PUERPERIUM CONSULTING:  NEEDS OF WOMEN FROM THE NURSING PERSPECTIVE – EXPLORATORY STUDY

Kleyde Ventura de Souza¹, Patrícia Regina Quinsacara Carvalho² Adelita Gonzalez Martinez Depinote³ Valdecyr Herdy Alves⁴, Bianca Dargam Gomes Vieira⁵, Bruno Augusto Corrêa Cabrita⁶

1 Federal University of Minas Gerais; 2,3 Catholic University of Paraná; 4,5,6 Federal Fluminense University

ABSTRACT

Objectives: The research aimed to understand the health needs of postpartum women in the nurse's perspective, considering the integration of actions. Method: The research was conducted as a Exploratory type. 15 nurses who participated in puerperium consultations in nine health units of the Sanitary District Cajuru the Municipal Health Secretariat from Curitiba / Paraná, Brazil. For the data collection we used an instrument with objective questions, applied in the period from February to March 2007. Data were analyzed based on descriptive statistics. Result: It was found that the set of requirements for good living conditions has been appointed as 41.2%, and least cited: needs guaranteed access to technologies, and 4% bond with the host and the professional / health team, 2%. Discussion: It may wonder about the notion of completeness is being incorporated into puerperal consultations. Conclusion: There are still important gaps in meeting the needs of mothers.

Keywords: Postpartum Period; women's health; maternal welfare.

INTRODUCTION

The maternal nursing is focused on woman in the reproductive cycle, her son and family. The profession has developed the knowledge, skills, abilities and tools to understand women in their context and in their demands. Thus, the nurses in this field of practice and knowledge have an important role in strengthening of health care models, which meet the needs of women and contemporary families⁽¹⁾. However, the quality of care practice in the postpartum period is still influenced, among other factors, for vocational training based on the biomedical model, which determines the direction of attention is in the clinic⁽²⁾.

To contribute overcoming this fact, in the context of health actions in cases of pregnancy, childbirth and post-partum period, the Ministry of Health (MH) established in June 2000, the Program for Humanization of Prenatal and Birth (PHPB). This program aims to improve the quality of care and ensure that woman goes to be seen as a subject of her health process ⁽³⁾.

The PHPB was joined en masse by the Brazilian municipalities, among them, Curitiba/Paraná. The proposal established by the Program designed a puerperal consultation as an essential criterion to all of the assistance, considering this activity, at the national level has been low frequency in the Basic Health Units (BHU). One of the factors to be analyzed is that, the services and health professionals regard the birth as the end of the process, driving their shares to the newborn. As a result, do not value the return of women to the health services, except as mothers, as this condition are essentials, in view of the responsibility in the care given to children⁽³⁾. Other factors mentioned are located in the failure of planning and implementation of assistance to puerperium and gender bias in the perception of care by health professionals ⁽²⁾.

In this exposed context and the potential know-how of the nurse in the field of maternal health it appears that efforts should be made so that the needs of these women are understood and met, in order to promote quality of life and health. To do so, is questioned: what are the health needs presented by mothers, in nurse's perspective taking into account the integrity of actions in health? To answer it was delimited as objective to know the health needs of postpartum women in the nurse's perspective, considering the integration of actions.

This article arose from a study that sought to steer a quality standard of nursing consultation on postpartum based on health promotion using the International Classification for Nursing Practice in Collective Health (ICNPCH^â) and, thus, included in the Institutional Program of Scientific Initiation Scholarships (PIBIC), 2006-2007, from Pontifical Catholic University of Paraná (PUCPR).

MATERIALS AND METHODS

An exploratory study, using the Intervention Theory of Nursing Practice in Collective Health (TIPESC). Its time, interrelated, include the capture of Objective Reality (RO); the interpretation of the RO, the construction of the intervention project in RO; the itself intervention and the reinterpretation of the RO⁽⁴⁾. This study addresses the time of capture of the RO.

The empirical field was formed by nine from 12 Health Units (HU) belonging to Cajuru Sanitary District, from Municipal Health Secretariat of Curitiba (SMS).

The population consisted of 27 nurses who queries puerperium consultations. From this set, volunteered, 15, ie 55.5% of the bounded population, randomly chosen, respecting the following inclusion criteria: length of service over than six months and effective post-partum period consultation in their routine. Nurses who were removed from their professional activities were excluded during data collection.

Data were collected from February to March 2007, through a questionnaire applied by the researchers, with closed questions and possibility of comments from the interviews. The questions were arranged from a typology consisting of five major sets of health needs and their forms of expression⁽⁵⁾ (Chart 1), and for each of these sets, the participants could point to one or more forms of expression.

Chart 1 - Health Needs and their forms of expression^(5) Curitiba, Feb-Mar, 2007.
Sets requirements	Expressions
Need for good living conditions.	Living in society; access to leisure, food housing, transportation and live in adequate environment.
Need to be someone with the right to difference.	Being subject to law and citizenship; equal and nominal; be included and respected in their special needs and able to exercise their sexual rights.
Need for autonomy and self-care in the choosing how to "walk" the life.	Make decisions connected between knowing and doing and respect your opinion.
Need to ensure access to technologies that improve and prolong life.	Participate in education and / or health information group, access to medicines, supplies and contraceptive methods of choice, exercise of reproductive rights, access to re-hospitalization.
Need to be welcomed and have a relationship with a health professional or team.	Be welcomed in any service you need, have access and be received in any health service you need, possessing bond with the service and with the team and / or professional.

The data were organized in a electronic spreadsheet. The analysis was based on descriptive statistics and discussions from bibliographic references on the subject.

This study was approved by the Ethics Committee in Research of the Pontifical Catholic University of Paraná, opinion No. CEP-1389 LST, with its feasibility approved by the Ethics Committee in Research by Center for Health from SMS Curitiba/Paraná. The participants signed a Statement of Consent (ICF), to join the research emphasis to the assurance of confidentiality and the possibility of withdrawal of consent any time, meeting the guidelines of Resolution No.. 196/96 of the National Health Council from Ministry of Health (CNS / MS).

RESULTS

The data for the purpose of the study were identified considering the sets of health needs and their forms of expression (Table 1): a) good living conditions; b) be someone with right to difference; c) autonomy and self-care in choosing to "walk" life; d) ensuring access to all technologies that improve and prolong life; e) be welcomed and have a relationship with a health professional or team ^(5.6).

The distribution of frequencies related to joint health needs can be found in Table 1

Table 1 - Frequency distribution of all the needs of mothers, from nurse`s  perspective. Curitiba, Feb-Mar, 2007.
Joint Health Needs*	Frequency	Percentage
Need for good living conditions.	42	41,1%
Need to be someone with right to difference.	35	34,3%
Need for autonomy and self-care in choosing how to "walk" the life.	19	18,6%
Need for guaranteed access to all technologies that improve and prolong life.	04	4,0 %
Need to be welcomed and have a relationship with a health professional or team.	02	2,0%
Total	102	100%

* Sum of the forms of expression that constitute each one of the sets of health needs.

It was found that the set of needs for "good living conditions" was the most noted in 41.1% of respondents, followed by the need to "be someone with right to difference", 34.3%, and the need for "autonomy and self-care in choosing how to walk "life", 18.6%. Were less pointed, respectively, the need for "guarantee access to all technologies that improve and prolong life," 4.0%, and the need to "be welcomed and have a relationship with a health professional or team", 2, 0%. Thus, the sets need for good living conditions and being someone with rights to difference amounted to 75.5%, while the remaining 24.5%.

Each set of needs consisted of what is called the forms of expression. The set of needs related to living conditions included four forms of expression. The set needs to be someone with right to difference included six forms of expression. The set of need for guaranteed access for all the technologies that improve and prolong the life was made up of five forms of expression; whereas the set on the need to be welcomed and have a relationship with a health professional or team had four forms of expression and finally, the set of needs for autonomy and self-care in choosing how to "walk" the life, two forms of expression. These sets of five major requirements are shown in Table 2.

Table 2 - Frequency distribution of forms of expression of sets from health needs of mothers, from nurse´s perspective. Curitiba, Feb-Mar, 2007.
Forms of expression of the Health Needs*	Absolute frequency (AF)		Relative Frequency (RF)
	n	%	%
Needs of a good living condition:
House	6		14,2
Feeding	7		16,6
Transport	3		7,1
Leisure	10		24
Appropriate environment	5		12
Living in social processes of inclusion	11		26,1
Total Class	42		100
Need to be someone with right to difference
Being a subject of law and citizen	6		17,1
Be equal to	7		20
Be nominal	2		5,7
Be respected in their special needs	6		17,1
Be include	8		23
Demand for the exercise of sexual rights	6		17,1
Total Class	35		100
Need for autonomy and self-care in choosing how to "walk" the life
Making decisions about your opinion	10		52,7
Make decisions connected between knowing and doing	9		47,3
Total Class	19		100

(*) For each of these sets, the participants could point to one or more forms of expression

Forms of expression of the Health Needs*	Absolute frequency (AF)		Relative Frequency (RF)
	n	%	%
Need for guaranteed access to all technologies that improve and prolong life
Participate in education and / or health information group	2		50
Having access to medicines and supplies	2		50
Total Class	04		100
Need to be welcomed and have a relationship with a health professional or team
Be welcomed in any service you need	2		100
Total Class	02		100

Regarding the forms of expression the two sets of health needs most often cited, namely, related needs of living conditions and need to be someone with right to difference observed that, in the first, the forms of expression most frequently mentioned were living in social inclusion processes (26.1%). We can infer the influence of this form of expression over the other, the same set, which were cited in the following order: leisure (24%), feeding (16.6%), housing (14.2%); appropriate environment (12%) and transportation (7.1%).

The second set of health needs further above, it was found that most forms of expression observed were: the needing to be include (23%) and be equal to (20%). These expressions seem to have influence over the other three of this set of needs, which had similar: to be subject and citizen (17.1%); be respected on the special needs (17.1%) and exercise of sexual rights (17.1% ),beside the need to be nominal was mentioned less (5.7%).

For the three less cited sets of health needs are the need for autonomy and self-care in choosing how to "walk" the life, form of expression of larger proportion was making decisions with respect to your opinion (52.7 %). The health need for guaranteed access to all the technologies and need to be welcomed and have a relationship with the professional or health team were seldom mentioned; 4% and 2%, respectively. The first group received 50% of nominations for the following forms of expression: to participate in education and/or health information group and to have access to medicines and supplies. In the second set and the least mentioned, the form of expression be welcomed in any service you need is more pointed.

DISCUSSION

The puerperal consultation set up in a stance where should disassociated the mother's health  from the newborn`s, characterized, priority, an important moment in the women's health<sup>(1.3)</sup> and, on the other, the combination of the practice`s fields and knowledge of women's health and maternal health. It was at this particular moment of action on health, which sought to meet the needs of women, in a singular moment of their lives, from the point of view of nurses, through the forms of expression of the health needs.

The health needs of postpartum women and their forms of expression^(3.5) from the perspectives of a group of nurses constituted the object of this study. It is noteworthy that human needs, by itself, constitutes a theoretical discussion and practical too complex.

Its concept is explained, in different historical periods, at origin in the human nature or in the culture. The necessity can be conceived in the disciplinary perspective of the philosophy, psychology, economics and sociology, among others, with functionalist matrices (where the need is extension of the human body that emerges from a process of learning and socialization) or interpretive (where the need has social character directly related to the historicity)⁽⁷⁾.

In this sense, to understand the needs from the conceptual point of view and put them into practice everyday in healthcare field is a challenge, in that meet in the same arena the complexity of this concept,  its understanding and incorporation by professionals, as well as mediation between its elements^(5,6). This context may bump into the ethical-political dimension that guides the actions of network services, which influences the work process within the private of the health institutions.

Regarding the set of needs related to living conditions, this is expressed in several models of care in the health field. Thus pointing to a problematic context which is realized in the absence or difficulty of access to essential aspects from the life of individuals, who are present and/or determine the procedures to get sick or keep healthy^(2.7). In this group, stand out the forms of expression live in social processes of inclusion and leisure, a fact that sent us to the question of inequality and social injustice that mark the Brazilian scene.

Brazil is a country known to be unequal and unjust. This situation is easily observable when one considers its great urban centers. In them, invariably, there are areas of poverty and misery that surrounds "islands" of wealth accumulation. These situations of inequality and injustice, added to inequalities/gender inequities are a major burden for society and for women, in a special way. The result of this process is the lack of autonomy and power, with disastrous consequences for sexual and reproductive health and to quality of life of this population group⁽⁶⁾.

It can be inferred also, the influence of this form of expression over others (food, shelter, adequate environment and transport), as observed in this study. These needs go beyond the technical and practical assistance in health and start to demand actions that coordinate and integrate sectors determinants of health and life, requiring also, the systemic understanding of the problem, recovery of intuitive thinking, cooperation values and partnership, in addition to exercise in the network, so that priority be given to the relationships between the actors of a particular social situation⁽⁷⁾. It is noteworthy that the figures quoted are considered rights and that, in an interpersonal relationships, are intrinsically tied to the recognition that the partnership is a key element among the members of a group⁽³⁾.

The group, need to be someone with right to difference, appeared as the second most reported by nurses. Examples that have expressed this set were defined as: being subject to rights and citizenship; be equal, nominal, respected in the special needs and be included⁽⁵⁾.

In light of these results we show that the nurses interviewed recognize that the health needs of postpartum women did not reduce the prevention and control of diseases. Points the importance of issues related to citizenship and health, as well as convergence between them. The focus should turn to the necessary overcoming of the idea of woman as object and her incorporation as an urgent social subject, so that it can expand her participation and autonomy within the family and place and, thus, her needs to gain visibility in these contexts, thus, strengthening, the construction of their citizenship.

The entirety, one of the principles of the Unified Health System (SUS), perhaps the most challenging of them, confirms the meaning of work in health and in nursing to trace the humanity people regarding their health needs ^(1.6). This principle is manifested in practice, from three sets of directions. The first refers to the implementation of public politics or responses to health problems, ie, the link between attendance and preventive actions, in order to control and disease prevention. The second set back to the organization of health services and, finally the third focuses on the health practices⁽⁵⁾.

Of note was the fact that the third, fourth and fifth sets of needs were less said about the first two. It can be inferred, at first, that these needs are met, although this inference deserves questions; still falling in fields hidden by social ills, especially, the social and gender inequalities, with negative consequences for health and quality of life of this population group, in particular.

Thus, it is emphasized that the sets of needs related to autonomy and self-care, ensuring access to technology and welcome by the professional staff were referred to four times less than the others. Could inquire about how the notion of integrality is being incorporated in this type of health practice.

The analysis of these needs and, consequently the actions/interventions from which generated demand (re)construction and development of health practices that strengthen the achievement of women's autonomy, particularly with regard to the expansion of their knowledge, as well as developing self-confidence to care and in choosing your mode to "walk" the life.

One issue to be highlighted refers to the concrete conditions of existence of these women, given that many of the problems and needs are from outside the subject. In this sense must go the space taken individually for the collective, ie, the actions must move to the spaces of determination of the health-disease process: spheres of the production process, of domestic work, of family microenvironment, finally, collective processes, to the extent that these go beyond the identifiable needs to individual level⁽⁷⁾.

The health technology encompasses a complex set of elements that acquire a social value or value in use and has underlined its importance from the necessity and  the singular moment in which each person lives⁽⁸⁾. Was verified from the observation that the production technologies of care – central core health care - can be arranged in the material dimensions or not to do in health, may be circumscribed in land called: a) mild: relational technologies, such as training ties; welcome and management; b) soft-hard: structured knowledge that operate in the work process, and, c) hard: represented by technological equipment, as well as the norms and organizational structures⁽⁵⁾. The nurse understands that the technologies, apart, can not answer the complexity of the health-disease process, requiring a balanced redefinition of technical, scientific and relational, in the humanization sense and committed to the construction of citizenship⁽⁸⁾.

The expertise of the nurse in the women’s health and puerperal consultation should consider the use of soft technologies or relational, in that they can foster the construction of relationships in which real subjects (nurses and postpartum women), in real situations (context of life and health) are able to identify needs and see ways of overcoming. Besides, relationships that are based on the user's listening and in a good quality of professional service, strengthen and promote the link between user and health services⁽⁹⁾.

It is noteworthy that, in a study at Pará, was realized that in the women’s vision, among the professionals of the healthcare team, nurses provide more listens, even faced to reality of the burden in daily activities⁽¹⁰⁾, which leads to believe that this technology, although only just incipient, gradually has been taken by the nursing staff.

Finally, the last group was the least mentioned, referred to needs to be welcomed and have a relationship with a health professional or team. In this set of requirements were not mentioned: have access and be received in any health service you need, possessing bond with the service and have link to the team and/ or professional.

Note, then, that from the standpoint of their programmatic bases the organization of the care is, in theory, covered. However, the same can not be said when one considers the working process, towards the qualification of the relationship and the area of intersection between professionals and users from the humanization’s perspective, the recovery of citizenship and empowerment, as well as the completeness of actions to promote health and care needs of women involved.

Accordingly, the host and the formation of linkages are fundamental aspects to nurse’s know how, should be built in go to make, concrete and abstract dimensions that characterize the living-health care.

CONCLUSION

It was found that the sets of needs for a good life and be someone with right to difference were three times more than the indicated sets of autonomy and self-care in choosing how to "walk" the life; ensuring access to technologies that improve and prolong life; and to be welcomed and have a relationship with the professional health team.

As to the first can be emphasized that the interviewees acknowledged that the health needs of postpartum women did not reduce to the prevention and to the control of diseases, reflecting an overrun of functionalist concept of human need. Points the importance of issues related to citizenship and health, as well as convergence between both.

From this perspective, the focus is the need to move beyond the ideology of woman as object and her incorporation as an urgent social subject, so that can expand her participation and autonomy within the family and place and so, needs to gain visibility in local and global contexts, strengthening the construction of her citizenship.

As for those less sets, if one side can be inferred that these needs are addressed and others, that fall in fields hidden by social ills, notably, the social and gender inequalities, getting low profile, although with negative consequences for the health and quality of life of this population group, in particular.

Considering the current Brazilian scenario and indicators, with regard to women's health and maternal health, you can inquire about the notion of completeness is being incorporated in this type of health practice. The percentage differences between the sets of needs indicate that, from the standpoint of integrated care, there are still important gaps.

It is recommended that nurses, in their know-how, in order to quality care, humane, culturally sensitive to the women’s needs, advance the incorporation of the sense of completeness in their professional practice and consider the importance of the multi/interdisciplinary and of intersectoral health actions.

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Received: 01/19/2011

Approved: 04/11/2012