ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL

DOI: 10.17533/udea.iee.v33n2a11

"Not worth doing prenatal care": an ethnographic study of a low-income community

"No vale la pena hacer prenatal": estudio de una comunidad de bajos recursos

"Não vale a pena fazer pré-natal": estudo de uma comunidade de baixa renda

Patrícia L. F. Santa Rosa¹; Luiza A. K. Hoga²; Jéssica Reis-Queiroz³

¹Nurse Midwife, Ph.D. Student. University of São Paulo -USP, Brazil. email: patriciasantarosa@usp.br.

²Nurse Midwife, PhD. Professor, USP, Brazil. email: kikatuca@usp.br.

³Midwife, PhD Student. USP, Brazil. email: jessicagreis@usp.br.

Receipt date: June 16, 2014. Approval date: April 30, 2015.

Article linked to research: Razões da não realização do acompanhamento pré-natal: estudo etnográfico em uma comunidade de baixa renda

Subventions: none.

Conflicts of interest: none.

How to cite this article: Santa Rosa PLF, Hoga LAK, Reis-Queiroz J. Not worth doing prenatal care": an ethnographic study of a low-income community. Invest Educ Enferm. 2015; 33(2): 288-296.

DOI: 10.17533/udea.iee.v33n2a11

ABSTRACT

Objective. The aim of this study was to explore the reasons why pregnant women do not seek prenatal care (PNC). Methodology. The ethnographic method was used in a low-income Brazilian community. Ethnographic interviews were performed with 11 postpartum women who did not seek PNC in their last pregnancy. Results. The cultural sub-themes used to express reasons for not seeking PNC included: "I found out I was pregnant too late and did not have enough time to receive PNC," "I did not receive PNC because I had to hide the pregnancy to avoid problems," "I had to address urgent issues and could not seek PNC," "The services are not good and going to the doctor when not ill is only for rich people," and cultural theme: "PNC is not worth pursuing: it is unnecessary and there are too many obstacles to receiving it." Conclusion. The main strategies that should be considered to increase adherence to PNC are better access and integrality through the use of adequate management criteria.

Key words: pregnancy; prenatal care; poverty; anthropology, cultural.

RESUMEN

Objetivo. Explorar las razones por que las mujeres gestantes no buscaron asistencia prenatal. Metodología. Se empleó el método etnográfico en una comunidad de bajos recursos en el Brasil. Se realizaron entrevistas etnográficas a 11 puérperas que no buscaron asistencia prenatal en la última gravidez. Resultados. Las razones para no buscar la atención prenatal fueron: me di cuenta del embarazo muy tarde y no dio tempo de hacer prenatal; no hice prenatal porque tuve que esconder el embarazo para evitar problemas; tuve que resolver problemas urgentes y no pude hacer prenatal; el servicio no es bueno e ir al médico sin estar enfermo es sólo para los ricos; y: "no vale la pena hacer prenatal: esta asistencia no es esencial y hay muchos obstáculos que enfrentar". Conclusión. La importancia de la facilidad de acceso y la integridad de la atención prenatal, desarrollada a través de los principios de buena gestión, son los principales aspectos a considerar en la promoción de la adhesión a la atención prenatal.

Palabras clave: gravidez; atención prenatal; pobreza; antropologia cultural.

RESUMO

Objetivo. Explorar as razões para as mulheres grávidas não procurarem assistência pré-natal. Metodologia. O método etnográfico foi desenvolvido em uma comunidade de baixa renda no Brasil. Entrevistas etnográficas foram desenvolvidas com 11 puérperas que não procuraram assistência pré-natal na última gravidez. Resultados. As razões para a não busca pela assistência pré-natal foram: Percebi a gravidez muito tarde e não deu mais tempo para fazer pré-natal; Não fiz pré-natal porque tive que esconder a gravidez para evitar problemas; Tive que resolver problemas urgentes e não pude fazer pré-natal; O atendimento não é bom e ir ao médico sem estar doente é só para ricos; e "Não vale a pena fazer pré-natal: esta assistência não é essencial e há muitos obstáculos a enfrentar". Conclusão. A importância da facilidade de acesso e da integralidade da assistência pré-natal, desenvolvida por meio de princípios de boa gestão, são os principais aspectos a considerar na promoção da aderência à assistência pré-natal.

Palavras chave: gravidez; cuidado pré-natal; pobreza; antropologia cultural.

INTRODUCTION

Health institutions that represent the main professional categories responsible for prenatal care (PNC) recommend a minimum of four appointments for the care of healthy pregnant women. These institutions also recommend an increase in this frequency as clinical and obstetric needs emerge during the pregnancy.¹ Based on this premise, the Brazilian Federal Government implemented the Humanization of Prenatal and Childbirth Care (HPCC) to improve the availability of PNC, among other reasons.² The reasons for not seeking PNC mentioned by historically disadvantaged groups were explored by many researchers around the world. The main determinants for not seeking PNC were financial problems, ^3.4 scarcity of health care facilities, difficulty scheduling appointments, long distances between homes and health care facilities⁵, transportation difficulties, low trust in the quality of care, a lack of family and social support for attending appointments, and beliefs and cultural values ⁶.

Studies conducted in Latin American contexts indicated that the main reasons for not seeking PNC were socioeconomic deprivation, low education levels, difficulties related to transportation, long distances to health care facilities, lack of childcare for mothers' other children, and unplanned pregnancies.⁷ PNC coverage in Brazil has increased in recent years as a result of efforts by the government and non-governmental organizations.⁸ Between 2011 and 2012, 73.1% of Brazilian women made six or more PNC appointments.⁹ However, mothers of more than 52,000 children born in 2010 did not have any PNC appointments.¹⁰ Results of these studies came mainly from quantitative research, which gave little attention to the women's subjective perspectives.

However, the reasons that lead pregnant women to not seek PNC must be explored in depth and with consideration for the socio-cultural context. An essential premise of culturally congruent nursing care¹¹ is to consider the perspectives and, especially, the needs of the people who are recipients of nursing care. These come from their personal, family and socio-cultural environments. Based on this rationale, this research was performed to find the answer to the following question: what are the reasons why pregnant women who are residents of a low-income community do not seek PNC, given that this care is available close to their homes? This study aimed to explore the reasons why pregnant women did not seek PNC.

METHODOLOGY

Research approach. This research was performed using the interpretive qualitative approach and the ethnographic research method. This method is considered appropriate for exploring subjective dimensions of lived experiences and their socio-cultural contexts. The participant observation process (POP) was developed and the insertion into the culture was facilitated by the fact that one of the researchers works in the only hospital available in the community. It is located close to a Primary Care Unit (PCU) in Cotia City, which is located in the metropolitan area of São Paulo, Brazil. This article was based on research developed as a requirement for the conclusion of a specialized nurse-midwifery course taken by the authors of this publication.

Setting.The communityis located inan urban areabuthasprimarilyrural characteristics.This community, which includes the green belt of the city of São Paulo, had a Human Development Index (HDI) of 0.780 in 2010.¹² This is considered a high index, but it masks the socioeconomic inequalities that prevail in the area. The community is located in the area covered by the PCU linked to the Unified Health System (UHS), which provides free care, including PNC. The Family Health Strategy (FHS), a Brazilian Federal Government Program, has teams composed of a doctor, a nurse, a nursing aid and six community health workers (CHWs). Each team is responsible for the families in their territory, which is delimited geographically.¹³ However, not all of the PCU had an FHS.

Data collection. The list of women who had not received PNC was requested from the administration of the PCU. The informants in this study were randomly selected. Inclusion criteria were: having lived in the community during the last pregnancy and residing at a distance of at most 3000 meters from the nearest PCU. The exclusion criteria were the presence of physical and cognitive deficits, which can interfere with verbal expression. The POP was conducted intermittently on weekdays and weekends from August 2010 to March 2011. During the POP period, data were collected about the women's daily lives. Behaviors, cultural practices, beliefs and values of the community's residents were observed. Field notes were taken regarding the ways the women utilized health care facilities, including for PNC. In addition to performing the observations in the informant's homes,¹¹ the researchers maintained a field diary to record the observations and ethnographic interviews.¹⁴

The first informant was a pregnant woman recommended by a CHW who was linked to the PCU and responsible for the area of coverage where the community under study is located. She was asked to recommend potential new informants. This method of finding participants for qualitative studies, known as the "Snowball Technique" or "Snowball," ¹⁵ was used to obtain new informants to the point of data redundancy, which indicates the deep exploration performed of the topic under study. The following items were explained to informants: the purpose of the research, the ability to refuse participation and the need to tape record the interviews. Before the beginning of the interviews, the women signed a consent form to participate in the research.

The question used to begin the interviews was: "Tell me about your daily life and the reasons that led you to not seek PNC." All of the interviews were performed at the women's residences. They lasted between 30 and 55 minutes and were fully audio recorded. Of the 11 mothers invited to participate in the study, none refused to participate. Two were considered key informants, and the others were considered general informants; they are detailed in Table 1. The criteria to consider them key informants was having lived in the community for a longer time and having deeper knowledge about the topic assessed in this research and about the socio-cultural environment.¹¹

Data analysis. After the full transcription of the interviews was made, data analysis was performed according to Leininger (2006),¹¹ who proposed an interpretive analysis and the development of sub-themes and cultural themes. The sub-themes and cultural themes were shown to the key informants, and their titles and content were validated by them. The informants were identified with an "E" by their sequence numbers, which corresponded to the order of the interviews. The research was authorized by the Ethics Committee for Research and accredited by the municipal government where the PCU is located.

RESULTS

Data related to the cultural environment. Women wearing clothes that were dirty with soil were observed waiting at the primary care unit and at the hospital, including the pregnant women. When asked about the reasons for this, the women explained that they worked the land to grow food, especially vegetables, which contributed to the clothes being dirty. The neighborhood has large areas without pavement, running water and public sewage systems. It is a community characterized by the transition between rural and urban settings, where crops, horses and cows are near advanced urbanized neighborhoods. The people living in the community suffer the consequences of the long distance to the institutional resources they want to access. Major services, such as health care facilities, educational institutions, and shopping centers, are concentrated in the downtown area. It is common to see people using old cars with over 30 years of use that are in bad condition. When asked about this situation, the women said that having a car, even one that is old and precarious, represents an important transportation strategy in emergency situations, such as needing medical care. The distance to the downtown area, the high cost of transportation and the precarious transportation conditions, especially at night, on weekends, and on holidays, are causes for concern for these citizens. The sociodemographic characteristics of the study's participants are presented in Table 1.

Table 1. Sociodemographic characteristics of the women

Table 1.

Cultural sub-themes

I found out I was pregnant too late and did not have enough time to receive prenatal care. Living with irregular menstrual cycles caused by the misuse of hormonal medications delayed the identification of pregnancy, hindering the use of PNC: I have noticed about my pregnancy when I was with five months of pregnancy, my menstruation was not regular (E4, E6, E7, E11); I was using pills through self medication (E4, E11); I was taking injectable hormones to avoid pregnancy, and I was not having menstruation (E8). Even when they suspected they were pregnant, the women did not take a pregnancy test. They feared the confirmation of the pregnancy and the need to face the problems caused by it: I did not do exams to confirm the pregnancy because the confirmation of pregnancy provoked feelings of fear (E4).

I did not receive prenatal care because I had to hide the pregnancy to avoid problems. Sharing their pregnancy status with other people, especially an employer, could result in losing their job and, consequently, becoming homeless: I hid the pregnancy until it was possible, because I was afraid of being sent away of my job. If that happened, I would have to leave the house that belonged to my boss, I'd be out the house, on the street with my children (E2). A single teenager who was living with her parents also hid her pregnancy. This teenager had fears related to her parents' hostility and she would be at the mercy of their decisions: I had strong fears in relation to my mother´s reactions towards pregnancy. She was always very angry and I was ashamed to say that I was pregnant. Surely, she would do something (E7).

I had to address urgent issues and could not seek prenatal care. A detailed analysis of the obstacles that must be overcome to access and receive PNC and the benefits of overcoming these challenges was performed by the women. This assessment, which is vital in a life full of adversities, always led to the conclusion that it was not worth receiving PNC: I did not have money for bus (E01, E10); I did not have a person to take care of my other children (E3, E9, E10, E11); My life is very difficult, with a sick mother needing care, to take her to the doctor, three children to create, depending only on me to support them (E01).

The services are not good and going to the doctor when not ill is only for rich people. The women perceived themselves as poor and had a deep-seated cultural belief that medical care should only be sought in cases of extreme necessity and in emergency situations. Some women saw pregnancy as a normal condition that does not require medical support. Others, in turn, saw themselves as relaxed due to failing to give the necessary attention to their own care during the pregnancy: We are not well attended in health care facilities. I seek for medical care only when extremely necessary, when I'm very serious problem " (E1); Pregnancy is a normal thing. I was sure that my baby was fine, that would not do anything! (E5); I was being very relaxed. Oh, I was! (E4); The poors go to the health care facility when is sick, and really needs to be attended, to go to the doctor without being sick is a thing for rich (E1, E3, E10).

The discomforts of pregnancy and other factors, such as long distances between their home and the health care facility, contributed to not seeking PNC: I had difficulties to go to the health care facility, I was fat, I did want to sleep, I was too lazy, I could not walk, the leg was swollen (E3, E5); The health care facility is too far, there is the need to walk a lot (E10, E1, E5, E09). The women felt that the health care facilities that were available had many limitations. They shared their experiences of having problems scheduling appointments due to the insufficient quantity of care providers and the providers' lack of commitment to the provision of adequate care. They also knew that consultations would be scheduled two to three months ahead. Therefore, the women concluded that the pursuit of PNC was a waste of time: It takes two to three months to schedule an appointment! There is lack of physicians!!! So, we think: to seek medical for what? (E1)

Cultural theme

Prenatal care is not worth pursuing: it is unnecessary and there are too many obstacles to receiving it. The women's lives were permeated by personal, family and social difficulties. When they became pregnant, the previous difficulties became worse, and the search for and continuity of PNC became impracticable: I am busy with many things to do, I do not have a person to help me. There are twenty-four hours of work with these children. (E1, E3). The daily life, filled with household chores and the related to paid work, did not allow women to take care. Consequently, they could only realize they were pregnant when the pregnancy was already advanced: My life is full of things to do, I was pregnant but did not perceived it: I have continued working ... (E1).

Even when the women suspected they were pregnant, they did not take tests to confirm the pregnancy. They did this because pregnancy was a feared condition that required them to face undesirable consequences. I would be kicked out of employment, I would have to leave the house, where would I go with my children? (...) My mother sent me out of my house, she would not look me (...) (E7). The lack of family and social support was the main reason for did not seek for PNC: I did not do prenatal because I did not have a person to give support for me, taking care of my other children (E9, E10); Who has little children, and no have a person to give support, it is too difficult do prenatal (E3). Deficits in the quality of care also contributed to the lack of seeking PNC. The prenatal is disorganized, when you can go to the consultation, the doctor is not available, or is in license (E6); Did not like going to the prenatal consultation because it was too early ... it is very bad, in the morning, too cold ... ah, it's horrible (E5); I do not ask for PNC because the consultation is scheduled for three months, or more! And, it is too difficult to have a doctor! (E1). The favorable and unfavorable aspects of PNC were constantly evaluated. When assessing the product of this evaluation, the women concluded that it was not worth receiving PNC because the investment does not result in the desired benefits.

DISCUSSION

In summary, the reasons given for not seeking PNC are directly and indirectly related to the conditions of poverty, which produce negative effects on women's personal lives and on their family members. They did not seek PNC immediately after noticing amenorrhea because they did not know their own bodies well. Consequently, pregnancies were usually confirmed at an advanced stage. The problem of low education and the consequent difficulty in accessing information resulted in absent or inadequate self-care practices. These results indicate that there is a need to develop strategies to promote women's empowerment. The adoption of such strategies can increase the number of people who seek guidance regarding health care resources available in communities.¹⁷

The professionals who provide care through FHS have the ability to adopt strategies aimed at improving women's empowerment. The development of such programs requires adequate linguistic and cultural preparation. The elements involved in this type of proposal must be identified and designed together with the target population, which improves the respect of the perspectives of the target population.¹⁸ However, we must consider that the majority of PCU do not provide care through FHS. Consequently, facilities that offer health care, including PNC, are very difficult to access. Pregnant women consider PNC to be an opportunity to receive answers to their questions and to feel welcomed and respected. When this is realized, they feel that health professionals are committed to the quality of care and, consequently, they have the opportunity to feel empowered.¹⁹

The lack of quality services was one of the main reasons for not seeking PNC. It is noted, therefore, that the perception that the public health service does not offer qualified care is already internalized among the people who receive health care in public care facilities.²⁰ This statement was reiterated by the participants of this study. In addition to the poor structure of the health facilities, as reported by Duarte et al. (2011),²¹ the lack of family and social support for the care of the women's other children was another problem discovered that contributed to women not seeking PNC. This reality was highlighted by other researchers, indicating the urgent need to adopt strategies to make it easier for women to access PNC.

The FHS has structural conditions to improve this situation. Treating pregnant women well during home visits and offering alternative times for prenatal appointments are important initiatives. For example, making PNC available on Saturdays, as done in some campaigns, can make it easier for women to receive the family support they need to go to their consultations. Another possibility is the creation of settings inside PCU to keep children safe and entertained while their mothers are in prenatal consultations. These strategies are important in settings where there has been a significant increase in the proportion of women who are heads of household. This rise was generated by the increased participation of women in the labor market, the increase in the life expectancy of women and the high number of broken marriages.²²

While the Brazilian government has guaranteed the right of employed women to receive PNC, the results of this study indicate that the fulfillment of this right is difficult for too many women because some of their key needs have not been met. In a study conducted in Marilia City in São Paulo State, Brazil, researchers concluded that the fragmented nature of the health care is one aspect that provokes fear and insecurity among women. Women do not feel well received during PNC appointments and do not receive appropriate care in hospitals.²³ Difficulties related to transportation were mentioned, although the maximum distance between the patients' homes and the health services facility was less than or equal to 3000 meters. One might suppose that this difficulty was associated with others of greater magnitudes and depths, indicating that professionals should actively seek out pregnant women and provide personalized and contextualized care, as recommended by the FHS.²⁴ This strategy is effective for expanding PNC programs. Supplying women with transportation tickets has also significantly increased the adherence of pregnant women to PNC. To address this, the city of São Paulo developed the "Paulistana Mother Program." Among other benefits, this program provides free transportation to attend prenatal appointments. This benefit is widely used by pregnant women who live in the city, and it has provided positive results in terms of adherence to PNC.²⁵ Therefore, we believe that this strategy should also be implemented in other care settings.

In summary, women's daily experiences are characterized by a large number of obligations and the confrontation of personal, family, social and economic difficulties. These difficulties result in women not receiving PNC. A difficult daily life is associated with negative beliefs regarding the quality of available health care; this contributed to the low adherence to PNC. Similar problems occur in other scenarios, suggesting that the traditional roles of wives and mothers are deeply rooted in Brazilian culture. Therefore, it is essential for professionals to receive training in an integral approach to health care and be sensitive to identify and meet women's PNC needs.^6,21 Although the prevalence of healthy newborns among mothers who did not seek PNC is high, the importance of PNC cannot be understated. Pregnancy is characterized by physiological and emotional changes that require adequate support. PNC should aim to promote the quality of life, self-esteem and sexual health of couples, in addition to providing guidelines for health care. Thus, pregnant women may feel that the effort required to seek PNC is worth it.

Conclusion. The results of this study reinforce the need to provide pregnant women with a feeling of being welcomed and integrally supported in the physical, emotional, social, economic and cultural dimensions during PNC. It is up to PNC facilities and their professionals to engage in improving the quality of care so that pregnant women can believe that receiving PNC is worth facing these obstacles.

REFERENCES

1. Al-Saleh E, Di Renzo GC. Actions needed to improve maternal health. Int J Gynaecol Obstet. 2009; 106(2):115-9.         [ Links ]

2. Brasil. Ministério da Saúde. Programa Humanização do Parto, Pré-Natal e Nascimento. Brasília: Brasil; 2002.         [ Links ]