Educational technologies to encourage ( self ) care in postpartum women

Objective: to evaluate national and international literature regarding the use of educational technologies to encourage self care in postpartum women. Method: an integrative review of the literature. The articles were collected from the CINAHL, SCOPUS, PubMed, SciELO, LILACS and Cochrane databases; the time period for the articles referred to January/2004 to July/2014; the languages used in the articles were Portuguese, English, Spanish and French; the articles were selected from the following descriptors: postpartum care period, educational technology, nursing and self care. Twenty-seven articles were selected for analysis Results: based on the information found, the scales, counseling and home visits were among the most recommended educational technologies. Conclusion: the technologies promote communication, but are sometimes dependent on computer and internet access, which hinder their use by low-income women. Descriptors: Postpartum Period; Educational Technology; Nursing; Self Care; Review. RESUMO Objetivo: avaliar a literatura nacional e internacional sobre o uso de tecnologias educativas para promoção do autocuidado de mulheres no pós-parto. Método: trata-se de uma revisão integrativa da literatura. As produções foram coletadas nas bases CINAHL, SCOPUS, PubMed, SciELO, LILACS e Cochrane, utilizando como recorte temporal o período de janeiro/2004 a julho/2014, nos idiomas português, inglês, espanhol e francês, selecionadas a partir dos descritores: postpartum period, educational technology, nursing e self care. Ao fi nal, procedeu-se à análise de 27 artigos. Resultados: dentre as informações, observou-se que as escalas, o aconselhamento e a visita domiciliar foram as tecnologias educativas mais recomendadas. Conclusão: as tecnologias favorecem a comunicação, mas por vezes são dependentes de computador e internet, difi cultando o acesso para mulheres de baixa renda. Descritores: Período Pós-Parto; Tecnologia Educacional; Enfermagem; Autocuidado; Revisão. RESUMEN Objetivo: evaluar en la literatura nacional e internacional el uso de las tecnologías educativas para promocionar el autocuidado de mujeres en el posparto. Método: revisión integradora de literatura. Se recolectaron las producciones en las bases de datos CINAHL, SCOPUS, PubMed, SciELO, LILACS y Cochrane, en el periodo de enero de 2004 hasta julio de 2014, en los idiomas inglés, español, francés y portugués brasileño, siendo utilizadas las palabras clave: postpartum period, educational technology, nursing y self care. Se llevó a cabo el análisis de 27 artículos. Resultados: en las informaciones encontradas, se observó que las tecnologías más aconsejadas fueron las escalas, los consejos y la visita al hogar. Conclusión: las tecnologías ayudan la Educational technologies to encourage (self) care in postpartum women Tecnologias educativas para promoção do (auto) cuidado de mulheres no pós-parto Tecnologías educativas para promocionar el (auto) cuidado de mujeres en el posparto


Educational technologies to encourage (self) care in postpartum women
Tecnologias educativas para promoção do (auto) cuidado de mulheres no pós-parto Tecnologías educativas para promocionar el (auto) cuidado de mujeres en el posparto INTRODUCTION Promoting women's self care during postpartum is part of the nursing care process in the gravid-puerperal cycle.It is therefore necessary to investigate the relationship established from the time that the clinical nurse and pregnant/postpartum woman first meet.One of the other factors that requires attention is the woman's ability to satisfy her needs through self care.This research will help the clinical nurse make medical decisions and, consequently, define the significant goals and interventions regarding the new experiences and meanings in the woman's life (1) .
Planning the important activities for these women is therefore a challenge for nursing care.For this reason, it is necessary to encourage the creation and use of educational technologies that are able to mediate care between nurses and women in the form of information dissemination.Amalgamating educational aims to share knowledge and practices in a horizontal relationship, in which the nurse could be the carer and educator, and to add popular expertise to its scientific and technical know-how (2) .
Regarding the evolution of health care, specifically in the nursing care context, it is observed that technologies are being planned and implemented while taking into account the need to translate the technical and scientific knowledge into tools, processes and materials that are created or used to disseminate such knowledge, and thus improve care quality.Understanding these technologies is not a simplistic factor without considering the knowledge conveyed by culture, or their involvement in everyday problem solving (3) .The technologies are categorized into two types: dependent, when they rely on electrical resources for their use (computer, internet, television commercial); and independent, when they do not depend on electrical resources for their use (posters, annuals, albums, folders, brochures, cordel literature manuals, guides, comics, newspapers, textbooks, murals) (4) .
In this context, the three most widely used educational technologies in the field of Nursing are: technologies for technical and higher student education, technologies for community health education and technologies for ongoing education with professionals (4) .The objective of all of these options is to increase the possibilities for which nurses can perform their practices as care producers.
This research discusses the tendency of technologies used for community health education, based on the understanding that these technologies do not represent an end in themselves, but rather act as tools to provide quality care.Thus, the technologies that contribute to the nurses' clinical judgment and the consequent selection of priorities for the promotion of self care are differentiated; and, on the other hand, the same can be said regarding the technologies used for health education with postpartum women.

OBJECTIVE
To evaluate the national and international literature regarding the use of educational technologies for encouraging (self) care in postpartum women.

METHOD
Our research is an integrative review, developed in six steps as proposed by Mendes, Silveira and Galvão, namely: Step 1 -identify the hypothesis and select the theme or research question to develop the integrative review; Step 2 -establish the inclusion and exclusion criteria for studies/sampling or literature search; Step 3 -define the information to be extracted from the selected studies/ categorization of the studies; Step 4 -evaluate these studies in the integrative review; Step 5 -interpret the results; and Step 6 -present the review/synthesis from this knowledge (5) .
The objective was to answer the following guiding question: Which educational technologies have been developed or used by nurses for women's (self) care in their postpartum period?
The following databases and portals were selected for collecting the data: Cumulative Index to Nursing & Allied Health Literature (CINAHL), SCOPUS, PubMed, Scientific Electronic Library Online (SciELO), LILACS -Latin American and Caribbean Health Sciences Literature database and Cochrane.The survey was conducted in July 2014 using the following keywords available in the Medical Subject Headings (MeSH) and Boolean operators: postpartum care period AND educational technology AND nursing AND self care.Some of the databases had their own descriptors, which were added to the search: technology and education (CINAHL); technology (LILACS); technology assessments (Cochrane).
The following inclusion criteria were established: articles published between January 2004 and July 2014; articles written in Portuguese, English, Spanish or French and available in full or via proxy server at the State University of Ceará (proxy.uece.br).Duplicate publications, integrative and systematic reviews, theses and dissertations were excluded.
The sample comprised 24 articles following the application of these criteria.The subsequent task was to perform a superficial reading of the titles, abstracts and articles, followed by a reading in full.Collecting the information from the studies involved using an previously developed instrument, adapted from Ursi, to emphasize the following dimensions: article title, authors, year, journal, data base, country, language, target audience, technology, study type, objective, methods, results, recommendations/conclusions (6) .
Figure 1, built according to recommendations from the PRISMA 2009 Flow Diagram (7) , clarifies the inclusion process for the articles found.
The presentation and discussion of the results were conducted on two main axes: 1) characterization of the studies based on the data collection instrument and the recommendation grade classification and the level of scientific evidence from the Oxford Centre for Evidence-based Medicine (8) ; and 2) knowledge synthesis, with the presentation of the main contributions of the publications in regards to the topic under study, Interviews, image exhibitions and a self-care pamphlet Before the intervention, there was an average level (52.3%), with an overall average of 24.5 ± 10.4; after the intervention, the level of knowledge increased (100%), with an average of 94.5 ± 1.2.

Characterization of the studies
The study sample was made up of 24 articles that can be seen in Table 1 according to their title, year, country, design, number of patients, treatments and outcomes.
Twenty articles were written in English, two in Portuguese, one in Spanish and one in French.As regards the trends in the technologies, 18 were technologies used in health education actions with postpartum women, in addition to five including pregnant women (articles 15, 17, 18, 21 and 23) and four including the women's partners (articles 8, 9, 21 and 22).Among the technologies for ongoing professional education, which play a part in the nurses' clinical judgment and the consequent decisions regarding priorities to encourage self care, six studies involving nurses are worth highlighting (articles 1, 10, 11, 12, 13 and 14).
As regards the methodological aspects of the sample, the quantitative research design types in the studies are: non-experimental (articles 8, 13, 16, 17, 19, 20 and 22) The task-oriented counseling strategy was the obstetricians from the women and the subjectoriented one allowed the women to express their feelings and emotions better.
Barbosa EMG, et al.Individual and group education for postpartum adaptation While there was a statistically significant difference between the groups in terms of prenatal adjustment (p < 0.01), no difference was found in postpartum adaptation (p = 0.077). 16

Descriptive, prospective study n=8
Focus groups with primiparas on breastfeeding self-efficacy, attitude and intention, perception of support and anticipated barriers In the prenatal groups, the major themes included beliefs that breastfeeding benefits both the mother and baby (benefits for mother and baby, availability of support, uncertainty regarding breastfeeding), and in the postpartum groups there were themes on the perception of breast-feeding itself and the importance and role of supportive others). 18

The effectiveness of a nurse-managed perinatal smoking cessation program implemented in a rural county 2006 United States
Quasi-experimental study n=194

Correlational study n=240
Chinese ritual as social support to reduce risk of depression It was found that a higher the level of social support received by women in the first postpartum month resulted in a smaller the risk of depressive symptoms.
Table 1 To be continued DISCUSSION Article 22 is an example of a descriptive design whose goal was to describe experiences of using videoconferencing to offer counseling to new parents.This study revealed that videoconferencing can support very premature cases after delivery by making the transition to motherhood/fatherhood easier, which enables new parents to be monitored by an obstetric nurse.The results from this study indicate that this technology can also be applied in rural areas at a future time (9) .The non-experimental studies include those of a descriptive nature, which summarize the state of the phenomenon, and those of a correlational nature, which examine the relationships between variables but do not involve manipulation of the independent variable (10) .
The authors from article 8 developed a cross-sectional study to describe access to technology by postpartum women; their views on the information given regarding postpartum weight and parent counseling; and whether these factors varied according to income level or race/ethnicity.122 of the respondents had access to a computer connected to the internet at home (84.1%), with daily use of internet (77.6%), e-mail (75.4%), mobile (97.1%) and text messages (66.7%).There were significant racial/ethnic differences in terms of domestic internet access and frequency of internet and e-mail use, with individuals of white ethnicity using these more than ethnic minorities.Overall, 35.9% of women expressed significant interest in an internetbased weight loss program, 38.9% in a weight loss program by mail, 44.8% in internet-based parent counseling and 38.6% in parent counseling by mail.Women with lower incomes were generally more likely to express greater interest in parent counseling by mail, while the higher-income women expressed greater interest in receiving information via the internet regarding weight loss and parent counseling (11) .
The treatment used in study 21 was an online support system for parents, regarding breastfeeding and baby care, along with a discussion forum.The satisfaction and self-efficacy of parents significantly increased during the postpartum period for both the treatment and control group.The affective skills related to self-efficacy were better than the cognitive and behavioral skills.However, no effect from the treatment was found.Studying the long-term effects and more specific parent groups would be a matter of interest in the future (12) .Quasi-experimental designs involve manipulation but have no comparison group and no randomization group.Powerful quasi-experimental models have controls to compensate for the missing components (10) .
Study 23 involved randomly recruiting women to a control group and a treatment group.Both groups participated in

Parent counseling through videoconferencing
The parents felt confident with using the technology and taking control of their privacy and also felt confident having their concerns heard and receiving replies.No statistically significant differences were noted between the treatment and control groups in breastfeeding prevalence at 12 weeks or in selfefficacy during hospitalization (65% versus 64.7%, p = 0.83).

24
Effects of listening to music on postpartum stress and anxiety levels 2010 China

Randomized clinical trial n=77
Relaxing music The study does not provide evidence that preselected music reduces stress and anxiety levels among postpartum women.breastfeeding classes, but the treatment group was given a breastfeeding magazine in order to evaluate the effect of this treatment on breastfeeding self-management and self-efficacy.There were no statistically significant differences observed between the groups in terms of breastfeeding prevalence or breastfeeding selfefficacy.There was a statistically significant difference between the groups in relation to conflicting counseling results, but these did not explain the breastfeeding self-efficacy.The decision to breastfeed was a statistically significant contributor to breastfeeding prevalence, more than the self-efficacy of breastfeeding (13) .These experimental models are considered by many to be the gold standard because these meet the criteria of causal relationship inference.To do this, they involve manipulation, control and randomization (10) .Both the experimental and the control group in study 24 received postnatal care, however the treatment (listening to music) was only applied in the experimental group.In addition, the music's effect on relieving stress and anxiety in postpartum women was evaluated.There were no significant differences in the levels of perceived stress and anxiety state between the two groups.Future research projects are recommended to consider stress factors that postpartum women are unable to control, even listening to relaxing music at home (14) .

Knowledge synthesis
Postpartum care should not be an aspect understood only by professionals, but principally by women and their family and social surroundings.In the context of nursing, based on philosophical foundations that constitute care, Orem's theory is evidenced, which asserts that self care is an act of individuals, influenced by cultural beliefs, customs and habits from the family and society, by age, stage of development and state of health.Thus, it is fitting that the nurse set out the knowledge and education that each woman has to guide her actions and avoid complications during postpartum (15) .
The individual must have sufficient self care know-how to meet her own needs.However, in situations where there is demand for care and the individual is not able to provide this, either partially or completely, themselves, the nurses are responsible for helping develop this practice.Thus, it is important that women are aware of their self care requirements during this period, as well as their own self care limits, to determine if of nurses are required to assist them (16) .
The primiparas have the greatest physical and psychosocial challenges in addition to those derived from caring for their newborn in the postpartum period.However, they do not receive adequate professional support after discharge from hospital, which does not help them adapt to their new role.In this sense, postpartum psychoeducational programs that include home visits and telephone calls have proven effective in improving women's health, preventing postpartum depression and guaranteeing greater social support for primiparas.Studies with non-English speaking women and those that include more hospitals are suggested for the future (17) .
Another effective strategy, which was implemented for the first time in a postpartum scenario with a view to facilitate communication between professionals and individuals who have recently given birth, was the advanced communication program, which increased the comfort and the competence of obstetric nurses to identify and care for women with psychosocial problems during this period.The effect of this approach must now be evaluated in terms of the results for women (18) .
Article 2 includes information about the development of an educational treatment by means of interviews and exhibitions, which are decided according to the needs identified by the adolescent mothers, using color photographs with graphic designs about self care practices, including aspects of hygiene, nutrition, breast care, sexual activity, physical activity and relaxation.The women were given a leaflet at the end of the treatment that summarized the issues addressed.The educational treatment had a significant influence on the level of knowledge possessed by the adolescents regarding self care practices during postpartum (15) .
As regards the most frequently discussed topic in the studies, namely breastfeeding (articles 5, 10, 16, 17, 21 and 23), phone counseling was provided by nurses.Phone counseling is considered effective for increasing the rate of exclusive breastfeeding in the first postpartum month, but not during the periods of four and six months postpartum (19) .The results from another study that used the scale as the technology provide evidence that this can be a valid and reliable measurement for predicting the initiation of breastfeeding, as well as the duration, self-efficacy and exclusivity of breastfeeding among adolescents (20) .
Given the key role that breastfeeding has for improving the general health of the community, breastfeeding counseling should be offered regularly, especially during the prenatal and postpartum periods, while the information provided should be consistent, realistic and evidence-based (21)(22) .Interactive methods are needed to increase the self-efficacy of parents during breastfeeding (12) .Article 23 shows that women's perceptions on their own ability to make decisions positively influenced the prevalence of breastfeeding up to 12 weeks after childbirth.Thus, encouraging women to participate in decision making regarding breastfeeding is a useful strategy to promote it (13) .
It should be noted that investment is needed by public managers to promote breastfeeding, mainly in terms of training and involving professionals in the process, as well as making them aware of it.The puerpera has adopted the practice of taking care of her family, failing to follow the guidance given to her by professionals.Thus, it is necessary to provide nursing students with new practical alternatives, moving away from giving care in outpatient and hospital institutions and moving towards domestic environment, which is vast and rich.It is suggested that breastfeeding is encouraged, and that the topic is discussed in the mass media in a manner that recognizes it as a normal part of life in the family and society (23) .
Technologies were also the focus for postpartum depression in three of the studies (6, 13 and 19).Behavioral coaching with the objective of increasing relational efficacy among depressed mothers and their babies was only partially evaluated.The care given to the control group by the nurse and the data collection process probably made the results confused, however the home visits performed by the nurse had a positive effect on all the participants (24) .
Postpartum depression screening scales were also developed and used, however, regardless of the screening tool, treating a woman with postpartum depression can only be effective when the woman agrees to accept help.The perceived treatment barriers include availability of resources, women's reluctance to seek help, reluctance of the family and economic issues (25) .In addition to the technologies already presented, the Chinese postpartum ritual of "doing the month" provides valuable social support and can help prevent postpartum depression in women from Taiwan (26) .
Other topics, albeit at a lesser frequency, were discussed in the studies, such as: Systematization of Nursing Care (articles 1 and 7), weight loss (article 8), sexual activity (article 11), satisfaction with childbirth (article 14), adaptation to motherhood (article 15), smoking (article 18), physical activity (article 20) and others.The developed or used educational technologies were varied, including: scales, counseling, home visits, interviews, telephone calls, internet forums, clinical simulations, magazines, video conferencing, focus groups, group education, software, photo exhibition, pamphlets, music, behavioral coaching, material by mail and others.
Despite the undeniable contributions that these technologies provide to nursing care during postpartum, unfortunately some of them, which are recommended in the publications, can only be practiced using a computer with internet access (dependent technologies), which limits their use by low-income women, for example, which necessitates the creation of more easily accessible technologies, such as annuals, brochures, magazines, booklets and others.This, access to information can become more popularized and benefit a larger number of women.
Our study is relevant is it enabled a bibliographic survey on care strategies and technologies that are being developed or used by nurses on women going through their postpartum period, thereby providing a synthesis of previously produced knowledge.In addition, the evidence provided in the studies allows for the best quality monitoring of the recent mothers, serving as an important device to be used by the health services to guide clinical practice in women's health care scenarios.

CONCLUSION
Educational technologies that cover postpartum care are related to both the child (breastfeeding and baby care) and the woman (mental health, weight loss, sexual life, smoking, adaptation, physical activity and relaxation).In addition, there is a tendency in international research include the woman's partner in such care, through new parent counseling, for example.
Technologies have also been developed, designed for students and professionals, as a way to facilitate the teaching and practice of professional Nursing in the care of postpartum women, which ensures that here is an improvement in care, either through the implementation of the Systematization of Nursing Care or the clinical simulation of obstetric care.
Furthermore, couples have been motivated towards self care and baby care through educational technologies, which have raised the level of knowledge and confidence during the postpartum period.The use of these technologies is therefore helpful in the process of communication and interaction between couples, nurses and students, the objective being to encourage healthy practices and discourage the inappropriate ones.

Figure 1 -
Figure 1 -Inclusion process for articles found