Low-risk antenatal care: family health strategy nurses' attitudes


Mirela Dias GonçalvesI; Ivonete Sanches Giacometti Kowalski II; Ana Cristina SáIII

I Nurse. Master in Nursing. Professor of the Nursing Course of the São Camilo University Center. Cachoeiro de Itapemirim, Espirito Santo, Brazil. E-mail: mireladg2013@gmail.com
II Nurse. PhD. Graduate Nursing Program at the São Camilo University Center, São Paulo. Brazil. E-mail: isg.kowalski@uol.com.br
III Nurse. PhD. Graduate Nursing Program at the São Camilo University Center, São Paulo. E-mail: anacrispsicoenf@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.18736




Objective: to identify the attitudes of Family Health Strategy nurses in the low-risk antenatal process. Method: in this quali-quantitative, cross-sectional study of 83 nurses in southern Espírito Santo State in 2014, a semi-structured questionnaire was applied and analyzed in the light of Bardin. Results: from the attitudes, three categories and the following subcategories emerged: considerate reception (persistence in consideration, and frustration); the educational process in antenatal care (description of the space and responsibility) and bonding (relationship with the community, dialogue and active listening). Conclusion: The results showed the nurses were dynamic and proactive, and contributed to the work process. However, some difficulties may represent limitations on performance of their functions. The needs that emerged highlighted the importance of continuing professional development to foster the qualifications and competences necessary for practicing the profession.

Keywords: Prenatal care; community health nursing; professional competence; continuing education.




Prenatal assistance is important in primary care (PC). In the care of women and newborns, the quality of the care provided is priority1. An increase in prenatal care coverage has taken place in Brazil in the last ten years. However, high inadequacy of care has been also observed, which indicates a need for improvements in several aspects, especially with regard to the quality of service2.

Despite advances in the access to health services, Brazil faces some challenges such as maternal and perinatal morbidity and mortality rates, which need to be reduced to overcome the negative outcomes and gaps in assistance to prenatal, delivery and postpartum3.

Health professionals, as partners in the realization of low-risk prenatal care in the Family Health Strategy (FHS), can detect and intervene early in situations of risk, which may reduce the major causes of maternal and neonatal death. Thus, they represent an important tool to change the Brazilian reality, where human resources become essential key components for the realization of health care management4,5.

Appropriate professional practices and the provision of quality prenatal care can contribute to reducing maternal and child mortality. Giving meaning to these issues, the Ministry of Health (MOH) points out that "Initiatives geared at expansion, qualification and humanization of attention to women's health [...] may be related to advances in reduced mortality from direct obstetric causes"5:21.

The analysis of a regional problem in context can be useful to discover local needs, targeting specific interventions that can guide the development of strategies to transform health practices6.

The motivation for this study came from the teaching commitment in the training of nursing professional to the exercise of their practices. From the perspective of benefit to the community, we sought an opportunity to address a regional problem in order to contribute to reducing maternal and child mortality in the Southern side of the state, as well as to improve nursing education.

Before the challenge of reflecting on issues involving professional health care practices, and to understand their dimensions and limitations and rethink the strategies to strengthening PC, it is important to identify the attitudes of nurses towards low-risk prenatal in the FHS in order to increase knowledge on the local reality, aiming at continuing healthcare education.



According to the MOH, the National Policy of Continuing Education in Health is a government proposal that meets the improvement of professional skills, with the idea of ​​transforming the educational processes and teaching practices. One of its purposes is the organization of health services, which was implemented in 2009 with the preparation of state plans 7.

Studies show that professionals working in the FHS should have a qualified listening to the needs of users, promoting humanized care and establishment of bond4-7-9. Regarding the care provided to pregnant women at the Health Unit, the MOH recommends that pregnant women be received by professionals with ethical and caring attitudes, in a welcoming environment and reducing risks to the mother and to the newborn5.

The MOH recommends that nurses develop their competencies and general skills in the training process: health care; decision making; communication; leadership; administration and management and continuing education. The latter, continuing education, relates to the ability of continually learn, both in the undergraduate training and during the practice, in addition to the specific skills and abilities10. These skills must be addressed in the Pedagogical Projects of Courses (PPC) in nursing, embracing the principles of the National Curriculum Guidelines (NCG)11. This is in line with the MOH recommendations with respect to the National Policy of Continuing Education in Health.

The competencies consist in the knowledge, skills and attitudes of individuals and it is recommended that they be defined in the NCGs and developed in accordance with the PPCs in which the curriculum and menus of the Nursing Courses are inserted12. With regard to the attitude, this is understood as "tendencies or acquired and relatively lasting dispositions to evaluate in a certain way an object, person, event or situation and act according to this evaluation"13:122.



Descriptive study with quali-quantitative and cross-sectional approach. The sample was composed of 83 FHS nurses from 23 municipalities of Southern Espírito Santo (ES). Nurses who were part of the teams at the time of research and who willingly agreed to participate were included in the study; and nurses who were out of work for some reason at the time of the research or who refused to participate were excluded from the study.

A semi-structured questionnaire was used for data collection. This had guiding questions based on MOH guidelines for low-risk prenatal care and was answered preserving the anonymity of participants. Nurses were identified with the letter N followed by a number corresponding to the sequence of participant's registration in the state. The instrument was tested with five nurses from one municipality for to evaluate and validate the instrument structure, which was consistent with the proposals of the study.

Data collection was carried out between January-February 2014, after approval by the Research Ethics Committee of the São Camilo University Center – São Paulo (SP), Opinion nº 496.121. Data were transcribed verbatim and submitted to three-stage content analysis; pre-analysis; exploration of the material; treatment of results14.

The material passed through organization and systematization of ideas and choice of contents to be used. It was subjected to an initial quick reading to know the text and to find the first impressions, respecting the rules of completeness, representativeness, consistency and relevance. The exploitation of the collected material began with the coding and decomposition of data. Excerpts were extracted from the data, classified and aggregated in categories and subcategories, gathering similar information in groups.

This article is limited to qualitative analysis.

For this analysis, responses were considered until saturation data.



Data analysis was constructed from the survey responses that allowed the identification of attitudes expressed by participants in relation to situations experienced in their day to day, resulting in the following categories and sub-categories: category: the hosting (subcategories: persistence in hosting and frustration); category: the educational process in the prenatal (subcategories: description of space and responsibility); category: the bond (subcategories: community relations, dialogue and active listening).

Category: the hosting

In this category, speeches originated two subcategories regarding the attitude of hosting pregnant women in low-risk prenatal care in the FHS.

Subcategory: persistence in hosting

In this subcategory, participants present answers that demonstrate the persistence in hosting the pregnant women, as follows:

I try not to give up, because trust is established gradually, and it is not imposed. (N32)

I never give up, I always insist until she understands that we, as a team, want the best for her. (N40)

During prenatal meetings, the hosting becomes more consistent and the important thing is not to give up on this pregnant woman. (N39)

The reports underscore commitment to practice the hosting, to build the bond of trust, as an attitude of strengthening the relationship between professionals and pregnant women. Do not give up the hosting is critical to the success of their activities. The attitude of persisting can express dedication of the professional, coupled with knowledge and ability to make an effective performance. Studies show that attitudes of commitment and humanization of care contribute to the establishment and strengthening of bond between health professionals and users5.

Subcategory: frustration

This subcategory includes the participants' expressions of frustration before unsuccessful hosting, as follows:

Frustration, but I do not leave the pregnant women aside, and I always offer the service to them whenever they need it, even if they are not followed up by the FHS. (N6)

Frustration, but I try to make her feel welcomed and change her opinion. (N22)

I get frustrated, but I do not show it. I try to leave time pass by, and through dialogue, when I have openness, I approach the subject again. (N66)

Participants stressed frustration for not having been successful in their actions of hosting the pregnant women. There was, however, no passivity in the attitudes of nurses. However, other participants reported having experienced difficulties in hosting the pregnant woman, as follows:

I sought new strategies, making home visits in an attempt to win the trust and inform about the importance of prenatal care. (N68)

When I cannot host the pregnant women, I ask support from other team members, and if necessary, from the Coordination of Women's Health. (N77)

They demonstrate positive attitudes in face of the difficulties that come up, such as seeking partnerships and changing strategies of action to host pregnant women. The attitude of seeking resources that can solve problems/situations can bring great benefits to the service, to individuals, families and to the community. It is essential that the team seeks to understand the women and their families in their life context, aiming at effectiveness of actions in prenatal care and welfare of the pregnant women assisted5.

Category: the educational process in the prenatal

In this category, we tried to know the attitudes of the participants in relation to health education activities for pregnant women, including two sub-categories that are discussed below.

Subcategory: description of space

It was observed in this subcategory that the participants conduct health education activities with pregnant women during low-risk prenatal care in the FHS, as the reports show:

I carry out health education at the moment of hosting and in rapid testing. (N7)

I give sporadic lectures, I have a bit of trouble because they do not go to consultations and do not want to go to lectures. (P22)

I have no place to carry out health education in the unit, which is very small. I just show some movies and try to answer their questions. (N66)

Participants reported many spaces to the realization of health education in prenatal care, but when we analyze the of use of these spaces, a limitation becomes evident with respect to recognizing other spaces, such as in the community, as the proposals of the FHS point out. Another factor is that the idea of the professional on health education may influence their conduct. In this scenario, it is important that health professionals be aware of fulfilling their duties in the development of educational activities as a key strategy in the health care of pregnant women and families15. It is noteworthy that "[...] there is a need to carry out continuing education actions with professionals, using the problematization of social reality and the present situation of services as axis, as well as the integration between management, pedagogical and political aspects present in the above mentioned space" 16:69.

Subcategory: responsibility

In this subcategory, the participants highlighted the responsibility of health education before the pregnant women in their area, and before other sectors/professionals, as follows:

In my area, health education for pregnant women is carried out by the coordinator of programs, in a meeting inviting all pregnant women of the area and with raffle giveaways. (N18)

Educational meetings are held by the Social Assistance Reference Center (CRAS). (P44)

Educational meetings are organized by the CRAS. Reference is made to the pregnant women, because they accept the situation better, because they get maternity kits. (N73)

It was observed that the participants understand health education as a collective or group meeting, but they do not identify other legitimized spaces to carry out the activity. Another noteworthy fact is the attitude of transferring the responsibility of the activity to other professionals, thereby reducing the opportunity of the health team to create bond with the pregnant women and their families. Faced with the responsibility for conducting health education activities, the MOH advises that health education activities should be developed by the team in individual and/or collective basis5.

It is important that educational moments be valued by professionals and be part of the strategies used in prenatal care. This aims to involve both the expectant mothers and their families, with relevant inclusion of fathers/partners in the activities17.

Category: the bond

In this category, the participants sought to express to how they establish bond from the contact with pregnant women through activities of the FHS. The speeches originated three subcategories, analyzed below.

Subcategory: community relations

In this subcategory, the participants presented in their responses attitudes that they use to strengthen the bond, from the time of contact at the work with family health. Here are the speeches.

I know well the families of the area, so this bond already exists. It has four years that I am in the same unit and the doctor is here for 12 years. (N5)

I try to create bond through trust and respect gained since the first contact. (N18)

As the area is small and it has already three years that I'm working here, this makes it easier for all already know me by name and I, as a nurse, also already know most people by name. (N46)

Participants demonstrated their relationship with families and with the community, valuing the trust achieved through their work. The attitude of trust was observed, when they mention that the time of professional action contributes to strengthen the bond of trust with clients, families and with the community. Studies report that the FHS team should focus on the establishment of bond with the community, facilitating the close relation between professionals and users and the knowledge about the area 4,18. Gestation is a time of many transformations for women. For this reason, they need to be followed by professionals who understand their feelings, making this moment the opportunity to build bonds5.

Subcategory: dialogue

In this subcategory, participants highlighted the effective dialogue for establishment of bond as follows:

I keep dialogue, explaining the importance of conducting prenatal, conveying confidence and professional ethics, hosting the pregnant woman at this stage. (N41)

Through dialogue, my commitment to their well-being, I try conveying them confidence. (N66)

In the consultation, since the first contact with the pregnant woman, I talk to her, I convey confidence and accessibility. (P77)

The expression of professional commitment was observed in the responses, using dialogue as a support tool to establish bond, as well as the use of trust. These attitudes can positively impact on the establishment of bond and contribute to the adherence of the pregnant women to prenatal care, besides providing quality care to the pregnant women. In the scenario of care practices in PC, it is worth emphasizing that dialogue is an important tool in relationships and can contribute to reflections and problem solving 19. The perception of the professionals that carry out the prenatal care is a basic condition for the establishment of this relationship with the pregnant women and their families, contributing to the monitoring and to a peaceful and healthier gestation4.

Subcategory: active listening

In this subcategory, participants expressed in their responses the stance and behavior used to listen with attention to pregnant women, as follows:

I pay attention to the pregnant woman, showing my co-responsibility, as a nurse of the team, with her health and with the health of the baby that is to come, trying to reduce the barrier that sometimes exists between professionals and patients. (N39)

Listen to their arguments, valuing them [...] conveying confidence and professional ethics, hosting the pregnant woman at this stage. (N41)

[...] through qualified listening. (N64)

The attitude of active listening in the care of pregnant women was observed in the responses, seeking to enhance the bond of trust as a necessary attribute to listening. Another evident factor was professional ethics and the demonstration of responsibility in prenatal care, promoting greater safety to pregnant women. One of the 10 steps to the quality of prenatal care is to promote active listening, considering intellectual, emotional, social and not only biological cultural aspects, which should happen without judgments and prejudice5,19.

For the National Program for Humanization of Prenatal Care and Childbirth, professionals must demonstrate ethical and supportive attitudes, seeking to create a welcoming environment for improving the quality of prenatal care 20.



A profile of pro-active nurses was observed, which can contribute to better results in low-risk prenatal care. However, difficulties and limitations in the exercise of their functions within the FHS were observed and these may compromise the quality of service.

In this context, the importance of the relationship between academia and service stands out, in order to contribute both to the nursing training process and to the development of competencies necessary for professional practice.

As for the needs that were evident in the study, challenges were detected and need to be overcome by professionals during the course of their professional career, highlighting the importance of continuing education in service to promote professional qualification.

It is expected that this study may strengthen the Public Policies of Continuing Education in Health in the South of the State of Espírito Santo, as well as become a foundation to the continuity of the teaching process of nursing professionals in low-risk prenatal care, as proposed by the Ministry of Health.



1.Castro ME, Moura MAV, Silva LMS. Quality of prenatal care: a perspective of new mothers. Rev Rene. [Internet] 2010 [cited on October 10, 2016]. 11 (esp.): 72-81. Available at: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/463/pdf

2.Nunes JT, Gomes KRO, Rodrigues MTP, Mascarenhas MDM. Quality of prenatal care in Brazil: review of articles published from 2005 to 2015. Cad Saúde Colet. 2016 [cited on October 18, 2016]. 24 (2): 252-61. Available at: http://www.scielo.br/pdf/cadsc/v24n2/1414-462X-cadsc-24-2-252.pdf

3. Viellas EF, Domingues RMSM, Dias MAB, Gama SGN, Theme Filha MM, Costa JV et al. Prenatal care in Brazil. Cad SciELO-Scientific Electronic Library Online] 2014 [cited on October 17, 2016]. 30 (sup): S85-S100. Available at: http://www.scielo.br/pdf/csp/v30s1/0102-311X-csp-30-s1-0085.pdf

4. Ministry of Health (Br). Secretariat of Health Care. Prenatal and Puerperium Technical Manual: qualified and humanized care. Brasília (DF): Editora MS; 2006.

5.Ministério da Saúde (Br). Secretariat of Health Care, Department of Basic Attention. Attention to low-risk prenatal care. Brasília (DF): Editora MS; 2012.

6. Ministry of Health (Br). Asis - Health Situation Analysis. Brasília (DF): Ministry of Health. 2015 [cited on October 19, 2016]. Available at: http://bvsms.saude.gov.br/bvs/publicacoes/asis_analise_situacao_saude_volume_1.pdf

7.Ministry of Health (Br). Secretariat of Management of Work and Health Education, Department of Management of Health Education. National Policy of Permanent Education in Health. Brasília (DF): Ministry of Health; 2009.

8. Ministry of Health (Br). Secretariat of Health Care, Technical Nucleus of the National Humanization Policy. HumanizaSUS: Basic document for SUS managers and workers. Brasília (DF): Ministry of Health; 2010.

9.Raimundo JS, Cadete MMM. Qualified listening and social management among health professional. Acta Paul Enferm. [Internet]. 2012 [cited on October 15, 2016]; 25(2): 61-7. Available at: http://www.scielo.br/pdf/ape/v25nspe2/pt_10.pdf

10.Ministério da Educação (Br). National Council of Education. Higher Education Chamber. Resolution CNE / CES nº 3, of November 7, 2001. It establishes National Curricular Guidelines for the Nursing Undergraduate Program. Brasília (DF): National Council of Education; 2001.

11.Benito GAV, Finato PC. Managerial competences in the training of nurses: documentary analysis of a pedagogical project of the course. Rev Eletr Enf. [Internet]. 2010 [cited on October 12, 2016]; 12(1): 140-9. Available at: http://www.fen.ufg.br/revista/v12/n1/v12n1a17.htm

12.Lourenção DCA, Benito GAV. Managerial competences in the training of nurses. Rev Bras Enferm. [Internet] 2010 cited on October 13, 2016]; 63(1): 91-7. Available at: http://www.scielo.br/pdf/reben/v63n1/v63n1a15.pdf

13.Coll C. Content in the reform: teaching and learning concepts, procedures and attitudes. Porto Alegre (RS): Artmed; 2000.

14.Bardin L. Content analysis. Translation by Luís Antero Reto, Augusto Pinheiro. São Paulo: Edições 70; 2011.

15.Anversa ETR, Bastos GAN, Nunes LN, Pizzol TSD. Quality of the prenatal care process: basic health units and Family Health Strategy units in a municipality in the South of Brazil. Cad Saúde Pública. [Scielo-Scientific Electronic Library Online] 2012 [cited on October 18, 2016]. 28(4): 789-800. Available at: http://www.scielo.br/pdf/csp/v28n4/18.pdf

16.Brondani JE, Aranda AL, Morin VL, Ferraz TR, Colomé CLM, Fedosse E. Perceptions of pregnant women and puerperal mothers about the waiting room in a basic health unit integrated to the Family Health Strategy. Rev Bras Promoç Saúde. 2013 [cited on October 10, 2016] 26(1): 63-70. Available at: http://ojs.unifor.br/index.php/RBPS/article/viewFile/2625/pdf

17. Ministry of Health (Br). Protocols of Basic Attention: women's health. Brasília (DF): Ministry of Health; 2016.

18.Pohlmann FC, Kerber NPC, Pelzer MT, Dominguez CC, Minasi JM, Carvalho VF. Model of prenatal care in the extreme south of the country.. Texto Contexto Enferm. 2016 [cited on October 17, 2016]. 25(1):e3680013. Available at: http://www.scielo.br/pdf/tce/v25n1/0104-0707-tce-25-01-3680013.pdf

19.Silva MRF, Pontes RJS, Silveira LC. Hosting in the family health strategy: the voices of everyday subjects. Rev enferm UERJ [online] 2012 [cited on October 15, 2016] (esp.2): 784-8. Available at: http://www.facenf.uerj.br/v20nesp2/v20e2a15.pdf

20. Ministry of Health (Br). Department of Health Care. Program of Humanization of Childbirth. Humanization in Prenatal and Birth. Brasília (DF): Editora MS; 2002.