Solicitude constituting the care of obstetric nurses for women-giving-birth-at-the-birth-house

Objective: This article aims to analyze the constitution of the obstetric nurses' care for women giving birth at the Birth House. Methods: The guiding thread of hermeneutics rests on the vague and median understanding of the obstetric nurses. Heidegger's phenomenology was the theoretical-philosophical-methodological framework. As a contribution of and to obstetric nurses, the hermeneutics of consideration and patience is presented, based on the concept of care inherent to the nurses' existential movement. Participating in the discussion on the right of the nurses in delivery care and quality of care, the Birth House David Capistrano Filho is appointed as a space of care different from the hospital model. Results: As a result, the obstetric nurses' care for women giving birth at the Birth House unveils itself as a construction based on sharing. Conclusion: Involved by this care, the nurse and the woman are in an existential movement that favors authentic care.


INTRODUCTION
The interest in studying the care model developed at the Birth Houses derived from the arguments opposed to the work the obstetric nurses implement there.
The objective in this study is to analyze the constitution of obstetric nurses' care for women who give birth at the Birth House, based on meanings of the experiences and life.In line with the objective, it is exactly the authors' experience in the field of delivery and birth, in the private context as well as in academic education and care practice, that motivated the development of this article on obstetric nurses care.
The discussion about the right to professional practice of nurses in delivery care and the quality of care delivered to users in Rio de Janeiro aroused the problematization in this research.
On the list of elements that constitute the legal support for this activity, Law 7.498 published in 1986 stands out, which rules on the nursing practice 1 , Ministry of Health Decree 985, which created the Normal Birth Centers in 1999 2 , and Federal Council of Nursing 3 (COFEN) Resolution 339, which since 2008 determines on the regulations and responsibilities of the nurse at Normal Birth Centers and/or Birth Houses.In the specific case of the research context, the Birth House David Capistrano Filho, since its inauguration on March 8 th 2004, has been exposed to publications from the perspective of medical organizations.The vast material that circulated among the medical entities discussed the Brazilian legislation about the participation of the medical specialties in delivery and birth, and mainly questioned the nurse-midwifes' competency to attend to deliveries outside the hospitals.Amidst the publications by the Regional Council of Medicine, the records of the 51 st Brazilian Congress of Gynecology and Obstetrics contain the sole justification for the implementation of the Birth Houses: "cities where there are no physicians, in the interior of the country" 4:6 .This gives rise to questions about the strictness or flexibility of the rules to guarantee good care to women in each region of Brazil.
Thus, physicians from all specialties were sensitized with arbitrary arguments.The pages of the medical publications, widely read newspapers and the Internet were overflowing with the theme, including false news items about problems resulting from deaths occurred there, in the attempt to influence the public opinion 5 .On June 3 rd 2009, the Health Service Surveillance and Supervision Division elaborated a document (Termo de Interdição Nº. 02203) to interdict the Birth House.The next day, the State of Rio de Janeiro Secretary of Health and Civil Defense published SESDEC Resolution Nº. 705, which determined the complete interdiction of the establishment 6 .This fact determined a series of other social organization events for the reopening of the Birth House in the city of Rio de Janeiro, such as: the Embracing the Birth Center, on June 09 th ; the mobilization on June 14 th , at Leme Beach, including the distribution of leaflets, summoning people to participate in the demonstration held on the same beach on the 21 st of the same month, and the Public Hearing on June 18 th at the Tiradentes Palace 7 .In the same month, pursuant to a legal injunction the state union of nurses obtained, the Birth House reopened.In 2013, a study indicated the Birth House David Capistrano Filho as a scenario of evidence-based care practices, respect for citizenship and promotion of maternal and fetal wellbeing 8 .
Birth care was studied as a phenomenon that demands a perspective that goes beyond the objective conceptions of the reality of facts, valuing the significations of the experiences.In other words, the delivery was considered as a phenomenon that is manifested and based on the human experiences.
In this paper, part of a research 9 is presented about the care considered as obstetric nurses care for women who give birth at the Birth House.The guiding question is focused on the possibility to understand the ways of being of the obstetric nurses who deliver care at the Birth House David Capistrano Filho and the unveiling of facets of the phenomenon of these nurses' care actions, as the care relation between the nurse and the woman who gives birth at the Birth House.

LITERATURE REVIEW
The historical trajectory of the Western scientific societies progressively overvalued technology to the detriment of nature, which includes the comprehension of health.As from the second half of the 20 th century, the disease logic absorbed the physiological phenomenon of delivery in hospital and the hospital-based model started to dominate the field of delivery.
In Brazil, governmental actions to improve obstetric care gained intensity as from 1998.Specifically in Rio de Janeiro, since the 1990's, the Humanization Policy of Delivery and Birth was linked to the strategy of ranking delivery care, with obstetric nurses attending deliveries classified as low risk.This fact moved the hospital practices and routines, provoking a strong conflict of competences between the medical and nursing categories 10 .
In nursing, as a result of the creation of the doctoral programs, since the mid-1980's, its researchers tend to develop studies on themes related to subjectivity.In that sense, Martin Heidegger's theoretical-philosophical-methodological framework, which discusses the entity to reach the being in his/her existential movement, is coherent with the humanistic principles 11 .In view of the importance of reflecting on nursing care in general, but also about each care situation in particular, Heidegger's framework again provides the contribution needed to approach the theory and care practice, based on the understanding of the phenomena.Therefore, in this research, the care relation between the nurse and the woman giving birth at the Birth House is focused on.
Between the lines of this discussion, departing from the theoretical bases of phenomenology, the aspects of the experiences in the field of delivery and birth can be read.Thus, it is considered that care delivery to women who give birth in a Birth House can be studies as a phenomenon that needs another perspective, which goes beyond the objective conceptions inherent in the positivist perspective of doing science.

Solicitude in the care of obstetric nurses for women-giving-birth-at-the birth-house
Zveiter M, Souza IEO To dive into this theoretical-philosophical field, this research uses the chapter "The being-in-the-world as being-with and being-a-self.The 'impersonal', from the work Being and Time 12 based on the Portuguese translation by Dulce M. Critelli 13 .Heidegger frequently uses the word care as the fundamental structure of being-there and its Latin meaning is: watching over, relating to something.
Differently from other theoretical reflection about the human relationship modes, this theme is not discussed by Heidegger based on measures or standards.Heidegger's theoretical-philosophical framework contains the question that remits to the route to approach the fundamental, which was overshadowed by the knowledge theories and models from the age of exact sciences.Being is the way of something being present, manifest, for someone, to be-there or Dasein.The fundamental characteristics of the human being, what Heidegger calls ontologic, refer to the being-there.Another name for these ontological characteristics of existence is the term existentialist, which refers to the ways of relating and living.
What is immediately perceived is ontic.In the same way as the ontological can be named existentialist, the ontic can be called existential.It is considered that the meaning of human life is being-with another person.In addition, it is being-with that the how of man's relations with other men is specified.Relating to someone in a significant manner is solicitude, which the properties of being considerate and patient.Far from representing moral principles, consideration and patience are way of living with the others, respectively, based on the experiences and perspectives 14 .

METHOD
A qualitative research with a phenomenological approach was undertaken.Qualitative research works with a universe corresponding to the space of relations, processes and phenomena, which cannot be analyzed through operations with variables that can be measured by means of mathematical inference or probability theory.Phenomenology gained notoriety at the start of the 20 th century through Edmund Husserl, who defined it as "going back to the things themselves".Husserl's awareness contains the basic device of intention, and is therefore always oriented to the world, oriented to something and consisting of acts that aim for something 14 .For phenomenology, by looking at things as they appear, what results is their description, not their demonstration.The target established in not to explain, but to reflect in order to permit a view of things, of the way they manifest themselves.The rigor in phenomenology lies in its concern with showing what exists in reality.
The scientific models constitute ways of talking about things.What is being talked about is the entity, which can be defined, in summary, as all things formatted by a discourse.Talking based on the thing also exists, which requires opening up and welcoming the thing in its existence 15 .It can be inferred that this talk based on is what happens in the opening to the being.The being can be defined as what is essential in the thing, what throbs in it 12 .
The choice of phenomenology as the theoretical-philosophical-methodological reference framework is based on the research problem itself.The meaning of care for the being-woman-who--gives-birth at a Birth House is the study phenomenon.The subject cannot be separated from the phenomenon, it is fundamental for both to be joined in the intentional structure of the experience.Therefore, concerned with the singular meanings attributed to obstetric nursing and the Birth House, the intent was to understand the nurses as subjects, whose life worlds is to be revealed and who can indicate a course to access the phenomenon.
The research context was the Birth House David Capistrano Filho, located in the neighborhood Realengo, in the city of Rio de Janeiro.The testimonies in this research were the 18 obstetric nurses from the Birth House, who were heard in phenomenological interviews between May and August 2010.Besides respecting the ethical and legal aspects included in National Council of Health Resolution 196/96, replaced by Resolution 466/2012 16 , approval for the research was obtained from the Research Ethics Committee of the Rio de Janeiro Secretary of Health and Civil Defense, in Opinion 322A/2009.It should be highlighted that this group contains two men, but reference is made to obstetrical nurses in view of the large group of female nursing professionals.
The obstetric nurses were contacted without any premise or preliminary category of analysis.During each meeting, while still during the ontic phase of the research, when asking the question -Talk about the care you develop with the women who give birth at the Birth House -an opening of the nurse entity was promoted.At this methodical moment of understanding, the entity's potential was opened to unveil the phenomenon of obstetric nurses' care for women who give birth at the Birth House.This discovery took the form of a pre-understanding.In other words, when this opening happened, in which the being-nurse-midwife-who-takes-care-of--women-who-give-birth-at-the-Birth-House was determined.This determination took the form of a preliminary understanding they have of themselves, as being, and of the other being-woman-who--gives-birth-at-the-Birth-House.
Considering that, in the phenomenology method, the field phase happens simultaneously with the analysis, the significant contents of the meetings were transcribed, read and understood and closed off when all obstetric nurses from the Birth House had been heard.The inclusion of all professionals was neither predetermined nor a methodological requirement, but derived from the nurses and the researcher's willingness.Thus, a set of possibilities was constructed for the interpretation of the essentiality of obstetric care for women who give birth at the Birth House.The nurse-midwife entities were questioned about the being-there-with of this care, based on and (un)veiled by the singular significations of delivering and being born in a Birth House.According to Heidegger 17 , questioning the being also means having the need to experience what all entities are, without the need to have knowledge about this.Based on the questioning of the entity, an ontic instance, the being was questioned, so as to achieve the ontological instance that permits unveiling the meaning of being.
Solicitude in the care of obstetric nurses for women-giving-birth-at-the birth-house Zveiter M, Souza IEO In Heidegger, the comprehensive analysis involves two moments: the vague and median understanding and the interpretive or hermeneutic understanding.In the subjects' description of the phenomenon experiences, the significations are highlighted.That is the first moment in the analysis, when the understanding is still vague and median.
In summary, the researcher's common steps in phenomenological studies are as follows: 1) suspending the world and its premises to capture the meanings of the other in the purest way possible; 2) opening up to the meanings of the phenomenon, as expressed in the subjects' statements; 3) highlighting the significant parts of the statements, considering them as essential structures of access to the phenomenon that is being investigated, to unveil the senses based on these essential meanings; 4) being capable of understanding the veiled meaning in the signification structures and unveiling facets of the study phenomenon 18 .

RESULTS
In line with Husserl's definition of phenomenology -a science that starts from the description of the experience 14 -the analysis of the meetings with the obstetric nurses of the Birth House is presented.After listening to the recordings a number of times and transcribing them, the significant structures were highlighted which, organized in groups, are called units of meanings.Next, the first methodical moment is presented, which Heidegger 12 describes as vague and median understanding, constituted by two units of meaning that derive from the comprehensive analysis of the meanings the nurses attributed.The caput of these units is displayed in italics and expresses the understanding of the meaning of obstetric nurses' care for women who give birth at the Birth House.
The obstetric nurses' care for women who give birth at the Birth House showed to be:

A care that is revealed since the prenatal period and continues in the postpartum period
The care of the nurse-midwife for the women who give birth at the Birth House starts during the first contact with the women and continues in the postpartum period, and is based on the woman who arrives there.Since the first consultation, the care is.The meaning of care includes contact with the woman.For the nurses, the meaning of care includes the way it is revealed throughout the period the women attend the Birth House.The nurses talk about the meaning of care involving this development, which occurs as from the moment when the women are received at the start of the pregnancy and continues at each contact.The obstetric nurses take care, transcending the moment of the delivery and the pregnancy, and considering all moments of the meeting between them and the women.Thus, care takes the form of a route that permits a comprehensive view of the pregnancy-puerperal cycle.This differs from what happens in the hospital care structure of maternities where actions are developed from the biological perspective, in which the birth is highlighted, considered as the end of the pregnancy process.The care of the obstetric nurses in the care structure of the Birth House showed to be a route mediated by a comprehensive view of the woman who experiences the cycle from the pregnancy until the postpartum.

A construction based on sharing, which involves the nurse and the woman
For the obstetric nurses who participated in this study, care creates possibilities for construction, based on sharing and listening, which facilitates the expression of emotions for the women as well as themselves.It is based on the women's experience that the nurses analyze and propose the care action, they talk about a care focused on what the women say.The meaning of care encompasses the freedom to identify themselves with the women, being friends and confidants.For the nurses, the meaning of care goes beyond the merely technical, involving the best of the human side.As it is not focused on the technique that rationalizes and standardizes the accomplishment of procedures and interventions, this care promotes the nurses' desire to be with the women.The meaning of the care comprises the nurse's listening, arousing respect and the valuation of the women's experiences.Situated in the articulation of a dialogue that involves the nurse and the woman, the care is not centered on the procedural obstetrical technique, based on what Heidegger calls tradition.On the opposite, in that care, the opportunity is offered for the nurses to be with the women, who then choose the ways and technical possibilities related to the kind of delivery they would like to experience.For the nurses, the meaning of the care includes receiving the women, who provide feedback and permit being taken care of.When the nurses are with the women who show that they are suffering, they raise a question that gives room for the women to tell what bothers them in order to be able to achieve a care that she considers good and satisfactory.This involvement also possesses the significant structure of manifestation the nurses attribute to the care.The desire to be with the women is translated in the meaning of the care as a relation of intimacy and proximity, which does not procedure knowledge about the woman, but a relationship with the women.The care permits the trust the women have in the nurses.In addition, it is very gratifying because it creates results based on emotion and freedom.
Before the comprehensive analysis, the opening of the nurse entity happened.This opening was only understood at this methodical moment in the research, that is, the opening of the entity's potentiality to the unveiling of the phenomenon care of obstetric nurses for women who give birth at the Birth House.The units of meaning reveal the provenance of the phenomenon, which lies in the nurses' statements.This nature of possibility "corresponds to the way of being of an entity that is understood" 12:208 .Based on this understanding, the analysis of the ontological dimension of the phenomenological interpretation could be developed, as presented in the discussion.

Solicitude in the care of obstetric nurses for women-giving-birth-at-the birth-house
Zveiter M, Souza IEO

DISCUSSION
After reaching Heidegger's ontic dimension, based on which the meanings of the obstetric nurses at the Birth house could be understood, the ontological dimension is reached, related to the meanings or the direction of being oneself.Hermeneutics, represented by the interpretive analysis, can unveil the meanings of the experience, facets of the phenomenon in question.Through Heidegger's method, one can go beyond the knowledge of what was understood and "elaborate the possibilities projected in the understanding" 12:204 .This relates to the hermeneutical interpretation, removing the concealment provoked by the statements, which were strongly linked to who heard it and which produces the veiling of the senses.
The obstetric nurses' care for the women who give birth at the Birth House shows to be a construction based on sharing, which involves the nurse and the woman, who facilitates the expression of emotions, of both.Another fundamental structure of the being-there is the being-with, which means someone in the presence of the other 13 .That is the characteristic and basic way of the human being to establish relations and live, which is called "existentially".
The nurses, in their way of being-for-the-others, are available to the women.When relating with the nurses, the being-women--who-give-birth-at-the-Birth-House establish this relation in a way that is involving and significant.Heidegger 13 calls this way of relating solicitude, whose main characteristics are consideration and patience, or tolerance towards the other.In the way of being of solicitude, the being-there "is linked to its being in relation to the world of his care and, similarly, to his authentic being in relation to the self" 13:41 .
In the characteristic consideration, the nurses have contact with the women, considering everything that was experienced since the prenatal phase.The nurses' being-there-with is with the women, considering the women's experience in the world.In this way of being, the nurses' care for the women who give birth at the Birth House is a care as a form of consideration, since each time the nurses take care of the women, they consider their current and preliminary obstetric history.Thus, they pay attention to the pregnancy and the adaptations that were necessary in the physical body, as well as in this women inserted in society in general and in the family, particularly determinant of the ways of being in the public, surrounding and own world.Care happens in the course of social life, opening in the relationship.Women are beings-in-the-world, they are considered as they are.

[...] I assess, according to what she tells me. About her life history, right, about her experience (Nurse 2).
It is important to observe that the consideration of what is experienced in the course of the meetings during the pregnancy also involves each prenatal consultation at all times.When the woman arrives to give birth, she is considered with her history.Thus, the other part in this care is not someone who suddenly arrived, at an abrupt and emergency time, to give birth at the Birth House.
Care ranges from the moment when she comes for the first prenatal consultation (Nurse 3).
[...] we know the woman, then we know more or less what will affect here during the delivery (Nurse 17).
Thus, the obstetric nurses' care for the women who give birth at the Birth House considers the entire prenatal period, beyond the information on the pregnant woman's file, as it includes the life lived and experienced in a singular manner.Science established the file and the obstetrical technique, which are necessary but, as they do not personalize the women's being, they are insufficient for the development of obstetric nurses' care at the Birth House.Although they are also appreciated and respected, as part of the pregnancy and delivery experience, they neither replace nor favor the possibilities that exist in the joint life and mutual sharing that were signified.
We feel this energy, because we participate together with [...] So… if I like to be well-treated and I identified with that philosophy (Nurse 16).

[...] of you being with the woman at that moment, with the family (Nurse 18).
Being patient means presupposing and waiting for something to happen 13 .Considering the women, the obstetric nurses' care takes the form of patience.Patient care when considering the women as parturient beings are seen as people who have the potential to give birth, who will give birth based on their own and sufficient resources.This view is not predetermined by the person who accompanies the woman giving birth at the Birth House.Thus, the care-for-the-woman-giving-birth-at-the-Birth-House demands patience.
Sometimes they are crying anguished, feeling pain, you think that she's giving birth [...] and then she tells everything, she puts it all out.And when the care ends, she leaves feeling well, very well [..

.]. I think that's fundamental in care [...] I always prioritize, a lot, beyond the technical issue [...] I attempt to engage a lot (Nurse 6).
Solicitude is the paramount characteristic of care, which in turn has two ways, which are: the first is its deficient way.It occurs when someone assumes the other's task of taking care of him/herself, dominating him/her.In Heidegger's words 13:41 "jumping in for the other".This way, the other's solicitude is excluded from its place and becomes dependent on who is taking care.At the hospital institution called Maternity, the tradition of obstetrical Solicitude in the care of obstetric nurses for women-giving-birth-at-the birth-house Zveiter M, Souza IEO science tends to determine health team members' making the decisions.In general and in most cases, the Maternity clients are considered as pregnant women, in a joint view with some or other characteristics -low, medium and high-risk group -; parturient women with indications for vaginal birth, or surgical birth; puerperal women in rooming in.Tradition describes the object of care during pregnancy, delivery and postpartum in its different forms.Through evidence-based procedures, the women are considered homogeneously in the care process.In this solicitude, the other can become overpowered and dependent "even if this domination is tacit for him or if it remains hidden" 13:41 .
The other form of solicitude is, instead of manipulating the other, "anticipating" him/her" 13:41 .In this mode, what happens is a care that favors the development of the other who, focused on the self in an authentic manner, unveils his/her own possibilities.Heidegger distinguishes this form of solicitude as authentic care.This form of solicitude takes care to allow the other to be free for him/herself.At the Birth House, the study context, the obstetric nurses take care of the women as a subject and not an object.In this care, as a form of solicitude, the women become clear to themselves and gain freedom to experience their pregnancy, giving birth in their way and being-with-their-child at the moment of birth.In the solicitude, the nurses' being-there shows to be linked to their being in the world of their care, being authentic to themselves.The women themselves permit this authenticity, showing themselves as the source and reason of the care.It is considered that there is no pregnancy without concept and no delivery without parturient.
The contact here is very different.[...] here we have the opportunity, together with the client, right, because we favor that for her.For her to choose the technologies she'll use, what type of delivery she would like (Nurse 4).
Care from the Birth House is different from care at the Maternity, a traditional hospital context, as it only happens based on the women who acknowledge themselves as beings with possibilities.It is considered that, in the course of prenatal care, the women gradually unveil themselves in the relationship with the nurses.In that sense, they can get to know the women and count on their potentials to generate, give birth and take care of their own child.The contacts between women and nurses are not watertight, there is a continuity, a movement of accompaniment in the course of the pregnancy, delivery and birth experience and life-with-the-child.
The first contact with these women is during the prenatal consultation… my care is developed in that… in that course, in these periods when this woman comes here (Nurse 2).
We attend to the woman since prenatal care [...] at all times, since the first until the final contact (Nurse 4).
In addition, the history preceding the woman's arrival at the Birth House includes her intention to participate in the care developed there, even before experiencing it.She has some experience with the Birth House, considering and being considered by who works there.When they reflect on their care, the nurses are also being-there, the care for the women who give birth at the Birth House permits the nurses' being-with-possibilities.

CONCLUSION
This paper discussed the phenomenon care of obstetric nurses for women who give birth at the Birth House David Capistrano Filho and, in a search that considers the facets of this phenomenon, unveiled solicitude as its fundamental characteristic.Interpreting the 18 nurses' testimonies, it could be understood that this solicitude appears in the authentic care mode.This possibility arose when relating the concepts of consideration, patients, proximity, dialogue and attention, based on Heidegger's philosophy.
In the obstetric nurses' authentic care as a form of solicitude, the women consider they are free to experience their pregnancy, their delivery and being-with-their-child at the moment of birth.In other words, they conquer themselves.The nurses are also free in care, they liberate themselves from the obstetric tradition's care mode, without neglecting the physiological needs of the bodily processes, dedicate themselves to the care that originates in the women and is constructed at each meeting with each woman who gives birth at the Birth House.
This care considers all experiences since the women's arrival at the Birth House and goes beyond, considering their life trajectory.By relating with the nurse in an involving and significant manner, the being-woman-who-gives-birth-at-the-Birth-House opens up, moving beyond the content of what can be registered in the files and prenatal forms.Thus, considering the women, the obstetric nurses also open up, being-with-the-women in care.
The obstetric nurses' care for the women who give birth at the Birth House demands patience or tolerance.The nurses are patient because they know that the woman can go through the pregnancy healthily, and is also capable of giving birth and taking care of her baby.The nurses await the development of the pregnancy patiently and the happening of the delivery, according to each woman's potential as a being with possibilities.
Both the nurses and the women depend on the self-conquest this care grants.That is so because the care happens in the relation, based on and shared with the women.Linked to the public health policy, the manuals have this hidden intention, but do not express this, because they do not consider the how but the what of care.
This study participates in the discussion about the nurses' right to professional practice in delivery care and the quality of care delivered to users in Rio de Janeiro, indicating the Birth House David Capistrano Filho as a singular care space, differently from the hospital model.The obstetric nurses' care for