ORIGINAL ARTICLES

The voice of the woman-mother of a premature baby in the neonatal unit: a phenomenological approach

Rita de Cássia de Jesus Melo¹, Ívis Emília de Oliveira Souza¹, Cristiane Cardoso de Paula¹

¹Federal University of Rio de Janeiro

ABSTRACT
Problem: Motherhood is an important moment for women, and being a mother of a premature infant admitted to a neonatal intensive care unit (NICU) requires greater adaptation to this existential moment.
Aim: To understand the experiences of women-mothers during the hospitalization of the child in the NICU.
Method: This is a qualitative study based on Heideggerian phenomenology, held in a public NICU.
Results: The experience of women-mothers allowed the creation of four units of meaning: fear of the environment and initially touching the child; being received in the unit; the chronological period, and; improved monitoring of the baby.
Discussion: Women-mothers, in the facticity of being thrown into the world of NICU, experience care, take part in conversations, fear for their child's life, and remain tethered to their occupations and daily tasks.
Conclusion: The reception, careful listening and understanding of the uniqueness of women-mothers represent a fundamental way of being in the NICU, allowing women to become mothers of their babies.
Descriptors: Mother-child relations; Nursing; Intensive Care Units, Neonatal; Infant, Newborn.

INTRODUCTION

The dream of being a mother is part of life for most women since they feel complete when they manage to give birth. Even today motherhood is seen as an integral part of the social life of women and they cause surprise or thrill when they relate negatively to this event that is culturally regarded as a feminine⁽¹⁾. Although regarded as part of female existentialism, adaptation to the maternal role may be difficult for many women. Motherhood is a product of culture and refers to actions that are expected regarding the relationship developed with one’s child⁽²⁾.

Thus, it is natural to feel insecure in the transition of this new role. The complexity of events involving a woman during pregnancy and the puerperal period implies knowledge of not only physical aspects, but several conditions that may be directly or indirectly related to her condition of woman-mother⁽³⁾.

A condition for which the woman is not prepared is the occurrence of premature labor. A study released by UNICEF in 2013 shows a high prevalence of preterm births in Brazil, for different reasons. The condition of prematurity is sometimes indicative of the hospitalization of newborns in a neonatal intensive care unit (NICU), which becomes a something difficult to confront, especially for the mother⁽⁴⁾.

The adaptation process a woman experiences in the maternal role, in which she will make adjustments between the real and the imagined baby, occurs both in a term pregnancy when the baby is born healthy and in premature labor. However, in the latter case, the degree of difficulty that women face due to the characteristics and risks that their baby presents is greater. These mothers do not realize the consolidation period, the moment in which they invest in the imaginary baby, including him in the family discourse and making preparations for his arrival^(5.6).

By having the child in the NICU, which is an environment endowed with technology and the impact of a different reality than that she had imagined regarding the arrival of the baby, the mother is faced with a fragile child who is accommodated by and connected to equipment and connections, which makes it even harder for the baby to be viewed as the imaginary baby. Thus, the mother needs to be integrated to this environment and adapt herself to the conditions of rules and routines; however, this is not a very easy process, since the focus in these units is still aimed at the biological aspects of caring for the newborn baby^(7,8).

Some studies point out that establishing effective communication with mothers in the NICU is still a challenge because it is an environment marked by a biological focus and for its technicality, where the focus of care is premature newborns⁽⁹⁾. The guidelines are provided in a vertical manner and professionals still fail to display more attentive listening. Although they consider family presence important in the unit^(10,11), studies reported a lack of time and preparation for dealing with those involved in the professional-family relationship, as well as in managing to get the family involved in the care process^(12-14).

While working as a clinical nurse in a NICU and understanding that the care given to the newborn goes beyond the client itself, given that it also involves the mother and the family, I was interested in knowing a little more about the experience of the mother in this environment. Since the profile of the newborns of this unit basically consists of premature babies, I tried to understand, through the speech of women-mothers, their experience in the NICU before the birth of the premature child.

Understanding the meaning of the experience of the birth of a premature child means seeking to redeem women’s own existence as a woman-mother. It means bothering to give them voice, approaching their life-world and revealing what is hidden there, aiming to meet their needs so they can gain confidence, overcoming fear in relation to the unit and to the fragile baby who was just born. It means not engaging in what is similar and frequently appears in their everyday lives in order to promote equal, standard and model care for all mothers. "Listening is comprised of speech" and can promote involvement with others in those who are health professionals; it means the action of being existentially open because "one can hear only where there is the existential possibility of speech and listening"^(15:222-223).

METHOD

This is a qualitative, phenomenological study, grounded in the thought of Martin Heidegger⁽¹⁵⁾. The researcher engaged in a phenomenological investigation must establish a relationship of empathy and encounter with the research participants, which is conducive to their demonstrations, spoken or silent, and takes advantage of an Attentive look at this individual in order to grasp his ways of thinking, feeling, and seeing⁽¹⁶⁾.

Thus, through the experience of these mothers, we sought to capture their manifestations in the daily life of having a premature baby in the NICU, aiming to unveil facets of the phenomenon experienced because it is only through the experiences lived that one can enter the world of essence. The conscious search can turn into "research" if the respondent is determined in a liberating way⁽¹⁵⁾.

The setting was a NICU of a public university hospital in Rio de Janeiro (RJ), registered in the state and municipal job regulation center. Initially, a welcoming environment was created in the unit, seeking to approach every mother through an empathic motion. Then the invitation to participate in the study was performed. We sought to conduct the interviews in the first five days of contact between mother and baby. For the selection of the interviewees, we used as inclusion criteria: being a mother of a prematurely born baby (PNB) that was hospitalized in the NICU, regardless of gestational age. And as exclusion criteria: mothers who presented some verbalizing difficulty that prevented understanding by the researcher. The nine ⁽⁹⁾ respondents were women-mothers in the period from March to May 2010.

The depositions were performed by means of phenomenological interviews. To this end a better time for the meeting was agreed with the interviewees. The room of the head nurse of the unit was made available and was prepared to receive the mothers. The interviews were guided by one question: How was it for you to have a child hospitalized in the NICU? The answers were captured by the recorder. The interviewees were identified by pseudonyms chosen by the researcher, from the names of Greek goddesses and their children by precious gemstones.

The study followed the guidelines recommended by Resolution 196/96 of the National Health Council⁽¹⁷⁾, through the approval of the project by the Research Ethics Committee (REC) of the study setting institution, under No. 54/2009 in January 2010. The field stage complied with the protection of individuals with regard to these principles: voluntariness, informed consent, anonymity, confidentiality of research information, justice, equity, risk reduction and benefit maximization, and protection of their physical, mental, and social integrity from temporary and permanent damage.

The data analysis was developed through a Heideggerian methodology, while the transcript of the testimonies and exhaustive readings were performed in full, in order to understand the essential structures captured in the statements. Then the meaning units were formed, as well as the vague and median understanding. In the second meth methodological moment the hermeneutics were developed in light of Heidegger's phenomenology, seeking, through the understanding of meanings of the ontic dimension, to unveil the senses^(14,16).

RESULTS

The experience of the woman-mother in the NICU concerning the birth of her premature baby allowed the creation of four units of meaning: being afraid of the environment and initially touching the child; being received in the unit; the chronological period, and; the monitoring of the baby's improvement.

Mothers expressed fear of their child’s unknown environment and the possibility of being able to touch him:
] When they mentioned the ICU [intensive care unit], I thought I would not be able to get in [...] They said the ICU is closed to visitors. I thought I would not be able to see her, only later, when she was discharged. (Aphrodite, mother of Crystal)

] When I received the news that she was in the pediatric ICU, my heart leapt? Had something serious happened to her? [...] I thought we couldn't pick up the child in the pediatric ICU; I thought we could not even enter the place. (Ariadne, mother of Pearl)

] The doctor said I could touch him. I thought I couldn't. (Artemis, mother of Ruby)

When someone mentions the ICU I get scared. It means risk of death. (Themis, mother of Topaz)

] Because we think that, if the baby is in the ICU, it means that the baby is in a bad condition and needs something, like saying that something bad happened. At first I was afraid of touching him for fear of harming or hurting him because he was there and I thought I could transmit something to him. (Circe, mother of Onyx)

They came to me and said that I could touch him, so I touched him with my hand. (Iris, mother of Agate)

They reported how they felt when they were received in the NICU:
They welcomed me. I came, washed my hands. The doctor and the nurse greeted me and explained to me everything that was happening. (Aphrodite, mother of Crystal)

] But here, with care, with us, the father and the mother. The father may stay until 7pm. Sometimes when we got kinda sad; there were words, so they said, "okay mommy?" Alright, that enlivened our hearts a bit, we saw that we also had assistance. (Ariadne, mother of Pearl)

I arrived at the hatchery; the girl taught me how to open it. I knew nothing. It seemed like I had ten hands [she makes a gesture showing the hands], how to get it, touch. (Ananke, mother of Emerald)

I got here and the doctor said I could touch him; I could lay my hands. For me it was a very big surprise. (Artemis, mother of Ruby)

] They said I could put my hand on him; they said that the father and mother could touch him with the hands. (Selene, mother of Quartz)

I came here and they explained to me that he had to stay here to gain weight. Only after he gained the weight he could go home. (Themis, mother of Topaz)

] I arrived. The girls here made me feel safe and they explained to me that I could touch him, cuddle, talk, and pet him, so he could feel that I'm there; that his recovery is better when he listens to the mother, when he feels her touch, the father's too. (Circe, mother of Onyx)

They reported the chronological time lived in the NICU:
] I come every day. I stay here almost 12 hours. (Aphrodite, mother of Crystal)

] I was always there. I went down every three hours, but I never got tired because my daughter was there and I wanted to stay with her. [...] I've already been here for 14 days and tomorrow it will be 15 days. (Ariadne, mother of Pearl)

] Every time I come to see her, so I will be known; my voice, my smell, my contact with her. (Ananke, mother of Esmeralda)

] I would come downstairs every day and look at her. I knew she was safe here. (Sofia, mother of Sapphire)

] Being in a hospital is not good. There is nothing better than our home, but we have to wait [...] It's good to know that I can stay here with him. Imagine if I had to go home and leave him here. I think that if they said that to me [...]. (Themis, mother of Topaz)

When I was discharged from the other hospital, I started to come almost every day. It was too bad to be away from her. (Iris, mother of Agate)

They reported the monitoring of the evolution of the baby in the NICU:
I saw her improvement [...] she's much better [silence]. (Aphrodite, mother of Crystal)
     
] But she was well cared for and treated. The staff is really helpful with the kids. (Ariadne, mother of Pearl)

] I saw that she is well, despite her being in the incubator; even being the seventh month, she is intubated, [...] so it is very gratifying for me; she's resisting there, she's all right, she's making it [...] today the nurse is taking a few things away, the tube, CPAP, so every moment is a victory that she conquers and so do I. I'm near her. (Ananke, mother of Esmeralda)

I felt his appearance was a little better [...] (Selene, mother of Quartz)

I came downstairs to see him and was happy to see that he was alright, that it's nothing hopeless. (Themis, mother of Topaz)

] I knew she was being well cared for because she was in good hands. I saw that little thing moving [pause] alive; I saw that there were professionals who were taking care of her with love and affection, I knew it [...]. (Sofia, mother of Sapphire)

] But I saw that my son is well, that the professionals are doing a great job and that it all depends on the recovery of the baby himself. I see he is recovering, that it's working. (Circe, mother of Onyx)

I would come every day, touch him with my hand [silence], it was very nice. But when I touched him, I felt like holding him; it makes me feel really sad, willing to pick him up, take him home. (Iris, mother of Agate)

DISCUSSION

Sustained in the concepts of Heidegger's philosophical thought, the step of the methodological interpretation of the senses was performed.

According to the situation experienced by the woman-mother in this study, in a premature birth there is a condition that affects both the baby and the parents because it is believed that early interventions are directed to newborns at a time of life when the dependence on the mother is prevalent; therefore, it is essential to meet both mother and child⁽¹⁸⁾.

The first unit highlights the women's voice when referring to the unit where their child was hospitalized. When referring to the NICU, they speak according to what they had in mind when they learned the concept of ICU in their everyday world, that is, they just know what they heard about it; thus they are presented in a speaking mode that "is the possibility of understanding everything without previously having taken possession of the subject"^(15:228-229). In everyday life, when talking about ICU, they almost always refer to the inpatient unit for people featuring serious medical and life-threatening conditions, in which strict rules were set. Currently, these sectors have already modified routines, but this discourse remains in circulation: "Things are as they are because people say they are this way"^(15:228).

In this spoken and repeated knowledge, the mother feared for the life of her child who was sent to the NICU. Studies show that mothers feel guilt, worry, anxiety, and grief for the fact that the baby is going through that moment⁽¹²⁾. Thus, given the veiled fear of death, something known, but never lived, just meant as an experiment, the mother-woman stood in the way of impersonality and inauthenticity.

In her facticity of being thrown into the world of the NICU for having a premature baby, the woman-mother is faced with a new environment, other than her surrounding world, which is, for Heidegger, the world closer to the ordinary "presence" and thereby she understands herself like a stranger, without knowing what to do. The hospital environment is usually not an environment where people enjoy being in the case of an idealized moment of experiencing the joy of the arrival of a baby; for the mother it is very sad to have to live with the reality of being in a NICU, far away from home and family in her first moments with her child.

The mothers reported that, when arriving at the NICU, they were welcomed by health professionals who guided and informed them on how to enter the unit and stay with their child. Such evidence agrees with other studies, although such information does not always occur in the form of dialogue, in which case only institutional routines are passed on^(8,13). In this sense, Heidegger states that the most fundamental way of being in the world means relating "with" the other. Solicitude is a way of relating to each other, of taking care of the other's existence, which is only possible through an engaging and significant relationship. "The being-there-with others is unveiled in the world for being-there with us, because only the being-there in itself is essentially being-with"^(19:38).

When the woman-mother began the process of knowledge or recognition of this new environment, she received information and guidance from the professionals who work there and thus came to be closer to her child and organized these moments using the chronological order: she appreciated their comings and goings to the sector to perform certain actions together with the baby—enter the unit, meet the staff, and see some equipment in use as the baby slowly became familiar to her. According to Heidegger, this condition means being attached to the manual, that is, to feel acquainted with what is not essential. It "shows in her being-in-the-world, committed to the occupations of the surrounding world, from the being that is at hand in the world" without even understanding how to get properly occupied^(19:39).

Thus she takes care of the child. This phenomenon determines the being in its daily life, performing the impersonal mode of inauthenticity, which refers to the mode of deficient concern, which is linked to the possibility of occurrence of facts.

In the NICU every day, sometimes it is observed that the mother and family do not seem to know situations of real importance in the course of improvement of the PNB, getting stuck in the everyday tasks of the unit. In the practice of dialogic education among professionals and mothers, studies warn against submission in this communication process, since we cannot always speak only what we think the mother wants to hear, as for example, regarding the improvement of the child⁽¹³⁾. An opening in the dialogue process can place the mother as an active participant in the recovery process of the baby.

The desire that her child would recover as quickly as possible and the credit of the care merely directed to health professionals placed the mother in a position of dodging the task of being-in-herself. This mode of disposition prevented her from understanding the lived facts, driving her to ambiguity. She believed that everything had already been understood, when in fact, it had not been, as the premature child has the possibility of improvement or deterioration in its clinical status.

CONCLUSION

When we learn the meaning of the experience of women-mothers of preterm infants in the NICU, we understand the importance of the understanding that taking care of the newborn also means taking care of the mother for the professionals working there. And for this purpose it is necessary to listen to the women-mothers’ experiences.

When women arrive in the NICU, one cannot view them just as mothers who had their premature child. They are first and foremost individuals experiencing an existential period of vulnerability and, therefore, need to be accepted and cared for in an individualized manner. It is important not only to pass on information that at times will not be treated at that moment, but to listen to them and allow them to express their fears, hopes and difficulties. Understand their silence, their gaze, their crying; know how to recognize that each woman-mother needs her own period of time, which is not only represented as chronological, but existential.

Since the nursing staff is closer to the newborn in the development of daily care, it is essential for it to plan guidelines and appropriate interventions according to the uniqueness of each woman-mother, facilitating approximation to the child in order to allow that the transition period will provide an opportunity not only for the mother to get busy with the baby, but also to worry about him. When the mother worries, she establishes a being-with-the-child, acknowledging herself and her child as beings of possibility.

By unveiling the facet of this phenomenon investigated, the study allows investment in other comparative and complementary studies. It favors the teaching of maternal and child health, providing a different look at women-mothers and the preterm infant during academic training, so that the study can meet the existentialism of every being.

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All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 07/04/2013
Revised: 04/01/2014
Approved: 04/29/2014