Expectations of a group of Portuguese pregnant women in the districts of Viseu and Aveiro regarding motherhood

Motherhood is a complex phenomenon, supplementedwith expectations about the new reality, the hopes of all going well, taking into account the expected care. In order to meet the needs of the Portuguese expectant mother, it is necessary to know what she deems essential for herself and her family, so that strategies may be developed to facilitate the transition process. This study was intended to gain insight into fulfilled and unfulfilled expectations of health care in motherhood with a group pregnant females in Portugal. This is a qualitative, exploratory and descriptive study, with 22 Portuguese women belonging to the Clusters of Health Care Centers of the districts of Viseu and Aveiro. The data was collected through semi-structured interviews and analysed using content analysis proposed by Bardin, supported by QSR NVivo 10. It was observed that fulfilled expectations surpassed those unmet, especially in terms of high quality health care and competent health care professionals. Regarding unfulfilled expectations, they mainly refer to maternity incentives, with an emphasis on the wish of greater financial familly supportfrom the government.


Introduction
The transition from woman to mother is a major event, as becoming a mother entails shifting from a known reality toward a new and unknown reality 1 .In particular first time mothers begin this transition phase at an early stage of the pregnancy, facing dificult periods throughout the pregnancy and after the birth, with a greater need of Support during these stages 2 .
Transition into parenthood implies significant changes and these must be taken into account given their great relevance in the life of the parents-to-be."Parenthood as a transition process encompasses a wide range of changes which represent a real challenge to parent's ability of adjustment" 3 .Throughout the whole phase of development and maturity leading to the role of 'parents' , several expectations arise, almost all connected to health care.During this process, the mother-to-be can find herself additionally vulnerable and, therefore, anticipate that her expectations are met for her satisfaction and personal fulfillment.The difference between conjectured and fulfilled reality generates experiences that are usually negative due to the frustration of expectations.This can determine the woman's future attitude and perspective on the subject of being a mother.Therefore, the more negative the experience, as being out of tune with her expectations, the harder the adjustment of the woman to her new situation will be.Women's expectations are constantly changing, and thus institutions must adopt conditions appropriate to their needs 4 .This will require an effective health care policy, including services providing integrated and high quality health care to expectant parents, through qualified and experienced professionals.This is the kind of high quality services and health care that most pregnant women, parturients and women who have recently given birth expect to receive.
Studies which approached this issue identified that women's expectations basically concern proper service, information on the status of labor, valuation and attention to their needs, and "the higher the expectations, the greater the woman's satisfaction" 5 .In most cases, expectations of women who had recently given birth were exceeded, although some less positive aspects were identified, such as the absence of identification of the delivery professionals, rendering it difficult to know the responsible people and the lack of accessibility to professionals for assistance in non immediate care, due to a shortage of human resources 6 .
Another concern of expectant mothers, which generates stress, is related to labor pain, and the measures to ease it, creating expectations that will influence the way parturients perceive that type of care 7 ."The more the parturient's expectations are in line with labor and birth, and with health care facilities and professionals, the deeper the relaxation" 8 .Lastly, "for a positive perception of the labor experience to happen, the adjustment of expectations during the whole period of transition into motherhood will be essential" 8 .
The assessment of health care quality, with a vision for a continuous improvement and increase in effectiveness, is a goal of modern health systems 9 .To this end, a good performance of the health system and professionals is, therefore, of crucial importance and a mission to achieve good health and well-being for expectant parents, as well as their satisfaction, facilitating adaptation mechanisms.
In light of the above, this study was aimed at gaining insight into fulfilled and unfulfilled expectations of Portuguese women regarding health care during motherhood.

Methods
This is a qualitative, exploratory and descriptive study.The sample was composed of 22 women, belonging to the Clusters of Health Care Centers of the districts of Viseu and Aveiro.The study included women who used health care services between February 2011 and February 2012, totaling 52 weeks.The eligibility criteria were: accepting participation in the study and having given birth less than a year before.
Data was collected through semi-structured interviews.A road map, divided into two sections, was used.The first section included the description of the participants, while the second included an open-ended question, in order to obtain data from the speech of informers themselves.Interviews took place in the facilities of participating Health Care Centers.They lasted between 45 to 125 minutes, with an average of 70 minutes.
It was followed by data analysis, based on the Method of Category-based Analysis of Content 10 , supported by the QSR NVIVO 10 software.Similar ideas were systematized and speeches were codified.
This study was approved by the ethics committeesof the respective Clusters of Health Care Centers involved in the study.The road map of the interview was submitted in advance to the Portuguese Data Protection Commission and authorization for its implementation was granted (Case 85/2011, no.191/2011).An informed consent for the interview and verbatim record was requested and obtained from all participants, after full clarification of the study.To ensure anonymity, each participant was identified by two letters of the alphabet (ex: BJ).

Results
The data analysis generated three categories: high quality health care, competent health care professionals and maternity incentives.The category high quality health care included five subcategories.The category competent health care professional included two subcategories, and the category maternity incentiveswas broken down into three subcategories, according to Table 1.
The category that stood out in terms of women's expectations was high quality health care, which had been fulfilled in most cases.Some statements illustrate this category, regarding fulfilled expectations: "I have no reasons to complain.On the contrary, I was positively impressed" (CL); "I expected free consultations and exams and I had that" (AA); "I was hoping to be followed by experts in the delivery room and I received full attention from the specialist nurses and doctors who were there.I did not have a problem" (CG).
Unmet expectations regarding high quality health care were not mentioned often, and quick access to consultations at a health care center and maternity hospital stood out.Unmet expectations are illustrated in the following statements: "All I have to say is that I waited a while to get an appointment to hospital A, approximately two or three months, due to blood pressure" (BG); "As for health, I have nothing to say, but I expected to benefit from some vaccines that have not been included in the national vaccination program yet" (BO); "If there was a pediatrician in this health care center, I would not mind paying something" (CM); "To start with, there should be more support in terms of house calls.For instance, a doctor or nurse should visit someone at home to see how that person is, not only during pregnancy, but also in the postpartum period" (AQ).
The second category that was more significant was that on competent health care professionals.In this category almost all expectations were satisfied.Fulfilled expectations regard the effective attention to the needs of mothers, which was connected with dedication, affection and good care.To illustrate these expectations, we highlight the statement of four mothers: "The doctor and the nurses exceeded my expectations" (BG); "I was expecting them to be colder and not show such dedication, as they deal with children and pregnant women every day.It exceeded my expectations" and "… I had the idea that nurses or doctors did not show much affection and it was more than I hoped for" (BK); "This was a luxury for me because I was not expecting to be so well taken care of at all" (CL) "… I expected that all would go well and that I would not be unfortunate to receive the care of less professional staff and it was so" (CE).Unfulfilled expectations in this category were related to the dissatisfaction with health care professionals regarding professionalism: "… as for the care I received, when I had my baby girl, they were way below my expectations due to their lack of professionalism" (CH).
The category maternity incentives is in the third position, and expectations on this issue were not met in its entirety.The subcategory greater financial contribution of the government to families stood out in this category in the opinion of seven mothers.Two of them mentioned: "… in Portugal, if we do not work for four months, we are paid our salary in full, if it is five months, we are only paid 80% of our salary and, if we are away six months, we do not get paid" (AA) and "… I believe it is wrong of the government not to provide children's allowance or aid to some people, as the Portuguese population is ageing.I don't know who they want to work so as to provide a pension to the old.I think this is a terrible policy" (BO).The subcategory maternity leave extension was mentioned by two mothers, as the statement of one of them illustrates below: "… I think that maternity leave should be one year because I go back to work when she is five months old, and then I will lose things children do during the first year of life" (BH).The subcategory use of parental leave by the father and mother at the same time was mentioned by one mother, who reports: "For example, the Portuguese government gives the option to use the leave for five months, but it pays between 100% and 80%, depending on whether the father uses his leave or not.I think they should always pay 100% of the leave" (BG).

Discussion
In this study, fulfilled expectations stood out compared to unfulfilled ones.Nonetheless, the difference between the two was not significant.Out of fulfilled expectations, high quality health care comes first, with an emphasis on health care focused on the needs of mothers.This finding is also significant in other studies and shows the growing value of user's perception in the scientific domain, as well as for the varied social partners, with a view to monitor the quality of health services and assess the effectiveness of corrective measures to be implemented 4 .It also points out the fact that users must be given the chance to express themselves regarding care offered by health services, as their opinion affects their relationship with health services and professionals 4 .In this respect, these mothers can contribute to a health system with improved quality.
Free health care was one expectation mentioned by only two mothers, one of them considering it fulfilled and the other deeming it unfulfilled.This outcome can be accounted by the fact that maternal and obstetric care have been free for many years in Portugal.Therefore, as it is an established right of Portuguese women, it may not be seen as an expectation.
Mothers also gave their opinion, although to a lesser extent, about monitoring by experts at the health care center and maternity hospital and the lack of professionals (medicine or nursing) for home care.These women wished that those professionals would monitor them during all the stages of motherhood.However, the functioning of the health care system in Portugal prevents women from experiencing that reality 11 .Similarly, other authors highlight that nurse home visits is not yet a systematic and widespread practice in Portugal 12 .Another group of authors pointed out in their study that pregnant women expect the midwives to assist them throughout the pregnancy, supervising and supporting, enabling them to deal with the changes in pregnancy and the preparation of the delivery 13 .Postpartum difficulties, after being discharged are evident in another study, where mothers expressed the need of long term monitoring, regretting the lack of support when troubles arise at home 14 .This need expressed by mothers finds an echo in the concerns of the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF).These bodies, aiming to reduce morbidity and mortality in newborn babies, recommend the performance of house calls, by a doctor or a nurse, during the first week of life of the child 15 .
As forhigh quality health care, unmet expectations were more significant in terms of quick access to consultations at a health care center and maternity hospital, followed by monitoring by a doctor or nurse at home.Similar to this study, other research reveals that access to health care and adherence to consultations, specifically consultations for prenatal surveillance, are important aspects for the satisfaction with health care units 11 .In this regard, literature shows that, when women are asked about their expectations regarding humanization of health care, they highlight swift service 16 .Other authors reveal the importance given to information and continuing services, as well as to health care services acess, by the discharged patients 17 .
The second category, competent health care professionals, was mentioned in the statements of more than half of the mothers, who considered that their experience exceeded what they anticipated, achieving a high degree of satisfaction.Based on the interaction between two or more people,aid relationship arises as a mutual contribution, in which the nurse undertakes to meet a need of assistance, in this case of the expectant mother, collaborating in their preparation for self-care, and enabling their self-healing 18 .Regarding support and assistance received from health care professionals, these mothers clearly benefited from a helping relationship which was formed between them and health care professionals, which is shown in the subcategory effective service provided to mothers.As another study shows, the attitude of health care professionals regarding care provided is a factor that generates satisfaction in the assessment of women according to the fulfillment of their needs, expectations and outcomes obtained 19 .In the study mentioned above, mothers brought upseveral times the professional class of Nursing, and most of them classifiedthe care provided by nurses as excellent.They regard the Nursing profession as involving a high level of skill and significant technical and scientific know-how.These data are corroborated by another study which also shows the importance attached to the nurse, who stands out among health care professionals as a trainer, and that expectations, in this case related to the type of labor, are influenced by health care professionals during pregnancy 20 .Respect and humanization of health care provided by competent professionals are predominant in the interaction they establish with users and family, enabling their participation in decisions and procedures to implement, as well as the fulfillment of their expectations 21 .Other research shows that knowledge of the perception of users on the Portuguese health system regarding the quality of service provided by professionals is an indispensable indicator of quality for its improvement, and that most users had assessed care provided by health care professionals positively, with an emphasis on nurses 22 .Despite this, nurses are not the only ones to assume an important role in the relationship with the mother-to-be, increasing her competence in her role of mother, and enabling her to fight the stress of motherhood.Competent health care shoud be provided by the entire care team, providing support and ease to the new mother, increasing her satisfaction and minimizing potential risks as postpartum depression 23 .
Lastly, non fulfillment of expectations regarding health care professionals in terms of professionalism was mentioned by two women, without indication of the professional class.Health care professionals have the duty to provide competent care, generating satisfaction in the users they care for.As a result, competence emerges as a value to respect in the professional relationship, being a challenge and an ethical requirement in the way of showing professionalism 24 .This category highlighted the competence of health care professionals as a key element in the satisfaction of their needs.Attention and support from professionals in the promotion of comfort, well-being, and provision of training to enable decision-making in a safe delivery are essential to ensure the woman's satisfaction and fulfillment of her expectations 25 .As demonstrated in another study these women expect to receive from the health care professionals not only information, but also empathy and commitment in the understanding of their beliefs and feelings, during the pregnancy and more important, during the delivery 26 .This need is even more perceptible when existing literature reveals women that consider the delivery as a synonym ofphysical and emotional suffering, pain and even death 27 .
The category maternity incentives came in third place regarding expectations of Portuguese mothers.Nevertheless, that expectation was unmet in its entirety.The most prominent subcategory was dissatisfaction with the financial contribution of the government to families.In Portugal, in case of a 150 days leave, the allowance may correspond to 100% of the benchmark salary, but for that to happen one of the parents must use the leave exclusively for at least 30 consecutive days 28 .The maximum leave granted is 180 days, under special conditions, in which 83% of the benchmark salary is paid 28 , which does not correspond to the expectations of these participants in the slightest.Another study also shows that, in addition to the emotional support required, it is essential to grant allowances so that the woman and her family may experience this life stage with less pain and suffering 26 .As for subcategory use of parental leave by the father and mothersimultaneously, a significant modification of the Labor Code, strengthening parental rights in that area, was recently observed.According to this new change, maternity leave may be used by both parents simultaneously between days 120 and 150 29 .The same law shows the inclusion of additional 30 consecutive days to the said leave, if the father or the mother uses it exclusively for 30 consecutive days or two times for 15 consecutive days, following the mandatory use of the leave by the mother 29 .On the other hand, and according to the same amendment to the Labor Code, the father is forced to take paternity leave for 15 business days, within the 30 days that follow the delivery, and five of these days must be used consecutively immediately after the birth 29 .Although one user mentioned she was displeased with the fact that her expectation had not been fulfilled, this new amendment to the law will benefit many other women who, like this woman, have the aspiration to be with their children during the first months of life, together with their partners, which is a significant progress in legal terms.Likewise this idea is corroborated by a study that promotes that the health care in the postpartum should be centred on the family and that the fathers'participation in this care should be increased and this new change is beneficial 30 .

Conclusion
In this study, we sought to gain insight into fulfilled and unfulfilled expectations of Portuguese women regarding health care during motherhood.Findings pointed out three categories of expectations: high quality health care, competent health care professionals and maternity incentives.Fulfilled expectations surpassed those unfulfilled, although this difference is not significant.
Results of this study show that in the category high quality health care focused on the needs of mothers stood out.This expectation was not met, in the opinion of some women, in terms of swift access to consultations at a health care center and maternity hospital; some consultations, exams and vaccines being free of charge; monitoring by experts at the health care center and maternity hospital; and monitoring by a doctor or nurse at home.
The category, competent health care professionals, was highlighted by half of the participants as a fulfilled expectation.On the other hand, category maternity incentives emerged as the less fulfilled expectation.
Conclusions confirm the need to increaseinvestment in the mentioned areas reported as most lacking, requiring research, with a view to generate greater satisfaction in this important moment of transition in the life of the woman.

Table 1 .
Portuguese women's expectations regarding health care during motherhood.