ORIGINAL RESEARCH

Context of antenatal care in late prematurity

Mariana Bello Porciuncula^I; Ana Lucia de Lourenzi Bonilha ^II; Cecília Drebes Pedron^III; Lilian Córdova do Espírito Santo^IV

^I Nurse. Doctorate Student, Universidade Federal do Rio Grande do Sul. Brazil. E-mail: mariana.bello@ufrgs.br
^II Nurse. PhD in Nursing, Professor at the Universidade Federal do Rio Grande do Sul. Brazil. E-mail: bonilha.ana@gmail.com
^III Nurse. PhD in Nursing, Professor of the Nursing Course at Ulbra – Gravataí, Rio Grande do Sul, Brazil. E-mail: cepedron@gmail.com
^IV Nurse. PhD in Medical Sciences. Nursing Professor, Universidade Federal do Rio Grande do Sul. Brazil. E-mail: espiritosantolilian@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.18040

ABSTRACT

Objective: to learn about pregnancy care for women who gave late premature birth, and their treatment in the Unified Health System. Methodology: this descriptive study was conducted at three Family Health Strategy clinics in Porto Alegre, Rio Grande do Sul, from November 2011 to December 2012, by semi-structured interviews of 13 women. The project was approved by the Porto Alegre City government's Research Ethics Committee (No. 001.039956.11.3). Results: two themes emerged in ethnographic thematic analysis: negligence in care during pregnancy and inadequacy of antenatal care. The patterns observed were: failure to complete antenatal records properly; potentially avoidable situations favoring late prematurity; and difficulty in communication between mothers and antenatal care professionals. Conclusion: learning about these women's antenatal care can represent the conceptions they hold about pregnancy, which are an important point of reference for professionals working with this population.

Keywords: Pregnancy; premature birth; prenatal care; pregnancy complications.

INTRODUCTION

Preterm refers to the birth of a child younger than 37 weeks of gestational age, and it is related to a number of special care for these newborns, who are referred to in the literature as preterm or premature^1-3. The World Health Organization estimates that 15 million children are born prematurely each year, highlighting the magnitude of this problem in the society³.

The interval between 34 and 37 weeks of gestation represents a critical period of fast growth for the human brain, which, in the event of a premature birth, develops in the postnatal period and without the protection of the fetus by the maternal uterus⁴. Studies suggest that, in order to influence positively the health outcome of these newborns, it is necessary to act in the prevention of adverse situations and in the operationalization of interventions especially directed to late preterm infants⁴.

In this context, one must consider the repercussion of the increase of late preterm births for the health system, since there are specific morbidities of this specific group. Late preterm infants cannot be considered as close-term babies as they present more sequelae and morbidity than full-term infants, and require specific care, especially with regard to neuromotor development⁵. In addition, they present a significant increase in the risk of death, especially in the neonatal period ⁶.

In view of the above, the objective of this study was to know the gestation care of women who had late-preterm infants, and their care within the Unified Health System (SUS).

LITERATURE REVIEW

The rates of prematurity in Brazil have been increasing, presenting values ranging from 3.4 to 15% of the births⁷. A study of perinatal cohorts, from 1982 to 2004, in Pelotas-Rio Grande do Sul (RS), has indicated that the preterm birth rate increased over 130% in the period. ¹. In the United States, the rate of prematurity reached 12.3% of births in 2003, indicating an increase of 31% of these births in comparison to the previous decade⁸.

Regarding the causes of the birth of preterm infants, they can be attributed in 80% to idiopathic causes or to premature rupture of amniotic membranes, and 20% to obstetric complications of other orders⁹. In this sense, it is recommended that the interventions performed are aimed at the qualification of healthcare for the reduction of these births and perinatal morbidity and mortality^10,11.

Despite the significant reduction in infant mortality rates, the current indicators have shown a smaller reduction than what is expected ¹². These deaths often occur due to preventable causes, some of them related to prematurity, and "mainly regarding the actions of the health services and, among them, prenatal, delivery and newborn care." ^12:15.

Thus, the evaluation of prenatal care becomes a central issue in the prevention of these premature births, and in the prevention of morbidity and mortality, both maternal and neonatal. For that, several studies have been carried out with the purpose of evaluating prenatal care in its qualitative and quantitative aspects^13-18. Qualified prenatal care is necessary so that pregnant women at risk are identified, minimizing possible complications¹⁰.

The relevant concentration of preterm births in the gestational age ranges between 34-36 weeks and 6 days; the so-called late preterm infants ^8,19 is a problem both in terms of increased morbidity and there is also the fact that these infants often receive usual health care ²⁰. Although mistakenly perceived as a group with low risk for intercurrences, late preterm infants present significant morbidity and mortality rates when compared to full-term births^21,22.

METHODOLOGY

This is a qualitative, descriptive study²³. The data collection was performed in three family health strategy units (FHS) in the city of Porto Alegre, RS, between November 2011 and December of 2012.

Thirteen women have participated in the study, observing the inclusion criteria - aged 18 years old or over, mothers of preterm infants with gestational ages from 34 to 36 weeks and 6 days at birth, whose infants weighed more than 1,500 grams and were not carriers of any malformation, with hospital discharge up to the 45th day of life, and who had the prenatal care performed by SUS. The participants have been selected based on the indication by the professionals of the FHS units of the referred areas births, and the inclusion criteria have been verified by the researchers. In order to preserve the identity of the women, they have been identified with fictitious names.

The data has been collected through semi structured interviews, totaling 43 interviews performed at the participants' domicile in the first, third and sixth month after the discharge from the baby of the maternity. The approach used in the interviews was ethnographic, with questions related to gestation, delivery, health care and care for the late premature.

The analysis material of the present study comprised the antenatal portfolios of the mothers of late preterm infants and the 43 interviews. The analysis was ethnographic thematic adapted by Douglas et al. ²⁴, that looks for identifying cultural patterns and themes.

The research project has been approved by the Research Committee of the Escola de Enfermagem from the UFRGS and the Research Ethics Committee of the city of Porto Alegre under the Opinion No. 001.039956.11.3 from 08-28-2012.

RESULTS AND DISCUSSION

The results and their discussion were based on two themes: neglect of care during pregnancy and insufficient prenatal care.

Neglect of care during pregnancy

This topic included the prenatal care and the experiences related by the mothers, which have been established as standards for the group in question. As standards, the late onset of the prenatal care, the lack of knowledge about the importance of care, and the duality between knowing whether to care for and not to apply the care identified as necessary have been observed.

The early prenatal initiation is an essential condition for adequate attention to the pregnant woman, for the initial assessment of gestational risks and the opportunity to link this woman to care throughout her pregnancy^12,14. It has been identified that the onset of prenatal care in this study varied between the 6th and 33rd weeks of gestation. Of the 13 women, it has been observed that only six started prenatal less than 12 weeks' gestation, and the average onset was 14 weeks, which is relatively distant from the current recommendations. It is also important to emphasize the importance of the care during the first trimester of gestation for a healthy pregnancy^2,12,25.

Despite the fact that they know they are pregnant, it has been observed that the first prenatal care took place only weeks later, varying between 2 and 20 weeks among the informants. These data corroborate what has been found in another study, in which, when working with women on prenatal capture, it has been identified that some women, despite being sure of their pregnancy, did not feel the urge to confirm it by doing tests or to initiate the follow up¹⁸.

Well, most of the time, [...] they do not care so much about the onset [...], or because they the symptoms took so long and such. Because there are people whose belly does not even show up. (Poliana)

[...] I think it's a lack of attention. Or many are not expecting the pregnancy, or it is an unwanted pregnancy, and they end up denying it to see if they can abort. (Silvana)

What has been reported by these women reflects the devaluation regarding the beginning of the pregnancy, as if it were not yet a fully established situation. It is known that, in addition to the psychological, organic and physiological changes caused by gestation in the first trimester, the affective ambivalence between wanting and not wanting it is present in most pregnancies²⁶, and it may influence the care of this woman in relation to this period that they are experiencing.

It is necessary to use the knowledge about pregnant women's perception about prenatal care in order to build a common knowledge with them, explaining their doubts and desires, impacting their health and their children's, individually and collectively. Transposing what is normative and prescriptive is also a challenge, since the pregnant women themselves refer to the care they must have during the pregnancy as necessary, but sometimes they do not perform or have it.

Oh, you cannot smoke, cannot drink, and cannot use drugs. I continued [smoking] [...] (Eliana)

Oh, I could not walk too much, I could not clean it, I could not do it ... I did everything! (Giovana)

The contradictions between the guidelines that should be followed, and those that have really been followed, characterize this individual way of experiencing the gestation. The notion that care was needed is explicit in the lines, but the transposition of such care into practices that imply changing individual habits has become somewhat distant. Does their understanding of the entire gestational process allow them to understand the relationship between the care that can and should be performed (and the repercussions that the lack of such care can have on the perinatal health)?

The importance of the "understanding that gestation, in addition to being a biological process, is also a social and cultural process"^27:108 , and understanding this process favors the establishment of a cooperation between the health team and the pregnant woman, and, possibly, the provision of more appropriate care to the context in which this woman lives.

Insufficient prenatal care

In this theme, the intercurrences in late preterm gestations and the reflections on the structuring of prenatal care have been related. The observed patterns were: inadequate filling of the prenatal portfolios; the potentially avoidable situations as facilitators of late prematurity; and the difficulty in communication between the pregnant woman and the prenatal care professional.

Some aspects of the prenatal portfolio records were: the use of acronyms for doing the register, the prevalence of records referring to medicines used and the spelling of difficult interpretation - which allows the questioning of who the information was registered for, whether for the professional himself or for the appropriate care for the pregnant woman.

No records have been found such as the name and the class council of the professional responsible for the appointment, or the behaviors derived from it, considering the need for awareness on the part of the professionals regarding this aspect, since the prenatal portfolio is the document that makes official all the care provided, and it is what subsidizes the behavior at the moment that the woman is referred to the maternity.

In the prenatal cards, it has been observed that blood pressure and weight were measured in all registered appointments. It should be highlighted that the weight in the beginning of the pregnancy was not registered in eight of the analyzed cards, being it a parameter to follow their evolution and to adjust the guidelines regarding feeding and physical activity. Regarding uterine height and fetal heart beat rate, these have been the most prevalent data in the prenatal cards, but still not recorded in all the appointments. These findings are similar to the survey carried out on prenatal care in the basic network in Pelotas/RS, in which uterine height, blood pressure and weight of the pregnant woman have been the most recorded data¹⁶. The higher prevalence of these records demonstrates the valorization of measurable (quantitative) data in detriment of subjective data, such as the pregnant women's complaints.

The lack of records related to both qualitative and quantitative aspects of prenatal care indicates gaps in the quality of care, since the recording of the observations and behaviors is a simple procedure that allows the professional to resume with the pregnant woman regarding the combinations performed.

Regarding the exams, studies have still presented low percentages of pregnant women who perform them properly^{14, 28}. In the city of Rio Grande/RS, in a survey with 2,557 women, the authors identified that none of the exams had been performed twice during the prenatal period when evaluating the routine of exams recommended by the Ministry of Health ²⁸.

It has been found that nine informants performed two examinations during their pregnancy, but they did not always observe the delimited periods as recommended. The time frames between the collection of the exams and return for the prenatal care were not adequate for the interventions that could have been performed.

I did the [urinary tract infection] treatment she asked me to. I did the exam again, and it was okay. Only after I got the baby [the infection] came again. (Poliana)

In the prenatal report of this deponent, there was a record of examining a 22-week urinary tract infection and a record of treatment at 28 weeks of gestation. After this episode, she has been hospitalized at 34 weeks' gestation, again presenting a urinary infection; and the delivery occurred at 35 weeks and 2 days. The 1-month and 10-day interval between the collection of the first uroculture and the beginning of antibiotic treatment has been observed in the prenatal card. These reports have expressed neglected situations during the prenatal care.

It is understood as necessary the evaluation of the urine test in the routines of the care of the pregnant women, in order to make both women and professionals aware of the importance of this control and the effective follow-up when a urinary tract infection is diagnosed. The priority of the care of the pregnant women in the health units would favor a greater observation, for later control activities such as the active search of pregnant women who had undergone the examination, or those who were already under treatment.

The occurrence of syphilis has also been observed in the records of three informants of this study, however, the disease has been diagnosed in the prenatal care of two of them, and the third one happened when she has been admitted to the maternity hospital.

As I had a suspicion of syphilis during the pregnancy, it was always 1:2 result, then I always used to do this exam and it was 1:2. [...] at the hospital they warned me that it could have infected the baby, who may have had syphilis during the pregnancy. [...] There they treated them [babies]. (Viviana)

It was not until the end of my gestation that one of my tests pointed out that I had syphilis, so she gave me an injection, and for my husband as well. (Jordana)

The third pregnant woman, who is not mentioned in the previous reports, was only diagnosed with syphilis at the time of delivery, and after the hospital discharge, she returned to her community of origin without having any contact with the health services that attended her. She received no guidance regarding the syphilis treatment for her and her partner.

It is known that syphilis is an important public health problem, which can be avoided and treated. Its adequate treatment with antibiotic therapy is effective and of low cost^29-31, and its incidence during the gestation is an indicator of the quality of the prenatal care ^30,32,33. Syphilis, when not treated or inadequately treated, may result in abortion, prematurity and even stillbirth³¹, in addition to determining a high rate of vertical transmission, which may imply short- and long-term sequelae in the development of the child ^32,34.

It is also highlighted that aspects related to the prenatal quality have been addressed in several studies, and that this component can influence the ways prenatal care impacts (or not) maternal and child health. In this qualitative component, the role of attentive observation and listening to the pregnant women, who can mention to the pre-natalist relevant information about their health status, not only with regard to infectious-contagious diseases, is highlighted³⁵.

My pressure was high, and they said, 'It's normal to go up a little, you come walking, right?' [...] I had high blood pressure when I went to appointments, but he always said it was normal, that I was agitated. But it's always been that way, high. [...] Then in the 30 weeks that the sick began, and they began to see that I wasn't feeling well [...], I swelled more in the last weeks, and then I started to fall from the stairs ... The doctor said it was a normal pregnancy, but it is not normal. [...] (Joana)

The previous report refers to a situation of potential health impairment that was not initially considered by professionals who performed the prenatal care. It reinforces a professional attitude that detracts from listening and devalues women's knowledge, even if it is in a situation of vulnerability. Despite the numerous complaints of dizziness, weakness, blurred vision, among others, the professionals disregarded the symptomatology pointed out by the pregnant woman, and these situations have not been even registered in her prenatal card.

It is known that hypertensive disorders during pregnancy favor the birth of preterm infants^9,10,36, increase the risk for an unfavorable perinatal outcome37, as well as being an important cause associated with maternal mortality.^38,39. In this context, it is emphasized that the diagnosis of hypertension during the pregnancy and timely interventions may be related to a greater possibility of preventing complications for the mother and the baby, the earlier this moment happens.³⁷.

In addition, it is essential that women are involved in their care and that they understand the relevance of prenatal care for the prevention of maternal and perinatal morbidity and mortality. The pre-natalist should involve the woman in the care, informing the reasons for the examinations and referrals, with a view to a healthy gestation, so that this moment is not only interpreted as a compulsory activity, that the pregnant woman does not understand well why it is happening.

The day I went to the first appointment here, she saw that I was a little ... A thing ... I don't know what it was that was down, then she sent me to the hospital, and they saw that it was down, but she did not explain to me what it was... (Taciana)

Yes, I already felt that I was pregnant, I started at the health unit, from the health unit they sent me to the hospital to do the prenatal care ... I cannot tell you why I was sent to the hospital. (Susana)

The difficulties are evident when women seek to explain facts that occurred during pregnancy, as can be seen in the last two. They refer to questions about how health education actions have been offered to these pregnant women, and what they effectively learned from what has been explained to them during the prenatal care. Although the guidelines given by the professionals are often forgotten or not apprehended by the pregnant women, the negative content emphasized by them when referring to some moments of the prenatal care, as well as the lack of clarity in the reported explanations, is highlighted.

The fact that they were born prematurely late was what brought this study closer to the reality experienced by these women, a reality permeated by lack of commitment and professional indifference. The roles and interests involved in this relationship are questioned, being understood that the health professionals and the pregnant women have a common interest in ensuring the health of the newborn, but it seems that the investment that each one is willing to offer to the consolidation of this interest is somewhat limited (for lack of dialogue, listening, empathy, bonding, understanding, among others).

Although an individual mobilization of the pregnant women has been observed during the research in order to guarantee the use of some resources as a strategy to improve health conditions and prenatal care, it was still not possible to avoid the late prematurity of their children. This prematurity, although involving multifactorial causes, is related to insufficient prenatal care³⁶.

CONCLUSION

Knowing the gestational care of women who had late preterm infants and their care within SUS can represent some of the conceptions they have about the gestation, and it is an important reference for professionals working with this population's health.

Many were the factors that contributed to the birth of these late preterm infants, and these should be understood as births due to a sequence of negligence and inadequacies in the prenatal care of these women. Understanding that these births are not causality, fatality, or family inheritance is a fundamental part of the health service; as well as the pregnant women, who need to understand their respective responsibilities, and from then on, it is possible to change their attitude.

It is worth emphasizing the role of the nurse in this context, as a professional who is capable of intervening in this process and promoting a more adequate care directed to the scenario in which the woman experiences this gestation. Nurses should consolidate themselves as an integrative link of practices that strengthen and potentiate actions and care in the prenatal care, exercising the role of listening to the demands of the pregnant woman and transforming them into a culturally centered care that prioritizes education in health and the autonomy of those who are involved.

Although the study presents as a limitation the fact that it has been developed in a single city, and with a small group of women (which prevents the generalization of the results), it is considered that it presents the breadth of the subject, which has been addressed in only a small part of its complexity, constituting itself as a recurrent theme, current and relevant for future studies, since there is much to be done in the prevention of these premature births, and in the qualification of prenatal care.

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