ORIGINAL ARTICLES

Feelings of women who experienced a high-risk pregnancy: a descriptive study

Laís Antunes Wilhelm¹, Camila Neumaier Alves², Carolina Carbonell Demori², Silvana Cruz da Silva³, Sonia Maria Könzgen Meincke², Lúcia Beatriz Ressel¹

¹Federal University of Santa Maria
²Federal University of Pelotas
³Federal University of Rio Grande do Sul

ABSTRACT
Aim: to know the feelings experienced by women who experienced a high-risk pregnancy.
Methodology: qualitative and descriptive study conducted at the University Hospital of Santa Maria, in the south of the country. Participants were selected based on the list of medical records of women who attended prenatal high risk consultations. Ten women over 18 years old, considered as those who experienced a high-risk pregnancy and who gave birth not more than two years from the date of study were interviewed. Data was analyzed and interpreted according to thematic content analysis of the operative proposal.
Results: the category “feelings of women who experienced a high-risk pregnancy” and subcategories such as feelings of fear, anxiety, sadness and happiness emerged from the study.
Discussion: we observed the exacerbation of feelings, often contradictory, because even with fear and anxiety the patients felt happiness, which is also described in the literature.
Descriptors: Nursing; Women's Health; Pregnancy, High Risk; Pregnant Women; Feeling.

INTRODUCTION

Pregnancy is a physiological phenomenon and, therefore, is largely uneventful. However, some women may have unfavorable outcomes during pregnancy, with significant complications on maternal and perinatal health, representing the group called “high-risk pregnancies”⁽¹⁾.

Assistance for women with a high risk pregnancy is a challenge in everyday health care, because the high rates of maternal mortality concern not only society, but also the authorities⁽²⁾. According to the Primary Care Information System (SIAB)⁽³⁾, 55,527 cases of maternal deaths in 2013 were registered in Brazil. The main reasons are related to obstetric direct causes, i.e., those resulting from maternal risk factors and complications arising during pregnancy, childbirth or the postpartum period⁽⁴⁾. They can be avoided with the appropriate treatment and management of high-risk situations in health services.

It is important to emphasize these measures at the beginning of prenatal care, as this is a tool for early detection of factors that can turn a normal condition into a high-risk pregnancy, and provide timely intervention for those which are modifiable⁽⁵⁾. It is observed that often the attention to prenatal care, as proposed by the Ministry of Health through programs and actions of attention to women's health, fails to meet some demands of pregnant women considered at high risk – especially those related to subjectivity, as the feelings that arise from their experience and the emotional support they require. So this ends up being a need which is neglected⁽⁶⁾.

Emotional support refers to “exchanges that connote a positive emotional attitude, an atmosphere of understanding, sympathy, empathy, encouragement and support; it is the sense of being able to rely on the resonance and the good will of others”⁽⁷⁾. Feelings, on the other hand, are considered the reactions that someone shows upon a situation, event or another person, and can be both pleasant and unpleasant⁽⁸⁾.

Pregnancy generates feelings that cause biopsychosocial changes, so it is necessary to develop care measures for the prevention of possible complications, necessary and mandatory, to minimize maternal risks. Women with high-risk pregnancies require multidisciplinary care and comprehensive evaluation, and also the recognition of aspects that relate to their sense of life and spirituality⁽⁵⁾.

It appears that it is essential to know the needs and characteristics of each patient through humanized nursing care, which can contribute to improve their quality of life during prenatal care and help to reduce their anxieties and fears, providing the way to a more peaceful pregnancy. These aspects are even more relevant in high-risk pregnancy situations. Based on these aspects, this article aims to know the feelings experienced by women who have gone through this experience.

This study is the result of a dissertation that had as the following research question: what are the feelings, care practices and challenges experienced by women who had a high risk pregnancy? The aim of the study was to understand the experience of these women.

METHOD

This is a descriptive qualitative study conducted at the University Hospital of Santa Maria, in southern Brazil. The selection of participants was based on the list of medical records of women attending the high risk pregnancy antenatal clinic, making it an intentional sample. For the definition of the study population, we considered as the inclusion criteria women over 18 years old, considered as a former patient with high-risk pregnancy and whose childbirth occurred within the last two years. Thus, with access to records, we selected those belonging to the group of women who met the inclusion criteria.

First contact was made through a phone call, in which the women were invited to participate in the study. After acceptance, the interview was scheduled according to the availability of each participant, and their houses were established as the data collecting site. So, the participants were 10 women attending the high-risk pregnancy antenatal care clinic from 2011 to the present day. It is important to note that data collection was terminated after data saturation, which is defined as the moment the testimonies of the participants start to repeat⁽⁹⁾.

The data collection method chosen was the semi-structured interview, which has closed questions concerning the characterization of women, and open questions guiding the theme in question. This type of interview allows the participant to discuss the proposed theme without being attached to the formulated question or to any conditions fixed by the researcher, expanding verbal communication⁽⁹⁾.

The interviews were conducted between May and September 2013, recorded, transcribed and later investigated by the thematic content analysis with operative proposal⁽⁹⁾. This type of analysis is characterized by two operating phases: the first covers the baseline determinations of the study, outlined in the exploratory stage of the investigation; while the second is the interpretation phase, which is subdivided into two more stages, as the sorting and classification of the data. The latter allows the researcher to understand the relevant structures and the central ideas, with the elaboration of a synthesis for the construction of a final report⁽⁹⁾.

The research followed the rules of Resolution 466/2012 of the National Health Council of the Ministry of Health, which regulates the guidelines for research with human beings. For this, the study was assessed by a Research Ethics Committee and obtained approval under CAAE number 13178713.3.0000.5346. The anonymity of the participants was done using the alphanumeric system for the representation of data, and the term "interview" followed by numbers according to the order.

RESULTS

Regarding the profile of the respondents, the following results were obtained: age between 24 and 37 years; predominance of women in stable relationships; regarding the education level, four women had not completed elementary school, two completed elementary school, three had finished high school and one had had incomplete higher education. As for the occupations, there were three housewives, two cooks, a manicurist, a nursing technician, a clerk, one student and one was unemployed at the time of data collection.

The factors that have characterized the interviewees as high-risk pregnant women were diabetes, hypertension and obesity, a high number of caesarean sections, pyelonephritis, preeclampsia, placenta displacement, marginal placenta, preterm labor, gestational diabetes mellitus and habitual abortion. It is noteworthy that the most frequent risk factors were gestational diabetes (three women) and hypertension (five women).

In addition to these aspects, multiparity in the studied women was observed: the numbers of pregnancies that predominated were five (in three women) and two (three women). With regard to abortion, four women had experienced this situation, and one of them also experienced the occurrence of a stillbirth.

Regarding the last pregnancy that characterized the interviewees as high-risk pregnant, eight women were able to have their babies healthily; a woman had a premature child who died after 20 days from birth with a diagnosis of pneumonia and septic shock; and a woman had a stillbirth at 37 weeks of gestation.

In relation to the feelings reported by women, fear (deponents number 3, 4, 7 and 10), anxiety (deponents 2, 10 and 6), sorrow (deponents 2, 3 and 5) and happiness (deponents 1, 8 and 9) were mentioned. As a result of the analysis of the statements of the women interviewed, the category “Feelings of women who experienced a high-risk pregnancy” emerged and is presented below.

Feelings of women who experienced a high-risk pregnancy
According to the information revealed by the deponents, from the feelings common in all pregnancies, fear, anxiety, sadness and happiness stand out, and were considered subcategories by this study:

Fear
This feeling was evident in most interviews. Fear refers to an emotional state resulting from a threat and/or danger, as can be seen by what was expressed by the interviewees:

We suffered when we discovered (that it was a high-risk pregnancy) because I was really afraid, I was afraid of what I had heard about it. (Interview 3)

I got scared, right! I was afraid I could not maintain the pregnancy. (Interview 4)

I was scared, but I didn’t tell them (children) I could die, right! (Interview 7)

Since I was scared, everything they (hospital staff) told me to do, to me was an order [...] I was more afraid that something could happen to him (baby) than to me. (Interview 10)

In the testimonies of participants (3, 4, 7 and 10) fear was reported in an exacerbated way. The women said they were afraid of what they had heard about a high-risk pregnancy, failing to carry the pregnancy to term, dying and that something might happen to the baby.

During a high-risk pregnancy, women experience a constant state of tension. Although they tend to wait for what they desire, they are afraid of unforeseen circumstances that may arise. The situation of the feeling of being put into in a risk group already puts them in tension and, in most cases, is not observed by professionals that deal with prenatal care.

Of the different situations of emotional overload, fear was the most mentioned feeling by respondents, reflecting their insecurity and helplessness in facing the risky situation. This fact invigorates the need for greater attention to listening and giving explanations of what is happening, because the lack of knowledge about what is happening can intensify the fear and the complications may arise. It is therefore important that the pregnant women feel safe in order that their adherence and permanence in prenatal care service occurs, and also they feel they can trust this service and be supported by it.

Anxiety
Anxiety is attributed to a mix of feelings that arise during this period, ranging from the acceptance of gestation to the wait for hospital services. The interviewees expressed themselves as follows:

That’s so many feelings together, you feel fear, you feel anxiety, it’s too much, it’s everything together. (Interview 2)

I had to wait, I was anxious of having to wait a month for a consultation. (Interview 10)

I lost my mind in the hospital, there was a child, it made me so anxious to see her - I had not yet accepted this pregnancy. (Interview 6)

During a high risk pregnancy women express fear, anguish and even the process of acceptance of the risky pregnancy. The degree of anxiety depends on the psychological characteristics of each woman, who often have difficulty adapting to this situation.

The announcement of the risky situation makes these women (re)organize their lives, and this adjustment process can raise the anxiety felt by them. This is the moment health professionals, including nurses need to strengthen the link with high-risk pregnancy patients to give them the necessary emotional support, helping them to live with this situation by adjusting, into every need, the conditions to improve the quality of gestation.

Sorrow
The sorrow is characterized by feelings of sadness and grief, present in the following lines:

Both I and my husband were sad, so much that when I said the pregnancy test was positive, he was paralyzed. We both cried in fear and sadness, because we had already lost one, right! [...] It's a mixture of feelings it’s happiness for being able to generate these little angels and the sorrow for not having any of them here with me. (Interview 2)

I wanted him (the child) so much that I sometimes felt sad, sometimes I cried a lot, wondering what might happen. (Interview 3)

It was very difficult to find out it was a high-risk pregnancy, it seemed that the world had collapsed upon us. My God, I kept thinking about the child being born with a problem, I imagined so many things in my head. I wept with worry and sadness, I became more emotional. (Interview 5)

The feeling of sadness resulted from different situations, as a previous loss in another pregnancy, or imagining all the negative circumstances that could occur during a high-risk pregnancy and from the lack of planning regarding having children.

During pregnancy, sadness is one of the feelings that significantly disturb women. In most cases, sadness during pregnancy is related to the loss of expectations. The patients who imagined a perfect pregnancy ended up unhappy when they discovered the risky condition. This feeling is also potentiated in cases where the mother had lost a baby, as seen in the statement of interview 2.

In this situation, we highlight the relevance of planning the pregnancy because of the unexpected events that may enhance negative feelings during gestation. As with other stages in life emotional issues need balance, otherwise women can become weakened and suffer, as in the interview statement 5.

Happiness
The feeling of happiness was also evident. This refers to the excitement of a true meaning that motivates people. In this case, it relates to the motivation to give birth to a child, as we can see in the statements:
The conclusion I drew is that despite being a high-risk pregnancy, with the support I received I managed to overcome my fears and anxiety, and I was very happy with it. I wanted to be pregnant and I did it. (Interview 1)

When I discovered the pregnancy, I wanted it, right! I was very happy. I kind of knew I was pregnant, I did the test and it was positive. (Interview 8)

I got a little scared, but at the same time I was happy with the discovery of pregnancy and because it was a little boy. (Interview 9)

Despite the emotional fragility and the mixture of feelings that occur during a high-risk pregnancy, the patients felt happy. They expressed that the feelings of fear and anxiety have been overcome by support they had received, and felt happy when they learned they were pregnant and when they enjoyed moments like discovering the baby's sex.

Faced with this reality, it is worth emphasizing that all professionals who deliver care to this clientele participate in this mix of feelings. So the approach adopted should also be directed to provide tranquility and psychological support to them. At the time that these professionals become receptive and welcoming, they share this responsibility because they provide comfort, well-being and balance to these women, participating with the pregnant patients and their families at this very special time in their lives.

DISCUSSION

When women face the constant threat of gestational risk, they become vulnerable, insecure and afraid of what might happen to them and their children. Fear turns out to be a feeling that permeates through the life of pregnant women, sometimes subtly, sometimes markedly, causing them to lose the peace, quietness and tranquility. It is common during pregnancy for women to feel fear and wonder about the changes raised by a situation or an unforeseen event, even if the baby is bly desired⁽⁶⁾. In a high-risk situation, that feeling may be more present, making them more vulnerable.

The way women experience a high-risk pregnancy, the way this experience is perceived, the information they receive throughout their life from family, close people or situations they faced before, about pregnancy and possible complications, may directly affect their perceptions and expectations about the experienced events. For this reason, it is important that the health professionals during prenatal care give a type of support to pregnant women which also encompasses emotional aspects, personalized assistance and considers their previous and familiar experiences.

In prenatal care, the evaluation of each pregnant patient should observe their individuality. The physical and emotional preparation must be provided with excellence by the health care professional, and this requires a comprehensive vision that considers their history, feelings and the sociocultural context of them, valuing each woman as a unique patient⁽¹⁾. This implies not only an approach to clinical obstetrics and contents, but to emotional aspects involved in the reproductive process, once the physical changes affect the psyche the emotional ones can affect the physiological course of pregnancy⁽¹⁰⁾.

As well as fear, anxiety also appeared in the interviews as a common emotional state in all the women, manifested by a diffuse feeling, perceived to be unpleasant and vague. It usually occurs when the patients face new, challenging or threatening situations and it enables them to take action to confront the threat⁽¹¹⁾.

In a similar study, which aimed at understanding the meaning for woman giving birth to a child in a high-risk situation, the women interviewed also expressed fear, anxiety and suffering in their statements when they were placed in the high-risk pregnancy group. The term "high risk" haunts them and is seen as something very serious and complex, which one usually has no control of⁽⁶⁾.

Feelings such as fear and anxiety experienced during high-risk pregnancy can be mitigated when the patient is well informed about the diagnosis and reasons for referral to a prenatal care risk group⁽¹²⁾. The health care provider, enabling the dialogue and the expression of doubts and fears, gives the opportunity to the creation of an understanding space in which the guidelines have repercussions as greater compliance and safety during pregnancy⁽¹³⁾. The health professionals must understand that dialogue and emotional support, which are core competencies of a multidisciplinary team for the production of humanized care in health services, can enable significant outcomes, minimizing such feelings⁽¹⁴⁾.

With regard to the feeling of sorrow, it was reported by participants that one of the reasons why they felt that way was a previous failed pregnancy. In a study to investigate the aspects that guide the nursing practices geared towards women in abortion situations, researchers⁽¹⁵⁾ found that a comprehensive hosting may encourage in patients an outburst of their painful feelings in a search for humanized attention. This is a signal that painful feelings, such as sadness, deserve attention and a special look into the care offered by health care professionals.

When a pathological medical condition pre-exists, pregnancy can be considered as a new chance in life for the pregnant woman and her family. However, the emotional burden of expectation and fear of complications can generate a break in the emotional balance previously acquired by the pregnant woman, so it is important that the pregnancy is planned in these situations, with preconception evaluation and timely initiation⁽¹⁶⁾. But when a hazardous condition is diagnosed during pregnancy, the pregnant woman passes through reactions linked to the experience of mourning the “death of idealized pregnancy”, and feelings of sadness, guilt and anger emerge⁽¹⁶⁾. Thus, the lack of information and dialogue can be reported as negative, awakening and reinforcing feelings such as fear, sadness and anxiety.

Unlike the expression of feelings such as anxiety, fear, sadness and concern, it was realized that happiness was also part of the experienced period. Participants reported that they felt happy even in the presence of often contradictory feelings (sometimes even scared they felt happy), especially regarding the discovery of pregnancy and the support received. They defined happiness as a feeling of joy for being pregnant and the possibility of this experience.

The high-risk condition does not prevent pregnant woman from having joy and satisfaction with pregnancy and nourishing hope to have a satisfactory outcome and a happy ending, contributing to the balance needed to face the adjustments and overcome such difficulties. It is worth mentioning that these women can be encouraged to believe in themselves and find out how they can feel safe, so that the pregnancy journey can be experienced in a positive manner, providing peace of mind and they can enjoy pleasant and happy moments in this unique period in their lives⁽⁶⁾.

It is also important to highlight that health professionals who treat high-risk pregnant women need to be prepared to capture the subjective signs of emotion that come from adversity of a high-risk pregnancy. This care is crucial to the balance and satisfaction in the attention. Professionals can provide significant care which is able to meet the actual physical and emotional needs of human beings assisted by them⁽¹⁷⁾.

CONCLUSION

This study allowed us to know the feelings experienced by women who passed through a high-risk pregnancy. The main feelings observed were fear, anxiety, sorrow and happiness.

The fear reported by interviewees was related to the uncertainty of the unknown, lack of information about a high-risk pregnancy and also to the loss of control of the gestational situation. With regard to anxiety, these were related to moments that had become common during the high-risk pregnancy, with feelings related to the acceptance of the risk factor, an anxiety that interferes with tranquility during pregnancy, which is critical to the pleasurable stage of motherhood. Related to the feeling of sadness, the testimonies showed that the loss of a baby in a previous pregnancy, the lack of planning and the negative situations that could occur during a high-risk pregnancy contributed to make them feel sad. However, despite this mixture of feelings that weakened their emotional state, the interviewees reported happiness as a result of overcoming problems, which was also a result of the support received. At the same time, they felt happy when they found out they were pregnant and with the discovery of the baby's sex, special moments occurred during the pregnancy.

Thus, we conclude that the feelings are interlinked and bonded in the experience of high-risk pregnancy. Therefore, the pre-natal program can not only be directed to monitoring the clinical aspect of the factors that lead to a high risk pregnancy, but also to the emotional aspect which is part of this experience, mitigating this way feelings such as fear, anxiety and concern, or helping pregnant women learn to deal with them and thus overcome some difficulties added to this experience, and have more tranquility during this period.

We hope that this study will contribute in the training of health professionals, especially nurses, who are often the ones who have the primary contact with the patients at the time of antenatal visits and can provide the emotional support they need. We expect the formation of critical professionals who are reflective and engaged in the humanization of assistance to high-risk pregnant women. Similarly, it is necessary that the readers think about this theme and that this research serves as a reference for other studies related to the emotional state during pregnancy, providing new insights into the different feelings.

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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: 04/10/2015
Revised: 08/17/2015
Approved: 08/18/2015