Grasel JT, Moro ASS. Obstetric Nurses: contributions to the objectives of the Millennium Development Goals. Rev Gaucha Enferm [Internet]. 2015 [cited 2020 Feb 26];36(Spe):94-101. Available from: http://www.scielo.br/pdf/rgenf/v36nspe/0102-6933-rgenf-36-spe-0094.pdf
  » http://www.scielo.br/pdf/rgenf/v36nspe/0102-6933-rgenf-36-spe-0094.pdf
• 25. Reis CSC, Souza DOM, Progianti JM, Vargens OMC. As práticas utilizadas nos partos hospitalares assistidos por enfermeiras obstétricas. EnfermObstétrica [Internet]. 2014 [cited 2020 Feb 27];1(1):7-11. Available from: http://www.enfo.com.br/ojs/index.php/EnfObst/article/view/3
  » http://www.enfo.com.br/ojs/index.php/EnfObst/article/view/3

NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the Monography -The professional trajectory of obstetric nurses who work in the assistance for planned home childbirth, presented to the Residence Program in Obstetric Nursing, of the da Instituto Fernandes Figueirada Fundação Oswaldo Cruz, in 2019.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Research Ethics Committee of the da Instituto Fernandes Figueirada Fundação Oswaldo Cruz, opinion No. 2,777,500, Certificate of Submission for Ethical Appraisal. CAAE: 92184618.0.0000.5269.

Publication Dates

• Publication in this collection
  11 Jan 2021
• Date of issue
  2020

History

• Received
  12 Aug 2019
• Accepted
  18 Mar 2020