RESEARCH ARTICLES

Promoting mothers' care for premature neonates: the perspective of problem-based education in health

Bárbara Bertolossi Marta de Araújo^I; Benedita Maria Rêgo Deusdará Rodrigues^II; Sandra Teixeira de Araújo Pacheco^III

^I Mestre em Enfermagem. Professora Assistente do Departamento de Enfermagem Materno-Infantil e Doutoranda do Programa de Pós-Graduação da Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil. E-mail: betaberolossi@gmail.com
^II Professora Titular do Departamento de Enfermagem Materno-Infantil da Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil. E-mail: benedeusdara@gmail.com
^III Professora Adjunta do Departamento de Enfermagem Materno-Infantil da Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil. E-mail: stapacheco@yahoo.com.br
^IV Recorte da tese de doutorado intitulada O cuidado materno em neonatologia: o discurso da educação em saúde na perspectiva do profissional de enfermagem, Programa de Pós Graduação da Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro, 2015.

DOI: http://dx.doi.org/10.12957/reuerj.2015.14779

ABSTRACT

This study discusses health education inspired in the problem-based education of Freire, with a view to nursing staffs' promoting emancipatory care by mothers for their premature babies. It focuses first on care by mothers in a neonatal unit, followed by problem-based education in health, and nurses' promotion of maternal care in the neonatal unit, all based on the principles of dialog and respect for others. Health education inspired in Freire's problem-based education should form part of the praxis of nursing teams, and especially of nurses. In this way, the premature baby's mother may be enabled to participate in care for her child, and in decisions on therapeutic conduct towards the child, thus redefining her place in the neonatal unit. Keywords: Mothers; premature; health education; neonatal nursing.

INTRODUCTION

Infant mortality has declined significantly in the last thirty years worldwide. In Brazil, despite the its substantial reduction of approximately 75%, far higher than the world average of 40%, it still remains above the figures for developed countries^1-3.

However, even with advances in the field of neonatology, since the end of the 80s, neonatal mortality is the leading cause of infant mortality in Brazil. Improvements in assistance and access to health, as well as the increased fetal viability, draws these death causes to the early neonatal period and points out the needs of changing in health care⁴.

In this respect, the public policies implemented, the investments in technology and specialized care, have been ensuring the survival of neonates with weight and gestational age bellow standards. In addition, some functional disorders such as motor, cognitive and sensory neurological disorders, along with delayed growth and development, and social and family repercussions have become public health problems⁵.

The incorporation of the premature being in society goes through a series that are closely related to factors correlated to mental, social and family health. In this perspective, the family, especially the mother, should be considered an ally in the process of growth and development of premature infants since their birth⁵.

Since the first contact with the premature baby it is essential the mother to have support to meet the child, in a way that she can identify their skills, competencies and understand the responses by the infants through their interaction with the environment.This support can be offered through promoting maternal care⁶.

Maternal care is a set of environmental and biopsychosocial actions that enable full attention to the mother and her child, so that he or she may develop well by the mother's side. Among the benefits of maternal involvement in the care of premature children, we highlight significant weight gain of the baby, the promotion of neuro-behavioral and cognitive behaviors of the child, the brain architecture modeling, and improvements in clinical treatment such as reducing the levels of dependence on artificial ventilation, early nonnutritive sucking development and the autoregulation. Finally, maternal care is also responsible for reducing the length of hospital stay, the caring costs, the demands in units of 24 hours emergency care after hospital discharge, and the number of readmissions in hospitals^7.8.

Given the above, this study focused on theorizing about the importance of health education inspired by the problem-based education system of Freire ⁹, which aims at the promotion of emancipatory maternal care to premature baby by nursing staff. Thus, it initially focuses on the importance of maternal care that is provided to the infant in the neonatal unit, then on the relation between the questionable health education and its principles and the promotion of maternal care by neonatal nursing.

In this regard, this study is justified by the relevance of maternal care in the empowerment of woman-mother and the benefits that come from this transformation in the care the premature children.

Maternal care in the neonatal unit

The commitment of maternal care to the newborn is directly related to emotional ties established between mother and child. Similarly, when the mother sees, touches and takes care of the child, she promotes the narrowing of the affective bonds.This phenomenon of concern and affection leads the mother to becoming committed to the child who is under her care during the first months or years of life 10.The power of this affection allows the mother to develop necessary sacrifices for the baby care, assuring protection, concern, provision of the child's needs at the expense of their own needs, day after day, night after night ¹¹.

Maternal care is of fundamental importance for the growth and development of premature newborns and the nursing team is responsible for providing subsidies along with the mothers to make it suitable, effective, emancipatory and responsible.

The simple stay of parents in the neonatal unit, as well as the stimulation to the touch and conversations with the premature infants can favor the development of deep and long-lasting affective bonds. This connection develops positive effects on growth and development of children. Thus, the baby snuggling by the parents, even when they are in incubators or under technical aid, should be encouraged.This contact promotes increase of the body temperature of the baby, which works in favor of weight gain and the health recovery of the premature child ⁴.

Touching is considered an essential tool to stimulate the development of the bonding. So when the mother touches and takes care of the child, the emotional bonds between them begin to narrow. Touching also has fundamental importance in reducing the maternal feeling of incompetence and the fear of handling her own son, because of their tiny and fragile appearance.The stimulation of touching makes them feel included in the child care process, as they starts to have more security in performing simple care and then trusting their mother skills after hospital discharge^12,13.

Problematizing education in health

Health education as a political-pedagogical process requires critical and reflective thinking. This allows clarifying the reality, and proposes transformative actions that foster the autonomy and empowerment of individuals as historical and social subjects with the ability to propose and give opinions about health decisions for themselves, their family and their community care¹⁴.

Thus, the concept of health education is anchored in the concept of health promotion, which deals with processes directed to the participation of the population in their daily life and not only sick people or the ones at risk of becoming ill. This understanding relies on the concept of health as a positive and dynamic state of well-being, integrating physical, mental, environmental, personal and social aspects¹⁴.

The Health Education inspired by Freire's thoughts witnesses his hope in a better world, and attests his ability to fight, his respect to different realities and his consistent presence in the world. Thus, in order to educate in health, one must be open to understanding the geographical, social, political, and cultural boundaries of individuals, including their family and their community ¹⁵.

The problematizing education envisioned by Freire is based on creativity, the stimulation of actions and the pondering of reality in order to meet the real mission of men. Therefore, this format of education is founded on the concept of man as a historical and authentic self, who is engaged in research and creative transformation ¹⁶.

Considering men as historical, unfinished and inconclusive beings, leads us to understanding that they are capable of choosing, deciding, transforming and fighting politically and ethically, in order to set up anthropological and philosophical bases for a problem-based education with emancipatory purposes ⁹.

The problematizing education conceived by Freire holds as one of its principles the act of teaching without transferring knowledge or content, but prompting the creation of conditions for its production or construction through an educational process based on dialogicity. In this format of education, Freire defends the discussion about the union between action and thinking. Also, he argues that there isn't an educator without a student, and that once the differences of each of the parties are preserved, they both become subject and should not be reduced to the condition of object of one another. In this sense, teaching and learning are reciprocal ¹⁷.

Dialogicity in health education

Dialoguing is a human phenomenon capable of revealing something that represents oneself, which is therefore the "word" and its elements. In the "word", we can observe two dimensions, the action and the reflection, expressing the practice and enabling the transformation of the world ¹⁷.

In the inauthentic "word", reality can not be changed, once it is depleted of its dimension of action, which also sacrifices the thinking and turns itself into "wordless", verbalism and "hollow word". However, when the thinking is sacrificed and the action emphasized, the "word" is turned into activism, denying the practice of action and making dialoguing impossible. In this thinking, the authentic "word", which means work, practice, transformation of the world, is a privilege of all men. It should never be told by anyone standing alone, not even prescribed for other human beings ⁹.

Dialoguing is the meeting of men, mediated by the world, in order to pronounce it, without letting go the relationship "me-you".Thus, dialoguing imposes itself as a way in which men receive their meanings as humans ¹⁷.

So, dialoguing can not be an act of depositing ideas from a subject in another or even the exchange of ideas to be consumed by each other. It is not a controversial discussion between subjects who seek to impose their truth. Dialoguing is the lonely encounter between the thinking and the acting of its subjects, addressed to the world to be modified and humanized.The dialogicity begins from the moment that the teacher-student wonder about what he or she will dialogue with their students in process of education, which is caring about the content of the syllabus⁹.

Therefore, the dialogic relationship becomes a relationship of rights and citizenship, in which the professional works horizontally with the user and not for him.

From this perspective, promoting maternal care in the neonatal unit through dialogue is an act that should be part of the practice of the nursing staff and, in particular, the nurse. Because, through the theory of dialogicity created by Freire ^9.15-17, people can wake up to the critical awareness of the world where they are, coming out of their oppressed condition to the condition of being more in the midst of the process of humanization, in response to their human vocation.

The promotion of mother care by the nursing staff

During the hospitalization of premature newborns in the neonatal unit, the nursing staff must establish effective communication with mothers in order to instrumentalize them and empower them to participate in the care of their own children. The participation of mothers helps to minimize the effects of deprivation and isolation of infants, and may reduce traumas from therapeutic processes¹⁸.

In addition, the safety and tranquility that come from the mothers during the child's hospital stay in the neonatal unit, can be reached when the mothers are taught to look after the baby, guiding and solving questions about the health conditions of their babies and about the caring to be given. The mothers who participate actively in the care of premature children and in the decision making processes during hospitalization in the neonatal unit, develop more skills and have less anxiety when they take responsibility of caring for the child after discharge^6.19.

In this perspective, the nursing staff should encourage mothers to see and feel their children, besides guiding them from the moment of the baby's admission to the neonatal unit. They must enhance aspects related to the baby characteristics, becoming able to provide guidance on breastfeeding, hygiene, cares with the umbilical stump, vaccines, prevention of respiratory and gastrointestinal infections. They also need to teach those mothers procedures for the common premature complications (regurgitation and colic), bath, diapers changing, bandages, medications, sleep and rest, heat loss prevention and baby overheating⁶.

It is necessary, however, that the guidelines on maternal care for children are daily and continuous, and the mothers need to be introduced gradually in the care process. Initially, it should stimulate simple care such as hygiene, bathing, changing diapers, touching, child feeding and then caring should gradually go deeper to comprehensive care¹⁸.

By learning the nursing team communication codes, the mother of prematures are empowered, in their way, in order to participate in decisions about therapies directed to their children. This empowerment is not always well accepted by members of the nursing staff, since they are used to decide among themselves the treatments to be provided to each patient. Thus, while the maternal empowerment causes some awkwardness and discomfort in the nursing team, the mother is led to redefine her own space in the neonatal unit. And once the mother exchanges her fragile image for a more assertive position towards the child, she begins to take over her place, enabling herself to "mother" her own son, which stimulates and improves interaction²⁰.

Women's empowerment allows themselves to demand their citizen rights and enables them to provide proper care for premature children, which includes her effective participation in the decision making along with the professionals who serve their children. Being empowered means to be informed enough to be free to decide²¹.

FINAL CONSIDERATIONS

Health Education inspired by the problem-based education of Freire, aiming the promotion of emancipatory maternal care to premature baby by the nursing staff should be part of the nursing staff practice and in particular of the nurse praxis. Because through the theory of Paulo Freire of dialogicity, people can wake up to the critical awareness of the world where they are, coming out of their oppressed condition, to the condition of the being more, in the middle of a humanization process, in compliance with a human vocation.

Therefore, mothers of premature children can qualify and participate in their children's care, and in the decisions on therapeutic approaches directed to them, allowing themselves to reset their space in the neonatal unit. From the exchange of her fragile image to a more assertive positioning towards the child, the mother begins to conquer her place, which enables herself to "mother" her own son, to demand her citizen rights and to provide appropriate care for her child, becoming effectively included in the caring process.

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