When to search for birth care: mothers narratives

Momento de buscar asistencia para el parto: narrativas de puérperas

Momento de buscar assistência ao parto: narrativas de puérperas

Jessica Reis-Queiroz¹;Luiza Akiko Komura Hoga²; Bruna Goulart Gonçalves³

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

²RN Midwife, Ph.D. Professor, USP, Brazil.email: kikatuka@usp.br.

³RN Midwife. Ph.D. Student. USP, Brazil. email: brunagoncalves@usp.br.

Receipt date: September 11, 2014. Approval date:December 4, 2015.

Article linked to research: Dissertation: "Entre o planejado e o imprevisível: processo decisório sobre o momento de ir para o hospital em busca de assistência ao parto". São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2013

Subventions: Bolsa do CNPq - Brasi.l

Conflicts of interest: none.

ABSTRACT

Objective.The aim of this study was to describe the experiences lived by the pregnant woman on the decision-making process about the time to go to the hospital, to ask for childbirth care. Methods. The narrative analysis was the research method. The thematic analysis of the narratives was performed and the descriptive categories (DCs) were validated by study participants. Results. Two DCs to reveal the collective experience: "Receiving guidance, social support and making choices: planning the going to the hospital" and "Between the planned and the unpredictable: decision process about the time to go to the hospital". Conclusion. The decision-making process of women is reasoned especially on the social support network, and also on the advises received from healthcare providers. The professionals involved in prenatal care should develop actions considering the pregnant women's social context, and the family members should be integrated in the provision of prenatal care. The adoption of these measures is essential for the improvement of the quality of care.

Key words: prenatal care; women's health services; obstetrical nursing.

RESUMEN

Objetivo.Describir las experiencias vividas por la mujer embarazada en el proceso de toma de decisiones sobre el momento de salir de casa en busca de asistencia para el parto. Métodos. El análisis de la narrativa se utilizó como método de estudio. Se realizó el análisis temático de las narraciones, la preparación de categorías descriptivas (CD) y la validación de las categorías con las participantes. Resultados. Los resultados generados fueron dos CD: "Recibiendo orientaciones, apoyo social y tomando decisiones: la planeación para ir al hospital"; y "Entre lo planeado y lo impredecible: el proceso decisorio sobre cuándo ir al hospital". Conclusión. El proceso decisorio de las mujeres se basa en la red de apoyo social y las directrices recibidas de los profesionales de la salud. Los profesionales que trabajan en la atención prenatal deben desarrollar acciones de acuerdo con el contexto social de la embarazada, integrando a la familia en la atención, lo que es fundamental para la asistencia de calidad.

Palabras clave: atención prenatal; servicios de salud para mujeres; enfermería obstétrica.

RESUMO

Objetivo.O objetivo desta pesquisa foi descrever as experiências vivenciadas pela gestante relativas ao processo decisório sobre o momento de ir ao hospital em busca de assistência ao parto. Métodos. O método de estudo foi a análise da narrativa. Foi realizada a análise temática das narrativas, a elaboração de categorias descritivas (CD) e a validação das categorias com as participantes. Resultados. Os resultados gerados foram duas CD: "Recebendo orientações, suporte social e fazendo escolhas: o planejamento da ida para o hospital" e "Entre o planejado e o imprevisível: o processo decisório sobre o momento de ir para o hospital". Conclusão. O processo decisório das mulheres é fundamentado na rede de suporte social e nas orientações recebidas de profissionais de saúde. Os profissionais atuantes no pré-natal devem desenvolver ações mediante consideração do contexto social das gestantes e integração da família no atendimento, o que é fundamental para a assistência de qualidade.

Palavras chave:assistência pré-natal; serviços de saúde da mulher; enfermagem obstétrica.

INTRODUCTION

In the early twentieth century, delivery care was provided mainly by midwives, who went to the homes of the pregnant women to provide healthcare.¹ The change of the birth care setting, from home to hospital, has created the needed of pregnant to seek birth care in health institutions.² In this new care setting, there were new demands, including the need to receive guidance regarding the appropriate time to leave home to search institutionalized care. The receiving of reliable guidance regarding signs and symptoms of labor and the opportune moment to seek care in hospitals, birthing centers or birth homes became a demand that must be met by health care providers. Are fundamental guidelines for women to deal with more peace of mind with the physical changes, which are intensified in late pregnancy, and the implications of psychological, family and social nature resulting from own transformations of this period.³ It is situation in which pregnant women feel insecure in relation to fetal well-being, feeling that can propel them to seek birth care in an early and wrong time. The uncertainty hovering in the minds of these pregnant women can be originate from internal sources, and negative previous experiences, or from external sources, particularly those generated in familiar, social and work environments.⁴

The planning of the birth care must take into account the available network of health services to pregnant women and health care conditions, as well as social and cultural aspects that predominate in the localities where they live. In this sense, care protocols should include the aspects related above, and these, in turn, require constant review so that the needs of pregnant women can be properly identified and met. The importance of the guidelines relating to the individual transformations during the pregnancy and the corresponding required support are recognized by the managers of public policies of the obstetric care field. Above all, the guidelines on signs and symptoms of labor are considered relevants.⁵ In this respect, it is necessary to consider that pregnancy is an experience that is shared between the pregnant women and the people living with her, especially her family. The social support provided by people close to pregnant women, especially those who have had the opportunity to live the experience of pregnancy, is an enabling factor in the process of becoming a mother. Such support is considered crucial for dealing with stressful situations and to preserve the mental health of pregnant women.^6-8 Involvement of the pregnant woman's family members in this important period of family life course contributes to a more effective adherence to prenatal care, which contributes significantly to the feeling of being safe getting support at this period of life.

Some aspects involved in the issue of the search for birth care do not yet have clear answers, among them, the factors that influence the decision making in relation to the time of seeking care. This issue has not been sufficiently explored in Brazil and abroad. Given this fact, we have developed this study aiming to obtain answers to the question: "What are the factors that influence pregnant women about the time of leave home in search for birth care?". The aim of this study was to describe the experiences lived by pregnant women relating to the decision-making process on the time to go to the hospital in search of birth care.

METHODOLOGY

This research was developed in the postpartum room in of a public hospital located in the East Zone of the City of São Paulo - Brazil. The hospital is a reference for 13 Basic Health Units (BHU), where pregnant women in the hospital catchment area receive prenatal care. The hospital has six birthing suites and 33 beds of postpartum hospitalization. In 2011, in this institution, were provided care for 3165 births, being the 1388 of primiparous women. The research approach was qualitative, adequate to explore the subjective aspects of experience, in this case, the factors that interfered in the decision-making process concerning the time to seek institutionalized birth care and the demands for social support from the perspective of the women.⁹ The research method was the narrative analysis, which allows to explore how the people organize and give meaning to a particular event. This method should be developed through five steps: accessing, telling, transcribing, analyzing, and reading the experience.¹⁰

To access the women's experiences, after obtaining authorization from the hospital's managers, the women who were admitted to the postpartum room in were interviewed. Inclusion criteria were spontaneous participation and the minimum time of 24 hours after childbirth. This time was established to respect the need for rest after labor. To ensure randomness in the inclusion of women, these were selected by lot, being included four women in each interview day. Women were addressed in the postpartum room in setting. Before starting the interviews, they were informed about the study objectives and the possibility of not participating. They listened for the researchers that if they did not want to participate, this decision would not cause current or future losses of any nature. The interviews were individual, face to face, and held in private room in the hospital. They were started following a script, which the first question was: "Tell me about your experience in relation to the time you leave home (or elsewhere) in search of childbirth care." The interviews were fully recorded and lasted approximately 30 minutes. There was no need to repeat interviews.

The interviews were conducted between January and February 2013 and the perceptions of the researchers were recorded in a field diary, to assist the analysis of narrative later. Among the 44 mothers invited to collaborate, 14 declined and 30 gave interviews. All who refused mentioned the fatigue as a reason. The interviews were fully transcribed, obeying the sequence of the women narration. To preserve the identity and facilitate the identification of women, the narratives were numbered with the letter "P" relative to the women, followed by the sequential number of interviews. This process was followed by another transcription, which consisted in building a more fluid and understandable text for the reader, without changes in the meaning attributed to experience lived and reported by their own mothers. In this way, the testimonies of mothers that illustrated the descriptive category were transcribed again in a single speech, aiming to incorporate aspects reported by the other women. At the end of the second transcription, the product was subjected to a comparison with the transcription, in order to ensure its reliability, as recommended by Riessman.¹⁰ The occurrence of the theoretical saturation was observed at 16^th narrative interview. However, 30 women were included, aiming to ensure methodological rigor, and the amount and quality of data.¹¹

Thematic analysis was made in interpretive and inductive ways. Firstly, a comprehensive reading of the statements was made, with care not to instill perceptions of the researchers on the phenomenon in the processing of the results. Keywords have been identified, emphasis given to certain situations and identified emerging issues, which were important to describe the phenomenon. Perceptions about the recorded interviews in field diary, as the tone of voice, the emphasis given to some of the narrative passages or a few words, helped in the task of group representative units of experience. Similar representative units were grouped, allowing formulate initial issues and help identify the components of each thematic category.^10,12

In the fifth stage of the research method, it proceeded to the connection between the representative units of individual experience to identified issues, to build descriptive categories (DC) that were representative of the collective experience and that answered to the aim of this study.^10,12 The confirmation of reliability of the DC was obtained by telephone with 11 women. It is an important procedure to ensure rigor in the development of narrative analysis method, whose main premise is to ensure the reliability of the elaborated results, which must be in accordance with the prospect of their own study participants. The 11 women approved the titles of descriptors and their main components and reaffirmed the correspondence between the lived experiences and elaborate DC. It was not possible contact with all women who participated in the study, because some refused to provide their telephone number and, in some cases, the contact number was incorrect.

Regarding the ethical aspects involving research with human subjects, the Informed Consent was presented to women and only after his agreement and signature, the interviews were conducted. The ethical and legal precepts of Resolution 466/12 of the National Health Council¹³ were respected. The study was approved by a Research Ethics Committee (REC) accredited, with the number 127190/2012. It was also approved by the REC of the hospital, with the number 139728/2012.

RESULTS

The interviews resulted in two DC that are described below.
 
Receiving guidance, social support and making choices: planning to go to the hospital at the delivery moment

The appreciation of the perceived social support was intensely present in women's narratives. Having these support by reference, women planned to go to the hospital trying to find delivery assistance. The received guidelines were related to signs and symptoms of labor, among them, the loss of amniotic fluid, begin and progression of uterine contractions, and pain in the lower abdomen. Such guidelines had been received, especially from the professionals who made the prenatal care of women. The support received from family and friends, especially partners, was perceived by women as an essential aspect. These supports contributed to women have felt safer. Women had received emotional support from family members and friends through the interest demonstrated in relation to the progression of pregnancy, encouragement by words of encouragement, and the physical presence during pregnancy and at delivery.

In (Table 1), are presented the DC 1, its representative elements, the interaction between these elements. Here after are highlighted excerpts that illustrate elements of DC1.

Table 1.

Some examples of the speeches in this category were:

Received guidance about the moment to go to the hospital trying to find assistance for delivery: They told me in the hospital that, if I felt pain, should come to maternity, but if I did not feel pain, would have come anyway to not pass 41 weeks. And they will induce the delivery (P4, P7, P11).

Support received from family and friends: It was an amazing experience, everyone was on my side, I had a lot of support from everybody the whole pregnancy; It was something that renewed me. Family support was essential and did not miss (P5, P15, P16, P17, P24, P26, P30).

To planning to go to the hospital at delivery moment through choices: We had it all planned. I had a plan A, which was to take the car of my father in law, a plan B was to call a taxi and a plan C was to call the ambulance. (...) I was sure that my husband would go with me to this hospital, because people say that the service here is good (P2, P8, P15, P16, P17, P22).

Existence of contrary cases: We had no plan, just knew that when she had pain had to come to the hospital (P24, P5, P9, P10); During the prenatal they said nothing about labor or the time to go to the hospital (P4, P21).

Between the planned and the unpredictable: the decision-making process on the time to go to the hospital trying to find delivery assistance

Although we observed the planning about the time to go to maternity trying to find delivery assistance, women were faced with unpredictable and had to take decisions immediately. This confrontation demanded improvements and/or changes in the planning.

Table 2.

Some examples of the speeches in this category were:

Having to decide between the opinions of family and friends and her own opinion: How was past the date by ultrasound, so stay my husband, my neighbor, everyone were concerned for me to go when I started to feel contractions. Everyone was talking and I was afraid something happens (P6, P11).

Considering past experience: I knew how it would be because of my other son, it was very similar to each other. This birth I was calmer as well, because I already knew how it would be and because my husband was with me, calming me (P14, P22, P30).

Perceiving signs and symptoms of labor: I started to feel contractions, but wanted to wait a bit to see the time between a contraction and another. As would only increasing I decided to come to the hospital. My husband was with me, but he just asked if I was okay and spoke to warn you when I wanted to go (P1, P2, P7, P8, P12, P17, P21, P24, P25, P29, P30).

Having concerns about the child's welfare: We get more anxious at the end, because stay worried about the baby, every little pain you wonder if it's okay or if it's time to be born. It is always eager to take the exam of the little heart to hear if everything is fine (P2, P4, P11, P15, P21).

Facing setbacks and unpredictable: When we got to the gate, we saw that the car's tire was flat and I was already a very annoying pain. We spent the tire repair shop close to home, quickly, arrived at the hospital and everything went well, thank God (P16).

DISCUSSION

The guidance received from health professionals were related, mainly, to the loss of amniotic fluid, pain in the lower abdomen and the need to remain attentive to the expected delivery date, so it does not exceed the 41 weeks of pregnancy. This information was received, mainly, during the prenatal and in some cases, reaffirmed during follow-up in the hospital in the last weeks of pregnancy, confirming the importance of providing detailed information to pregnant women during the pre-natal care.³ It is important to say that some women reported not having received information about signs and symptoms of labor or about the time they should go to hospital trying to din delivery assistance, contradicting the Ministry of Health recommendations on the guidelines to be provided to pregnant women during the pre-natal care.^5,14,15

who reported having received information about the signs and symptoms of labor were satisfied with the information because they helped in the decision making about the time to go to the hospital for delivery assistance. Similarly, in a study about satisfaction and expectations about prenatal care, women indicated to feel satisfied with the received information, but lacked some of the recommended information.¹⁶ A survey focusing on knowledge of nulliparous pregnant women, about signs and symptoms of delivery, found that 93.6% of them reported experienced lay persons as a source of informations.¹⁷ In this study, it was revealed that the guidelines made by family members and friends were related to the search for care at the hospital when the uterine contractions initiated or when there was loss of fluid. However, inaccurate information contribute to pregnant women seek health services in false labor, which highlights the need to include family and friends in prenatal care, making possible to get necessary information for the delivery and birth experience permeated by feelings of security and satisfaction.

The support received from family and friends was fundamental in planning the trip to the hospital trying to find birth care. A study focusing on the transition periods in the course of life described that, at the time of delivery, there is an increase in social support provided by family and friends.⁶ In addition, the perception of this support by women has been indicated as a protective factor for post-partum depression.^18,19 This fact was confirmed in this study, noting that women received social support during delivery, and considered it key to the positive experience of this moment. To plan her way to the hospital for delivery, women had to make choices based on the guidelines and social support received: from people who accompany her to the hospital and/or at delivery; from the most suitable transport resources; and the hospital to be sought for the deliveries. The participation of health professionals in this planning is very important for pregnant women can feel safe in the preparation process for delivery;⁵ however, this study did not observe the work of health professionals in this area.

Although many treatment protocols are publicly traded and professionals evaluate them positively, the use of these materials in healthcare practice still suffers resistence.²⁰ In the same way, the data founded in this study indicate that although professionals understand that women need guidance and assistance, in planning the way for the hospital trying to find delivery assistance, these guidelines have been made incomplete. Another aspect of health care in pregnancy and delivery was the proper functioning of the system of reference and counter-reference in the studied area, because of the existence of proper linkage between UBS and the referral hospitals in the region. This service avoid exposure to unnecessary risks, derived from the woman's peregrination process in labor trying to find assistance.²¹ Many women sought delivery care at this institution, although not be her referral hospital, with a view to good quality hospital . But it is an institution that has no vacancies available for all demand, which signals the need for investment in improving the quality of care in other hospitals in the region.

The second phase of the decision-making process includes the decision itself, about the time to leave home in search of childbirth care. Decisions in this area were taken from the interactions between the planning done in the previous stage, the opinion of family and friends, the perception of signs and symptoms of the labor start, the reflection on the previous birth experiences, concern with the child welfare and the setbacks and unpredictable arising at the time of making the decision. Even when the woman knew the delivery process, because of previous experience or guidance received during pregnancy, there was, in many cases, great pressure exerted by friends and family, so they were directed immediately to the hospital trying to find delivery assistance. The women concluded that this pressure was given by anxiety of their own families/friends, highlighting the importance of the preparation of the partner during the pre-natal care.³

Concern for the child's welfare was in the reports, especially with regard to decreased fetal movement and gestational age of 40 weeks. This concern has caused women to seek care at the hospital for tests attesting the healthiness of the child. The emergence of setbacks and unpredictable at the time of seeking assistance in leaving home has generated great anxiety for women, which had as main concern the possible emergence of harmful complications to their health and the child's health. To reduce this anxiety, pregnant women sought to preserve her own tranquility and, therefore, made changes in the initial planning and felt relieved with favorable outcomes. The results of this study highlight the decision process as complex and full of interactions among several factors. Bourgeois-Gironde,²² in their study of the rationality of decisions on human behavior, described this rationality as related to previous experiences, acting as modulators of current decisions. This fact was reiterated in this study because studied women reflected about the previous experiences of others or of family and close friends as their own experiences, which influenced their decisions about when to go to hospital trying to find delivery assistance.

As limitations of the study, it is highlight the use of narrative analysis as a research method requires attention to the subjective aspects of the employees of the study, which restricts what can be identified by the researcher. The study was conducted in a place where the reference and counter-reference system was well defined, which could have been avoided peregrinations described in the literature.

In conclusion was possible to observe, in this study, intense family participation in decision making when trying to find delivery care, including providing the necessary support for the way to the hospital. It was also found that, the planning for the time you leave the house had the participation of a healthcare professional by orientations related to the signs and symptoms of labor, women felt safer in the decision making about the time to go to the hospital. However, they revealed that the participation of professionals was quite limited, much less frequent compared to the interest shown by members of their own family.

Considering these results, it is concluded that it is essential that professionals providing prenatal care should understand the context in which the women belong, and try to involve members of their families. In this way, it will become possible to enhance the effectiveness of health actions in the field of prenatal care. The results of this study reinforce the importance of attention intended by health professionals to the planning of the pregnant woman way to the hospital at the time of labor. It is believed that, considering the involved elements of the different socio-cultural, geographical and care settings, the results of this study may be applicable to other contexts of prenatal and birth care.

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