Management of prenatal nursing care at a Health Center in Angola

Rev Bras Enferm [Internet]. 2019;72(Suppl 1):129-36. http://dx.doi.org/10.1590/0034-7167-2017-0685 ABSTRACT Objective: To understand how care management in prenatal care in a Care Center in Angola happens. Method: A qualitative study, which used the Constructivist Grounded Theory (GT) as a methodological framework. The theoretical sample consisted of 22 participants, including nursing professionals, pregnant women and nursing students from Huambo, Angola. The data were collected by interviews and analyzed according to initial and focused coding. Results: Five categories arose: Embracing the pregnant woman for prenatal care; Performing the prenatal consultation; Creating a bond and dialogical relationship with pregnant women; Establishing collaborative working relationships; and Inserting the pregnant woman’s family into prenatal care. Conclusion: The management of nursing care in the study setting is effective through complementary and interdependent steps, based on collaborative relationships among professionals and in the effort to establish bonds with pregnant women and their families. Descriptors: Prenatal care; Pregnant Women; Management; Nursing Care; Primary Health Care.


INTRODUCTION
The management of nursing care involves the articulation of the assistance and management activities in the nurses' practice, aiming at the quality of care in the health services (1)(2) .To manage care, it is necessary to establish relationships and interactions that allow the bonding and dialogue between the professional, the patient and his/her family, culminating in mutual interactive processes.In addition, it is fundamental the professionals' appreciation of the singularities and characteristics of the social context to reach the objectives of the care management (3) .
In the context of prenatal care, care management is important to ensure the quality of care during pregnancy and to facilitate the approximation of the pregnant woman, her family and the community to the health system, enabling the integrality of care through promotional activities, preventive, diagnostic and therapeutic (4) .In the global agenda of the World Health Organization (WHO), one of the main priorities is reproductive health, which highlights the need to formulate goals to reduce maternal mortality and improve the health of pregnant women (5) .
In this sense, aspects related to reproductive health have aroused the interest of health professionals, managers, researchers and society in general, making each country develop experiences to improve the management of prenatal care, according to their particularities (6) .In Angola, this movement began in the mid-1970s, when the country ceased to be a colony of Portugal.At that time, the first program of reproductive health and training of midwives was set up in cooperation with Sweden.In 1995, the government developed a program of Public Policies for Women's Health Care, which initially focused on the country's capital, but was expanded to other provinces as of the year 2000.Despite these efforts, mortality rates maternal and child health are among the highest in the world, with rates up to 15 times higher than developed countries (7)(8) .
As a strategy to reduce maternal and infant mortality rates, the Angolan Ministry of Health has launched the National Health Development Plan for the period 2012-2025.This Plan includes subprograms for the well-being of women, focusing on the revitalization of the municipalization of health services with a focus on reducing maternal and neonatal mortality, reproductive health product safety, sexual and reproductive health strategy in accordance with the strategic plan Reproductive Health for the WHO African Region (9) .
Considering the development of these programs and strategies, it is necessary to carry out research on the management of prenatal care in a Care Center in Angola, aiming at the discussion of strategies that may contribute to the quality of health care for pregnant women in this case.The scientific production on prenatal nursing care in the African context is scarce.For example, from a search in Gopubmed®, a free database available on the web that refers to the PubMed-Medline database, with the words Prenatal Care and Nursing, 4,742 documents were identified on August 5, 2017, 50 1.05%)originating in African countries, without any publication from Angola.Thus, we highlight the novelty and importance of a research on prenatal care management in Angola.Thus, the guiding question of this study was: How does the management of nursing care in prenatal care in a Care Center in Angola happen, and what relationships and interactions are established in this process?

OBJECTIVE
This study aims to understand how nursing care management happens, and the relationships and interactions established in prenatal care in a Care Center in Angola.

Ethical aspects
The ethical aspects of the study were fulfilled according to the recommendations of the Ministry of Health of Angola and the project was approved by the Direção Provincial da Saúde do Huambo (Provincial Directorate of Health of Huambo).All participants signed the Informed Consent Term.The interviews were identified with codes composed by the letter P of "professional" (sample group 1), PW of "pregnant woman" (sample group 2) and S of "student" (sample group 3).In all three cases, the letters were associated with Arabic numerals, according to the order of interviews.

Theoretical-methodological framework
The constructivist perspective of Grounded Theory (GT) (10) was the theoretical-methodological framework of this study, which allows, from the constant comparative analysis of the data, the understanding of a certain problematic and the process of interaction of the participants in a given context.From this, an explanatory model about the studied phenomenon is elaborated (10) .The method is useful, especially when the production of knowledge about the investigated object is scarce (10) , as is the case of the problem on screen.
Among the methodological currents of GT, the constructivist side maintains the rigor of the method, but it allows greater flexibility in the explanation of the studied processes.This is possible because this strand is based on the co-construction and reconstruction of data towards the theory from the reflective interpretation of the researcher, without the use of the paradigmatic model or coding paradigm advocated by the Straussian current (10) .

Type of study
It is a qualitative research that had as theoretical-methodological framework the constructivist perspective of Grounded Theory (GT) (10) .

Study setting
The study setting was a Health Center Maternal and Child in Huambo province, in the Center-South region of Angola.The Center provides services in the areas of Prenatal, Child Care, Gynecology, Obstetrics, Pediatrics, Adolescent Health, Clinical Medicine, Small Surgery, Family Planning, Pharmacy and Vaccination.It also has 38 beds for hospitalization.In the tangent to the number of queries, approximately 800 queries per month are performed.The Health Center has 96 employees, three nurses, 55 nursing technicians, seven nursing assistants, two doctors, two specialized

Data source
The theoretical sampling of the research was composed by 22 participants, divided into three sample groups.The number of participants was defined based on the theoretical saturation of the data, that is, the evidence of the repetition of information brought by the interviewees about the phenomenon studied and the absence of new elements relevant to the data analysis (10) .
Sample group 1 was composed of four nursing professionals, one nurse and three mid-level technicians, with a prenatal time of three to 26 years.The criterion of inclusion was to be a nurse or nursing technician in the sector, at least a year ago.For this group, the objective was to know the care management practices and the professional interactions established with pregnant women.
From the data collection with the sample group 1, there was a need to explore the view of pregnant women about the management of prenatal care and their interactions with professionals.Thus, sample 2 was composed of 12 pregnant women who met the criterion of inclusion of pre-natal consultations at the Center during the period of data collection.The pregnant women interviewed were between 16 and 42 years old.As to the number of pregnancies, six were secondarily pregnant, three were primigravidae, and three were multigestive.
As both professionals and pregnant women highlighted the participation of nursing students in prenatal care, sample 3 was formed by six nursing students, interns in the prenatal area, three of them in higher education and three in high school.The objective of this group was to understand the participation and contribution of nursing students in the management of prenatal care.The criterion of inclusion was to have completed the discipline of women's health until the time of data collection.

Collection and organization of data
Data collection was performed between February and May 2016, through semi-structured interviews, which were audio recorded and transcribed in full.The interviews followed a script for each sample group, considering the profile of the participants and the purpose of their inclusion in the research.In general, the questions were about the practices of care management, the organization of the service for prenatal care, the stages of conducting the nursing consultation and the interaction between professionals, students and pregnant women.The interviews were conducted by the first author of this article in the Health Center itself in a reserved place or at the participant's home, according to their availability and by scheduling the schedule.An electronic audio device was used to record interviews that had an average duration of 15 minutes.

Data analysis
Data analysis took place through an initial phase coding each data segment, incident per incident, followed by a focused phase that uses more significant or frequent initial codes to integrate, synthesize and organize the data into subcategories and categories (10) .The process of data organization and categorization was performed in NVIVO® software, version 10.
Five categories were obtained: (1) Embracing the pregnant woman for prenatal care; (2) Performing the prenatal consultation; (3) Creating a relationship and dialogue with pregnant women; (4) Establishing collaborative working relationships; and (5) Inserting the pregnant woman's family into prenatal care.Based on the articulation between these categories, the phenomenon was developed or the central category entitled: "Managing prenatal care through collaborative work relationships aimed at creating a bond and dialogic relationship with pregnant women".

RESULTS
It is described below the categories that explain how the management of nursing care and the relationships, and interactions of professionals and pregnant women in prenatal care.At the end of the results, the diagram of the articulation between the categories and the phenomenon of the study.

Embracing the pregnant woman for prenatal care
The first category presents the context of prenatal care and the activities that precede the consultation with the pregnant women.Prenatal care begins at 8 o'clock and the pregnant women start arriving at the unit at 5 o'clock in the morning.As the pregnant women arrive at the Health Center, they sit in the waiting room on a first-come, first-served basis and wait to be called to the doctor's office.Pregnant women who arrive when all the chairs have already been occupied, are waiting for the service to stand in a queue.Before the consultations, nursing professionals and students perform health education actions in the waiting room or on the balcony of the Health Center.These are lectures in which professionals emphasize the importance of prenatal consultations for the prevention of complications during pregnancy for both the pregnant woman and the concept.They also address aspects of hygiene and feeding that are important for pregnant women.This moment of the lectures is used by the professionals to establish an initial bond with the pregnant women.

Giving education to health, emphasizing the importance of prenatal consultations […] we held a talk before the consultations, because is better be safe than sorry. (P1)
Management of prenatal nursing care at a Health Center in Angola Simão AMS, Santos JLG, Erdmann AL, Mello ALSF, Backes MTS, Magalhães ALP.
[...] we emphasize the issue of hygiene and feeding of pregnant women.(P2)

[...] explaining the importance of prenatal consultations and their advantages, so we began to create the initial bonds with first-time pregnant women. (S5)
I also interact with them in the collective lectures before the beginning of the consultations, I always make a joke to entertain them.(P3) After the lectures, the nursing team collects the pregnancy cards (prenatal follow-up notebooks) and organizes them on a first-come, first-served basis, registering pregnant women who come for the first visit and separating pregnant women's cards from return visits.
We collect the return cards and enlist those women who are coming for the first time.Regarding the sequence of care, although the method adopted was the order of arrival, pregnant women who present health changes that require immediate intervention have priority service.This triage is based on the complaints of pregnant women and on the initial evaluation made by the nursing team.

We serve on a first-come, first-served basis. (P2)
We serve patients according to the order of arrival and by.(P4) When we arrive we do the screening, after detecting sick pregnant women prioritized them.(P3) Regarding the order of arrival method, the pregnant women commented that the care and access to the Health Center are better when they arrive earlier.

I think access in the first hours is easier. (PW5)
When you come earlier the service is in one way, when it comes later the service is in another.(PW4)

Performing the prenatal consultation
This category explains the steps that make up the prenatal consultation in the Health Center.Nursing professionals perform, on average, 40 prenatal consultations per day.The consultation begins with the displacement of subgroups of pregnant women from the waiting room to a room that is in front of the offices.In this place, the pregnant women wait until they are called by the name to enter the office.
We serve on average 40 pregnant women per day.(P1) […] after that balcony they call a number that fits here in this other place in front of the office […] after that group they call another group successively.(PW1)

Then call by name to enter the office. (PW8)
For prenatal consultations, the Health Center has two offices, one for first-time pregnant women and the other for return visits.Seven nursing professionals work in these two offices, four in first-time consultations and three in the return office.The prenatal consultation is organized so that each professional carries out a specific activity.In this way, a professional calls the pregnant women and makes the anthropometric measurements and, if necessary, records their personal data.Another professional carries out the physical examination of the pregnant woman (obstetric examination) and, finally, another professional prescribes and advises on the use of medicines for malaria prophylaxis, anemia and intestinal parasitosis, according to the national protocols adopted in the service.Throughout this process, professionals communicate constantly to facilitate the careflow and the continuity of prenatal consultation.The professional responsible for prescribing prophylactic drugs and finalizing the prenatal consultation is also responsible for encouraging the pregnant woman's self-care and emphasizing the importance of continuing prenatal consultations.
Every pregnant woman has to know that she must also take care of herself, which is why we talk about self-care in consultations [.

Creating a bond and dialogical relationship with pregnant women
In this category, the relationships established between nursing professionals and pregnant women are focused, which are marked by dialogue and bond creation.The pregnant women emphasized the receptive attitude of nurses and the importance of the guidelines they receive, showing satisfaction with the care Management of prenatal nursing care at a Health Center in Angola Simão AMS, Santos JLG, Erdmann AL, Mello ALSF, Backes MTS, Magalhães ALP.
received.The professionals show concern to serve the pregnant women, according to their particularities, seeking to talk and clarify their doubts during the consultations.

The interaction has been great, they cater well, I've done here three deliveries. (PW7)
With me there has always been good interaction with professionals.(PW3) The interaction with pregnant women has been good [...] usually when I notice that she has not expressed herself completely ask questions and sometimes I get a more productive interaction.(P2)

The interaction has been good because I really like to laugh; I really like to talk [...]. (P3)
In order to keep in touch with pregnant women, nurses must request their cell phone number or their family members and/or companions.Thus, they call the pregnant woman when she does not served one of the consultations and reinforce the importance of continuing prenatal care at the Health Center.
I exchange the telephone number with them so that in case of need they can call.(P1) [...] we exchange phone number to contact; we have a phone book in case the pregnant woman is not returning anymore.(P3)

Establishing collaborative working relationships
This category portrays the collaborative professional relationships established by the nursing team in prenatal care.The professionals seek to work as a team and also to establish personal ties through the sharing of everyday concerns.

Here our goal is to work, I came transferred to this Center two years ago and there was never a serious quarrel. (P4)
There is a collective aid agreement between the work team.According to this pact, when one of them finishes his activities earlier, he begins to assist the colleague who still has activities to be performed.In addition, when for some reason one of them misses work, another colleague assumes her activities.

We helped each other by cover the other office when we finished our part early, [...] if one colleague has an urgent concern, the others do the coverage on that day. (P2)
The division of the daily tasks of professionals varies according to the day.The criteria used to decide who will be responsible for each task is the professional's arrival time at the Health Center, that is, those who arrive first choose the sector that will act on that day.It is agreed that the person responsible for the measurement of vital signs also supervises the offices and accompanies the pregnant woman and/or her relatives to another section of the Health Center, if necessary.
[...] depends on who arrives first.Today, for example, I arrived first and I was performing the maneuvers of Leopold [...] The colleague who measures vital signs supervises the office, can go out to accompany the pregnant woman, or the companion in case of need, while the other two techniques are fixed in the office.(P2)

Inserting the pregnant woman's family into prenatal care
In this category, it is evident the professionals' practice of inserting the pregnant woman's family into prenatal care.The pregnant women usually serve the consultations accompanied by relatives, usually their husbands or their mothers.Whenever this happens, they are invited to follow the appointments and participate in prenatal care.In the care of adolescent pregnant women, the presence of the family is also valued by nursing professionals.The nurses talk to the mothers of these pregnant women in order to ensure that the family supports them, especially in the face of an early and unexpected gestation.This action has had positive results, as punctuated by some pregnant adolescents.
Among my relatives, only once I had the follow-up of my mother.She came with me on the first visit, and was welcomed by the nurses [...] there is no longer that tense atmosphere in the family just because of my pregnancy.(PW2)

[...] they talked to her to accept what is happening since I had an early pregnancy and she was very disappointed with me [...] I was very relieved after the nurses talked to my mother. (PW5)
From the articulation between the categories, the phenomenon of the study was obtained: "Managing prenatal care through collaborative work relationships aimed at creating a bond and dialogic relationship with pregnant women" as shown in Figure 1.The phenomenon of this study shows that the management of nursing care in the study setting occurs through complementary and interdependent steps between them.The process is based on the collaborative relationships of health professionals and the commitment to insert the family of the pregnant woman in prenatal care.

Management of prenatal nursing care at a Health Center in Angola
Simão AMS, Santos JLG, Erdmann AL, Mello ALSF, Backes MTS, Magalhães ALP. the importance of prenatal care.This finding is similar to the results of a survey carried out in Alagoas, where waiting rooms were used in the health unit for the embracement and presentation of lectures to pregnant women, while awaiting medical care and prenatal nursing (15) .Research carried out in Minas Gerais State also evidenced the realization of educational practices for pregnant women through lectures in which nurses emphasized the importance of prenatal care, focusing on the needs of pregnant women (16) .Similarly, a study developed in Mozambique emphasized the importance of health education in elucidating gestational myths and misconceptions (17) .
The prenatal consultations take place in a piecemeal fashion, that is, each professional is responsible for a stage of care.In addition, the influence of the biomedical model on the accomplishment of prenatal tests was emphasized, with emphasis on anthropometric data recording, obstetrical physical examination, on the request and/or evaluation of exams and prescription of medications.The influence of the biomedical model on prenatal care was also one of the research findings on prenatal care in Family Health Strategy units of a municipality in the south of Brazil (18) .Thus, the importance of developing strategies for a professional practice based on an expanded vision of the health-disease process, with the definition of careflows that foster interdisciplinarity, comprehensiveness and humanization as care management tools.
Regarding the prescription of medicines, the Angolan Ministry of Health authorizes prophylactic prescription by nursing, according to protocols.These findings converge with those of a study on the prescription of medicines by nurses in Brazil and Canada, where nursing professionals also prescribe drugs covered by specific laws, especially in Primary Health Care (19) .In addition, the emphasis on nursing practice in prescribing and counseling on the use of prophylactic drugs for malaria was also evidenced in a study in the Buikwe District in Uganda (20) .
Despite the piecemeal division of labor, the nursing team's concern with bonding and dialogical relationship with pregnant women during prenatal consultations was verified.This humanized posture of the professionals was recognized and valued by the pregnant women in the interviews.Similar findings were presented in a study on the perceptions of pregnant women about prenatal care in Paraná.The interpersonal relationship, the bond, the dialogue, the orientation and the embracement by the professionals were the most outstanding elements by the pregnant women (12) .A study on the perception of women with prenatal care at a Health Center in Nigeria also found that most were satisfied with the care and believed the host to be friendly and polite (21) .
Embracement, health education and humanized care enable a dialogical relationship between professionals and users, constituting as fundamental devices for a care management that seeks the quality and integrality of women's health care.Simple attitudes such as smiling and embracing raise more openness for patients to reliably report their health needs (13) .
Another positive aspect in the present study was the insertion of the pregnant woman's family into prenatal care, generally represented by the husband or the mother.This practice is in line with the Public Policies for Women's Health Care, which recognize the importance of the support of the women's social

DISCUSSION
The management of prenatal care at the Health Center where the study was developed focuses on prenatal consultations developed by nursing professionals.Prenatal consultations occur through the spontaneous demand of pregnant women, who are treated according to the order of arrival.Although professionals seek to identify and prioritize pregnant women who need priority care, there is no systematized host practice with risk classification.
The host with risk classification allows the recognition and prioritization of health care, distinguishing the users who demand immediate care in relation to the others.The nurse is the professional that stands out for the achievement of the risk classification in several places of the world, contributing to the improvement of the quality and the speed of care in the health services (11)(12) .In addition, the embracement of the woman and the companion are fundamental in creating a bond of trust with the professionals and health services (13)(14) .
Regarding the order of arrival service, it was verified that the pregnant women, due to this mode of access, serve the Health Center early to ensure care.Similar results were described in a study carried out in Paraná, in which pregnant women showed up at dawn at the health unit to guarantee care, since there were no previous consultations (12) .
The organization of service by queues in order of arrival and without risk assessment contributes to the disintegration of the various domains, favoring the fragmentation of work and disarticulation of the service network.The fragmented care makes it impossible to look holistically at the pregnant woman and constitutes a situation of vulnerability in the face of the intercurrences in which she may be exposed (14) .
Before prenatal consultations, pregnant women are received at the Health Center with lectures on care during pregnancy and Management of prenatal nursing care at a Health Center in Angola Simão AMS, Santos JLG, Erdmann AL, Mello ALSF, Backes MTS, Magalhães ALP.network and recommend to the professionals the embracement of the companion.The father (husband) is the companion who is most present and participates in the consultations.Mothers, mothers-in-law, friends and other relatives are present when the father cannot go to the consultations (22) .
In the tangent to the work organization for prenatal care, we identified the establishment of collaborative relationships among nursing professionals.Teamwork through mutual help among all members of the nursing team, coupled with good interpersonal relationships, are important for creating a healthy working environment and for the proper functioning of health services (23) .

Study limitations
One limitation of the study concerns the participation of only nursing professionals in data collection, generating a uniprofessional view.Thus, future studies including the vision of other professionals may contribute to the construction of interdisciplinary prenatal care management strategies, which was not the focus of the present research.It is also possible to consider that the scarcity of specific studies on the subject in the studied reality restricted the possibility of discussing the findings in the light of previous investigations in the same setting.

Contributions to the sector of Nursing, Health or Public Policy
The results presented may provide subsidies for improving the quality of prenatal care, contributing to the improvement of the practice of nursing professionals and reducing maternal and neonatal mortality rates in the setting investigated.The research results also contribute to give visibility to nursing work in the management of prenatal care in a Care Center in Angola.

CONCLUSION
The management of nursing care in prenatal care in the context of the study focuses on conducting lectures and prenatal consultations for pregnant women.Through these actions, nursing professionals and students emphasize the obstetric and neonatal benefits of prenatal care.Although the logic of access by order of arrival persists, it was observed the commitment of professionals in the construction of a relationship based on dialogue and trust with pregnant women, aiming at the continuity and integrality of care.Therefore, it is concluded that the management of nursing care is effective through collaborative working relationships centered on pre-natal lectures and consultations, aiming to build a relationship and dialogical relationship with pregnant women and their families.
Today I came downtown at 5 o'clock.(PW5) Pregnant women start arriving at 5 o'clock or 5:30 a.m. in the morning [...].(P3) I also know that first there is the waiting room [...], then going to the office.(PW3) Whoever arrives first sits in the first chair, the second sits on the second, and so on.(PW12) Whenever I come here I comply with the queue, according to the order of arrival […].(PW9) (P1) After the lecture we collect the cards […].(P4) [...] then the nurses come to receive the cards.And they will call by arrangement the order of arrival.(PW10) We share tasks [...] I work with two colleagues and sometimes with the trainees [...].We work with protocol that comes from the Health Department.(P3) [...] we distribute the tasks to each colleague to facilitate the careflow: one make the measurements and record, another evaluates the physical state of the pregnant woman and the maneuvers of Leopold and the last one passes the recipes and makes the recommendations.(P4) [...] the protocol must be obeyed as I see here in the Center.(S4) Here in this office of returns we are three nursing professionals and we distribute the procedures.(P2) [...] I passed to another nurse who gave me the prescription for pregnancy supplements, iron, folic acid and Fansidar® to prevent malaria.(PW9) ..]. (P1) [...] at the end of the consultation I speak to the pregnant woman and the husband, if she is present, about self-care at home [...].(P3) In most cases, they are accompanied by the husband and sometimes by the mother [...]if the companion wishes to watch the consultation I accept [...].(P2) [...] my cousin had accompanied me, but she was outside.(PW6) [...] those [pregnant women] who come with the husband or other companion I allow, if they wish to enter with the person and can watch the consultation and participate in the dialogue.(P3)

Figure 1 -
Figure 1 -Articulation between the categories of the study

Management of prenatal nursing care at a Health Center in Angola Simão
AMS, Santos JLG, Erdmann AL, Mello ALSF, Backes MTS, Magalhães ALP.midwives, two pharmacy technicians, eight laboratory technicians, and other administrative staff and hospital support staff.