The effects, beliefs and practices of puerperal women's self-care

Abstracts

Objetivou-se neste estudo exploratório-descritivo conhecer as crenças, influências e práticas que permeiam o autocuidado das mulheres no puerpério. Foram informantes quinze puérperas de Rio Grande-RS. Colheram-se os dados em setembro e outubro de 2010, com entrevistas semiestruturadas, realizadas entre quinze e trinta dias pós-parto. Adotou-se a análise temática para o tratamento dos dados. Fundamentadas no cuidado/autocuidado durante o puerpério, o qual provinha da orientação familiar realizada em âmbito doméstico, delinearam-se duas categorias: uma referente a restrições, aquilo que devia ser evitado por gerar malefícios; outra envolvendo incentivos, ou seja, práticas que traziam benefícios à puérpera ou ao recém-nascido. Este estudo mostra a importância dos profissionais terem consciência a respeito da quarentena, pois é uma herança cultural que ainda perdura nos dias atuais. Concluiu-se que o saber popular é muito valorizado por essas mulheres e, embora careça de embasamento científico, não se mostrou como desencadeador de problemas ao binômio mãe-bebê.

Período pós-parto; Autocuidado; Fatores culturais; Enfermagem materno-infantil; Educação em saúde

ORIGINAL ARTICLE

The effects, beliefs and practices of puerperal women's self-care

Influencias, creencias y prácticas en el autocuidado de las puérperas

Daniele Ferreira Acosta^I; Vera Lucia de Oliveira Gomes^II; Nalú Pereira da Costa Kerber^III; Cesar Francisco Silva da Costa^IV

^IRN. Master's student, Graduate Program, School of Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IIRN. Ph.D. in Nursing. Full Professor, School of Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IIIRN. Ph.D. in Nursing. Full Professor, School of Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IVRN. M.Sc. in Nursing. Assistant Professor, School of Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^{Correspondence}

ABSTRACT

The objective of this exploratory-descriptive study was to identify the beliefs, effects and practices that permeate women's self-care during puerperium. The participants were fifteen puerperal women from Rio Grande/RS. Data collection was performed in September and October of 2010 using semi-structured interviews, performed between fifteen and thirty days postpartum. Thematic analysis was used. Two categories emerged regarding self-care during puerperium, which was performed based on the family guidance received at home. One referred to restrictions, or activities that should be avoided to prevent harm; the other involved encouragement, i.e., practices that promoted benefits to the puerperal woman or newborn. This study shows the importance of professionals being aware of the quarantine period, as it is a cultural heritage that remains in effect today. In conclusion, common knowledge is highly valued by these women, and despite the need for scientific evidence supporting such knowledge it was not a trigger for problems in either the mothers or infants in this study.

Descriptors: Postpartum period; Self care; Cultural factors; Maternal-child nursing; Health education

RESUMEN

Se objetivó en este estudio exploratorio-descriptivo conocer las creencias, influencias y prácticas que afectan el autocuidado de mujeres en el puerperio. Fueron entrevistadas 15 puérperas en Rio Grande-RS. Datos fueran recolectados en setiembre y octubre 2010, mediante entrevistas semiestructuradas efectuadas entre quince y treinta días postparto. Hemos adoptado un análisis temático para el tratamiento de datos. Se delinearon dos categorías fundamentadas en la orientación familiar sobre cuidado/autocuidado puerperal. Una, referente a restricciones, aquello que debía evitarse por generar eventos no beneficiosos; otra, involucrando incentivos, prácticas positivas para la puérpera o el recién nacido. El estudio muestra la importancia de que los profesionales tengan conciencia respecto de la cuarentena, herencia cultural que perdura en la actualidad. Se concluye en que el saber popular es altamente valorizado por esas mujeres y, aunque no responda a bases científicas, no se muestra como desencadenante de problemas para el binomio madre-bebé.

Descriptores: Periodo de posparto; Autocuidado; Factores culturales; Enfermería maternoinfantil; Educación en salud

INTRODUCTION

This study focuses on the puerperium, considering the particularity of popular practices in women's self-care. The puerperium is that period of the pregnancy-puerperal cycle when the local and systemic modifications in women's organism as a result of pregnancy and birth return to the pre-pregnancy condition⁽¹⁾. During this period, it is common for women to feel emotionally vulnerable, in view of the insecurity, anxiety and doubts that permeate childcare, the family readjustments needed and self-care.

Popularly known as quarantine or protection period, during the puerperium, the care received and self-care involve influences, beliefs and practices transmitted from generation to generation. These influences originate in the reports on successful and unsuccessful postpartum experiences of women in the family. These stories and experiences often arouse that much confidence that they end up being perceived as absolute truths and, thus, are followed without any questioning.

In common sense, the protection period gains an important meaning for women, who respect the culturally learned standards and rules, aimed at avoiding any relapse due to complications resulting from inappropriate self-care⁽²⁾. This action refers to the care human beings take of themselves, through practices that are considered favorable to preserve their health.

Numerous sources can influence women's preparation for adequate self-care during this period, including the health team, the media and advice coming from mothers, grandmothers and non-professional friends. Nevertheless, lack of orientation on the need for puerperal consultations upon discharge from hospital⁽³⁾ and professionals' lack of knowledge on the practices used in the home context⁽⁴⁾ can contribute to women's adoption of unhealthy conducts.

It should be reminded that it is in the domestic sphere that knowledge, decisions and practices operate which are sometimes conflicting with maternal health care needs. Therefore, it is fundamental for health professionals to get to know popular practices, encouraging health promotion practices and problematizing harmful conducts that put the wellbeing of mother and child at risk.

Studies reveal that puerperal women's main doubts relate to diet, bodily hygiene, physical exercise and sexual intercourse^(2,5-7). The belief in hypogalactia makes them emphasize foods that are considered lactogenic, including canjica, milk and rice pudding⁽⁵⁾. Daily baths continue according to each woman's customs, but washing the head is prohibited during the protection period. Surrounded by meaning, the worst consequence of this practice is presented as death⁽⁶⁾.

Consequently, some women also believe it is fundamental to rest, whether through care like not sweeping the floor and not carrying any weight for example⁽²⁾, or by staying at home during the quarantine. Feelings and concerns related to sexual intercourse, then, are mainly related to fear of pain, belief in the need to respect the quarantine, the partner's desires and childcare⁽⁷⁾. Therefore, each puerperal woman should be approached holistically, considering not only the biological body, but extending care beyond the woman's physical assessment, sharing with her what the birth of a child represents and also attempting to understand what she thinks about the changes in her body and how she performs her self-care.

Therefore, professional assistance needs to be based on comprehensive care, departing from each puerperal woman's sociocultural context, understanding popular knowledge and contextualizing self-care beliefs and practices. It is known that changes have taken place in family structures and customs every day, but some traditions related to the protection period still continue, so that health professionals need preparation, efforts and additional knowledge with a view to the passage of the puerperal period.

As nurses who are committed to women's health and in the attempt to improve actions and interventions for puerperal women, we considered it is important to understand how popular knowledge is being used in these women's self-care, with a view to problematizing these conducts and alerting nursing professionals as to the need for further attention to home care in that period. Thus, this study was guided by the following question: What beliefs, influences and practices permeate puerperal women's self-care? The aim is to get to know the beliefs, influences and practices permeating puerperal women's self-care.

Scientific knowledge should reach women through clear orientations and an accessible vocabulary, with a view to reinforcing health education; the imposition of conducts should be avoided, making room for negotiation and knowledge sharing.

METHOD

An exploratory and descriptive study with a qualitative approach was carried out, which permits understanding phenomena, meanings and personal values⁽⁸⁾. The study was developed at the maternity of the Hospital Universitário in Rio Grande/RS, Brazil.

The research subjects were 15 women aged 18 years or older, between two and four weeks postpartum, attended in the Brazilian public health system SUS and living in the urban area of the city. This time period was chosen in view of two possibilities. First, we believed that puerperal women would be willing to perform actions to preserve their health, i.e. self-care. Also, we supposed that, during this period, these women had already received visits from relatives, friends and neighbors who, in turn, share experiences, help with care for mother and child and influence these women to adopt self-care practices. Anonymity was preserved, using the woman's initials to identify the discourse, followed by her age.

The puerperal women were contacted at the maternity, when they received information about the study aims and were invited to participate in the research. Women who accepted to sign the informed consent term were asked for a telephone number to schedule the interview, to be held at home, or to thank them for their interest in case of data saturation. After each interview, significant data were registered in a field diary.

The data were collected in September and October 2010 through an interview, guided by a script that was elaborated to characterize the informants and get to know the influences, beliefs and self-care practices during the puerperium. The interview was fully recorded with the informants' authorization for the sake of easier analysis. The number of interviews was defined according to the data saturation criterion.

Thematic content analysis⁽⁸⁾ was used to treat the testimonies, which were interpreted in the light of scientific literature on the theme. The project received approval from the Research Ethics Committee at Universidade Federal do Rio Grande under opinion 101/2010.

RESULTS

All interviews took place between the 15^th and 30^th day postpartum. The presentation of the results was divided in two: first, the informants were characterized and, then, analytic categories were outlined based on the criteria of relevance and repetition of units of meaning.

According to the care and self-care actions accomplished during the puerperium, two opposed categories emerged, one related to restriction, that is, to what should be avoided because it causes some harm, and the other to incentives, that is, to practices that benefitted the puerperal woman or infant. It should be highlighted that most of these actions derive from orientations family members provide in the attempt to help the puerperal women to get through the puerperium healthily. In the family context, these orientations are called advice.

Characteristics of the informants

Study participants were 15 women between 19 and 38 years of age, mostly married and with two to four children. Eleven lived in neighborhoods covered by the Family Health Strategy (FHS). As for education, more than half had finished primary education, four secondary and three higher education. Ten interviewees were housewives, four were on a maternity leave and one was self-employed. Most of the infants' fathers had a paid job.

Concerning obstetric antecedents, one puerperal woman did not participate in prenatal care (PN), three did so in the FHS and the remainder in hospitals in the city or through health insurances. What the delivery type is concerned, eight were caesarean sections and seven normal births, three of which involved episiotomy.

Restrictions: ...better be safe than sorry.

The practices adopted during this period referred to bodily hygiene; sexual abstinence; rest and temperature variations, avoiding exposure to cold or heat.

Restrictions associated to bodily hygiene

The only restriction in terms of bodily hygiene was related to not washing one's hair. Among the puerperal women who did so, the interval ranged between seven and 20 days. Their argument was the risk of a mental problem. According to them, breaking a cultural standard can be dangerous, so accepting it is better than taking risks.

I didn't wash my hair for a week... Because they say we get crazy... Ah! People say so, my own mother used to say that, when we wash our hair we can get crazy (C, 30y).

...they told me: - do not wash your hair before 40 days. My neighbor who wants to be his godmother. - She: don't wash it. The mother too: - don't wash your hair (M, 28y).

To keep up the tradition, frightening reports by experienced women in the family exemplified the danger of this action. Interference by one puerperal woman's mother-in-law during the interview underlined the danger of this action, describing cases in which disrespect of the quarantine caused a relapse.

... there's an aunt of mine who's in bad conditions because of it. No harm?... No harm my eye... There are people who say it doesn't do harm. No, no it doesn't... and Lúcia is crazy until today. Hell that it doesn't­ (A's mother-in-law, 23y)

Alternatives were used to keep the scalp clean. Relatives improvised the cleaning of the hair, taking care not to wet the puerperal woman's hair too much due to vulnerability to diseases.

I didn't wash my hair for 20 days, but my mother used to pass alcohol .. With water... More alcohol than water, you see? Without wetting it too much. Because they used to say I could get crazy, that stuff of old people, and as I'm really a coward for that stuff, I did it correctly (R, 26y).

The influence of family and acquaintances makes them modify habits related to self-care. Through advice, case reports and even cultural impositions, standards are followed, whether because they believe in these practices or are afraid of violating them.

Restrictions associated with the type of delivery

Women submitted to caesarean section believed that, because they had been submitted to this type of surgical procedure, they needed to take some care, including the avoidance of environmental temperature variations.

...I used to walk barefoot all the time and now I can't anymore. I don't know... lots of things, also because I had a c-section and it's dangerous to catch a cold, humidity, those kinds of things... (C, 27y).

As opposed to the cold, during the protection period, the belief exists that exposure to heat also has a negative effect on the surgical wound (SW). Therefore, they avoided making food, to that the hot temperature would not reach the incision or prevent the stitches from healing.

Ah! I just wasn't cooking, staying close to the stove, make very strong movements... They say it's bad for the stitches (G, 26y).

... and you can't have any heat touching the side there! Like, at the side of the cut, the heat of the stove, which is at our height. And the fridge... They say that cold and heat are bad (M, 28y).

This type of care women subject to caesarean sections mention was also present in women after normal birth.

Ah no! I didn't make food, didn't stay close to the stove, didn't strain myself... Ah! I can't tell you why, but... It's like a c-section, everybody says, when you get home, don't go and stay by the stove. I don't know why! (R, 26y).

Hence, the belief that cold and heat represent threats to their health made the puerperal women protect themselves during the protection period. Other housework was also avoided as a form of protection.

...that's why they say that! About the effort! Everything's open there! How on earth are you going to..., to lift something heavy..., you'll fade in blood. That's why they say that we need this whole protection (M, 28y).

... if I'm going to sweep the floor, take the shovel to kneel down and join the garbage, she [mother] doesn't let me: - Ah no! Don't kneel down! Don't get down because of the stitches (K, 29y).

As for sexual intercourse, 14 out of 15 women interviewed chose abstinence, ranging between 15 and 30 days. Among the main reasons, the following stand out: await the end of the quarantine, the time spent on care for the infant and the need for the body to return to the pre-pregnancy condition.

Well, it's because everyone says that, during the quarantine, you can't have sex so I follow what the others say (R, 23y).

...first because we really don't want to... but, the thing is, there's no time [laughs] You wake up to breastfeed and, when you can, you sleep too! So we are trying to get organized (A, 38y).

...I had ten fingers of dilation! And, you see, I didn't get any stitches. Do you think she [vagina] will get back to normal already after fifteen, twenty days? She will get, like who looks says it's normal, but the bones really, to close down inside... and things like that... it will take a long time, so that's why I get like... You get crazy (M, 28y).

Dietary restrictions

Cultural aspects during the puerperium also interfered in food intake. In this respect, maternal self-care was indirectly aimed at the infant's wellbeing, in that the restriction to consume certain foods was aimed at preventing colic.

Ah! like orange which is acid I don't eat. Some vegetables, greens, 'cause it causes colic! I avoid eating them. Better be safe than sorry... So everyone says cabbage causes colic, that a lot of acid causes colic, so we don't eat is so as not to... Many people say it, my mother does so, my sisters, neighbors...(G, 26y).

Not eating a lot of green stuff, a lot of beans 'cause it causes colic in the infant, nothing cold... They say it also causes colic... My sister-in-law and mother say so. They say not to drink alcoholic beverage because of the breastfeeding, not to drink mate and not to eat anything green (L, 19y).

Incentives: ...some things I was advised

This category basically focused on aspects of maternal self-care that could benefit the infant, including dietary care to facilitate the establishment and maintenance of breastfeeding and care to maintain or recover breast integrity.

Dietary needs

Many women used to believe that the diet interfered in breastfeeding, so that some foods were consumed in abundance because of their presumed stimulating effect on milk production.

.... I even took some things I was advised, such as cotton root bark tincture... (R, 36y).

... They advise us to eat a lot of oatmeal, milk with oatmeal, a lot of liquid, tea (V, 26y).

Using drugs to increase the milk production was also mentioned in this study. One puerperal woman used metoclopramide.

Breast integrity

The practices described in this subcategory were used to cure cracks and breast engorgement.

...put banana skin on your breast because it was very swollen, now it's really good...(K, 29y).

...my breasts started to crack, bleed and a friend told me to put on papaya to heal... It healed, she's feeding well (K, 17y).

Ai, my mom said it's good to put on fruit skin, papaya, banana, melon (C, 30y).

During this period, most self-care actions are motivated by the influence of people who are close and aim for the recovery of mother and child.

DISCUSSION

Many women consider the puerperium a difficult period, as it demands women's new adaptation to the baby as well as to the changes in their body. In addition, they believe that different self-care actions are needed during this period to protect and maintain their health.

This care is justified as, popularly, during this period, women are at the margin between health and illness⁽⁹⁾. Hence, the self-care practices considered necessary to avoid complications were the same among women submitted to caesarean section or normal birth, evidencing the belief in cultural constructions.

The restrictions these women usually obey include not washing their hair. Not all women followed this ritual, but those who did not wash their head during some days did so out of fear of triggering madness, caused by the inversion of the blood flow⁽¹⁰⁾, besides the risk of death⁽⁵⁾.

Some women took the risk of reducing the indicated time interval or adopted strategies to keep their scalp clean. They believe that it is better to follow tradition, although somewhat modified, than to deny it and suffer some consequence. In addition, family members' testimonies reinforce the negative aspects, legitimizing this belief through examples.

The influence of lay people in self-care gains an unquestionable dimension in the experience of older women, mothers or grandmothers. The puerperal women's attitude also demonstrates this, when they turn to midwifes even before visiting a health institution⁽¹¹⁾.

Another practice that is loaded with meanings is their exposure to environmental temperature. The functioning of the human organism depends on the balance between hot/cold, and external influences like diet and environmental temperature can interfere in this process⁽¹²⁾. Thus, with a view to good surgical wound healing, the women believe they should abstain from these variations by avoiding getting wet, walking barefoot, being exposed to humidity. As the puerperium is considered a cold period that makes women vulnerable, dressing warmly, consuming warm food and avoiding colds are conducts to be stimulated, as the warm and cold disease theory defends⁽⁹⁾.

Perceptions of the body as open and vulnerable to currents of air are still common among puerperal women and their relatives in the 21^st century. Reports exist that the cultural traditions of quarantine are aimed at closing the body, which is the central goal of postpartum recovery⁽¹³⁾. Therefore, they adopt popular knowledge, as they are aware that people who indicated certain types of care were successful when adopting the same conduct. Rest is another fundamental practice during this period, which relatives encourage to facilitate a healthy recovery, helping with housework. The men present see puerperal women as fragile at this dangerous time and also prevent them from doing activities that demand physical effort⁽¹⁴⁾. According to popular knowledge, abstaining from these tasks helps to recover the uterus and avoids hemorrhages⁽¹¹⁾.

Respect for the quarantine even extends to sexual activities. Respecting this restriction puts their desires to the background but, according to the interviewed women's belief, it is fundamental. In that sense, far beyond simple pleasure, intimate contact is surrounded by feelings, exchange of affection, so that many partners understand women's need to maintain sexual abstinence⁽⁷⁾. On the other hand, some men do not understand this need⁽¹⁰⁾, either out of fear, lack of desire or simply to comply with a belief. Each woman should return to her sexual intimacy when she feels prepared though, and the partner's support is fundamental in this process.

What food is concerned, it is perceived that, today, the human diet has moved beyond the meaning of nutrition, that is, feelings and religious, economic, social and cultural practices direct people's attention to their diet. In that sense, myths and taboos could be identified with regard to certain foods, basically aiming to extend care to the baby.

The aim of dietary restrictions and incentives was to avoid colic in the infants and guarantee milk production, respectively. The intake of vegetables, beans and acid fruit is culturally contraindicated during the puerperium. In popular language, besides affecting the baby, these foods can cause inflammation of the stitches⁽¹⁰⁾. As for beans, cultural controversies exist, revealing both benefits and harm related to its consumption. On the one hand, one current says that it should be avoided, due to the possibility of causing problems for the baby, while the other encourages it based on its galactogenic effect⁽¹⁵⁾.

In this study, cotton root bark tincture and metoclopramide were used for the same reason. The former is associated with the increased production of milk cows when they consume cotton seed cake together with their fodder⁽¹⁶⁾. Metoclopramide, then, indicated in case of nausea and vomiting⁽¹⁷⁾, stimulates the production of prolactin, as a dopamine inhibitor, resulting in increased milk production⁽¹⁸⁾. Despite its proven lactogenic effect, collateral effects do exist, including increased serum prolactin levels in the infant and the probability of causing depression in women with a history of depression⁽¹⁸⁾.

Scientifically, no dietary restrictions exist for this period. A balanced diet is recommended, including sufficient quantities of carbohydrates, proteins, vitamins and fluids to attend to mothers and infants' needs.

As for the breast care practices the puerperal women adopt, popular beliefs and knowledge grant their followers the faith and conviction of positive health effects and the consequent solution of problems. According to the breastfeeding women, the use of melon, banana and papaya skin make the breast feel fresh and relieve the pain of breast cracks. Despite the healing effect, however, banana and papaya skins contain toxins that can harm both infant and mother⁽¹⁹⁾.

That is one of the reasons why health professionals need to take part in these women's relational context to get to know and discuss the true meaning of self-care practices, encouraging positive behaviors and problematizing conducts that are harmful to health.

CONCLUSION

The meanings and practices related to care for the maternal body during the protection period evidence that this period of life is ruled by the reinterpretation of biomedical language. It is in the domestic sphere, in relations with relatives and neighbors who are considered more experienced, that beliefs are learned and adopted in self-care, often prevailing over scientific knowledge.

In this study, the main influences, beliefs and practices the puerperal women experienced in their self-care were evidenced, concerning some restrictions related to personal hygiene, the delivery type and diet; as well as relatives and friends' advice regarding dietary care and breast integrity. Practices based on popular knowledge did not trigger problems for mother and child, showing that, in some cases, scientific knowledge and common sense can be associated without harming the mother or baby.

That does not exclude the need to problematize some of these practices though, like not washing one's hair for example, as puerperal women can be equipped to accomplish qualified and health-promoting self-care through a clarifying and reflexive dialogue. It is fundamental to alert professionals as to the need for greater attention to home care during the puerperium, considering that, at the same time as there are beneficial practices, others are harmful to health.

What cannot happen is these puerperal women's distancing from health services during this period, which is considered important in maternal care, because their beliefs are trivialized. When inappropriate, these practices need to be problematized and clarified, instead of simply imposing new conducts on these women.

This study shows the importance of professionals' awareness of the quarantine, which is a cultural heritage that continues until today. Despite other information means, including the media, internet and newspapers, the belief in popular knowledge still exists, which therefore needs to be present in professional work.

Knowledge on popular practices contributes to a health education process, which permits the encouragement of healthy and the discouragement of inadequate practices, without impositions, as well as negotiations on self-care conducts, addressing each woman's needs. Understanding this care dimension is a duty of all co-participants in this process.

REFERENCES

Received: 03/26/2012

Approved: 05/07/2012

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Correspondence addressed to:

Daniele Ferreira Costa

Rua General Osório, s/n - Centro

CEP 96201-900 - Rio Grande, RS, Brazil

Publication Dates

• Publication in this collection
  30 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  26 Mar 2012
• Accepted
  07 May 2012