NURSE TRAINING IN JAPAN : CONTRIBUTION TO THE FOUNDATION OF THE CASA DE PARTO BIRTHING CENTER IN RIO DE JANEIRO

This study was performed using a historical-social approach and aimed at discussing how the Brazilian nurse midwives trained in the Japanese birthing centers helped implement Casa de Parto in Rio de Janeiro-RJ in 2003. The primary sources of information were written and oral documentation found in collections and semi-structured interviews. The analysis happened in three steps: organization, classification and data triangulation. In order to support the analysis, concepts of habitus, field, symbolic capital and power were adopted. Results showed that the training of nurses at the Japanese birthing centers by taking a course on birth assistance was a government strategy to reconfigure the obstetrics field, which updated the habitus of these nurse midwives. Both Rio de Janeiro nurses appointed by the City to take the training course acquired better positions, which contributed to the foundation of the Casa de Parto birthing center in Rio de Janeiro. DESCRIPTORS: History of nursing. Humanizing delivery. Women’s health. Obstetrical nursing. Education, nursing. CAPACITACIÓN DE ENFERMERAS EN JAPÓN: CONTRIBUCIÓN PARA LA IMPLANTACIÓN DE LA CASA DE PARTO EN RIO DE JANEIRO RESUMEN: Estudio cualitativo histórico-social que discute las contribuciones de la capacitación de las enfermeras obstetras brasileñas en los centros de parto normales japoneses para la implantación de la Casa de Parto en Rio de Janeiro-RJ, en 2003. Las fuentes son documentos escritos y orales obtenidos en acervos y a través de entrevista semi-estructurada. Las etapas del análisis: ordenación, clasificación y triangulación de los datos. Para basar el análisis se utilizaron los conceptos de campo, habitus, poder simbólico y capital. Los resultados revelaron que la capacitación de las enfermeras obstétricas en el Curso de Asistencia al Parto en las Casas de Parto de Japón fue una estrategia del Gobierno Federal para reconfigurar el campo obstétrico que actualizó en habitus de estas enfermeras. Las dos enfermeras propuestas por la Secretaría Municipal de Sanidad-RJ al regreso del curso de formación ocuparon cargos institucionales que viabilizaron el funcionamiento de la Casa de Parto. DESCRIPTORES: Historia de la enfermería. Parto humanizado. Salud de la mujer. Enfermería obstétrica. Educación en enfermería. 193


INTRODUCTION
Federal decree No. 985 of August 1999, which regulated the operation of Natural Birthing centers and Birthing centers under the Unified Health System (SUS, as per its acronym in Portuguese) 1 , was influenced by the document resulting from a workshop for the preparation of the Regulation Proposal of Casa de Parto de Sapopemba birthing center, held in March 1999.This event was sponsored by the State of São Paulo Secretariat, the Qualis Project of the Family Health Program and the head of the Casa de Parto birthing center in Sapopemba 2 .
This governmental initiative was a result of the ideological and cultural context of the change in the hegemonic model of obstetric care, which included the active participation of civil society representatives, particularly the women's movement, and the adherence of public health management to the idea of humanization.
In the early 2000's, public health management actions aimed at improving the efficiency and effectiveness of health care activities.At this juncture, the managers of the Municipal Health Department of Rio de Janeiro (SMS-RJ) increased their level of assistance and made architectural changes towards humanizing delivery in municipal maternity wards.Subsequently, they drafted the proposal for the establishment of a birthing center in the public health network of the city of Rio de Janeiro. 3 In 2002, the Ministry of Health requested cooperation from the Japanese government for the training of nurse midwives in humanized childbirth.Therefore, Japan sent experts to assess the obstetric situation in Brazil, which revealed a deficit of specialists in the country.They proposed holding a course for the assistance of humanized childbirth at birthing centers in Japan.The general objectives of this course were focused on reducing infant and maternal mortality, with the implementation of appropriate practices according to the principles of humanization of childbirth in the SUS. 4 It should be explained that from 1996 to 2001, the Government of Japan, through the Japanese Agency for International Cooperation (JICA), had already participated in collaborative actions with the Ministry of Health to implement the Project for the Improvement of Maternal and Child Health in Northeast Brazil. 3This agency qualified obstetric professionals with the objec-tive of reducing the Caesarian section rates.It also promoted the exchange of experience between Japanese midwives and nurse midwives in developing countries. 6n 2003, Brazilian nurse midwives were nominated by the Brazilian health departments to participate in this training in Japan.Among them were two nurse midwives from SMS-RJ public maternity hospitals.This training took place prior to the inauguration of the Birthing Center of Rio de Janeiro (Casa do Parto).
Concomitantly with this bilateral cooperation, the same department created the Group for the Implementation of the Birthing Center in the municipal health network through Resolution No. 921/2002.This group consisted of eleven nurses from this network and one representative from the academic area, Professor Maysa Luduvice Gomes. 7s a result of these events the present study was elaborated, aimed at discussing the contributions of the Brazilian nurse midwives trained at the Japanese Natural Birthing Centers towards the creation of the Birthing Center in Rio de Janeiro.
The relevance of this study is to highlight the participation of nurses in the construction of Brazilian obstetrics and in the institution of humanized practices, which have contributed to the reconfiguration of the medical obstetric model.

METHODOLOGY AND THEORETICAL CONCEPTS
This is a socio-historical study utilizing a qualitative approach that is linked to the project entitled "Participation of the nurse in the reconfiguration of the obstetrics field: the fight for the implementation of humanized birth care practices", of the Faculty of Nursing at the Rio de Janeiro State University, RJ.
The primary sources of this study consisted of written and oral documents.It should be noted that all testimonies collected and used in this research were donated by the witnesses to the collections of the Nalva Pereira Caldas Memory Center of the Faculty of Nursing at the Rio de Janeiro State University, in order to preserve the knowledge and provide as primary sources for new studies.
All primary sources, oral and written, were organized in order to facilitate their classification, which was the next step of the analysis process.For classification, extensive readings of the documents were performed; shortly afterwards relevant structures were identified, including the social actors, the core ideas that the subjects transmitted and key movements that were related to the research goal. 8Next, data triangulation was performed 9 in order to compare the oral source findings with the written documents and the theoretical background.
To support the study, we used theoretical notions of the field, capital, symbolic power and habitus developed by Pierre Bourdieu in his Theory of Social World.In this study, obstetrics is seen as a field where agents build and maintain relationships of power that depend on their social positions.Their position, in turn, depends on the volume of capital that the agents have.The more capital an agent has, the more symbolic power he wields in the social world.This symbolic power is invisible and may be exercised only with the complicity of those who exercise it and are subject to it.Since the notion of habitus indicates acquired knowledge, or even an incorporated postural provision resulting from a learning process, it is the product of the contact of the agents with different social structures. 10he research was guided by the ethical and legal principles governed by Resolution 196/96 of the National Council of Health, Ministry of Health, which regulates research involving human subjects.We requested permission to use the name of the institution by sending the terms to the Ethics Research Committee (CEP) of the Municipal Health and Civil Defense Department of Rio de Janeiro (SMSDC), which was approved under Protocol number 188 on September 11, 2009.

RESULTS AND DISCUSSION
The Course for Assistance of Humanized Childbirth at the birthing centers in Japan occurred on five separate occasions, from 2003 to 2007, and the Administrative Commission was comprised of the following members: Prof. Dr. Yasuhide Nakamura, of Osaka University, chairman of the commission responsible for the planning of its curricular structure; Dr. Kiyoshi Haneda, Director of Makabe Hospital; Mrs. Chiruzu Misago, representative of the National Institute of Public Health of Japan; Mrs. Miyuki Fijiwara, representative of the Technical Cooperation Agency of Japan (JICA), and Mrs. Taeko Mohri, representative of the Mohri Birthing Center. 4...] had an agreement with the Ministry of Health, Ministry of Foreign Affairs of Japan and JICA, which would be a representative entity that would accept nurses for five years [in Japan].There were nurses from several states in Brazil (Silma de Fátima da Silva Araújo Nagipe).
In 2003, Nurse Midwives Leila Gomes Ferreira de Azevedo (RJ), Basile Anatália Lopes de Oliveira Basile (Brazil), Lucia Cristina Florentino (SP), Dionice Furlani (SC), Joana D'Arc Gonçalves (MG), Silma de Fátima da Silva Araújo Nagipe (RJ), Alexsandra Nascimento (PE), Eliane Rabelo de Sá (MG), Maria Cristina de Camargo (BA), Nurse training in Japan: contribution to the foundation of the... Amália de Oliveira Carvalho (PI) and Arabela Antonia Nery de Melo Costa (PE) were selected to go to Japan.For three months, they all attended lectures, practical sessions and technical visits to various institutions where they experienced the Japanese model of childbirth care. 4MS-RJ chose nurse midwives Silma de Fátima da Silva Araújo Nagipe and Leila Gomes Ferreira de Azevedo to integrate the first class of the course, which was conducted from February 3 to April 26, 2003.When the referred nurses were appointed, city administrators embraced obstetric nursing; they would now have contact with the Japanese obstetric care model, based on a culture where autonomous midwifery is practiced in the birthing centers.
At that time, the Women's Health Program Coordinator of SMS-RJ was involved in fighting for the creation of the birthing center; it was the first to be created in the city and would be located in Program Area 3.3, in the neighborhood of Realengo, on land located 7 km from the Alexander Fleming Birthing Center.
[...] we went to Japan.I am sure I was selected because they expected me to go to this birthing center [...].They hoped that the two of us would go to that birthing center.They expected something more from the two of us, and, well, they chose us (Silma de Fátima da Silva Araújo Nagipe).
Thus, it became evident that the appointment of these agents was strategic for the creation of this health facility, for both agents held managerial positions in institutional structures.Nurse Silma de Fátima da Silva Araújo Nagipe was head of the nursing service of the Alexander Fleming Maternity Hospital, while Nurse Leila Gomes Ferreira de Azevedo was head of the obstetric center at the Leila Dinez Maternity Hospital, which was the first municipal maternity hospital in Rio de Janeiro created with the humanized model in mind. 11uring the course in Japan in a statement made to the nurse midwives, Dr. Kiyoshi Haneda, director of Makabe Hospital, emphasized that many things could be done without spending money to humanize childbirth working from imagination and creativity.He further noted that the Birthing Centers developed in Brazil should be financially independent. 4In this case, it is understood that this statement refers to light technology and the autonomous practice of the obstetric nurse, who would be a potential promoter of natural childbirth and important in the reduction of public expenses in Brazilian obstetrics, which was expensive due to the use of medication and technology.
Thus, the training of Brazilian nurse midwives in Japan, in the context of the implementation of the Centers for Natural Childbirth in the Brazilian health system, was consistent with the actions of the State, which promoted differentiation strategies for quality access to services through cost rationalization and technological simplification in healthcare, constituting a division between the central and peripheral zones of the cities in terms of the distribution and provision of assistance and professional resources. 12n this sense, it is worth noting that the Birthing Center of the city of Rio de Janeiro is located in a peripheral region, where a large resident population lacks access to public health services in comparison to those in better financial condition who live in central neighborhoods.
At the beginning of the course, content was developed which aimed at reducing the culture shock between the realities of Brazilian and Japanese nurses.This content included classes on Japanese language, culture and aspects of the Japanese model of health care, in addition to specific content regarding obstetrical care at the Birthing Centers with Japanese midwives.
We went through several classes, and gained a huge respect because they taught us the Japanese language and culture.We visited schools, went to congress, to the homes of the Japanese to learn how they lived, partake of the tea ceremony, see the culture, and take part in typical ceremonies.The most pleasant part was the contact with these women, [professional midwives/nurse midwives of Japan] who were true angels and very courageous women (Silva de Fátima da Silva Araújo Nagipe).
From a theoretical standpoint, the lectures given by experts from various sectors related to obstetric care in Japan enabled these nurses to have access to new knowledge.The idea was that they would return to Brazil with new knowledge i.e. with the professional habitus upgraded to use in their states and municipalities in obstetric practice in the humanized care model and the Birthing Centers.
In this regard, habitus promotes cultural and social transformations, generating practices and actions of both individuals and communities.Therefore, the habitus of the subject can both generate and transform his/her practices.This depends on the inclusion and movement of agents in their social fields, the struggles among individuals within these fields and/or a reflective analysis of their own provisions. 13urses have accumulated knowledge on the use of Oriental medicine in obstetric care, female leadership, aspects of a favorable environment for childbirth, protecting the perineum, baby care, breastfeeding, the transfer of high-risk women and newborns from Birthing Centers, the secondary role of the hospital in childbirth, sexual and reproductive rights, family planning and violence. 4he practical part of the course was held in several institutions.They visited hospital referral centers for obstetric care in Japan, university hospitals for maternal and child care practices and attended practical classes at four birthing centers: Mohri, Takizawa, Ohtani and Ayumi.
To begin practicing at these Birthing Centers, the required care for nurse internship at these facilities was addressed.During the internship, it was possible to learn the philosophy and administration of each of the centers.The situations experienced by the nurses reflect the different systems of care in this field that would ultimately influence the professional practice of each one of them upon returning to Brazil. 14t the end of the course, the Brazilian nurses developed an action plan to be applied in Brazil, which encompassed the knowledge acquired.Nurses Silma de Fátima da Silva Araújo Nagipe and Leila Gomes Ferreira Azevedo, representatives of Rio de Janeiro, drafted a text called "Plano de ação para a implantação da assistência humanizada nas casas de parto do Rio de Janeiro" [Action Plan for the Implementation of Humanized Care in Birthing Centers in Rio de Janeiro].They were the only participants who developed a plan with another intern.

The purpose of the action plan was to bring the Japanese reality to Rio's Birthing center. Leila Gomes Ferreira Azevedo was very happy; she made very good use of what she saw and implemented the physical part, the part of the meetings and the creative part. She joined what she saw and adapted to the reality of Brazilian women, which is completely different. Our plan was totally focused on the implementation of those actions at the David Capistrano Birthing Center [...].
We created a single action plan because it was not worth creating two plans if our goal was singular, so we were the only pair (Silma de Fátima da Silva Araújo Nagipe).
The action plan focused on concepts for the creation of physical space and enhancement of professional standpoints that reduced the distance between professionals and the women/ families they served.The professional attitudes should be flexible and expanded in order to recognize the different forms of communication and measures that would avoid unnecessary intervention during childbirth. 4o implement this plan, Nurses Silma de Fátima da Silva Araújo Nagipe and Leila Gomes Ferreira Azevedo defined four strategies: presentation of the action plan to SMS-RJ; discussion of the proposals with members of the National Program for Integrated Healthcare for Women (PAISM) and promoting events for dissemination; partnerships with educational institutions for the purpose of discussion, and transfer of the knowledge acquired.
Finally, the plan included a schedule of activities to be initiated within 10 days after arriving in Japan, which reflected the fact that the process of creating the first Birthing Center in Rio de Janeiro was already well underway, with its agents and strategies practically defined.
But when I came back from Japan, [we went in February 2003 and returned in April 2003], the Birthing Center had already made a lot of progress (Silma de Fátima da Silva Araújo Nagipe).
From the incorporation of new knowledge, the course held in Japan contributed to expanding the competency and authority of the nurses involved.Accordingly, the aggregation of new capital increases the chances of profit for the agents in their social field. 15hus, Nurses Silma de Fátima da Silva Araújo Nagipe and Leila Gomes Ferreira, upon returning to Brazil, were able to occupy new roles (spaces).In 2003, they were included in the implementation group of the birthing center, participating in the drafting of the Assistance Protocol of the David Capistrano Birthing center.
After Japan, there was preparation for when the girls [Nurses Silma and Leila] returned.The staff became more involved in the overall context of the protocol (Glória Maria Francisco Carlos dos Santos).
When I returned from Japan, we had already gone a long way with the issue of the creation of the Birthing Center, i.e. the Ministry of Health had already granted the land, and the city would contribute with human and financial resources for implementation and creation of the Birthing Center.Then, later on, we would have a selection process for the nurses.When I returned, I was included in that group to cre-Nurse training in Japan: contribution to the foundation of the...

ate the protocol of the Birthing Center (Leila Ferreira Gomes Azevedo).
During the process of establishing the Birthing Center, it was determined that the benchmark maternity hospital for the referral of pregnant women who did not fit into the protocol of the David Capistrano Filho Birthing Center (Resolution 1041/2004) would be the Alexander Fleming Maternity Hospital.
This maternity hospital was chosen as a referral center due to the geographic proximity between the facilities and the consolidation of nurses' participation in assisted birth, which started at this institution back in 1998 with the implementation of the Project of the Nursing Care for Childbirth.
In 2003 to 2004 we already had about six years of obstetrical nursing experience.At that time we had about 70% of deliveries assisted by nurses; today we have around 60% (Silma de Fátima da Silva Araújo Nagipe).
Nurse Silma de Fátima da Silva Araújo Nagipe, upon returning from Japan, was established as head of the nursing service at the Alexander Fleming Maternity Hospital.
Silma [de Fátima da Silva Araújo Nagipe] had also gone to Japan, had also been considered, but we [managers of SMS-RJ] needed someone at Fleming [referral center for the Birthing Center], who could ensure referrals (Kátia Maria Netto Ratto).
Nurse Leila Ferreira de Azevedo took the position of Coordinator of the David Capistrano Filho Birthing Center.It is understood that the agents occupying top positions in the field have accumulated political capital and are capable of guiding processes from their decisions, thus they establish a legitimate political area. 10 Leila [Gomes Ferreira de Azevedo] returned from Japan [...] so we [managers of SMS-RJ] chose her as the coordinator [of the Birthing Center] [...].So that was already being considered beforehand (Kátia Maria Netto Ratto).
Accordingly, both of them increased the volume of their capital through their training and, therefore, their symbolic power in the field structure.On the one hand, the head of nursing services of the Alexander Fleming Maternity Hospital should exercise her power to ensure all hospital referrals of parturient and pregnant women whose obstetric profile did not fit the Protocol of the Birthing Center; in addition, she should maintain the practice of obstetrics of the nurses in the obstetric center of this same institution.It is highlighted that, according to the data of productivity and the service profile of the birthing center, from March 2004 to December 2009 156 parturient women and 26 postpartum women , a total of 182 women, were transferred to the referral facility.
On the other hand, the coordinator of the Birthing Center, inaugurated by the SMS-RJ on March 8, 2004, achieved a higher position in the obstetric field, i.e., took a coordinating job so that her symbolic power made feasible the implementation of obstetric nursing practices as per the guidance of her habitus updated in Japan.
The effects on women of the obstetric practices implemented in the Birthing Center, in accordance with the provisions incorporated by the nurses (including training in Japan) can be seen from institutional data.
Thus, from March 2004 to December of 2009, a total of 37,138 prenatal consultations and 9,269 educational sessions took place at the Birthing Center in the city of Rio de Janeiro.The most frequently provided care was oriented towards the relaxation and comfort of the women in labor, including breathing exercises, ambulation, warm baths, body massage, music and pelvic movements. 16n relation to delivery, 1,477 natural (vaginal) deliveries took place, of which 94.9% occurred with the presence of a person accompanying the women during labor; episodes of neonatal asphyxia (live births) where Apgar scores were below 7 at the fifth minute of life represented only 0.3% of newborn births.Cases of severe neonatal asphyxia, i.e.Apgar score below 4 at the fifth minute of life were not reported.Of the total births, 22.5% occurred in the lateral position, 14.2% in the upright position, 20.0% in the semi-vertical position and 14.2% in the squatting position.Included in the semi-vertical position are the mothers who adopted this position by choice, wither in the tub or in the labor bed. 16egarding the condition of the perineum during labor, most (73.6%)women experienced a laceration.The perineum remained intact in 22.5% of pregnant women and episiotomy was performed in 3.9% of deliveries.Considering all women whose perineum was lacerated during childbirth, the vast majority (82.4%) were firstdegree tears.The frequency of third-degree tears was 0.37% among women with lacerations.There was no occurrence of fourth-degree lacerations. 16

CONCLUSION
It was recorded that in 2003, a group of Brazilian nurses joined the first class of the Course for Humanized Childbirth Assistance of Birthing Centers in Japan, and that the representatives of the city of Rio de Janeiro, Nurses Silma de Fátima da Silva Araújo Nagipe and Leila Gomes Ferreira de Azevedo, attended it.
The choice of these nurses by city administrators happened in the context of the creation of the Birthing Center; therefore, this appointment was a battle strategy used to reconfigure the field of obstetrics in Rio de Janeiro.
Upon completion of the course in Japan, the nurse midwives added a larger volume of capital to their professional habitus, which gave them greater symbolic power to fight for the implementation of less interventionist obstetric practices.
In the specific case of the Rio de Janeiro nurses, upon returning to Brazil they were part of the group constructing the assistance protocol Birthing Center.Simultaneously, Nurse Leila Gomes Ferreira de Azevedo held the position of Coordinator of the Birthing Center, while Nurse Silma de Fátima da Silva Araújo Nagipe remained as the head of the nursing department of the maternity hospital, which was chosen as a referral center for the Birthing Center.
These positions held by the nurses enabled the creation and consolidation of the Birthing Center, with the development of creative obstetric practices that were focused on minimal intervention, centered on the role of women in sensitive care; that is, practices that fit with the nurse's upgraded habitus in view of her experience in Japan.
After five years of operation, results at the Birthing Center confirmed that the nurses involved in this process were generating obstetric practices that distinguished them in the field because these practices, different from those found in hospitals offered to patients of the Unified Health System of Rio de Janeiro, offered the opportunity to manage and give birth.This knowledge is essential to the exercise of choice by the patient and therefore constitutes a new social demand in the field of obstetrics.Women who have experienced a primary and active role in childbirth will no longer be passive in the face of routine medical interventions performed on their bodies.