Nursing Training and Practice on Humanization Actions in Monitoring the Delivery in Brazil

Method: this is a integrative review of the literature, conducted from October to November 2014 from crossing the descriptors “Humanizing Delivery” “Obstetric Nursing”, “Prenatal care” and “Training” in databases SciELO, Lilacs and BDENF, published between the years 2004 and 2014, in Portuguese language, which identified 75 articles, and after reviewing them, based on the established criteria, 28 were selected for analysis.


Introduction
Nursing training in Brazil began in 1890 with the creation of the Escola Profissional de Enfermeiras (Professional School of Nurses), inside the Hospicio Nacional dos Alienados, in Rio de Janeiro.Later, other private and public schools were created in several Brazilian states.Since that time, several modifications have been incorporated in obstetric care, shaping nurses' actions in this area and then, specialist nurses, trained by specific courses for nurses in maternity hospitals attached to medical schools, started replacing midwives [1].
These modifications, which are related to care during pregnancy and delivery, are set in the historical context, professionals' behavior, people's culture, training of professionals serving women during pregnancy and childbirth and, above all, the leading role of women [2].
In recent decades there has been, in Brazil, an increase in the number of cesarean deliveries that reached, in 2011, a ratio of 52% in the SUS and 88% in private service [3].These percentages exceed the ceiling of 15% of cesareans recommended by the World Health Organization [4].Percentages of cesarean births above the recommended by WHO were also observed in Europe (19%), Latin America and the Caribbean (29.2%),North America (24.3%) and Asia (15.9%) [5].Only Oceania (14.9%) and Africa (3.5%) had rates below those recommended by the WHO, but one of the factors that justify these percentages is the access barriers to care for the population and the lack of availability of medical care [6].
Over a decade ago, the Ministry of Health (MOH) estimated that over 90% of cases of maternal deaths could be prevented with adequate care during prenatal and childbirth care [7] and over 20 years ago, the higher incidence of caesarean sections was related to more economically advantaged regions, to the organization of obstetric care, and to socio-cultural, legal and institutional factors [8].Another recent survey showed insufficient medicines and equipment to meet emergency situations, inconsistencies in the information collected in medical records regarding the use of inappropriate practices, not being prioritized the use of best care practices at delivery and birth, and showed that only 16% of births are performed by nurses [3].
Beneficial actions recommended during the prenatal care are very important, since they favor the reduction of maternal mortality and encompass the promotion of maternal health, risk prevention, nutritional support assurance, criteria for investigation of pregnancy risk and inclusion of pregnant women in the basic component of prenatal care model [9].
Regarding actions during childbirth, these are based in institutional care, skilled professional care, restricted use of oxytocics in the active phase of labor and episiotomy, performance of traditional midwives in certain contexts, use of appropriate technologies, including the partogram, upright positions during labor, management of placental stage and prophylaxis of postpartum hemorrhage [10].
In 2009, the National Policy for Comprehensive Care to Women's Health (PNAISM) sought to consolidate the advances in the field of sexual and reproductive rights, and one of its goals was the improvement of obstetric care [11].As part of the concept of comprehensive care, and in order to humanize care, the MOH launched the National Program for Humanization of Birth Care (PHPN) [12] , complemented by the Humane Care Standards for Low Birth Weight Infants; operationalized by the Program for Humanization of Labor and Delivery [13] and the National Policy for Humanization -Humaniza SUS [14].
In 2011, based on the PHPN recommendations, the MOH enacted Ordinance No. 1459, which regulates the "Stork Network," a strategy for organizing a network of care in health care level to ensure women the right to reproductive planning [15].According to the MOH, humanizing the care of pregnant women presupposes a relationship of respect during pregnancy, childbirth and postpartum process established between health professionals, mothers and caregivers, and provides access, information and preparation for childbirth [12].
In care practice, the obstetrician nurse facilitates the guidelines for proper breathing in each step of labor, encourages freedom of movement, the establishment of the bond between professional and laboring women, stimulates the presence of a partner and the use of physical touch [16,17].Their performance in teaching is guided in the conduct of courses in the area of women's health, in general, and also in assisting the prenatal care, delivery and postpartum care, gynecological care and newborn health [18].
On the beneficial aspects arising from the performance of the obstetric nurse in the care of pregnancy and childbirth, there is still little information on the training of nursing professionals in the perspective of humanized delivery as well as of the care practice of these professionals.To elucidate reflections on this theme, authors chose the theme concerning the training and practice of obstetric nurses to boost this study in order to conduct a review of the scientific literature to identify what studies portray on the training and practice of nursing professionals regarding humanization of care for pregnant women and mothers in Brazil.

Method
Researchers conducted an integrative review of the literature, taking the recommendations proposed by Mendes, Silveira and Galvão [19] as theoretical framework.As these authors recommend, the following steps were followed: formulation of the research question, establishing criteria for inclusion and exclusion of articles, definition of information to be extracted and categorization of studies, evaluation of the included studies and interpretation of results.
The first step followed for the preparation of the study was the definition of the following research question: what do studies show and discuss on humanization actions in the training and practice of nurses regarding care for pregnant women and mothers in Brazil?
The inclusion of articles corresponds to the second step, and was directed by the following criteria: bibliographical survey conducted from October to November 2014, by crossing the descriptors "Humanized Childbirth", "Obstetric Nursing", "Prenatal Care" and "Training", in the databases SciELO, Lilacs and BDENF.The choice of such databases occurred because: they are large sources of research data that bring together studies held in Latin America and specifically in Brazil.To be included, articles should have abstracts and texts available online, in full, in Portuguese language, which had as object of study the training or practice of nurses for the humanization of actions in delivery care in Brazil, published from 2004 to 2014.This period was chosen because it comprised studies published over the past decade, thus portraying the broad and current context of publications.
The search identified 85 articles, of which 20 were located by the intersection of the descriptors "Humanized Childbirth", "Nursing" and "Training", 25 by "Obstetric Nursing" "Prenatal Care" and "Training", and 40 by "Training" and "Humanized Childbirth".The third step of the review corresponds to the definition of the information to be extracted from selected articles based on convergences and divergences.Before seeking relevant information by reading the articles, authors have chosen as a central theme the training and practice of obstetric nurses for the humanized delivery.So, after reading the abstracts of all articles, those whose main object of study was not nursing training or practice for humanizing actions in care delivery, those that were not carried out in Brazil, and those that were repeated in more than one database were counted only once.After identifying the articles in the databases, they were separated according to the base and selected for full reading as shown in the Figure 1.The final sample consisted of 28 articles that were organized in table (Table 1), including the title, year of publication, objectives and study design.Identifying and discussing the actions in these times when the woman's body gives rise to another life.

Qualitative
Of the selected articles, only one portrayed the training and practice in its title, not specifically mentioning the nurse's performance.There were studies with qualitative and quantitative methodological approach, and review studies.Review studies were used to support the search for original studies and were not included in the final sample.
The analysis of the selected articles took place according to the criteria of content analysis proposed by Bardin [20].This step was the fourth step of the review, in which authors performed the floating reading of the material to choose, organize and systematize the studies, which originated the units of meaning according to the emerging, convergent and divergent ideas.The analysis was conducted by the first author (HF) and confronted by the second author (MYM).
Subsequently, the fifth step was carried out, which consists in the interpretation of results to enable critical evaluation of the included studies, comparison with the theoretical knowledge, identification of conclusions and implications resulting from the integrative review which will be presented and discussed in the following themes that emerged from the analysis articles: nursing training for the humanization of care actions in pregnancy, labor and birth; and nurses' practice in humanized obstetric care in Brazil.

Results
The articles selected were based on empirical research published in Nursing and Public Health journals.The studies that supported the publications were held in the Northeast, Southeast and South regions of the country, especially in the states of São Paulo, Rio de Janeiro and Ceara.Among the original articles, 16 used qualitative approach, 11, quantitative approach and one, quantitative and qualitative approach; 25 were carried out in health institutions and three were conducted institutional and teaching environments, respectively.

Nursing training for humanization of care during pregnancy, labor and birth
Based on the selected it articles was identified studies that portray the issues of nursing education to promote humanized birth since graduation, specialization and obstetrical residency, as well as the discussion of the intrinsic ethical issues in education and the impact of training actions proposed by nurses.
Academic nursing education is still incipient for the promotion of humanized birth [44].Teaching in nursing, however, has been undergoing transformations with advances in the social, political and ethical context, as new learning strategies that focus on the intention to broaden dialogue, students' participation and understanding of the various aspects involving a more liberating, creative, reflective, constructive and questioning approach, so that there is support to the actions taken by nurses [23].
The training of nurses during graduation in the South of Brazil, directed to obstetric care, was completed in the 50's and only from 1972 the nursing course started to carry out practical activities linked to the University.In this period, there were obstacles in the field of practice that limited the work of nurses trained to meet the second stage of labor, which was greatly reduced compared to the amount of medical students [24].
In addition to the difficulties found in the practical performance of nurses, it is noteworthy the training policy of five higher education institutions, one of each geographic region of Brazil, which showed the presence of disciplines in the area that only met the government proposals centered in pregnancy and childbirth, although there was some influence of social political movements, underpinning the PAISM.There were also knowledge gaps regarding the emerging content in family health, subjectivity, violence and gender issues, among others [26].
Aspects of obstetric training were mentioned in the teaching and learning process of medical school obstetrics area, and these corroborate the findings already listed on the conflicts on the notion of humanization that counteract the care models presented in reality, if compared with the ideal models proposed by professors, putting on the agenda the discussion of the profession ideal itself and of its field of competence [29].
In 2004, there was discussion on the need to modify the usual model of teaching how to care with emphasis on humanization with students of an undergraduate Nursing course, by mentioning that humanization aims to favor a welfare state; that, with awareness, care can have a humanistic character; and that professors can make the human care a life practice [22].
In Northeast Brazil the appreciation of education during specialization aimed at proposing improvements in the performance of nurses who worked in social assistance, reflecting positive results in administration and teaching areas.These results enabled awards for the implementation of care models proposed by the Ministry of Health, such as the initiative of the Baby Friendly Hospital, Galba de Araujo Award, Kangaroo Mother Care, Sunrise Project and Human Milk Bank, encouraged mostly by nurses who were sensitized during training in the obstetric nursing specialization course [18].
Obstetric nurse specialization is encouraged by the Ministry of Health when it proposes to finance specialization courses for professionals working in the health system, which confirms the study conducted in Rio de Janeiro that points out that the State has been financing the qualification of nurses.However, some difficulties were highlighted, such as the lack of leave of absence from full-time jobs to complete the course and the non-participation in delivery care after the end of the course, indicating the need for curriculum reform with emphasis on the humanization care model and the creation of Normal Birth centers [28].
Another factor that hindered the success in training nurses to perform humanizing actions in care delivery by graduate nurses fromobstetric residency at the State University of Rio de Janeiro was the need to improve the theoretical content and the direct supervision of preceptorship, in addition to the great demand of activities, requirements and tasks to be accomplished and poor working conditions even after graduated in the course [32].
It is worth mentioning the importance of valuing education for the humanization of delivery care, by considering the obstetrician nurse as a strategic agent for the implementation of humanization practices [47].Such practices were discussed during the training of nurses and physicians, through awareness-raising workshops, using educational activities with use of body language, body dynamics and relaxation for the development of behavioral manifestations not expressed in words.
These activities, however, were not enough for physicians to incorporate the humanized care model, and the participation of obstetric nurses contri-buted to the incorporation of practices, enabling the dissemination and support of professionals'actions in the humanized model [47].
Despite the positive results arising from professionals' training, several factors have interfered negatively to the achievement of such training in various regions of the country, as in Santa Catarina and Rio de Janeiro, that portrayed difficulties even in 1960 for the implementation of nurses' practice [31].
With an emphasis on nurses' training process to foster humanized childbirth care, it is worth mentioning the initiative of the Brazilian Government, taken in 2002, so that obstetric nurses, indicated by health departments, attended a training course on humanized birth care in Japan.This training aimed to reduce infant and maternal mortality, with the implementation of appropriate practices to support the principles of humanization of care during labor and birth in the SUS [30].This training reflected positively on institutional data, contributing to the expansion of the competence of the nurses involved.Those who participated in the group developed the care protocol for the childbirth center and contributed to the development of creative, less interventionist obstetrical practices, centered on the role of women and in sensitive care [30].
Nurses' professional practice is rooted in the "fragmentation of knowledge in health and nursing areas" as a "dehumanizing factor of care" and can be seen from the need of change in the relations between agents in order to enable the implementation of the Program for Humanization of Prenatal and Childbirth [48].
In Santa Catarina, a study evidenced lack of awareness of nursing assistants, obstetric nurses and obstetric physicians for the importance of humanized care; the authority of the team members who overrode any attitude of women and their companions, enhancing the moment of fragility and uncertainty and the lack of recognition by the team on humanized birth as a professional duty and a women's right [48].In this sense, it is noteworthy the shortcomings found in the professionals'training also derived from the team's ignorance about PHPN guidelines.

Nurses' performance in humanized obstetric care in Brazil
According to the studies analyzed, nurses' performance in obstetric care in Brazil has been linked to the actions directed from the family health strategy [49] to hospital care [33].
One of the actions carried out in the Family Health Strategy consists of educational practices at community level, carried out by undergraduate nursing students during the weekly group meetings conducted in the community, where they discussed issues on preparation for childbirth, breastfeeding, self-care, postpartum depression and baby care [50].
In hospital care, the practice of invasive or noninvasive procedures without well-defined criteria raised nurses' reflection and the recognition that this fact is associated with the knowledge gained during academic training directed by the "medicalized" model of childbirth care.In the professionals'perception, this model can be rebuiltas they perceive themselves as agents with potential for change, able to carry out changes in the environment in which they work, influencing even other professionals to find in their care the basis on which they constituted their practice with an emphasis in the physiology of labor, in non-intervention and in the women's role [33].
Still on the work of nurses in hospital care, some difficulties were expressed by nurses in post-partum care, such as obstetric violence, characterized by the abandonment of women in that period, by the veiled violence in the name of a technique, on behalf of a treatment, as if the woman was ill, in addition to hierarchical gaps that are sharpened, as health professionals, in the particular case of nursing, have power over the body of woman in labor, indicating what to do or even invading it without her permission.This fact indicates a great challenge for professionals, which is the development of the indicators for organization, disorganization and reorganization in search of improving nursing care [35].
In this sense, it is worth mentioning the importance of obstetric nurses, expressed by women in a public maternity hospital in the city of Curitiba / PR, by mentioning that the obstetric nurse is fundamental in changing the care model in the delivery process and the valorization of this professional in institution, as they can significantly contribute to the humanization and the promotion of women and newborn's safety [46].
One of the nursing staff functions in the delivery room is to provide guidance to the mother'scompanion, but often these guidelines are not held by fear of the unknown, especially the lack of ability to deal with an affective interaction towards the woman and her companion [51].
The presence of the companion in childbirth scene has enabled changes in the attitude of professionals, who have developed a more humane and less routine practice.It has encouraged health professionals to rethink the meaning of birth, and has also enabled a more comprehensive care by allowing the expansion of observing the mother and the communication of their needs [51].
In addition to the fragmentation in the training of obstetric nurses, other factors -such as lack of remuneration for performed deliveries, difficulties of nurses in carrying out deliveries in the first years of service, lack of motivation, few qualified professionals in the area, dispute for space, acting just as an observer during delivery, practice restricted to the antepartum and postpartum periods, nurse's role restricted to the second stage of labor and, above all, the strategies of nurses to perform deliveries in the event of strikes by physicians-have not positively reflected for preserve the practice of obstetric nurse in this reality [31].
In primary care, for example, physicians claim to be against the practice of nurses performing prenatal consultations without being specialists in Obstetrics [52].In the hospital environment, limitations for professional practice are related to the institutional barriers, tight labor market, opposition byphysicians, lack of professional recognition and poor working conditions that justify the difficulties of these professionals to stay in this area of expertise [32].
However, these difficulties stem from a hybrid professional identity, which favors accumulation or deviance of functions in professional practice, with the displacement of the obstetric nurse from prenatal and delivery care to other areas of nursing, generating work overload, frustration, demotivation, conformism and submission [1].
It is worth mentioning the fact that the medical model training differs from the standard training of the obstetric nurse, for nursing education is directed to provide care and focused on the physiological, emotional and sociocultural aspects of the reproductive process.In this perspective, the authors propose that physicians and obstetric nurses work in partnership since pre-birth to allow a less interventionist care performed by nurses and a more targeted care of physicians to high-risk cases.Thus, physicians have not strived to incorporate elements of the proposed humanization to their routine and have devalued the use of alternative methods [53].
This fact led to a competition in labor market and favored a valuable discussion so that work is truly performed by the team, involving the simultaneous participation of physicians and obstetric nurses in the process and that childbirth care institutions have widely publicized protocols, conduct periodic discussions on maternal and perinatal outcomes through indicators, and describe the limits and responsibilities of the professional performance [52].

Discussion
The studies in question refer to a reflection on the training and practice of nursing professionals for the humanization of actions in the care of pregnancy, labor and birth in Brazil.
The articles that portrayed the training of professionals showed a gap of knowledge in undergraduate courses, for teaching is still ruled by interventionist practices, so that not all professionals are sensitized to act in a humane way in childbirth care in health services.Although there have been improvements that aimed to improve the humanized care, nursing practice is still supported by the biomedical model [29,54].
For WHO, qualified professionals are those who have skills necessary to provide care during pregnancy, childbirth and the postpartum period, and these may be obstetricians, obstetric nurses, professional midwives or midwives [4].
Authors identifies the studies that discuss obstetric nurses' performance in prenatal care, hospital care, maternity centers, and especially in teaching [55, 16,30,56].These studies have showed that in addition to the gap in undergraduate nursing courses, the quality of teaching in obstetric nursing courses is incipient, and this signaled the need for further investigation through different methodological designs that can portray and deepen the knowledge of the specificities of this training.
It is important to note that the care provided by professionals should be related to education.In view of this, there must be appreciation and investment in the educational process of health professionals who provide care, so that they can understand women who have experienced the labor and birth in a holistic manner.In such a situation, some studies have highlighted that the articulation of knowledge acquired during academic education and care practice may favor the existence of a "medicalized" or a humanized model of care.
Since 1999, Obstetric Nursing specialization courses(CEEO in Portuguese) have been implemented and funded throughout the country through the Women's Health Technical Area, seeking to ensure better access to coverage and quality of prenatal care, assistance to childbirth and the postpartum period.From 1999 to 2004, 76 CEEO were lectu-red throughout Brazil, specializing 1,366 obstetric nurses [57].
This initiative encouraged the development and extension of obstetric nursing residency courses, which are seen as a new educational modality with the potential to qualify nurses with technical skills to provide care under the principles of humanization and scientific evidence.However, this panorama of training has been a substantial educational challenge to be faced by residency programs because of ambivalences and contradictions found in health services that lead to difficulty in practice fields so that students can develop skills in this sense.
In addition to the investment in the training of professionals, it is worth noting the importance of training programs directed by birth humanization programs and policies aimed at awareness.With a view to achieving a humanized delivery care, there is the need of articulating health promotion, health education and care, these that require investments and changes in the training of professionals, aiming at overcoming the biomedical model culture that sustains the "medicalization" of childbirth.
It is worth highlighting the fact that evaluating training is a difficult task, because there has been an effort by educators to insert different proposals of teaching and learning, curriculum changes, insertion of active methods, however, these are hampered by the limitations of the nursing category itself, which is characterized by workload, professional devaluation and lack of incentive on the part of institutional management [44,23,47].
It is important to emphasize the quality of education in undergraduate and graduate programs, and reflect how the practice of nurses under training is largely hindered.In fact, some health institutions have been adapting to the new care model based on humanizing care actions to the woman, however, when in the practice field, it is evident the disputeof professionals to delivery care, the lack of access of the patients and also the large number of professionals in training who seek improving their performance.
So, the suggestion [24] for nurses to return to midwifery is current and valid and thus it might be set a quota so that nurses can provide care during delivery in university hospitals so that they do not cease to learn midwifery and exercise the actions of a space they have already conquered legally through Professional Practice Law, No. 7,498, of June 25, 1986 [57].

Conclusions
This study has allowed the understanding of the intrinsic factors in teaching and practice of nurses for the humanization of childbirth in Brazil, which points to the need for development in the training of professionals for the humanized practice of nurses, whose performance is still hampered by poor working conditions, by the biomedical model that ignores the subjective needs and by cultural factors interfering in care.
There was a paucity of studies in relation to nurses' humanizing actions in teaching and practice.Despite the incentives offered by the MOH policies and programs published since 2000, focusing on the humanization of care, much remains to be implemented.
Practices carried out by nurses were identified in primary care, birth centers, hospital care and teaching that contribute to the "non-medicalization" of hospital delivery care, by enabling the mother to develop skills to control labor.
The study suggests that nursing practice should be guided in the true sense of humanization of obstetric care, focused on less interventionist and more emotional care and on respect for women's sexual and reproductive rights.
The findings evidence the need to expand the debate on humanization of delivery care, overcoming hostility as its implementation, need for greater visibility of the nurse's role in this process, intersectoral arrangements in the professional training and performance.This study is intended to encourage critical reflection of health professionals, professors and students, educational institutions professionals, as well as women, signaling an urgent modification of knowledge and practices that permeate the humanization of pregnancy, labor and birth.
International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Figure 1 :
Figure 1: Search description of articles in databases.

Table 1 .
Description of the selected articles according, year, journal, objectives and study design -Campinas, SP (2015).
Knowing the childbirth care practices developed by health professionals in the care of teenagers in labor.Descriptive 2011 Rev. Brasileira de EnfermagemEvaluating the implementation of a care philosophy of a teaching maternity hospital under professionals' perspective.QuantitativeInternatIonal archIves

of MedIcIne sectIon: obstetrIcs & GynecoloGy ISSN: 1755-7682
Analyze the inclusion in SUS of the graduate nurses from Obstetric Nursing specialization courses of EEUFBA from1998 to 2004, describing the socio demographic and functional characteristics of these nurses and identifying the facilities and difficulties for their performance.
Evaluating the effectiveness of non-pharmacological strategies to relieve the pain of mothers in labor.Quantitative 2008 Rev. EscEnferm USP The construction of the meaning of "non-medicalization" for obstetric nurses.Qualitative 2008 Rev. Acta paul.enfermagem Identifying factors associated with quality of care and possible predispositions to inequities in labor care.Quantitative 2008 Rev. RENE Evaluating the effectiveness of non-pharmacological strategies to relieve pain of mothers in labor.Clinical Quantitative trial 2008 Rev. Cad.Saúde Pública Characterizing hospital delivery care and identifying obstacles and facilitating factors for the implementation of humanized care based on women's perception on the received care.