Reflections in the literature on the performance of nursing to prevent obstetric violence in primary care

This research aims to search, based on the scientific literature, the main concepts, and practices of obstetric violence, emphasizing the importance of the nurse's role in the prevention of this practice with an emphasis on qualified and effective prenatal care. This is an integrative literature review carried out in the main databases, where the studies found in Portuguese were read and with a time frame of five years (2017-2022), and after analysis, 15 articles were selected for sampling. Final. Regarding obstetric violence and nursing care aimed at preventing this practice, it is essential to conceptualize about the practices of violence that occur prepartum, delivery and puerperium (PPP). We emphasize the importance of health professionals offering quality, effective, individual, and humanized care, solving and clarifying all doubts and legal rights that are guaranteed by law to pregnant women and their companions, in addition to reinforcing the need for a trained team that knows how to handle, identify and intervene in V.O. From this, the need for actions aimed at education to face obstetric violence by nurses is reinforced and it is expected that the analysis of the topic in question will serve as a subsidy to lead to public guidelines and policies that are carried out by professionals against violence to obtain satisfactory results regarding the safety of these women and the reduction of these practices, the development and training of these teams.


Introduction
Until the mid-eighteenth century, childbirth was a natural event, with a predominance of activities performed by midwives. With the advancement of technologies and migration from home births to hospital births, this biological event is no longer the protagonist of the woman and now is understood as a medical practice, where the professional takes the lead and starts to lead this entire process (Zanardo et al, 2017). However, with the passage of time and changes in the form of delivery, different types of deliveries emerged: natural, cesarean and forceps. All these usually occur in the presence of trained professionals such as doctors and/or obstetric nurses to assist them, uses of septic techniques, medications, and maneuvers that would help contribute to the acceleration of childbirth. Implementation of innovative technologies has brought benefits, but also contributed to the dehumanization of childbirth and opened the way for obstetric violence (OV) (Ismael et al, 2020).
According to Bernardo et al (2020), OV can be understood as a set of practices carried out by a professional, whether healthy or not, who provides any form of care for women in their pregnancy phase or in the puerperium, whether in prenatal care or in-hospital care. OV can be classified in several ways : physical, sexual, moral, psychological, institutional, and verbal; and imply harmful consequences, loss of autonomy, protagonist, and freedom to choose their birth and birth plan. It consists of the violation of rights in the short and long term, such as lack of information, autonomy, and consent to interventions, without forgetting to mention that the practices are mutilating and harmful, mostly carried out without the authorization of the parturient, where they stand out episiotomy and Kristeller's maneuver. These, which are used without restrictions, where a need is claimed, are most often used with a single objective, which is to accelerate childbirth (Conceição et al, 2021).
Hence, the scope of this paper is centered around the impact of this topic previously addressed in primary care practice, with deep reflections on the context of violence, especially obstetric violence. A hidden dehumanized acts in the context of OV, in direct ways and even indirect, contribute to maternal morbidity and mortality, could be considered a complex problem of public health and obstetrics issues.
This study aimed to present the general concepts and practices of obstetric violence, highlighting the importance of the nurse's role in prenatal care as an instrument to prevent obstetric violence. Additionally, the objective of the review was to discuss the evidence of different forms of obstetric violence, evidencing its practices, and identify the role of nurses and their role in prenatal care as a way of preventing obstetric violence. Therefore, because of the above, this work was based on the Research, Society andDevelopment, v. 11, n. 12, e380111234668, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i12.34668 3 following guiding question: What is the role of nurses during prenatal care to prevent obstetric violence found in the scientific literature of the last five years?

Methodology
The present study is based on an integrative review of literature on obstetric violence and nursing care, defined as a mechanism for obtaining, assimilating, diagnosing, and summarizing the publications related to a specific topic. It makes it possible to carry out an extensive analysis of the literature, including debates about methods and results (Ganong, 1987;Whittemore & Knafl, 2005).
The database of search was conducted on SciELO, BVS/BIREME, Latindex and Google Schoolar, using the keywords "Obstetric Violence", "Nursing Care" or "Humanized Childbirth". The descriptors were crossed using the Boolean operator "AND" for a simultaneous search of subjects. The inclusion criteria considered qualitative or quantitative empirical research, written in Portuguese, and the search was limited to the period 2017-2022. The exclusion criteria were articles that, although addressing the theme, writing in languages other than Portuguese, not found in the selected period time, repeated in the databases, incomplete, theses, article on book and chapters. (Galvão & Pasani, 2015;Page et al, 2021) After the review, the eligible articles went through a standardized data extraction process as shown in the Figure 1.

Results and Discussion
To compose this study, 15 articles were selected, 6 (40%) of which were studies from 2020 which were predominant on the subject and the other 5 (33%) from the year 2021, 1 (7%) from the year 2019, 1 (7%) from the year 2018, 1 (6%) from the year 2017 and 1 (7%) of the year 2022 as shown next in Graph 1:  (2022) A total of 15 publications were selected, read in full length, which are listed in Table 1 with some conclusions by the authors of each paper. The present study shows us an increasing number of cesarean sections, the loss of women's autonomy over the decisions of their birth, highlighting the mistreatment and reinforcing the perspective of seeking professional training to improve and contribute to the issue of gender violence against women, providing you with safe environments and quality service. With the advancement of technologies and processes to accelerate the birth mechanism, women in their pregnancy stage have fears and apprehensions of childbirth, due to their own previous experiences or reports from acquaintances, so there is a great need for greater knowledge, information and prevention measures and this highlights nursing as an important part at this time, both in prenatal care and birth. Attention to the different types of obstetric violence: disrespect, negligence in care, verbal violence, abusive and unnecessary use of interventions, abuse of power, aggressive and dehumanized treatment, neglect of information to women, prohibition of the right to a companion and social and racial discrimination. To describe the performance of health professionals in a Basic Health Unit of the Municipality of Belém, on obstetric violence with a focus on prenatal care.
Descriptive, qualitative, experience report type study.
It was possible to observe that just like the professionals, pregnant women, puerperal women, do not have much affinity with the topic of OV, with a lack of knowledge, this highlights the importance of deepening the theme through the training of these teams and passing it on to patients, since that these professionals are responsible for health education.

5
Lima et al To analyze scientific evidence regarding obstetric violence and the performance of the nurse in its prevention. Literature review.
The main maneuvers and practices that characterize the OR were identified through the study, among them: Kristeller maneuver, episiotomy, excessive vaginal touch, verbal and emotional aggression, indiscriminate use of oxytocin, as well as the restriction of companions. In addition to presenting some measures applicable to nursing professionals in order to prevent such practices. 6 Neto et al This article aims to develop an analysis through an integrative review on the relationship between women's health and obstetric violence in the context of childbirth and birth in Brazil.
Literature review.
The study shows us that hospital obstetric violence from reception to time of delivery and postpartum care, both for the mother and the baby, impact significantly, interventions such as vaginal touches, excessive medication, episiotomy, disrespectful attitudes, making the woman feel silenced, in this context humanization and actions on the part of professionals are in fact very important to welcome and promote a safe practice and complete care with this woman before, during and postpartum.

7
Oliveira; Elias; Oliveira (2020) Understanding the meaning of obstetric violence for women. Study qualitative, with a Heideggerian phenomenologi cal approach.
The importance of offering information, clarifications and instructions throughout the prenatal period is highlighted, with the professionals responsible for ensuring health and dignity in all care, in order to provide knowledge for the identification of OV.

8
Costa et al (2020) To describe the health education carried out during prenatal care to prevent obstetric violence.
Experience report.
The study showed the importance of prenatal care as a tool to prevent VO practices and how educational actions on the subject are relevant, guaranteeing autonomy and security for these women in terms of mother-baby binomial.

9
Ismael et al Describe the violence obstetrics and nursing care in the promotion of safe delivery.
Literature review.
The study showed a higher incidence of VO practices in the hospital environment and highlighted the importance of the nurse's role in this scenario, through humanized, safe and effective care, in addition to the need to implement strategies aimed at health education and monitoring throughout prenatal care as a way to combat obstetric violence.

10
Conceição et al (2021) To analyze how the health care offered by health professionals during prenatal care can contribute to the prevention of obstetric violence, Literature review.
The study reports on the dehumanized and automatic care of professionals and emphasizes the importance of preparing professionals since graduation, in addition to the need for effective public policies that reinforce this issue and care for women.

11
Marinho et al (2021) To describe the importance of the nurse's role in preventing obstetric violence.

Literature review.
Obstetric violence is a fact that greatly impacts women, causing them to be afraid of that moment, whether by any type of physical or verbal violence that wants to or does not end up violating the rights of your body, the nurse is the professional who is included in every pregnancy-puerperal process, it is very important to bring information and qualified listening to these women promoting empowerment and strengthening them at this very important time in your life.

12
Feitoza; Niculau e Menezes (2021) To analyze cultural aspects intrinsic to obstetric violence in Brazil.

Literature review.
The analysis of the study showed that obstetric violence occurs all over the world, whether due to cultural aspects, low economic level, lack of knowledge of women and professionals who place themselves in a position of power, imposing and removing the autonomy of patients and their own choices.

13
Ribeiro et al (2021) Describe how obstetric violence is characterized in scientific production in the last 12 years. Literature review.
It highlights the practice of abuse during childbirth (episiotomy, forceps, Kristeller maneuver), exaggerated administration of synthetic oxytocin, physical, emotional and sexual abuse by the intimate partner, lack of information regarding fasting during labor and use excessive vaginal touching.

14
Rodrigues e Rockembach (2021) To identify the importance of the birth plan for pregnant women who undergo prenatal care in primary care. Literature review.
The birth that used to take place in the comfort of the home over the years became hospital environments with teams that most of the time are not qualified enough to promote the reception of these pregnant women, making them pass unnecessary interventions and situations, it is emphasized the importance of care from the first consultation in a health, the bond created with the nurse and during these consultations the information about their rights and the way to give birth, approached the importance of having a plan of childbirth so that this pregnant woman has her wishes respected. Physical and verbal abuse cause psychological impacts, as do enemas, episiotomy, absence of a companion, cesarean without indication, lack of analgesia, in this aspect, the importance of care in all phases of care is highlighted, being the nursing a fundamental piece: promoting programs and training for make pregnant women aware of their rights and ensure that these women are treated more humanely.

Obstetric violence and its practices.
We can conceptualize obstetric violence as a lack of respect for women, their bodies, and all their reproductive capacity (Feitoza et al., 2021). In addition, it can be characterized by any and all relevant actions carried out by health professionals, about to procedures that involve female reproduction and that transgress their bodies, resulting in psychological trauma (Conceição et al, 2021).
According to Lima et al (2020), the following can also be added to the definition of OV: interventions seen as routine and mostly unnecessary; excessive medicalization to accelerate the physiological process of childbirth; abuse, verbal and psychological aggression; shortage of materials and inadequate and/or insufficient infrastructure; practices performed by professionals without the consent of pregnant women and postpartum women with the absence of necessary information, birth plans or clarified doubts, whether due to cultural, economic, religious or ethnic distinctions.
According to Ribeiro et al (2021), fasting practices related to labor, the indiscriminate use of synthetic oxytocin, and lack of emotional support for the woman followed by orders of silence, nicknames and maneuvers are considered violent and unnecessary. Lima et al (2020) show in their studies the most frequent practices, namely: episiotomy, restriction to companions, repetitive vaginal touches, Kristeller maneuver, verbal, and psychological violence and lithotomy as the only position to give birth. In addition, consequently, it can mentioned that the psychological damage caused by these interventions, which include feelings of fear, anguish, anger, impotence, and even traumas that imply the decision not to develop other pregnancies .
In 2010, a study was carried out by the Perseu Abramo Foundation, as cited by Bernardo et al (2020), which was concluded that within the Brazilian reality, one in four women suffers some type of OV. This same study reinforces the fact that this aggression is a violation of Article 5 of Human Rights. In addition to infringing Article 196 of Section II of the Federal Constitution of 1988, where, in short, it is understood as "no one being subjected to torture, treatment or cruel, inhuman and degrading punishments" and the declaration on "health being everyone's right and a duty of the State", respectively, bringing to light the role of the State as a way of guaranteeing political, social and economic measures to reduce the risks of diseases , grievances and defend universal and equal access with actions and services that guarantee the promotion, protection and recovery of the individual.

Nurses' performance in prenatal care as an instrument to prevent obstetric violence.
Prenatal care consists of consultations carried out monthly and interspersed by doctors and nurses, which in turn are offered at the Basic Health Units (UBS). These units are reference points of the health system for pregnant women (Costa et al, 2020).
Carrying out prenatal care is extremely important because, in addition to serving as a preparation for women for the phase of motherhood, it aims to identify early pathologies and possible diseases that put the mother-fetus binomial at risk and provide a healthy development for both. Especially when we take into account that with this monitoring, changes in habits are possible, such as adequate nutrition, folic acid supplementation, reducing and/or abandoning alcoholism, smoking; All with the aim of reducing maternal and neonatal mortality rates, with reducing the risk of miscarriage, neural tube defects, stillbirth and low birth weight or premature newborns (Bernardo et al, 2020).
It is worth mentioning that according to studies by Oliveira, Elias, and Oliveira (2020), in the nursing consultation carried out during prenatal care the professional-pregnant bond is established, where the nurse is responsible for fully welcoming the pregnant woman and her companion. In the study, the importance of the nurse's role was highlighted. Since it is the responsibility of the professional to provide information to pregnant women, solve their doubts, clarify their rights as users of the health system, and safely guarantee their rights and dignity of these women throughout the care at the UBS. In addition to showing that this professional must, together with his team, build a strategy to prevent OV, always respecting the role and autonomy of women throughout the prenatal period and bringing up important issues for the team as empathy, humanization, and ethics.
Welcoming is the ideal time for health professionals to be attentive, available and interested in listening and understanding the expectations, fears and anxieties of these pregnant women, clarifying all doubts about pregnancy. In this way, the professional can analyze and instruct this family in the best possible way, within the presented context, with qualified, individualized care and ensuring that this pregnant woman feels safe, aiming to avoid future situations of stress and anguish (Neto et al, 2020).
Creating conversation habits on the subject with these women can be considered another form of prevention, since, by using conversation circles among these pregnant women, an environment of trust is established, creating bonds and exchanging information, with clear, frank conversations favoring the exchange of experience, when multiparous, they can share their moments, anxieties and doubts. (Lima et al., 2022) It was evidenced by Oliveira, Elias & Oliveira (2020) that another way to prevent obstetric violence is directly associated with childbirth planning and compliance with humanization actions established from childbirth to the puerperium.
This same birth plan can be used as an instrument for reflection and knowledge about women's fears and needs, through relevant information and offering support to patients.
The studies by Marinho, et al. (2022) and Rodrigues and Rockembach (2021), addressed educational processes, emphasizing that they are important tools that should be adopted, as a strategy and guarantee of quality and safety in care with the objective of training professionals, aiming to reduce the complications that they often occur due to lack of information, since most of these women do not have the slightest knowledge about obstetric violence or physical and physiological changes that their body will undergo during this period of pregnancy.
The prenatal consultation is a valuable tool where there are exchanges of experiences, learning aimed at a better mother-baby development. Thus, when carrying out health education, the main objective is to prevent OV. The appointment effectively favors not only the pregnant woman, stimulating and serving as an incentive for these women, strengthening their self-confidence and emphasizing their role in childbirth and decision-making power in the face of procedures that involve their body, but also guides them on the physiological processes and on the procedures that involve childbirth and the puerperium. (Costa et al, 2020).
In this context, it is of great importance that nursing professionals, in addition to having technical knowledge, are attentive and involved with psychological aspects. So that they can listen, understand, and welcome these women, offering all the necessary emotional support and respecting their autonomy, fears, and anxieties. In addition to demonstrating their commitment to the profession, receiving this woman with respect, ethics, and dignity, to rescue her active role in the gestation process. It is noteworthy that younger professionals showed greater flexibility and interest in good practices and humanization when compared to older professionals who showed resistance to changes involving women's health care because according to reports, the perception of normality in the face of these practices ended up naturalizing obstetric violence (Ismael et al, 2020).
Thus, there´s must be a change in the obstetric care model, which can be through the curriculum in the training of these professionals to differentiate the traditional training that is already rooted in the health system (Moura et al, 2018). In addition to emphasize the role of nurses as professionals who are trained and able to develop educational strategies and actions that promote mother-baby health, whether through lectures, campaigns, conversations with pregnant women and an integral reception, in a way that with this professional to create a bond and participate directly in stimulating this protagonism, autonomy and guidance to these pregnant women in an effective and humanized way (Costa et al, 2020).

Conclusion
The analysis of the articles he responded to main question of this study, concluding that the nurse has an extremely important role regarding these practices and their performance, emphasizing that it is this professional who has the greatest bond and accompanies these pregnant, being yours responsibility to clarify, resolve doubts and guide the pregnant woman about her rights, procedures performed, through a qualified, effective, complete and humanized care, guaranteeing and ensuring that this woman is fully prepared and oriented on the pregnancy and postpartum process. Finally, the need to expand the development of this theme in the scientific field is highlighted, considering the great social and individual impact.