Group of pregnant women and / or pregnant couples: a collective construction process (1996-2016)

Objective: To understand how the process of construction of the Group of Pregnant Women and/or Pregnant Couples of the Federal University of Santa Catarina from 1996 to 2016 was established. Method: Qualitative research of a social historical nature, involving nine health professionals who participated in the group of pregnant women and/or pregnant couples in this period. The date of collection took place between February and May 2017. Data analysis was guided by Orem's Self-Care Theory and Bardin's content analysis technique. Results: The process of construction of the group of pregnant women had strong influence from the public health policies of the University Hospital Maternity and its assistance of the time. Likewise, it was created based on the need for guidance to pregnant women and their companions to deal with the pregnancy-puerperal process with the perspective of a multidisciplinary and integral work, stimulating self-knowledge and self-care. Conclusion: The group emerged as an extension project and strengthened by public health policies, its scientific evidences and by the assistance philosophy of a maternity school. The group building process involved a set of actions, planning and execution of activities, building an educational space, free of charge, with an exchange of mutual experience and open to the community.


INTRODUCTION
The support groups have been considered an effective instrument for the achievement of educational practices. In the health area, they have several fields of works, being performed from a determined group of persons´ needs, to teach and develop effective and safe care practices, spreading knowledge for the community. Besides, they are mediated by professionals specialized in the approached area, who guide their orientations and activities towards the target population. 1,2 The group of pregnant women is a highlight in the performance of groups in the health area, which provide a space for the health education, encouraging the parents´ protagonism and empowerment through a collective teaching-learning process within the group. 3 Inserted in the context of group of pregnant women, it stands out the educational practice integrated in the hospital context, aiming at increasing the link between the pregnant woman and the maternity. Corroborating with such aspects, in this research the department of nursing of the Federal University of Santa Catarina in partnership with the University Hospital Polydoro Ernani of São Thiago (HU-UFSC) is stood out, a teaching hospital, which treats exclusively by the Single Health System (SUS). Its maternity was inaugurated, in 1995, and in the following year, in 1996, the Group of Pregnant Women and/or Pregnant Couple was created, following the assistance philosophy of this maternity. 4,5 The construction of the maternity assistance model was organized by a group of professionals from the obstetric and neonatal area, respecting the recommendations of the World Health Organization and the scientific evidences of the time. Thus, a set of 12 philosophical principles was born, which has been recognized as "the philosophy of the maternity", contemplating three aspects: general aspects of the assistance, integration between the professionals and the service and the users´rights. 4 Therefore, named from the beginning, the Group of Pregnant Women and/or Pregnant Couple, a space addressed to the health promotion, to the humanized care and to the participants´ autonomy. It is an education, free and interdisciplinary environment developed as an extension project of the department of nursing of the UFSC in partnership with the maternity and professionals of the HU-UFSC. 5,6 In 2016, the group completed 20 years of uninterrupted existence, endorsing, thus, its importance and relevance for society and academic community. This historical landmark is justified, considering as an important transition phase in the coordination and organization of its activities, renewing the health professionals and teachers of the group. Based on the above considerations, it is questioned about the influence of the group historical process during the period from 1996 to 2016 to its target population, health and academic area professionals, since no other studies that would explore the historic course of groups with the same purpose of it was found. Another factor that emphasizes the importance of the performance of this group and its study is the curricularization process of the university extension. It aims to strengthen the consortia and integrate the teaching, research and extension activities. 7 By understanding the issues involved around the pregnant group, it is used in this research the Dorothea Orem´s Self-care theory, for the study theoretical foundation. Orem integrated, in her theory, concepts used for the strengthening of this process, including mainly "educate the other", provided by the nursing and other health professionals in an interdisciplinary way, facilitating the teaching-learning. 8 Is

METHODOLOGY
Qualitative research of social-historical nature, using oral and documental sources. The historical sources are used regarding the past, constituting an ethical attitude of the researcher and the responsibility of the building and record of a new source of information. 9 The technique carried out for obtaining data from the oral sources was the Thematic Oral History, involving elements of collective memory and expanding the time for the observation of any aspect "of the other". 10 The technique of the sources selection was the " snow ball" that occurs after the localization of " key informants", and the interviewees being the indicators of new participants with research interest characteristics, successively up to sample saturation. 11 To select the oral sources of this research, was established as inclusion criterion -health professional who work at least during one year in the pregnant group and/or pregnant couple of the during the period of the research (1996 to 2016). As exclusion criterion -health professionals who fit into the inclusion criterion and that did not answer the contact by telephone or by electronic means or health professionals without record of contact by the research subjects.
The documental sources used were materials provided by the study participants, such as: chronogram of groups, presences and subscriptions lists, meetings evaluations and experiences reports, photos, folders, scientific articles and posters. These served for data validation obtained by means of oral sources.
The data collection occurred between February and May 2017. For the collection of oral sources, a semi-structured route map in an interview way was developed. The interviews were carried out by the main researcher and recorded in digital media with a 30 to 60 minutes duration. After recording, we transcribed and transformed the language of words, expressions and punctuations of colloquial use for the text in scientific format. After transcribed, these were submitted to the participants for the respective validation and signing of the Term of Assignment of the Interview respecting the Resolution 466/2012 of the National Council of Health. 11 The participants enabled the divulgation of Group of pregnant women and/or pregnant couple Vieira AN, Padilha MI, Costa R, Gregório VRP, Silva AR name in the study because this is a historical research, valuing participation in this process. The research proposal was approved by the Ethical Research Committee with Human Beings of the through the respecting the Resolution 466/12 of the National Council of Health.
We conducted the data analysis by the content analysis technique proposed by Bardin 12 relating with the theoretical framework of Orem 8 . First, it was performed the pre-analysis, organizing all documents to be used in the research. Subsequently, we made the exploitation of the material by defining the categories and sub categories with regard to the thematic found. Finally, the results´ treatment was performed by interpreting them and detaching the most relevant themes.

RESULTS
The results of this study are presented in thematic categories to facilitate the understanding, organization and clarity of data. 12 Such categories were defined after the organization of the collected data, its interpretation and critical analysis, and are confirmed and faced through the documental sources in order to guarantee its originality and veracity.
The participants in this study totaled nine, of which seven nurses (78%), one sociologist (11%) and one psychologist (11%). Age ranged between 25 and 64 years, three participants (33%) with age between 25 and 39 years and six (67%) participants aged 40 to 64 years old. On the performance in the group, five participants were coordinators (56%), one health professional (11%) and three were college extension scholarship (33%). Regarding the academic title, four participants have Master (44%) and five have Doctoral degrees (56%). As to the period of activity in the group of pregnant, five participants worked in the group between 20 and 11 years (56%) and four participants between 10 and 01 years (44%). These characteristics show that the participants have high level of long period of performance and participation in the group and involvement with the area of health.

The building process of the group of pregnant women and/or pregnant couple
The building process of the group of pregnant women since the idea of its creation has arisen during the implementation of the maternity of the HU-UFSC from a need at the time and of its objectives. Regarding the implementation and philosophy process of the maternity of the HU-UFSC between 1993 and 1994, there was a commission in support of this implementation, formed by professionals of diverse areas and by some teachers of the UFSC. The building process of the philosophy of the maternity started by the physical space, available human resources and planning of routines.
[ Despite the HU-UFSC already count on the group of pregnant women of the last semester which began soon followed by the inauguration, it showed itself insufficient, since it did not supply the needs at the time due to the restriction. It is mentioned that the professionals Zaira, Odaléa and Maria de Fátima have been the creators of the idea of the group, foundresses and leaders at the time, already emerging as a group with multi and interdisciplinary actuation composed of nursing, psychology professionals and other health professionals who were included in the meetings. These data are confirmed by activities schedules of the Group of Pregnant Women and/or Pregnant Couples at the time.
[...] The Odaléa and I began to coordinate the meeting of pregnant women of the third quarter. We began in December 1995 this work until the first semester of 1996 with the maternity in its first months, focused on the humanization, training of the health professionals, since it already had the written philosophy and we thought: "well, let us start doing a more extended work, larger from a multidisciplinary perspective", since one of the principles of our philosophy is the multidisciplinary work, trying to be inter and we thought about the structure of this group to begin, since the third quarter was more focused on the birth, in only one afternoon. We thought about structuring a work to involve more professionals and had more time and space for women and companions could reflect on this process [ Regarding the achievement of the group activities, it discusses the moment that the first meeting of the first Group of Pregnant Women and/or Pregnant Couples started and who are the persons involved in this beginning. The group was created as a project of extension from the Nursing Department since the teachers from the department did not have direct link.
[...] The first group was done on April 18, 1996 Regarding the objectives of the Group of Pregnant Women and/or Pregnant Couples, generally, the objective are linked to the pregnant women, companions and community in general as the empowerment, autonomy; self-knowledge, safety and self-care practices regarding the pregnancy-puerperal process; process of teaching-learning and strengthening of academic activities and professional autonomy for the student´s training; involvement of health professionals from various areas of activities and training: qualifications of health professionals among other factors involved.
[...] Offering for the community a space that could help empower the woman and be conscious about her importance in this process and be the protagonist of the birth. Our principles of the philosophy were to offer this support for the woman, clarify doubts and make her much more empowered to the point of arriving at the time of the birth process and birth and, including, be able to reflect with the team about inadequate postures and such things. It´s a whole approach of health promotion and of the psycho--affective development with the baby, the insertion of this new member into the family, the concern to reflect and debate the impact of the birth on the life of a couple or a woman who is alone [

[...]Each day it was a specific theme, the Women´s Health Programs and what the SUS used to recommend was the base for the discussions [...] (Student Saionara -2010/2011).
One may notice the concern of the coordinators and components of the group in passing on to the pregnant women and their companions, scientific evidences and recommendations that were really indicated and recommended by the Ministry of Health.

The influence of the University Hospital on the building of the group of pregnant women and/or pregnant couples
The influence of the University Hospital was essential to the success of the Group of Pregnant Women and/or Pregnant Couples, mainly, in the first groups when the pregnant women and the community, on the whole, did not know the work of the group and its coordinators.  Roberta -1998Roberta - /1999).

[...]In the first groups we, even sought to do a link of whom was part of that group of pregnant women had the right to gain. We had a small rub stamp and this small rub stamp stayed into the pocket of the pregnant woman as a record for participating in the group of pregnant couples, then she would have the right to gain in the UH. This was in early,
It strengthens the role of the group of the pregnant women, serving as support to the activities of the maternity, mainly with regard to the visits. It also addresses the importance of the group of pregnant women for the maintenance of the maternity philosophy, since some professionals showed resistant as to the inclusion of the companion at the moment of the birth and in the pregnant women´s empowerment of being responsible for their own decision-making decision.
[...] The group had an important role in order to maintain the maternity care philosophy, because there, there was a discussion around the companion´s participation. The doctors did not want the companion. The free access of the mother, the father to the neonatal, the woman chose the birth position that she wanted. Then, some changes were placed when there was the opening of the maternity and had been having resistance within the team and here the group of pregnant women had been talking with the women, strengthening this approach. This laboring women, when they went to the put pressure on the professionals who were "on the fence", shall we say, put pressure the maintenance of these orientations [..

.] (Coordinator Maria Isabel -2000/2016).
The maternity and its philosophy influence the educative activities of the group and in a way the orientations provided in the group also exert an influence on the maternity and on their professionals´ actions. Either by the support regarding the visits to the maternity and/or by instructing their pregnant women and companions to the moments of birth and after childbirth.

DISCUSSION
The women´s health public policies in Brazil and in the world have been evolving over the years. Justified by the need and strengthening of the female role in the society, expanding and allowing visibility of the woman figure. These policies are stimulating and essential so that the health institutions can construct their internal norms and orientations of health practices. 13 Regarding the creation of the Group of Pregnant Women and/or Pregnant Couples was not different, the health policies and programs were strong influences for its construction and its activities were guided by the MS and scientific evidences proven. Self-care activities proposed by Orem also help, since these are formed from a social need, being carried out by the individuals in their own benefit, maintenance and optimization of their health and well-being. 8 In the year 1995, simultaneously with the year in which the idea of formation of the group of pregnant women arose, the Fourth United Nations Conference in Beijing/Japan, that treated the women´s health. In this Conference, twelve areas of priority concern were identified, among them the inequality in access to education, training and to health services. The Beijing Platform of Action consecrated three innovations as potential transformers in the struggle by the promotion of the situation and women´s rights: the gender concept, the notion of empowerment and the focus of the transversality. 14,15 From the self-care deficit or care with individuals, these specific factors were raised, contributing Group of pregnant women and/or pregnant couple Vieira AN, Padilha MI, Costa R, Gregório VRP, Silva AR to the individuals´ s integrality and their development as human being. 8 These innovation were already included in the principles of the group of pregnant women and/or pregnant couples and met the philosophy of the maternity, envisioning the education of the social and academic community, the training of the professionals and the access to health services with prior knowledge about their rights.
From the Beijing Conference, the MS has been creating programs, policies and ordinances, in addition to supporting the legislation that addresses specifically the issues of the women´s health and of the NB. These policies are extensively disclosed by the municipal and state departments, however not all policies incorporate to the health services. 16 They are the basis and the stimulus to the creation and consolidation of the group of pregnant women and/or pregnant couples ideas, strengthening their ideals and being support to the carrying out of their activities.
Among the influential policies of the process of construction of the group of pregnant women of the, is the IHAC created, in 1990, by the World Health Organization and by the United Nations International Children´s Emergency Fund (UNICEF) with the objective to promote, protect and support the breastfeeding. The basis of this project initiative is the implementation of the "Ten Steps to Successful Breastfeeding", used to train all hospital team that work with the health of pregnant women and babies, by orienting on the advantages and the correct management of the maternal breastfeeding, as well as the disadvantages of breast-milk substitutes, bottles and pacifiers. [17][18][19] It can be seen that the training for parents, health professionals and students involved in the group, was one of the points worked that meets the "caring of other" and " teaching the self-care" of Orem by integrating health policies, educative and care practices. 8 The recommendations of most common practices used during labor were published, in 1996, by the WHO, in order to establish good practices in the conduct of labor without complications based on scientific evidences. These recommendations are divided into four categories: A) Practices verifiably useful that should be encouraged; B) Practices harmful or ineffective that should be eliminated; C) Practices whose evidence is insufficiently verifiably and should be used in a precautionary manner and; D) Practices frequently used in an inadequate manner. 20 These recommendations envision the care practice until the present day and are incorporated in the care philosophy of the maternity being a reflex for the orientations and practices recommended by the group of pregnant women and/or pregnant couples integrating and stimulating these practices in their educative and care activities. The health professionals were opened to the learning process and ready to educate the other, providing adequate educational experiences. 8 Another program that was influencer in the process of consolidation of the group of pregnant women and/or pregnant couples was the PHPN instituted in 2000, by decree no 569. This program considers that the pregnant woman and her NB must be received in a dignified and qualified manner during the pregnancy, birth and after childbirth, being her rights of citizenship. It also aims of the need for reduction of high rates of maternal, perinatal and neonatal morbimortality of the country, considering important the adoption and complementation of some of the measures already established by the MS. 21 Before this, were based on the PAISM launched, in 1983, by the MS, as the first program that contemplated the regulation of the fecundity regulation, being pioneer including on the world stage, by proposing a reproductive health care of women, within the scope of the health integral care and not using isolated actions in family planning. 22 Another theoretical support for the group of pregnant women and/or pregnant couples was the entity, which is an organization of the civil society active at national level in association at national level form, since 1993. Its main objective is to divulge the care and perinatal care based on scientific evidences, having a fundamental role in the structuring of the "humanization of the labor and birth", in order to reduce unnecessary interventions and promote actions regarding the pregnancy-puerperal process in a natural and physiological form 23 . This policy reflects in the group of pregnant women that spreads these ideas in whom search for them, stimulating and empowering for a healthy and physiological birth, promoting the self-knowledge and the woman´s desire at the time of birth. 8 Despite having the same theoretical support, the group of pregnant women is a project of extension of the university independent of the maternity, a public institution that cannot guarantee assistance to the birth for those pregnant women who participate in the group. It is evaluated according to the number of available vacancies, clinical condition of each pregnant woman and proximity to her residence, however it was addressed in the beginning with a focus of the public´s interest. The maternity was a model for structure knowledge, philosophical principles and care dynamics. 24 One discusses the importance of the visit and prior knowledge of the maternity before the parturition, which affects positively the users´ satisfaction, safety with the team and the approximation process with the labor place. 25 The visit in the maternity provides the pregnant woman and her companion with the prior knowledge of routines, orientations on the companion´s role, orientations about the care provided in each phase of the labor and birth and care provided to the newborn. 8 In addition to the benefits for the community and health professionals, the group of pregnant woman still offers undergraduate students of the the opportunity to insert in this teaching-learning process, one of the objectives of Orem´s Theory. 8 Considering also that such group arose as a project of extension, its activities are incorporated into the new guidelines, called curricularization of university extension. These predict through decrees, the incorporation of academic activities in different modalities, previously, focused inside the classroom, but now expanded to other territories. Therefore, it aims at involving and integrating three functions of higher education, activities of education, research and extension, strengthening thus the student´s teaching-learning proccess. 26 This insertion reflects in a positive way in the formation and Group of pregnant women and/or pregnant couple Vieira AN, Padilha MI, Costa R, Gregório VRP, Silva AR professional growing of the students, becoming them more safe, committed and independent to mediate conflicts and activities of education in health. They still stimulate readings and prior knowledge about the themes addressed and support in the discussions and in the health practices. 8,24,27 The maternity was the first maternity of Florianópolis to stimulate and allow the presence of the companion of the woman´s free choice from the time she enters into the institution to the hospital discharge. This practice was instituted since the implementation and inauguration of the maternity, in 1995, and inserted in the care philosophy, promoting the users´ participation and integration with the health professionals. In addition to the encouragement of the participation of the companion, the maternity was the first to encourage the choice of birth position and to offer non-pharmacological methods for pain relief with bath techniques, massage, ball use and of "horse". 28 These practices were innovator at the time and gave a good visibility to the hospital and its maternity and consequently to the group of pregnant women that followed the same principles. 6,8,28 The educative practices give support to the individuals to engage in the self-care, by constructing a sum of actions to be carried out in a given time, by reaching the requirements of self-care through the use of methods of actions. 8 The Group of Pregnant Women and /or Pregnant Couple has the function of instrument the pregnant woman and her companion for an active participation in the moment of the birth and puerperium. These actions stimulate and strengthen the philosophy of maternity principles and integrate the health professionals, developing the care practices according to the guidelines of the institution. 4,5 Such actions are essential to the development of the education process of the health professionals and self-care requirements by the pregnant women and her companions, transforming them into process protagonists. 8

CONCLUSION
We concluded that the building process of the Group of Pregnant Women and/or Pregnant Couple involved a set of actions, persons, planning and execution of activities, in order to form a free, educative space, with exchange of mutual experience and open to the community born, thus as an extension project of a nursing department. It comes to meet the theoretical principles of Dorothea Orem that seeks to teach the other to develop requirements of self-care, identify its need and search for help when necessary.
In view of that, one can see that the group of pregnant women is strengthened by health public policies and its scientific evidences, link with a maternity-school, multidisciplinary and integrated work, insertion of students and health professionals qualified and committed to the wellbeing of the pregnant woman, family and community. These findings stimulate the planning and involvement of health professionals and nursing students to develop support groups that link research, teaching and assistance replicating the good practices in a safe and pleasant way for the social and scientific community.
It is believed that this study had limitations as to the number of participants, not being possible to embrace all health professionals involved in the trajectory of the group, due to the long period of activities (20 years) making it difficult to capture these professionals. Another limitation of the study was the carrying out of the research only with coordinators, health professionals and students, since it does not encompass all those involved in the building process. However, it is justified by the fact of it can cause bias in any historical event.
Group of pregnant women and/or pregnant couple Vieira AN, Padilha MI, Costa R, Gregório VRP, Silva AR