RESEARCH ARTICLES

Serological test for Hepatitis B offered during antenatal care: the women's experience

Cristiane Ferraz da Silva^I; Carla Luzia França Araújo^II; Marcela Matvijc de Araújo^III

^I RN. Intensive Care and General Medical and Surgical Clinical Specialist. Rio de Janeiro, Brazil. E-mail: cris_fs@yahoo.com.br
^II Ph.D. in Collective Health. Associate Professor. Universidade Federal do Rio de Janeiro. Anna Nery School of Nursing. Maternal-Infant Department. Rio de Janeiro, Brazil. E-mail: araujo.ufrj@gmail.com
^III RN. Family Health Specialist. Escola Nacional de Saúde Pública. Fiocruz. Rio de Janeiro, Brazil. E-mail: enf.araujo@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.4935

ABSTRACT

In order to reduce B Hepatitis vertical transmission, more effective antenatal care is necessary. Objectives: to identify how, from the women's standpoint, the serologic test for Hepatitis B was offered during antenatal care. This quantiqualitative study using collective subject discourse was conducted at the rooming-in ward of a maternity hospital school in Rio de Janeiro, Brazil. Between January and March 2011, 41 puerperal women were interviewed. When asked how the test was offered, most answered that it was requested together with the other routine antenatal tests; health professionals merely read the result. Despite the Ministry of Health recommendation that Hepatitis B testing be offered and performed, therre shortfall in the way the subject is addressd treated with women about to give birth.

Keywords: Vertical transmission; Hepatitis B; prenatal; nursing.

INTRODUCTION

Health professionals are familiar with viral hepatitis. Due to the high incidence and high diagnostic and treatment costs of this disease, it is considered a relevant research theme in the global context and currently represents a public health problem.

The national average for Hepatitis B cases in Brazil reached 6.9% in 2010. The Southeast concentrated 36.6% of the cases according to an epidemiological bulletin in 2012¹.

The Ministry of Health recommends serological screening for some diseases during prenatal care. Examples are serological tests for Hepatitis B, HIV, syphilis and toxoplasmosis. Regarding Hepatitis B, the HBsAg is recommended for all pregnant women in the third trimester of pregnancy with a view to prevention through the (passive and active) immunization of infants whose mothers had a positive prenatal test. The maternal diagnosis for the Hepatitis B virus (VHB) is fundamental to be able to immunize the infants, thus preventing the vertical transmission of the disease².

The VHB is important because of its widespread geographical distribution and great potential to cause a chronic illness like cirrhosis and hepatocellular carcinoma³. The estimated number of VHB carriers around the world is about two billion⁴.

In perinatal exposure, the mother/child transmission of VHB can happen during birth, through the infant's exposure to blood or amniotic fluid (where the VHB is present) while passing through the vaginal tract, through contact with secretions, breastfeeding and, rarely, through trans-placental transmission.

The chance of becoming chronic in cases of neonatal infection is much higher than that in cases of adult infection, with about 90% of the infants evolving to the chronic form, who may present cirrhosis and/or hepatocellular carcinoma in the future, differently from individuals who catch the disease in the course of life, with approximately 30% chance of developing chronic Hepatitis B⁵.

During the nursing consultation with pregnant women, the patients' active participation through interaction with the nursing professionals is fundamental with a view to the exchange of knowledge and information to promote self-care. In that perspective, through the nursing consultation as a moment of dialogue between nurse and client, targets and objectives can be defined to improve the health conditions of mother and child.

Nurses play a fundamental role in the pregnant women's prenatal care monitoring. Sexually transmitted diseases (STD) are difficult to diagnosis in pregnant women due to the absence of clinical symptoms. The possibility of the pregnant women having an STD can negatively influence the pregnancy process. The importance of a more profound approach of STD in pregnant women is highlighted, because women have also been the most frequent victims of health problems associated with sexual practice⁶.

To reduce the infection levels by VHB through vertical transmission (mother/child), more effective monitoring is needed during prenatal care. In Brazil, there are few Hepatitis B screening studies in pregnant women. Although the Ministry of Health recommends the early screening for Hepatitis B as part of routine prenatal care tests in public services, this is still trivialized⁷.

Studies on the vertical transmission of Hepatitis B are rare in Brazil, as this test was only included in the prenatal care routine as from 2005, when the Ministry of Health started to recommend the marker in HBsAg infection⁸.

This research is focused on the offering of the serological test for Hepatitis B during prenatal care.

Concerns with preventing the vertical transmission of Hepatitis B motivated this study, in view to the recommendation to apply the screening test and the possible consequences for maternal and child health. This could enhance the care, prevention and health promotion process, contributing to a better quality of life for mothers and children.

Due to the persistent prevalence of Hepatitis B infection in the population, serology screening is important in prenatal care with a view to early treatment and the avoidance of vertical transmission⁹.

This research aimed to identify how the serological test for Hepatitis B was applied in prenatal care according to the puerperal women.

THEORETICAL FRAMEWORK

Nurses are responsible for nursing consultations and nursing care prescriptions; as members of the health team: medication prescriptions, as established in public health programs and routines approved by the health institution; nursing care delivery to pregnant women, women giving birth and puerperal women, and for health education activities¹⁰.

Health education activities are very important throughout all phases of the pregnancy-puerperal cycle, but it is during prenatal care that women should be advised so as to be able to experience the birth positively, have less risk of puerperal complications and more success during breastfeeding. Considering prenatal care and birth as unique moments for each woman and a special experience in the female universe, the health professionals should act as educators who share knowledge, aiming to return the women their self-confidence to experience the pregnancy, birth and puerperal period.

When the pregnant women are sensitized, they can take better care of their health and thus contribute to the professionals in order to improve the quality of care delivery¹¹.

It is relevant to mention that, today, in Brazil, prevalence studies for VHB are scarce and most studies are delimited to a specific population group. Individual behavior is the determinant fact of vulnerability to VHB infection¹².

It is highlighted that, in Brazil, advances are observed in the coverage of prenatal care, but the quality of this care is far from ideal so far ¹³. As regards the serological test for Hepatitis B, as it is only a recommendation in prenatal care, the professional and the prenatal care service are responsible.

Counseling practice is a fundamental tool for the interaction among subjectivities, in which the exchange of knowledge and feelings can be reciprocal. Thus, it can be affirmed that prenatal counseling is an instrument that permits breaking the transmission chain of sexually transmissible infections, as it allows the pregnant women to reflexively think about the infection risks and the importance of preventing these diseases¹⁴.

Fundamental prevention measures exist for strategic planning, based on reducing the mortality rates in the population under one year of age. These measures can be achieved through information about the infants' biological conditions in the course of a pregnancy, the quality of prenatal care and the moment of birth, as well as about the causes of deaths and the way to avoid them¹⁵.

METHOD

A descriptive and exploratory research with a quantitative and qualitative approach was undertaken. The study was developed at the rooming-in unit of maternity teaching hospital in the city of Rio de Janeiro. The research subjects were puerperal women who had received prenatal care at health services in the city of Rio de Janeiro.

Mothers who were seropositive for the Human Immunodeficiency Virus (HIV), who had an abortion and/or received prenatal care in another city were excluded from the research.

The data were collected through semistructured interviews. The instrument included the puerperal woman's profile, the offering of the serological test for hepatitis B during prenatal care and the knowledge on the serological test for Hepatitis B. The interviews were held with 41 puerperal women who were present at the place of study and willing to participate in the research. The data collection took place between January and March 2011 at the rooming-in unit. The interviews were only held after the reading and signing of the informed consent form and were recorded and later transcribed.

To analyze the data, the software QUALIQUANTISOFT® was used. The interviews were transcribed and then registered in this software. The quantitative data were submitted to statistical analysis with absolute and percentage frequency calculations. The qualitative data were separated by thematic categories, based on key expressions, central ideas and the collective subject discourse (CSD) was constructed. The CSD were numbered from 1 to 5. The qualitative data were treated using thematic analysis and the conceptual reference framework related to the offering of the serological test and the aspects of vertical transmission of hepatitis B, including the puerperal women's knowledge.

This study received approval from the Institutional Review Board, research protocol CEP/ME – Universidade Federal do Rio de Janeiro – Number 15/2010, CAAE: 0015.0.361.000-10.

RESULTS AND DISCUSSION

In total, 41 puerperal women were interviewed. Divided per age range, 13 (31.7%) were between 19-23 years of age, 10 (24.4%) between 24-28 and the same number between 29-33 years. Less representative, 5 (12.2%) were between 34-38 years old and 3 (7.3%) between 39-43.

The analysis of the data found on the accomplishment of prenatal care during pregnancy shows that 40 (97.6%) puerperal women were present at this service, while only one (2.4%) did not attend the prenatal consultations. Almost all of the interviewed women had access to prenatal care, a service available in the Unified Health System whose coverage is increasing in Brazil.

When asked about whether they had taken the serological test for Hepatitis B during prenatal care, 21 (52.5%) puerperal women affirmed they had taken the test, while 19 (47.5%) said they had not.

Positive interventions in cases of Hepatitis B are possible with regard to pregnant women and infants; priorities are its prevention, early diagnosis during pregnancy and care for the fetus of diagnoses mothers, considering its prevalence, heterogeneous vaccine coverage rates in Brazil, thus highly reducing the vertical transmission of VHB¹⁶.

The laboratory screening of VHB aims to discover the mother's serological status and reduce the risk of vertical transmission during pregnancy. The tests should be taken during the first prenatal consultations, independently of the gestational age, guaranteeing results within 15 days with a view to proper forwarding⁶.

The puerperal women were also asked whether they had received orientations about hepatitis in general during prenatal care. In total, 26 (65%) reported they had not received any information in this respect, while 14 (35%) affirmed they had received some kind of information. This information indicates how concerning the situation is, mainly due to the fact that the health professionals do not give advice when asking the pregnant women to be tested.

Accomplishment of Hepatitis B test during prenatal care

In this phase, the quantitative results and the CSD constructed based on the central ideas are addressed.

Concerning the number of puerperal women who answered the question about having taken the test, 17 (44.74%) women reported that the health professional did not offer them the serological test for Hepatitis B during the prenatal consultations, 18 (47.37%) were offered the test for VHB but the professional did not provide explanations, i.e. did not offer counseling, and 3 (7.89%), i.e. the majority, received some kind of information when the test for VHB was requested.

Based on the results found, it is noteworthy that, although Hepatitis B is currently acknowledged as a public health problem and its epidemiological control to reduce the number of infected people is mainly based on transmission prevention, the health professionals working in prenatal care do not manage the offering of the VHB test appropriately yet. It is observed that, when the health professionals offer this test, they do not explain its importance and the possible consequences of the result for the pregnant women or simply do not offer the test, as the minority offered the test and explained something about the theme to the women interviewed in this study.

The first discourse relates to the puerperal women to whom the health professional did not offer the serological test for hepatitis B in prenatal care. During the prenatal consultations, some important serological tests are recommended to detect diseases in the mother that can be transmitted to the infant, among other routine tests. When the health professionals request these tests to the women, mainly those related to a positive serum status for vertically transmitted conditions, they should advise them about the test, explaining its purpose and possible findings.

Without serological test for Hepatitis B

Nobody said anything. It was not requested at any time, if it was they did not tell me. I only know that I did all of the tests. She gave me the papers and I came here to the laboratory and they took the blood. They took blood so many times that I can't even remember if it was done. He asked to do the test and said that everything was normal. I took so many tests that I don't know. (CSD1)

According to the first discourse, however, the professional who attends to the pregnant women requests the prenatal laboratory tests as part of a daily work routine, bureaucratic in many situations, without understanding the importance of these tests for maternal-infant health. Hence, to prevent the vertical transmission chain of Hepatitis B, a trained health professional is needed who dialogically passes information to the pregnant woman, respecting her rights and showing her possibilities to deal with the different existing situations.

With serological test for Hepatitis B

The gynecologist requested it. She explained that it avoids various kinds of diseases and that you can treat it when the baby is still in the belly. I remember that she explained me that even after the baby is born [...] she said that I'd have to take the vaccination after giving birth. Because, in case of another pregnancy, some problem could happen. (CSD 02)

The analysis of the second discourse, concerning the pregnant women who were offered the test, reveals the relevance of the information provided to the pregnant woman during prenatal care, no matter the content addressed. The woman can know more about herself, about the risks she is exposed to and the way to prevent vertically transmitted diseases, in this case Hepatitis B. In addition, it allows the woman to solve doubts regarding the theme and also sere as an information multiplier in her community.

When the puerperal women were asked what they knew about the serological test for Hepatitis B, 33 (80.49%) said they did not have any information on the theme and 8 (19.51%) described something on the VHB test. These data indicate that, during prenatal care, when the health professionals offered the VHB test, they did not discuss the theme with the pregnant women or the way they presented the theme was not appropriate for them to understand it.

Independently of what theme is addressed, high-quality prenatal care stands out as the primary target to be achieved in the attempt to reduce the maternal and perinatal morbidity and mortality rates and, therefore, to put the programs in practice, continuing competent and up-to-date professional actions are required¹⁷.

Lack of knowledge on Hepatitis B

I know hardly anything, I don't remember. I've heard about hepatitis, but not in detail. She did not tell me anything. When you're gonna have a baby, you get immune at the moment of the cut, it's tetanus. [...] it's kind of a lack of blood, anemia, [...] to know if the blood is according to mine and the baby's. (CSD3)

When the puerperal women were asked what they knew about the serological test for Hepatitis B, the majority said they did not know anything about the theme. The third discourse reveals mistaken concepts on the theme, such as mixing up the VHB test with the vaccine against tetanus, anemia or blood compatibility.

Knowledge on Hepatitis B

Because you have to do it if you haven't taken the vaccine. [...] to prevent both the mother and the child. I've seen on television that you catch it through the pliers. That you can catch it in sexual relations too. I know it's a disease that needs to be detected because it's dangerous during pregnancy, you can pass it to the child [...]. (CSD4)

In the fourth discourse, the puerperal women describe information on Hepatitis B. Nowadays, the Ministry of Health disseminates national campaigns to prevent hepatitis B transmission, mainly linked to the media (television and internet). But it is during prenatal care that the theme can be addressed more specifically with the pregnant women and their partners. It is also a way to screen for cases positive to Hepatitis B, i.e. early diagnosis in the pregnant women and subsequent treatment for mother and infant.

At the primary care level, the primary health care units and Family Health Program develop actions. The following are part of these professionals' action sphere: health promotion, prevention, serological screening and patient monitoring. As regards the prevention of vertical Hepatitis B transmission, two important actions are described: the first dose of the anti-Hepatitis B vaccine, which should be applied after birth, during the first 12 hours of life and, in infants whose mother is a VHB carrier, the administration of human anti-Hepatitis B immunoglobulin as well¹⁸.

It can be observed that, concerning the puerperal women's experiences with the serological test for Hepatitis B in prenatal care, 36 (87.8%) indicated no experience with the theme, while five (12.2%) reported they had some experience.

Through the search for articles on vertical Hepatitis B transmission, the analysis in a health database revealed that most studies published discuss the prevalence of serological screening for Hepatitis B in pregnant women and the subsequent treatment if the result is positive. Nevertheless, there are no reports on the pregnant women's knowledge or experience regarding the theme.

The World Health Organization justifies the accomplishment of routine tests to detect Hepatitis B in pregnancy, due to: the severity of the problem the disease represents, the availability of reliable and accessible tests that are acceptable to the population and the existence of highly effective prevention means to be applied in positive cases¹⁹.

Experience with Hepatitis B test

During my first pregnancy, I attended a lecture and took the test. It must be to protect the baby. If you prevent it in the mother, you also prevent it in the baby because, before the worst happens, they treat the mother, so the child won't have this problem in the future [...] I think it's very interesting because there weren't so many resources in the past, today you've got everything, you can detect not only Hepatitis B [...]. (CSD5)

The final discourse presents reports of pregnant women who experienced situations related to the Hepatitis B test during pregnancy, that is, they had contact with some information that provided them with important knowledge. During prenatal care, the health professionals can address relevant themes with the pregnant women, using different strategies, whether in individual or group activities, enhancing teaching-learning techniques and using information transmission vehicles. The professionals should always pay attention to the pregnant women's demands and needs and their family and community contexts in order to intervene actively in the health-disease process, always focusing on the health promotion and prevention aspects.

CONCLUSION

The research permitted the achievement of the initially proposed objective. Concerning the identification of how the VHB test was offered in prenatal care, despite the Ministry of Health's recommendations to offer and accomplish the serological test for Hepatitis B during prenatal care, the insufficient way in which the theme is discussed with the women is known; or, in many cases, in which the health professionals merely request the test, the lack of explanation on its importance.

As regards the puerperal women's knowledge on the serological test for Hepatitis B, the minority indicated something pertinent on the theme and described it as important to prevent the vertical transmission of Hepatitis B. Hence, when the health professionals inform and advise the pregnant women during prenatal care about something related to this test or any theme related to viral hepatitis, the women can recognize its risks and modify them in view of the possible results of the VHB test.

Nurses play a fundamental role in prenatal care, as they are responsible for nursing care delivery to the pregnant women and for promoting the control of transmissible diseases like Hepatitis B. During prenatal consultations, it is fundamental for the nurses to discuss both the offering of the test and prevention and treatment forms.

One study limitation is the fact that the data were collected at a single maternity hospital. In future studies, data should be collected at more than one maternity with a view to a broader range.

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