RESEARCH ARTICLES
The influence of obstetric nurses’ practice in building a new social demand
Juliana Amaral PrataI; Jane Márcia ProgiantiII
IObstetric nurse. M.Sc. in Nursing at the School of Nursing of the University of the Rio de Janeiro State. E-mail: juaprata@gmail.com
IIObstetric nurse. Ph.D. in Nursing. Professor at the Mother-Child Nursing Department of the School of Nursing of the University of the Rio de Janeiro State. Researcher of the Research Team on Gender, Power, and Violence in Health. Researcher of the Pro Science Program of the University of the Rio de Janeiro State. Rio de Janeiro, Brazil.E-mail: jmprogi@uol.com.br
ABSTRACT
This research aims at discussing women’s perceptions on obstetric nurses’ practice, as well as at analyzing the effects of such practice on women. It is a qualitative study on the basis of Bardin's content analysis technique.Interviews with 16 women took place at Hospital Maternidade Alexander Fleming and at Casa de Labor David Capistrano Filho in Rio de Janeiro, RJ, Brazil, from May to June, 2011. Under the light of Pierre Bourdieu’s key concepts, women’s testimonials indicated they acknowledged professional and distinctive attributes of the obstetric nurses’ practice. This practice encouraged women to overcome their fear of pain and experience normal labor; in addition, it transformed their mental representations on childbirth. We concluded that the professionalhabitus of the obstetric nurse, materialized in the implementation of their actions, is a b ally in the humanized model of labor assistance, as it establishes a new social demand.
Keywords: Women’s health; humanized labor; obstetric nursing; power.
INTRODUCTION
Prevailing childbirth care model in Brazil is characterized by excessive technological intervention upon women’s body and, therefore, by increasing cesarian section rates. In 2009 Brazil was leading the ranks on cesarian sections, displaying a rate of 44%1.
However, since the late 80’s, the humanized model of labor assistance and childbirth has introduced continuing debate in the Brazilian society in favor of changes in labor assistance models as well as in the elaboration of Public Policies encouraging normal childbirth through female empowerment.Reference ideas of the model are based on the 1985 publication by the World Health Organization (WHO). It criticized interventive obstetric practices, and through evidence-based medicine, suggested technologies suited to labor and childbirth, as well as changes in hospital routines, and encouraged the participation of obstetric nurses in normal childbirth2.
In the 90’s those suggestions motivated municipal managers to invest in the inclusion of obstetric nurses in labor assistance. Since the mid 70’s they had been the only non-medical professionals with legal support to act in normal childbirth. Along that, the Brazilian Health Ministry (HM) created provisions on the federal level, which valued the action of obstetric nurses, fact which has strengthened the empowerment of those agents in the obstetric realm and has facilitated the actions of local managers3.
In that context, nurses displayed motivation to act on the basis of the suggestions issued by WHO, by the humanized model movement, and by local managers. They participated and organized national and international events and specialization courses in obstetric nursing, places where new knowledge circulated, which they were willing to incorporate4,5.
Along that struggle, quite a few of them took up strategic positions in order to implement minimal-intervention normal childbirth, on grounds of shared decision-making in the care relation with women, respect for their human rights, and encouragement to their active participation in the parturition process. By incorporating those practices, obstetric nurses were differentiated in the realm, obtaining higher self-reliance and symbolic profit out of the actualization of their habitus in the context of humanization of labor and childbirth6.
In view of that scene, this paper aims at discussing women’s perceptions on obstetric nurses’ practice, as well as at analyzing the effects of such practice on women. This investigation adds primarily to the formulation of public policies. It sheds light onto the necessary changes in formulation and implementation of childbirth assistance-related actions meant to meet the rights of an emerging social demand in the obstetric realm, integrated by women who seek delivery experience free of invasive and unnecessary intervention.
THEORETICAL FRAMEWORK
This research is theoretically grounded on Pierre Bourdieu’s concepts of habitus, mental representations, and symbolic power. Habitusworks as matrix of perceptions, appreciations, actions, and dispositions incorporated by agents upon their insertion in a social realm. It is simultaneously lasting and subject to actualization as the agents’ struggle reconfigures a certain realm. As a set of acquired pieces of knowledge and incorporated dispositions, the habitusgenerates practices and representations which, “[…] are acts of perception and appreciation, of knowledge, and identification in which agents invest their interests and basic assumptions”7:112.
Symbolic power is exercised by agents who are in higher ranks in a hierarchical realm. It can structure perceptions social agents have of the social world and signals to a power implemented in social relations in a way that “[…] it can only be exercised with the complicity of those who will not acknowledge they are subject to it or even that they exercise it” 7:7-8. In other words, it is invisible power exercised without the association of physical power, but that can mobilize one for being identified as natural.
METHODOLOGY
This qualitative piece of research is anchored in the project entitled Nurse’s participation in reconfiguring the obstetric realm – struggle for the implementation ofhumanized practices of labor assistance, of the School of Nursing of the Universidade do Estado do Rio de Janeiro (University of the Rio de Janeiro State).
The scene for this research was set up by two health institutions with obstetric nurses acting in childbirth and delivery, namely Hospital Maternidade Municipal Alexander Fleming and Casa de Parto David Capistrano Filho, both of them under the management of the Rio de Janeiro Municipal Health Secretariat.
The subjects of this research were comprised of users of the Unified Health System (SUS) of the City of Rio de Janeiro, who volunteered to participate.Inclusion criterion contemplated those women whose deliveries and normal deliveries were assisted by obstetric nurses. Exclusion criterion was determined by the identification of any events on the course of any phase within that time span.
Testimonials by 16 women were collected from May to June, 2011, through open-question interviews. Average age of interviewees was 22 years old, twelve of which primiparous mothers and four of which multiparous mothers. Interviews took place during puerperium, about five days after delivery. The interview script aimed at assessing the following: women’s perceptions on assisted delivery by obstetric nurses and those social-related aspects conditioning their perceptions on delivery before their childbirth experience. Women confronted their perceptions from those two perspectives.
Testimonials were methodologically treated on the basis of Bardin’s contents analysis8. The process started with pre-analysis, consisting of the reading of the interviews for identification of record units.After this step, record units were defined to be associated to signification units and, after that, grouped in thematic categories of analysis. As a result of this analytic process, two theoretical categories were constructed: Mental representation of women on the practice of obstetric nurses: professional qualities and distinctive features of those agent; and The effect of symbolic power of obstetric nurses upon women.
In compliance with Resolution 196/96 of the HM9, which provides for research involving human beings, an Informed Consent was elaborated stating objectives and ends of research, volunteer participation, and protection of subjects under anonymity. In this respect, women’s names were replaced by the letter E (interviewed), followed by the corresponding interview number.
The project was submitted to the Ethical Committee of the Rio de Janeiro Municipal Health Secretariat for appreciation and approval of the research protocol number 05/2011, on March, 28, 2011. The institutions on the scene of this research have consented on the use of their names through the request form for disclosure.
RESULTS AND DISCUSSION
In the analysis process and in the light of the theoretical framework presented, discussion of women’s perceptions on the practice of obstetric nurses was translated in the professional qualities and distinctive features found in mental representationsof the interviewees produced by those professionals.
As product and producer of social relations, an agent’s identity is acknowledged by others since it works as a social resource which signals to qualities and social values of a group. This granted, their behaviors and their characteristics are acknowledged and assimilated collectively, comprising objects of representations7.
During parturition, women acknowledged and valued a few qualities related to the obstetric nurse’s practice. Those qualities integrate the habitusof that professional and, therefore, thehabitusis naturally manifested when she relates to women. In this sense, all interviewees highlighted patience and attention as distinctive:
The nurse’s distinction turns out to be her patience with the people she gives care to … very patient, helpful, very good!(E6)
Acknowledgement of those qualities denotes symbolic effectiveness of the nurses’ practice, for their actions were not regarded as arbitrary by women, and were therefore found legitimate by them10.
The women’s mental representationsalso signaled to distance abridging attitudes as qualities of the obstetric nurse’s:
[...] what stood out most was thatshe was there by my side. She kept me company all the time […], sat at the edge of the bed and said: now I’m staying here and will only leave when it’s time for delivery.(E5)
This was the best experience of all because the nurse by me […] held my hand.(E15)
The way an agent acts in the realm turns out to be the manifestation of his/her habitus, which consists of three dimensions:ethos, principles and values interiorized in the practical state; eidos, comprised of logical and cognitive schema for classification of objects in the social world, which are translated as the intellectual seizing of reality; andhexis, which is manifested as posture schema, body technique and tools wrought with signification and social values11.
Thus, expressions in the speeches of interviewees such as - she was there by my side; sat at the edge of the bed: was by my side; held my hand – are postures and gestures on the part of the obstetric nurse that break barriers between her and the woman, favoring the building up of trust and assuring further exchange, which is translated as emotional support12-14.
To put that in a different way, during the interaction with the nurse in the obstetric realm, the women’s speeches signal their acknowledgement of body language, the hexisdimension of the nurses’ habitus. On the other hand, the ethos dimension also showed in the testimonials, as enhancement of technical-scientific knowledge:
To me it was very important to have her at the time. I felt fully reassured!(E7)
It was great to me, a competent person who would reassure me [...]. All of them are reassuring and reliable!(E12)
Reassurance, trust, and credibility acknowledged by women are made possible by the technical support and scientific knowledge of the nurse during her practice15. These qualities of the nurses’ practice, highlighted by the interviewees, evince women acknowledge the obstetric nurses’ scientific capital, which made the women feel reassured. This type of capital results from the accumulation of several specific capitals for a specific realm. Thus, in the incorporated state, it expresses the practical competences which allow the agent to have scientific authority, and, therefore, is directly related to knowledge and to the acknowledgement of the one who has it, the bearer16.
It is interesting to highlight that all professional qualities valued by women stand for the volume of capital accumulated by obstetric nurses, which has resulted in the transformation of their habitus in the context of humanization of assisted childbirth and has ascribed them with symbolic power. In this sense, the obstetric nurse manifest her habitusand, therefore, her symbolic power through her practice.
Is spite of subtle nature of its manifestation, symbolic power is identified in the women’s testimonials. This research shows two tightly connected effects of the nurses’ power.
The speeches of the interviewees demonstrate the nurse’s symbolic power moved women into overcoming fear of pain and potentialized women’s power:
They stopped me from being dominated by fear […] fear of pain everybody talked about. And they changed before my delivery!(E7)
I was tired and feeling weak to push further. She turned, pulled me and said: Yes, you can really make it! She supported me to push further so that my daughter could be delivered!(E9)
During interaction with the woman, the nurse encourages her active participation in childbirth, offering her support and stimulus12,13,17. Thus, we believe that when women overcame fear of pain and became b, they incorporated their leading position during childbirth into their habitus, according to one of the principles of the humanized paradigm of labor assistance.
That process was triggered because the obstetric nurse’s habitus generated practices that respected the physiology of delivery and the power of the female body. Thus, women identified those dispositions of the nurses and incorporated them, unaware that relation bore the exercise of a power, since they ignored it as arbitrary.
Symbolic power can confirm or transform cosmovisions7. In this sense, transformation of women’s mental representationsemerges as another effect of the nurses’ symbolic power.
Representations are elaborated along the agents’ socialization. They are changeable in face of the relations set up with family, school, work, and institutions. In the case of women, they built up images and ascribed values to the parturition process.
Interviewees’ speeches let out that their mental representationson childbirth were elaborated from perception schema from other people in their social circles, and that, in most part, they mirror medicalization of childbirth assistance in our society.
Under that model, normal deliveries are regarded as a pathological event which requires medical control, a fact which has resulted in the appropriation of female body by medical power. By making women into objects of manipulation, interventions emphasize biological aspects irrespective of the subjectivities of that event to the women. Normal childbirth is then configured as a medical act, and its practice is socially discouraged18.
I thought it was horrible! They said it was death’s pain. I was so scared […] and so much that I prayed to have C-section.(E1)
We would hear it was unbearable pain! They put a lot of stuff into our minds […] that C-section was better because you would not feel so much pain!(E12)
In relation to obstetric practice, quite a few interviewees reported what they heard about professionals acting in childbirth assistance:
In general, they said all professionals were bad, that everybody mistreated you.(E1)
On the hospital, they said some were not patient. No, they would not say nice things about it!(E11)
Everybody says when you get to hospital to have a baby you cannot put on a scene! You cannot burst into tears, otherwise you can be mistreated! (E13)
Thus, like women’s representations of childbirth, their representations on obstetric practice were elaborated from the medicalized model cosmovision. In the obstetric realm, manifestation of the professionals’ medicalized habitusmade them fearful and unsure, feelings which interfere negatively onto the physiological process of childbirth19,20 and which can account for Brazil’s leading position in the world ranking of Cesarian sections.
However, when those women interacted with the obstetric nurse, their representations of childbirth were transformed:
I dreamed of having C-section, but not now [...] Normal delivery is way better! (E1)
It’s very different! People would say they feel a lot of pain, they said they would die […], but to me that’s all nonsense! (E8)
I finally realized it was not what they made of it! (E12)
We can say the practice of the obstetric nurse presented those women with a new view on childbirth as well as on obstetric practice, according to the following speeches:
But not here, they were kind to me and that’s not that big deal people talked about!(E3)
At the beginning it’s that fear[...] they are not doctors, all that prejudice! I broke the prejudice! I broke all that taboo and I feel very happy about it!(E7)
The picture I used to have on the professionals was really very bad. I was scared to death! It was after I came here that things got better. I opened up my mind! I got relaxed about the whole of it!(E11)
I could not imagine it was the way it is! Now I see different! They helped me. I realized it was nothing like what we had in mind! (E15)
We noticed women acknowledged a distinction between the nurse’s obstetric practice and the medicalized obstetric practice. The nurses’ distinctive qualities are provisions of the symbolic power for women ackowledged them, and as from that ackowledgement, their representations of childbirth and obstetric practice were reconstructed.
Those transformations in their representations demonstrate the effect of the obstetric nurse’s practice, that is, the symbolic power of those agents capable of helping women acquire dispositions that can guide them into a new conception of childbirth.
Additionally, we have stated that, by appreciating normal deliveries assisted by the obstetric nurse, women credited and legitimated the practice of those agents. As part of the construction of representations by other people, the representations by those women will be socially reproduced and will create a new demand to the obstetric realm, for the construction of a demand results from a negotiation process culturally mediated by those agents, and permeates interests of a group busy with brainwashing forms of desire in face of a specific situation21.
CONCLUSION
Women’s mental representations demonstrate that obstetric nurses’ professional qualities were identified and highlighted by the former as distinctive properties in the practice of those agents. In that sense, in spite of not being distinctive-moved in the exercise of their practice, nurses’ distinctive signs were acknowledged by those women, for an agent is capable of identifying spontaneous differences as meaningful distinctions.
The power in the practice of the obstetric nurse strengthens women’s power, transforms theirmental representations of childbirth, and create favorable conditions to normal deliveries.
On the basis of the results, we can state the professionalhabitusof the obstetric nurse, materialized in the implementation of their actions, is a b ally to the humanized model of childbirth assistance because it creates a social demand.
In view of the discussion, we suggest further research on strategies to be used by managers on the political scene in order to meet the social demand of the SUS users, created by obstetric nursing.
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Received: 26.09.2012
Approved: 14.01.2013