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ORIGINAL RESEARCH

 

First Comprehensive Health Week: actions of healthcare professionals in mother-and-child home visits

 

Altamira Pereira da Silva ReichertI, Anna Tereza Alves GuedesII, Victor Egypto PereiraIII, Tarciane Marinho Albuquerque de Vasconcellos CruzIV, Nathanielly Cristina Carvalho de Brito SantosV, Neusa Collet VI

I Nurse. PhD. Associate Professor. Federal University of Paraiba. João Pessoa, Brazil. E-mail: altareichert@gmail.com
II Undergraduate Nursing student. Fellow of the Institutional Scholarship Program of Scientific Initiation, Federal University of Paraíba. João Pessoa, Brazil. E-mail: annaterezag@gmail.com
III Undergraduate Medical student. Federal University of Paraiba. João Pessoa, Brazil. E-mail: victoregypto@gmail.com
IV Nurse. Master. Student of the Doctoral Program, Federal University of Paraíba. João Pessoa, Brazil. E-mail: tarci_marinho@hotmail.com
V Nurse. PhD. Adjunct Professor. Federal University of Campina Grande. Cuité, Brazil. E-mail: nathaniellycristina@gmail.com
VI Nurse. PhD. Associate Professor. Federal University of Paraíba. João Pessoa, Brazil. E-mail: neucollet@gmail.com
VII Project financed by the National Council of Scientific and Technological Development served by process number 447572 / 2014-8.

 

 


ABSTRACT

Objective: to analyze the actions of health professionals during first mother-and-infant home visits. Method: this qualitative, descriptive study was conducted from February to June 2016, drawing on semi-structured interviews of 11 mothers of newborns, who were visited at home during the neonatal period by health professionals working at family health clinics in the city of João Pessoa-PB, Brazil. The resulting data were subjected to thematic analysis. Results: weaknesses were found in care for the mothers, which was limited to care for the surgical wound in caesarean cases. Care actions towards the babies were notably comprehensive, involving physical examination, immunization, promotion of breastfeeding, scheduling of appointments at the health care facility, and guidance as proposed by the First Comprehensive Health Week. Conclusion: although there is potential in making home visits, weaknesses in health personnel's performance of mother-and-child care undermines the comprehensiveness of care, making it necessary to invest in training.

Keywords: Comprehensive health care; postpartum period; newborn; home visit.


 

 

INTRODUCTION

Despite advances in infant survival rates in developing countries, maternal and neonatal mortality still show slow progress. Therefore, the World Health Organization (WHO) points out the importance of health interventions implemented in this period, primarily in the first hours after birth and in the first seven days of life, so it is possible to identify the difficulties faced by the mother in self-care and caring for the baby1.

According to WHO, 800 women and 7,700 newborns (NB) still die each day from complications during pregnancy, delivery and the postnatal period. In Brazil, the neonatal mortality rate is high, about ten deaths per 1,000 live births, representing approximately 70% of infant mortality, with most deaths recorded in the first 24 hours of life2. This shows weaknesses in care to the mother-newborn binomial and represents a challenge to achieve the fourth Millennium Development Goal of reducing infant mortality by two-thirds3.

In this sense, the Ministry of Health established the Agenda for Commitments for Integral Health of the Child and Reduction of Infant Mortality among the policies for the health care of children, seeking to integrate basic and hospital care, with actions centered on the child in all the contexts, without losing opportunities for integral care 4. In the guidelines of the Agenda for Commitment, the "First Week of Integral Health", which includes actions that must occur in the first week of the baby´s life, with an evaluation of the child´s health, mother´s health, breastfeeding incentive and support to the difficulties presented by them, and to scheduling the postpartum consultation for follow-up care5.

Therefore, the home visit (HV) was established as a low-cost instrument, to enable the follow-up of health care and promotion, aimed at the potential to reduce neonatal morbidity and mortality6. However, even the HV allows health professionals to know the reality of the population and to promote early interventions in care and attachment to the newborn, mother and family7, weaknesses in the offer of this action are identified, which may hinder maternal experience in this critical period of her life and the baby. The performance of the HV outside the period recommended by the MS, with limited information, or lack of systematization of the actions to be performed constitutes the most important fragility. Thus, it can compromise the quality of child care in Primary Health Care (PHC) and increase the risks of morbidity and mortality in this period.

In this context, it is essential to direct the professional actions to comprehensive care, which includes general aspects, as well as the specifics of the child in front of their family and social context. Given the above, the question is: What are the actions of health professionals in the first home visit to the mother-baby? Therefore, the objective of this study is to analyze the actions of health professionals during the first home visit to the mother-baby.

 

THEORETICAL REFERENCE

The home visit of the health professional to the mother-newborn binomial is an indispensable tool for the construction of care even in the first week of life, since recognizing the family and social context is basic to planning and implementing health actions. This strengthens the link between the team and the family and allows the service to be the first choice in health need and entry of the individual into the Health Care Network 6.

However, it is fundamental that during the HV, the professionals are available to listen and clarify doubts from an efficient dialogical attitude with the mother and/or family of the newborn to favor the trust relationship, mutual ethical commitment of the subjects involved, as well as responsibility for instrumentalizing mother and family for autonomy in care6,8.

 

METHOD

Exploratory research with a qualitative approach, carried out in three Integrated Family Health Units, with four teams each, belonging to the Health District III (DS-III) of the municipality of João Pessoa - PB. The study subjects were 11 mothers of newborns who met the inclusion criteria: be enrolled in the coverage area of one of the Family Health Units; Be a mother of a child less than 28 days old; Have been visited by a professional of the family health unit during the first 28 days of the newborn´s life; And have cognitive and emotional conditions to respond to the interview. Mothers with newborns who had been hospitalized were excluded. The criterion for closing the data collection was saturation, that is when the content grasped by the empirical material was sufficient to respond to the proposed objectives.

Eleven mothers aged between 18 and 40 years old participated in the study, most of them married and having completed high school. Regarding the home visit, it was identified that only two visits were performed in the first week of life of the NB as recommended by the Ministry of Health.

Data collection took place from February to June 2016, from a semi-structured interview, guided by a script containing the guiding question: "Tell me what actions were developed by health professionals during the home visit in the first week of life of your son." The interviews were conducted at the mother´s home, with privacy and free of external interference. They were recorded on digital media and transcribed in full for greater reliability of the content. The interviewees signed the Informed Consent Term (TCLE). Each interview was identified by the letter "M" of the mother, followed by the numbering corresponding to the chronological order of accomplishment to guarantee the anonymity of the participants. The data were submitted to thematic analysis, including three stages: pre-analysis, material exploration and treatment, data inference and interpretation9.

In the material exploration stage, the registration units and the thematic in relief were highlighted, given the recurrence of empirical data. This process allowed to choose the thematic units contained in the set of discourses, in a classification movement. Subsequently, the central thematic unit was built, whose dismemberment allowed the identification of the empirical category "care to the mother-baby in the first home visit." The results obtained were interpreted based on the theoretical basis that guided the study9.

The study was developed by the guidelines and norms established in Resolution nº 466/12 of the National Health Council (CNS). Considering that this research is a subproject of a larger research entitled "First Week Integral Health: construction and validation of an instrument for the home visit to the newborn," adopted the dictation issued by the Committee of Ethics in Research (CEP), under protocol number 008/15, CAAE: 39801714.2.0000.5188.

 

RESULTS AND DISCUSSION

Care to the mother-baby at the first home visit

The first maternal care of the newborn at home can be imbued with insecurity and fear because it is a helpless and a dependent human being. Therefore, the home visit during this period of life of the child is an opportune moment for the health professional to provide qualified listening and welcoming, with a full care in the face of adversities that may arise in this period of such vulnerability.

Based on this focus, it was identified that the HV for the mothers of this study, is a positive experience for the child to feel confident and able to take care of her child at home.

Then, she was attentive. Because besides coming to assist me, it is the service we need, right? After delivery, in the postpartum period, she picked me up, examined the baby, and raised doubts, she added, to my knowledge, mainly because I am a first-time mother. (M1)

The mother recognizes the need for the care provided by the health professional in the postpartum period, evidencing the importance of having her doubts corrected at this moment so important for the child´s self-care and health care.

This attitude of the health professional is essential for the care of the mother-baby at this stage, since the postpartum demands a qualified care for the prevention of risks and injuries, and the promotion of the physical and mental comfort of the mother, in the sense of empower her to take care of herself and her child.

From the perception of reality as a "mother" inserted in a context of domestic assignments and care for the child that the doubts and fears emerge before the new phase, requiring the intervention of a professional to support the construction of care10.

Despite the need for the intervention of a professional in the puerperal period, a study carried out in China showed that the number of women who receive the home visit in this period is still insufficient. However, 90% of those visited were satisfied with the professional´s interaction during this critical phase of their life11. Therefore, the relevance of the HV to the integrality of care to the mother-baby in primary care is highlighted, as it is associated with reductions in neonatal mortality in places where access to the Family Health Units is unfavorable, according to a systematic review with Studies from South Asia12.

From the perspective of integrality, among the actions implemented by the health professionals in the HD is the evaluation of maternal nutrition, considering the direct influence on the health of the mother and the baby.

[...] he asked if I was feeding well, he asked if I was feeling any pain, he wrote down, that I took a lot of liquid that was not to give anything more to him but the chest. He asked if I was eating at the right time. (M6)

The nurse asked if I was okay, how the kids were if they were nursing. Then, he examined me and looked at my surgery. She asked if I was feeding well because I was anemic. (M10)

Mothers indicate that nurses are concerned about maternal nutrition to encourage and strengthen breastfeeding, as they inquire about this moment and the presence of possible changes, and look for important guidelines. This is pertinent, considering that until the six months of life, the baby depends on the mother, through exclusive breastfeeding13, for its nutrition leading to a reduction in infant morbidity and mortality.

Also, caring for maternal nutrition is important to prevent anemia, one of the causes of mortality in women. In Africa, the World Health Organization estimates that approximately 55.8% of pregnant women and 41% of women of child-bearing age are diagnosed because of insufficient intake of bioavailable iron.

On the other hand, an important gap was identified in the construction of integral care to the mother and the baby, since most of the mothers reported that the professional who did the HV stopped only "evaluating the surgical wound," as reported below:

[...] she took my stitches, told me to do the proper cleaning, right? With alcohol at 70% and only. With me, she just took the stitches. (M4)

The nurse came here, but she did not do much with my son, she went with me to take the stitches and said that my surgery was dry, it was not inflamed, it was nothing. (M8)

She looked at the stitches; my aunt tried to pull off and could not. Then, the nurse tried to take it too, but could not, then told me to go to the hospital, I went to the hospital. She just came to see if she could get the stitches. (M9)

These reports show weaknesses in the care offered to the puerperium in the first week of postpartum since the professional did not value the opportunity to evaluate the biological, psychic and social aspects of the mother, important information to make the maternal experience quiet and uneventful10.

Thus, it is necessary for the health professional to recognize the potential of this moment to centralize their activities in the specificities of the subjects to favor the construction of bond with the mother, the newborn and the family and to promote a space of empowerment for adequate care10,14. Linking to users means having an integral, longitudinal and humanized view under the singularities of the subject, and, therefore, an assistance aimed at health promotion and disease prevention in PHC15.

It can be stated that although breastfeeding is a widely disseminated issue in society, recurrent difficulties in this process can lead to the abandonment of this practice. Problems in the communication of the health professional in not clearly explaining or not addressing this issue during this dialogical encounter can contribute to the mother´s continuing doubts and insecurities, show weaknesses in the conduction of HV.

What I missed was that she did not teach to wean, no one taught me how to wean, in this case weaning, no excuse, milk, and it was the thing I needed most. Because when he started taking the supplement, he did not want to suck anymore. Because I had a little milk. [...] There, in two days, almost everything in my chest diminished, so I did not know, no doctor, no obstetrician, no pediatrician taught me, no one from the FHP taught, and this could have been taught on that first visit. So, breastfeeding is so difficult, so the more things you know, the better. (M3)

A study carried out in Londrina-PR is in line with these data, evidencing that mothers assisted by a Basic Health Unit needed to obtain information about breastfeeding with friends and relatives, the internet and books and magazines. Also, the guidelines of health professionals were limited to exclusive breastfeeding time and proper management, not guaranteeing resolution and, neither, prevention of injuries16.

In this study, only one of the mothers stresses that the nurse gave a broader look because besides to curative procedures, she worried about the well-being and quality of life of the mother in this unique moment of life.

Then, she addressed the issue of breastfeeding; she said: oh you are in the place that is not appropriate. Only that where I was, it was totally inconvenient. Then, she went and taught me: you have to have a cushion, you have to sit well because you will not take it, I would get the pounding aching and maybe I could not nurse him. So, there were very good directions she gave me. (M3)

In this discussion, the importance of the insertion of the professional in the family life space for the care encounter is prioritized. There is the possibility of knowing the woman´s life history, being acquainted with the environment in which she lives and the customs and habits that will potentiate professional actions to promote maternal health and expand her support network for integral child care. Thus, the professional will be highlighting the singularity of the patients and promoting the prevention of diseases through health education17.

Regarding comprehensive and resolute care for the newborn, it is essential for the professionals working at the FHU to know how to conduct a home visit. This powerful tool for the construction of care for the newborn enables risk factors to be identified even in the first week of life, considering their family, social and epidemiological reality, as advocated by the First Week Comprehensive Health for the child.

In the mothers' reports, the actions performed during the first home visit are directed to the physical examination of the newborn, guidelines for breastfeeding and prevention of diseases, as well as the follow-up of the consultations in the health unit. This indicates the responsibility of the professionals to implement the actions proposed in the First Week of Integral Health18.

She evaluated the baby´s vaccines, read them, did all the follow-up, shortly after she went to examine the baby in the crib, took off her clothes, listened to her heart, listened to her lungs, I believe, right? She checked the cheektooth; skin color and everything, right. She asked about the baby´s suckling, checked the how he breastfeeds, all that. She has already scheduled the next baby´s appointment, with 30 days in the PSF, already left marked. Then, she guided the cleaning of the navel, the procedure of the suckling, the alternation of the breast to suckle. (M1)

All the time she was very polite, she said teaching everything, how I should act with my baby, right? She checked on her, if she had something abnormal, she tipped the right position to breastfeed. She said she only wore cotton pants or a disposable diaper. (M4)

She asked how many kilos he was born, explained the importance of sunbathing; she asked if he was born with jaundice that little yellow, the size of the little head he had been born. He took all the summary of my birth, which the hospital gave me and made all the notes, gave me something to make the SUS card of him. Then, she asked if I was breastfeeding, then she advised me that if he spent time without poop, it was normal. (M5)

Performing the complete physical examination is essential in the care of the child. The professional should do it and discuss the findings with the family, facilitating the perception of the baby´s needs. It is recommended that in the first weeks of life, aspects of growth and motor and psycho-affective development should be evaluated, considering the general state and possible changes in the skin, breasts and umbilical stump, as they may compromise the health of the newborn19.

However, even with the actions implemented by the First Week Integral Health, it is still possible to find limitations in the work of the professionals, because in none of the reports of the mothers there is the evaluation of the developmental references of the newborn identified. This fact is worrying since the surveillance of child development must happen from birth, since the first two years of life correspond to the singular period and ideal for early interventions for healthy development20.

Regarding the importance of early interventions in the intercurrences, it was possible to identify an action consonant with the policy of integral care to the child, since the professional advised the mother on how to proceed to care for the baby with abdominal colic.

I said she had colic, then she came and taught how I could do it, right? To soften her cramps more, I give compress, and she said it was not good, the milk without being the mother. Then she told me the foods I should eat and marked the next appointment, to go there. (M2)

This is consistent with increased and timely care because colic is one of the most commonly reported complaints by mothers, predominantly in the first three months of the baby, requiring guidance on proper feeding to prevent as well as interventions such as administering medications, when necessary and according to medical prescription21.

This assertion corroborates the results of this study, in which a similar performance can be observed by the nurse. The presence of a trained professional represents a differential to effect the HV as a powerful tool for the integrality of care to the neonate. Added to this, there is the concern about the continuity of child care, based on immunization guidelines and the scheduling of child care consultation of the newborn in the health unit, an important principle for the longitudinally of child care in the PHC.

[...] He also talked about taking the girl to take a vaccine when she was two months old. (M2)

[...] Then, he spoke to two months from now to take the vaccine and marked the girl´s appointment. (M4)

[...] He examined them (twins), he asked if they were okay with them, and he said that at the end of the month I would take them for the first consultation. (M10)

It is possible to infer that there is the responsibility in the care of the professionals with the continuity of the care of the newborn through the appointment scheduled in the unit. The mother should be advised to return to the FHU with the child for childcare consultation, which should be seven in the first year of life, with the first two still in the first month of life (15 and 30 days); Two in the second year (18 and 24 months) and the others annually19.

It is worth mentioning that the first contact of the professional with the patient is opportune to facilitate the insertion of this in the Network of Health Care (RAS) since the scheduling prevents her from attending the unit several times during the puerperium18.

This raises reflections about the professional performance, as it suggests a concern to comply with the recommendations of the MS on the schedule of consultations for the monitoring of the child, an indispensable condition to identify possible early changes that may compromise the development of the child´s potentialities, intervening in a timely manner and promoting a healthy life23.

 

CONCLUSION

This study demonstrated that, even with potential in the home visit, the fragilities in the professionals´ performance in the care of the mother-baby compromise the integrality of care. In this sense, it is understood that health professionals need to be trained and sensitized about the importance of conducting the home visit in the first week of life as a tool to reduce health problems for the mother and child, promoting the bond and providing follow-up care and the resilience of child care.

Therefore, it is necessary to reflect on the work process of the professionals, in the sense of transforming curative actions and practices into other consonants to integral and good quality care, from the permanent education in health to the construction of effective care in the PHC.

 

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