ORIGINAL ARTICLES
Experiences of women in a pregnant group: a descriptive study
Paula Rueder Neves1, Natalia Salim1, Glauce Cristine Ferreira Soares1, Dulce Maria Rosa Gualda1
1University of São Paulo
ABSTRACT
Aim: To understand the experiences of pregnant women in a group and the role of the group in pregnancy, childbirth and postpartum.
Method: This was an exploratory descriptive study in which a qualitative approach was used. The instruments for data collection were interviews and observation. Five women participated in the study.
Results: The thematic content analysis allowed the identification of five categories related to the significance of participation in the group: the importance of the group for pregnant and postpartum women; the group as a place for learning; bonds and exchanges; the role of the group in the delivery process; the role of the group in the motherhood experience.
Discussion: Participation in the group proved to be important in the birth process. The group was seen as an opportunity for exchange, and proved to be a facilitator in the formation of bonds.
Conclusion: The practice of pregnant women participating in a group should be encouraged and implemented in prenatal care.
Descriptors: Health Promotion; Pregnant Women; Humanization of Assistance
INTRODUCTION
Pregnancy, childbirth and the postpartum period are events in the reproductive period of life characterized by major changes in both the physical and the psychosocial contexts. Each woman deals with these changes according to the subjectivity and perception of her own body and of herself(1). Thus, healthcare for women during this period should include attention to the physiological processes of pregnancy, as well as to offer support and welcome through the exchange of knowledge, experiences and interaction with obstetric care professionals.
In this context the health educational process is an action that occurs dynamically, and allows knowledge socialization and experience exchange between participants and health professionals. This action has therapeutic power and proves to be an essential tool for promoting the health of the individuals concerned(2).
Currently, in Brazil, the Ministry of Health (MOH) has encouraged the development of programs of assistance to women that encompass actions for health promotion in the puerperal cycle. Of these, the one that has been mostly developed relates to prenatal care. The Program for the Humanization of Prenatal and Birth (PHPN-MS), established in the year 2000, has as its main objective the desire to ensure improved access, coverage and quality during the prenatal monitoring, childbirth and postpartum periods(3). Recently the Stork Network was established by the MOH within the Unified Health System. This initiative focuses on ensuring women’s right to reproductive planning, to humanized and safe care during pregnancy, delivery and postpartum, in addition to ensuring the right to birth, growth and healthy development(4).
Attention to pregnant woman should have, as an essential feature, quality and humanization. By humanization we mean the appreciation of the different actors, users and professionals involved in the process of healthcare and the co-responsibility among them; the establishment of supportive bonds and collective participation and the identification of social health needs; commitment to the ambience of the healthcare context and improvement in working conditions and services(5). Thus, the main goal of care during the puerperal cycle proposed by the MOH is to welcome women from the beginning of pregnancy, ensuring, at the end of pregnancy, the birth of a healthy child and the guarantee of maternal and neonatal well-being(5).
The grouping of pregnant women works as one of the strategies used by the health service to give support to women and families during pregnancy, and to prepare for childbirth and postpartum. This practice enables the creation of a space for dialogue and for reflection on the physical transformations and social roles during this period(2).
A study performed with a group of pregnant women in a university hospital showed that the group was characterized as an opportunity for mutual understanding. In such a grouping the women involved reported the importance of sharing their experiences, and thus having part of their individual demands met(6).
The group concept can be considered as a set of interconnected individuals meeting across time and space, and is articulated by their mutual internal representation which focuses on a specific purpose(7).
This study suggests that the group, in terms of the conception of Pichon-Rivière, acts as an instrument for the transformation of reality. Its members start to establish relationships when they begin to share common goals, which allows a creative and critical participation, as well as the perception of their own interaction and the formation of bonds(8).
Group processes create a learning space that demonstrates the possibility of further elaboration of knowledge. Interaction and communication are inseparable in the group context, in that the centrality of this practice is based on the relationship and interaction of those within the group. The possibility of learning and interacting in groups leads to a critical reading of the reality, in order to make room for new questions and concerns(8).
Given the above considerations, this study aimed to understand the experiences of pregnant women participating in a group and the role of the group in pregnancy, childbirth and postpartum. Nurses and midwives act directly on primary healthcare through assistance, with the focus on health promotion. Among the activities undertaken is the creation of groups of pregnant women. Thus, it becomes important to know the experiences of women regarding their participation in these groups so that it is possible to develop practices that are congruent and consistent with the demands and realities of these women and to strengthen knowledge production for prenatal care. Thus, this study is expected to contribute to the improvement of healthcare of women in pregnancy and childbirth, and with the training/work of the professionals involved in this context.
METHOD
This is an exploratory descriptive study. The qualitative approach was adopted, as it explores the universe of meanings, motives, aspirations, beliefs, values and attitudes that refer to a deeper space with regard to relationships, processes and phenomena that could not be reduced to the operationalization of quantitative variables(9).
The methods used for data collection were semi-open interviews and observation. The observation is what allows the researcher to know the social context of the research and to approach the participants(10). The semi-open interview was chosen because it facilitates the interaction between the researcher and the research participant.
The research was conducted in a childbirth facility that is located in the south of São Paulo. The home supports low risk pregnant women during prenatal, delivery and postpartum, and is guided by anthroposophic thought, which operates primarily in terms of the integral development of the human being. In this place, contact of the woman with professionals and with the environment is made during early prenatal care. The house operates with its own resources, providing free care to the women of the region.
The meetings of the pregnant women group were divided into themes according to gestational age. The meetings held during the first and second trimesters were related to pregnancy, fetal development, the nutrition of pregnant women and physical and emotional changes during pregnancy. The meetings during the third trimester had as their theme, childbirth, postpartum, breastfeeding and baby care. The groups were held every fifteen days. However, during the third quarter, they became more frequent, occurring weekly in order to provide and emphasize issues related to the preparation of delivery and the adjustments needed during the postpartum period.
Data were collected from December 2011 to May 2012. The study participants were five women. The criteria for inclusion were: women attending the group of pregnant women from the Childbirth House and whose gestational age was 24 weeks - the period stipulated by the house for participation in the group with regard to issues related to the preparation for childbirth and motherhood. The number of interviews was determined at the time the objectives were achieved. Two interviews with all participants, one at the end of pregnancy and another after childbirth were undertaken, and had a script containing the following guiding questions:
Interview at the end of pregnancy: 1) How did you start to participate in this group of pregnant women? 2) What was it like to join this group? 3) Has any family member been involved with you in the group? What did s/he think about it? 4) Which of the topics covered did you think were important in the group? 5) Have you thought about your delivery? What do you think? 6) How do you think it will be after childbirth?
Interview after childbirth: 1) How was your delivery? Was it the way you had imagined? 2) Did the subjects covered in the group of have anything to do with the childbirth experience? 3) Did the subjects covered in the group have some relationship to your activities with the baby and your experience of being a mother?
The interviews lasted, on average, 50 minutes, and were transcribed for further analysis and interpretation.
The data from this study were analyzed using thematic content analysis following the steps proposed by Gomes(11). After transcribing the interviews, comprehensive readings of the material were undertaken, seeking to acquire a vision of the whole and to understand the particularities of the reports. After this process, a scheme of thematic classification was performed in terms of the dialogue between the parties of the reports in order to find groups of meanings. In this process, different parts of the text were regrouped to determine themes grounded in the study’s objectives.
The research project was approved by the Ethics Committee in Research of the School of Nursing, University of São Paulo (CEP), subject to the requirements of Resolution 196/1996, the National Health Council (no. process: 1076/2011/CEP- EEUSP).
The authorization of the board of the Childbirth House was initially requested, observations were made, the first contact with the women was initiated, and interviews were scheduled. The interviews were recorded with the consent of the women. All the study participants signed a consent form and received a copy of it, with optional participation in the research. Fictitious names were used in order to preserve the anonymity of the participants.
RESULTS
The thematic analysis of the data resulted in the identification of five categories related to the experiences and meanings of the women in terms of their participation in the group: the importance of the group for pregnant and postpartum women; the group as a place for learning; links and exchanges; the role of the group in the delivery process and; the role of the group in the experience of motherhood.
1. The importance of the group for pregnant and postpartum women
Participating in the group was important during pregnancy, childbirth and postpartum:
The group information helped me during labor, delivery and postpartum.
If I am 100% honest, the importance of the group is 200%, 1000%. Let's say the group was the pivot (Alice - postpartum interview)
The fact of being in contact with other pregnant women and the possibility of sharing experiences had a calming role, because it allowed identification with typical situations of the case:
I think the most important thing is that none of what I was feeling was very strange; I saw that the other mothers were going through very similar things. Several mothers experience very similar things and you think, "Hey, it's not just me! It is normal, in the end it's alright; anger, fear and all this is not just me.” Then everything is fine, and we feel reassured and then it is fundamental, wonderful (Silvia - postpartum interview)!
I have several questions that arise, because it takes a lot of responsibility in many ways, and then I think that, in the group, I share some of these issues and then I see that it happens not only with me. And when you see that all of them go through it, you think: so I will survive too! (Silvia - interview at the end of pregnancy)
For Silvia, joining the group had great relevance because, after this experience, she decided to participate in other types of groups:
This practice group in prenatal care encouraged me to join other groups, so now I participate in other groups because of this experience! (Silvia - postpartum interview)
The group was reported as an environment in which knowledge and learning could occur:
The meetings allowed me to clarify my doubts and learn a lot of stuff I didn't know. (Carla - interview at the end of pregnancy)
And I feel as if it were a real process of training, right? Training for childbirth and motherhood. (Silvia - interview at the end of pregnancy)
For Alice, the group had a role in terms of making her feel empowered, which influenced the delivery process:
What I realize is the empowerment; it is very b for me. If I had not gone through this whole process, I would have had the baby as many mothers had, and would have decided for a cesarean section. (Alice - postpartum interview)
Participation in the groups during pregnancy and on completion of pre-natal at the Birth Center enabled the creation of bonds between the participants and the institution:
So now, every time I come back here, I feel that this place is getting closer to my body, creating a b bond. (Carla-interview at the end of pregnancy)
I made many friends there that I believe I will retain for my whole life. (Alice - postpartum interview)
The participation in the group and previous contact with professionals in the Childbirth House allowed the interviewees to feel secure and developed a degree of trust:
It was good, especially for the bond that I could create with the house and its professionals. In childbirth I felt totally at ease with the people who were there with me on such an important day for me. (Carla interview - postpartum)
Knowing that at any moment I can come back here and ask questions; I had a doubt about breastfeeding and had the option of getting in touch to ask what I should do, so it's good to know you have a place to go! (Maria - postpartum interview)
Alice and Livia identified the Childbirth House as a home and place of welcome:
In the house I feel it as an extension, I feel that this is more like my home than any other place, such is the warmth that I feel here! (Alice - interview at the end of pregnancy)
My son has come, my sister has, my husband has and all of them really like it for the opportunity to obtain knowledge and for the welcome we get here. (Livia - interview at the end of pregnancy)
For the interviewees, the group was seen as a place to share experiences:
Well, I like it a lot because we exchange information with women who are already pregnant, women who have never had children, and women who are being assisted, so for me it is very good to participate and to be able to develop knowledge. (Livia - interview at the end of pregnancy)
The subjects covered in the group were important for the women during the birth process:
The issues discussed in the group were totally related to childbirth. I learned a lot. (Carla - postpartum interview)
Maria reports that experiencing positions and tools beforehand during her participation in the group, made it easier at delivery time and in her choices during the process:
The meeting about positions for childbirth was the one that helped me most. I was able to experience positions and equipment, and this gave me an idea, at that moment, of what was best for me. (Maria - postpartum interview)
Everything I learned, the entire luggage I took to my delivery, was acquired in the group, in trades, Google; everything I learned throughout the pregnancy was there with me. And it made a big difference, because I got there empowered. Although it didn't mean that I wanted it, delivery was still mine, and the decisions I took, although many of these decisions were not possible in the way I wanted, they were explained to me. They helped me a lot to prepare myself as much as was possible in that short period of time, for childbirth! (Alice - postpartum interview)
The group of pregnant women allowed me to prepare for childbirth. We learned all the positions and equipment. It helped a lot because, during delivery, I remembered how it was and I moved my body as I’d been shown. (Maria - postpartum interview)
5. The role of the group in the motherhood experience
Postpartum women reported on the changing role of the mother after birth, and how the House of Delivery, along with the links created, acted directly in this change:
With the baby at home, they helped me in the preparation of the diaper bath. Wow! He loves it. He always sleeps after a diaper bath! (Maria-postpartum interview)
In the group of pregnant women there is the part that helps a lot with the baby which is breastfeeding. I think that the information on breastfeeding helped me a lot. (Alice-postpartum interview)
Sure, I'm a better mother! If I hadn’t done the course, I'd be a little lost and desperate. There is too much to adapt to at once, and the group prepares us for that. (Carla-postpartum interview)
DISCUSSION
During pregnancy, there are physical and emotional changes that are experienced in a unique way on the path of life and the subjectivity of each woman(1). Many women experience fear, anxiety and fantasies, and a desire to know what is happening to her body(12).
Thus, attention during pregnancy must be of good quality in order to cover the need for technical competence, the relationship and interaction between health professionals, women and their social network of support(13). The recommendations of the Ministry of Health include the development of pregnant women groups as part of prenatal care(5), as it is considered an important resource to enable to fully meet the needs of pregnant women and their support network.
In this sense, the category "The importance of the group for pregnant women" includes comments that show how the participation in the group was important for the whole process of pregnancy, childbirth and postpartum, and is even considered as the main focus of care for one of them. It was also presented as a motivator for participation in other groups, enabling, in our view, the development of the importance of the collectivity and the acceptance of new practices based on health promotion.
Also, the participation in the group played a reassuring role, since it allowed identification with other women and the situations and feelings experienced mutually, thereby reducing fear. The authors, Hoga and Reberte(6) also found that understanding how other pregnant women go through similar situations, with similar doubts and feelings, reinforces the sense of normality, and reduces the sensation of fear in relation to the events that occur during pregnancy.
In the category "The group as a place for learning", the comments show that this space allowed to clarify doubts and the approach to new content, considered by interviewees as a process of training and empowerment. Research by Zampieri et al.(2) also found that, by means of meetings, expectant mothers and their families can develop feelings about the experienced moment, generate new knowledge and supplement issues that are revealed, contributing to the construction of knowledge.
The group proved to be an environment that favors the approach to new content that is often not addressed during prenatal consultations, with an impetus to encourage the exchange of knowledge through non-hierarchical relationship between participants and professionals. Thus, it contributes to the autonomy and empowerment of women, both in relation to pregnancy and to childbirth, as well as to health in general. This finding is consistent with another study(6) conducted on this topic, which has also observed the transformation of individual and collective reality, through discussions and reflections experienced during activities in groups of pregnant women, the product of discussions, reflections and interactions arising among the participants.
In the category “Links and Exchanges”, reports show that the exchange of experiences was perceived and evaluated as being positive, and the participation in the group and in prenatal consultations, led to the creation and strengthening of ties between women and professionals in the Childbirth House. This link shows support for women and their families. With frequent site visits, pregnant women and their families come to know the work of the nurses more closely, which has proved a means of generating trust and confidence for women during childbirth. The reception provided proved to be a facilitator for the integration of women into the group and being able to share their experiences. The bond built by means of meeting in the group with care professionals acting as facilitators in terms of problem solving, enabled the realization of practices and interventions on the part of the team, consistent and appropriate with assisting the pregnant women(14).
Participation in the group stimulates feelings of acceptance and a sense of belonging to the place in which it occurs. A recent study(2) shows that the possibility of belonging to a group enables the strengthening or creation of an identity, which allows the participant to be located situationally, and to develop strategies that can generate change.
The MOH states that the hosting should be part of all meetings of the health service and acts as a commitment to addressing the needs of citizens. Thus, it can be regarded as an ethical stance which involves mainly listening to the users, recognizing their role in relation to the processes of health and disease, and the responsibility of the resolution, thus creating a knowledge network that could be shared(15).
The category "The role of the group in the delivery process" presents comments that affirm the importance of participation in groups for the birthing experience on the part of pregnant women. In this study, we found that knowing the process which the female body will go through, in addition to having prior contact with care professionals and an exposure to potential techniques and positions used during delivery, facilitated the way in which the interviewees experienced this moment.
Research carried out by Basso and Monticelli(16) also states that the interaction of women previously accomplished with obstetric care professionals, with the possibility of clarifying doubts, knowing the actions to be undertaken at the site of delivery and discussing issues according to their interests, favors women’s empowerment, and encourages their participation in decisions about proposed obstetric procedures at delivery.
The category "The role of the group in the experience of motherhood" demonstrated that, after delivery, the interviewed women retained the information and skills acquired in the pregnant women’s group. During the meetings, issues were raised concerning changes in the postpartum, breastfeeding, and care of the baby. Thus it appears that to be able to participate in the group and talk about these issues during pregnancy, may have been a facilitator in the postpartum period, which is considered a time of vulnerability in women's lives. One study showed that during postpartum, women have to deal with physical, emotional and role changes, and need to deal with different settings, requiring new adaptations. This points the postpartum period as a period of crisis. This study showed the importance to addressing and discussing issues related to the postpartum period(17).
The realization of groups of pregnant women is translated into a practice of proper care during prenatal care, because, according to this work, it impacts positively on the experience of women and their families, and contributes to the construction of maternity/paternity. Therefore, as recommended by the MOH(5) it should be encouraged through public policies and in terms of many places and models of attention to prenatal care and delivery. The main focus of the group is to offer a space/environment that provides information, integration and support to the women and their social network of support during the puerperal cycle.
CONCLUSION
The group of pregnant women is an important tool for a quality prenatal experience because it facilitates the creation of bonds between pregnant women and obstetric care professionals, in addition to providing an environment of learning and exchange. The possibility of sharing experiences makes women relate the group to the individual and to collective learning, providing autonomy and empowerment. The group proved to be an important environment in which pregnant women and families can share their fears, hopes and difficulties during this period. It works as a therapeutic environment; therefore it is a practice that should be encouraged and routinely introduced into prenatal care.
This study made it possible to understand that the practice of groups of pregnant women contributes to the preparation for motherhood/parenthood, offering an environment that enables the sharing of experience and knowledge, reflections and discussions about pregnancy, childbirth and postpartum. This exchange was shown to be closely related to the way women experience these processes in life, and has proved to be of great importance in the experience of these women.
Despite the group experience being reported by interviewees as a positive and important practice during pregnancy, it was observed that many women who underwent prenatal in the Childbirth House did not attend such a group. Therefore, many meetings were held with a small number of women. Thus, it is critical to conduct further studies on this topic by including women from different socio-cultural and care contexts, with the possibility of covering a larger number of participants. This might permit the identification of possible barriers that women encounter in terms of participation in such groups. These factors have limited this study.
Moreover, as the need for the realization of groups in the prenatal care situation is widely held by nursing and midwifery professionals, even in multidisciplinary teams, we highlight the importance of inclusion and the discussion of topics covering theoretical and practical aspects of working in groups that focus on women's health during the training of these professionals. It is important to emphasize that this is an exploratory study and that we intend to continue working on this theme in the future by addressing a range of different issues.
REFERENCES
1. Gualda DMR, Praça NS, Merighi MAB, Hoga LAK, Bergamasco RB, Salim NR, et al. Woman's health and the body. Rev Esc Enferm USP. 2009; 43(spe 2):1320-5.
2. Zampieri MFM, Gregório VRP, Custódio ZAO, Regis MI, Brasil C. Processo educativo com gestantes e casais grávidos: Possibilidade para transformação e reflexão da realidade. Texto & contexto enferm. 2010; 19(4): 719-27.
3. Brasil. Ministério da Saúde. Humanização do parto: humanização do pré-natal e nascimento. Brasília: MS; 2002.
4. Ministério da Saúde (Brasil). Portaria n. 1459, de 24 de Junho de 2011. Institui no âmbito do Sistema Único de Saúde – SUS – a Rede Cegonha. Diário Oficial da União 27 junho 2011; Seção 1.
5. Ministério da Saúde. Pré-natal e puerpério: Atenção qualificada e humanizada. 3. Ed. Brasília: MS; 2006.
6. Hoga LAK, Reberte LM. Pesquisa-ação como estratégia para desenvolver grupo de gestantes: a percepção dos participantes. Rev Esc Enferm USP. 2007; 41(4): 559-66.
7. Pichon-Riviére E. O processo grupal. 6. ed. São Paulo: Martins Fontes; 2000.
8. Bastos ABBI. A técnica de grupos-operativos à luz de Pichon-Rivière e Henri Wallon. Psicólogo informação. 2010; 14(14): 160-89.
9. Morse JM, Richards L. Qualitative research design. In: Readme first for a user’s guide to qualitative methods. 3rd ed. Los Angeles: Sage; 2013. p. 87-116.
10. Rubin HJ, Rubin IS. Qualitative interviewing: the art of hearing data. 3rd ed. California: Sage; 2011.
11. Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In Minayo MCS, Deslandes SF, Gosmes R, organizadores. Pesquisa social: Teoria método e criatividade. Petrópolis: Vozes; 2007. p. 79-107.
12. Cianciarullo TI, Gualda DMR, Silva GTR, Cunha ICKO. Saúde na Família e na Comunidade. São Paulo: Ícone; 2011.
13. Barros MEO, Lima LHO, Oliveira EKB. Prenatal care in the city of Quixadá: a descriptive study. Online braz j nurs [ Online ]. 2012 Aug [ cited 2012 sep 03 ] 11(2):319-30. Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/3782/html. http://dx.doi.org/10.5935/1676-4285.20120029.
14. Cremonese, L, Ressel, LB, Wilhelm, LA, Rodrigues, BOC, Scaramussa, SC. Grupo de gestantes como estratégia para educação em saúde. Santa Maria: UFSM;2012.
15. Ministério da Saúde. Dicas em Saúde: acolhimento. Brasília: BVS; 2008.
16. Basso JF, Monticelli M. Expectations of Pregnant Women and Partners Concerning their Participation in Humanized Births. Rev latinoam enferm. 2010; 18(3):390-7.
17. Salim, NR, Santos Junior HPO, Gualda DMR. Everyday behavioral and physical changes in women during the postpartum period a qualitative approach. Online braz j nurs [ Online ]. 2010 Apr [ cited 2013 sep 03 ] 9(1). Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/2785 http://dx.doi.org/10.5935/1676-4285.20102785.
Authors’ Contribution:
Conception and design: Paula Rueder Neves, Natália Salim, Glauce Cristine Ferreira Soares and Dulce Maria Rosa Gualda;
Analysis and interpretation: Paula Rueder Neves, Natália Salim, Glauce Cristine Ferreira Soares and Dulce Maria Rosa Gualda;
Artigo writing/critical review of the article/ final approval of the article: Natália Rejane Salim, Glauce Cristine Ferreira Soares, Dulce Maria Rosa Gualda;
Data colection: Paula Rueder Neves;
Bibliographic Research: Paula Rueder Neves, Natália Salim, Glauce Cristine Ferreira Soares, Dulce Maria Rosa Gualda.
Received: 05/02/2013
Revised: 03/09/2013
Approved: 28/10/2013