PARENTHOOD OF PARENTS OF NEWBORNS HOSPITALIZED DUE TO CONGENITAL SYPHILIS IN THE LIGHT OF THE TRANSITION THEORY¹

ABSTRACT

Objective:

to understand the transition to parenthood of parents who had a newborn hospitalized due to congenital syphilis.

Method:

a qualitative study performed with thirteen mothers and four fathers of newborns hospitalized because of congenital syphilis, in rooming-in and the neonatal unit of a university hospital in Rio de Janeiro between September 2014 and May 2015 using the Life Narrative method and thematic analysis.

Results:

in the theme “the discovery of being a mother/father of a newborn child with congenital syphilis and the impact of the diagnosis in the parenting construction “ it was verified that the parents were aware that their child could be hospitalized for congenital syphilis, blaming the vertical transmission of syphilis and the fear of suffering stigma. In the theme “experience of transitions to parenthood due to the hospitalization of the child with congenital syphilis”, it was identified that parenthood was an experience considered good, happy and filled with resilience, however the child´s hospitalization triggered suffering and stress. Family support and nursing care were facilitating aspects of the transition to parenthood, which provided parents with new knowledge and the ability to reformulate their identities.

Conclusion:

nurses have an essential role in caring for parents who experience transitions to parenthood due to hospitalization of the child with congenital syphilis, they also have an essential role in strengthening the mother-father-newborn bond, empowering parents to provide parental care and prevent the reinfection of syphilis.

DESCRIPTORS:
Congenital syphilis; Hospitalization; Parenting; Nursing; Transitional care

RESUMO

Objetivo:

compreender a vivência de transições na parentalidade de pais que tiveram um filho recém-nascido hospitalizado por sífilis congênita.

Método:

estudo qualitativo realizado com treze mães e quatro pais de recém-nascidos hospitalizados por sífilis congênita, no alojamento conjunto e unidade neonatal de um hospital universitário do Rio de Janeiro, entre setembro de 2014 e maio de 2015, utilizando o método Narrativa de Vida e a análise temática.

Resultados:

no tema “descobrir-se mãe/pai de um filho recém-nascido com sífilis congênita e o impacto do diagnóstico na construção da parentalidade” verificou-se que os pais tinham a consciencialização de que o filho poderia ser hospitalizado por sífilis congênita, emergindo a culpa pela transmissão vertical da sífilis e o medo de sofrer estigmas. No tema “vivência de transições na parentalidade em face da hospitalização do filho com sífilis congênita”, identificou-se que a parentalidade foi uma experiência considerada boa, feliz e de superação, todavia a hospitalização do filho desencadeou sofrimento e estresse. O apoio dos familiares e os cuidados da enfermagem foram aspectos facilitadores da transição na parentalidade, que proporcionaram aos pais novos conhecimentos e reformulação de suas identidades.

Conclusão:

constatou-se que os enfermeiros têm um papel essencial no cuidar de pais que vivenciam transições na parentalidade devido à hospitalização do filho por sífilis congênita, fortalecendo o vínculo mãe-pai-recém-nascido, empoderando os pais para o cuidado parental e para prevenir a reinfecção da sífilis.

DESCRITORES:
Sífilis congênita; Hospitalização; Poder familiar; Enfermagem; Cuidado transicional

RESUMEN

Objetivo:

comprender la transición a la paternidad de padres que tuvieron un recién nacido hospitalizado por sífilis congénita.

Método:

estudio cualitativo realizado con trece madres y cuatro padres de recién nacidos hospitalizados por sífilis congénita, en el alojamiento conjunto y unidad neonatal de un hospital universitario en Río de Janeiro, entre septiembre de 2014 y mayo de 2015, utilizando el método Narrativa de Vida y el análisis temático.

Resultados:

en el tema “descubrir madre/padre de un hijo recién nacido con sífilis congénita y el impacto del diagnóstico en la construcción de la parentalidad” se verificó que los padres tenían la conciencia de que el hijo podría ser hospitalizado por sífilis congénita, emergiendo la culpa por la transmisión vertical de la sífilis y el miedo a sufrir estigmas. En el tema “vivencia de transiciones en la parentalidad frente a la hospitalización del hijo con sífilis congénita”, se identificó que la parentalidad fue una experiencia considerada buena, feliz y de superación, sin embargo la hospitalización del hijo desencadenó sufrimiento y estrés. El apoyo de los familiares y los cuidados de la enfermería fueron aspectos facilitadores de la transición en la parentalidad, que proporcionaron a los padres nuevos conocimientos y reformulación de sus identidades.

Conclusión:

los enfermeros tienen un papel esencial en el cuidado de los padres que experimentan la transición en la parentalidad debido a la hospitalización del hijo por sífilis congénita, fortaleciendo el vínculo madre-padre-recién nacido, empoderando a los padres para el cuidado parental y para prevenir la reinfección de la sífilis.

DESCRIPTORES:
Sífilis congénita; Hospitalización; Responsabilidad parental; Enfermería; Cuidado de transición

INTRODUCTION

Congenital syphilis results from the hematogenous dissemination of Treponema pallidum of the untreated pregnant woman or the inadequately treated fetus via the transplacental route. It is one of the major challenges for public health policies, with high prevalence and perinatal morbidity and mortality, despite being an infection that can be prevented during the gestational period.^1-3

There has been a progressive increase in the incidence rate of congenital syphilis in Brazil, in the last 10 years: from 2.0 cases/1,000 live births in 2006, to 6.8 cases/1,000 live births in 2016; with 10 states, reporting even higher rates (7.1 to 12.5 cases/1,000 live births), including Rio de Janeiro (11.8 cases/1,000 live births), far exceeding the Pan- American Health Organization and World Health Organization aim of 0.5 cases/1,000 live births.⁴

Among the actions to reduce the vertical transmission rates of syphilis, Rapid Testing (RT) has been implemented in prenatal care routines - an effective strategy for early diagnosis and treatment - and a health program called Pré-natal do Homem which is pre-natal care aimed at men to increase male acceptance and adherence to preventive care and, consequently, to reduce preventable diseases and related morbidity and mortality, such as congenital syphilis.^5-6 In addition, furthering technical knowledge, training, permanent education of health professionals and supervision in services is relevant to its control.⁷

The present study was taken from the Master’s Nursing thesis, entitled Vulnerability and parenting in the hospitalization of a child with congenital syphilis in light of the theory of transitions. The need to carry out research on this theme emerged from the finding of high incidences of newborns with congenital syphilis requiring intensive care, and the parents’ difficulty in performing parenting with the hospitalized child in the city of Natal, Rio Grande do Norte, Brazil.

Parenting is a complex process, not only a product of biological kinship, but becoming a parent, which begins before conception, is present through gestation and the post-partum period and continues throughout life. The term encompasses the formation of feelings, functions and behaviors in the fulfillment of maternality and paternality.⁸ It is one of the most challenging developmental transitions in the contemporary family and can be experienced in different ways by women and men.⁹

Therefore, it is of high importance to nursing care, given the need to provide knowledge and training to parents who experience the transition to parenthood in order to care for their children diagnosed with congenital syphilis.

Transition consists of moving from one stable state (place or condition) to another, and requires the person or people to incorporate knowledge, change behaviors and change their definition of the self. When triggered by critical events, such as the hospitalization of the newborn, the nurse’s attention, knowledge and experience is required, since it corresponds to a period of greater vulnerability for individuals who find it difficult to care as well as to provide self-care.¹⁰ At that critical moment, nursing interventions are needed for the promotion of family health.⁹

During data collection, 8 publications which were published until November 20^th, 2017 were found in the computerized databases of the Virtual Health Library, based on the subject descriptors, selected from Boolean operators (OR/AND) “Congenital Syphilis AND Transitional Care OR Family Power OR Parent-Child Relationships OR Family Relationships OR Mother-Child Relationships OR Mother-Child Relationships OR Father-Child Relationshiís. Among these, 90% emphasized the clinical and epidemiological aspects of the disease, particularly in relation to strategies for the elimination of the vertical transmission of syphilis.

It is extremely important to carry out qualitative studies that contemplate the aspects of the parenthood of mothers/fathers of children diagnosed with congenital syphilis, as well as the father´s participation, as the men are of fundamental importance in the reinfection process of the partner.¹¹

Using the guiding question “How did the mother/father with a newborn child hospitalized for congenital syphilis experience the transition to parenthood?” The present study aims to understand the experience of transitions to parenthood of parents who had a newborn child hospitalized due to congenital syphilis.

METHOD

This is a qualitative study, using the life narrative method, based on the methodological framework of the sociologist Daniel Bertaux, which is characterized by addressing issues related to the singularities of the interviewees and the socio-historical context to which they are inserted into through the free dissertation of the participants on a subjective experience in relation to what is being asked by the interviewer.¹²

The study was conducted from September 2014 to May 2015, in a rooming-in and neonatal unit of a University Hospital, located in the city of Rio de Janeiro, a pioneer in the treatment of Sexually Transmissible Infections (STIs) especially syphilis, since 1928. Its choice as a research field is justified because this hospital is a reference for the care of pregnant women and high-risk newborns.

The study participants consisted of thirteen mothers and four fathers. The inclusion criteria were: to be a mother or father of a newborn with congenital syphilis who was born alive, who were accompanying the hospitalization of their child in the rooming-in or neonatal unit. Parents who presented themselves as incapable of reasoning or giving consent were excluded from the study.

It is worth noting that nine parents did not meet the inclusion criteria, as they were not present at the data collection locations ,accompanying their child during hospitalization, for the following reasons: five mothers reported that their partners were working and could not attend the hospital; three reported no longer being in a relationship with the partner, one because of the diagnosis of gestational syphilis and two because of domestic violence; and one teenage mother reported that her companion only visited the child sporadically.

The participants were approached through the curricular component entitled Estágio de Docência of the Master´s Course in Nursing of the Universidade Federal do Estado do Rio de Janeiro (UNIRIO), when one of the authors supervised the nursing students of the same institution in practical activities related to care in the mid-term and immediate nursing care of newborns, which occurred in the scenarios of the present study. Participants were invited to participate in the study after establishing a connection with the nurse-researcher, who also conducted the interviews.

After signing the Informed Consent Term, and the Assent Term for minors with consent given by a legal guardian, the life narratives were recorded and obtained from an open interview with the following guiding question: Talk about what you consider important about your life, related to your experience as a mother and a father during the hospitalization of your child for congenital syphilis. The reports were transcribed by one of the researchers at a later stage. The number of participants was not previously established, they were included on demand until data saturation was achieved.¹²

The interviews lasted an average of 20 minutes and took place in a private location in order to guarantee the privacy of the participants. Their preferences regarding the date, time and place for the data collection were respected and they were guaranteed the right to decline from participating in the study. In order to ensure confidentiality and anonymity, the participants were identified with the letter “M”, which represents the mothers, and the letter “P” to identify the fathers. The interviewees were classified according to the number of the newborn (NB) hospitalized for congenital syphilis, and correlated according to the order of admission into the study.

Thematic analysis was the adopted analytical process. The transcripts of the interviews was initiated with the the analysis of the narratives and floating reading, in which the phrases containing relative information were written down and any relevant themes were noted. After the exhaustive reading, a title was elaborated for each relevant information, and the similar titles present in the other narratives were observed; 58 thematic units emerged from this data coding stage

The recoding stage was next which was performed through successive readings, seeking the possibility of discovering new themes and aiming to construct groupings of the units by thematic affinity. Six clusters emerged. The analysis category “the experience of transition to parenthood in relation to the hospitalization of the newborn due to congenital syphilis”, which consisted of two analytical subcategories: “the discovery of becoming a mother/father of a newborn child with congenital syphilis and the impact of the diagnosis in the construction of parenthood “and” experience of transitions to parenthood when faced with the hospitalization of the child with congenital syphilis.” Two subcategories which were analyzed in light of Meleis´s Transition Theory are discussed in this text.¹⁰

This theoretical framework addresses specific phenomena and concepts that reflect the practice¹⁰, allowing detailed knowledge of the transition process experienced by the participants and discuss which nursing interventions facilitate this process of achieving a healthy transition when faced with congenital syphilis.

In order to meet the requirements established by Resolution 466/2012 of the National Health Council - which deals with research standards involving human beings - the present study was approved by the Ethics and Research Committee of the Universidade Federal do Estado do Rio de Janeiro in September 2014, Opinion no. 804997, CAAE-34385514.0.0000.5285.

RESULTS

The study participants were between 16 and 33 years of age. The mean age was 25; about 60% had completed elementary school education. Approximately 82% of the interviewees had a family income less than or equal to three minimum wages (R$ 788.00, minimum wage at the time), 69.2% of the women did not work. As for the marital situation, 64% lived with their spouses, 58.8% of the participants had other children and 11.8% had had another child with congenital syphilis. Regarding treatment, 53% of the women had treated syphilis during pregnancy in order to prevent congenital syphilis, and one partner had received syphilis treatment.

It was possible to verify that the participants of this study experienced two critical events simultaneously: the birth of the child and the hospitalization of the newborn due to congenital syphilis. These critical points triggered two simultaneous transitions: the transition to parenthood and in parenthood, which were demonstrated in Figure 1.

Figure 1
Transition to/in parenthood. Rio de Janeiro, RJ, 2015

After the investigation and analysis process of the data collected, the following subcategories were presented:

The discovery of being a mother/father of a newborn child with congenital syphilis and the impact of diagnosis in the construction of parenthood

Most of the interviewees (13) were aware that the child could be hospitalized due to congenital syphilis, they felt sadness, fear, worry and fear that their child would be born with health problems due to congenital syphilis.

[...] I was afraid she would have something, like a crooked mouth, some problem with her legs... I was afraid that she could be born with some problem [...] (M2).

[...] with her in my belly I did everything with fear, when I came back and went to prenatal consultations I was terrified ... my fear was that she was going to be born with this problem, this disease, you know what I mean? [...] All these months, nine months, I couldn´t stop thinking: Oh, my God, is she going to be born? Did I take this injection, but is it working? I had this concern [...] (M7).

One of the participants rejected the child during pregnancy; however, when she was diagnosed with syphilis, she started to construct and develop parenthood. During the prenatal consultations, she began to accept and mother the child in her womb, worrying about the child´s well-being:

[...] I did not accept the child inside me ... I would not eat, because if I ate I thought I was feeding him inside my belly ... I beat my belly [...] But my belly was growing and I was feeling it, but what made me more emotional was when I discovered about the syphilis, that he was at risk and I felt a little guilty about putting my son’s life at risk [...] that was how I began to accept him, to care for him, to take care of myself during the pregnancy [...] (M9).

It can be affirmed that early diagnosis interfered positively in the process of parenthood, allowing the mother to perform self-care and the primary prevention of parenthood, which consists in trying to prevent the onset of congenital syphilis.

The confirmation of congenital syphilis was experienced in different ways by the participants: a) surprise at the lack of knowledge of congenital syphilis; b) fear and concern about the health and prognosis of the newborn; c) feelings of frustration at the failure of the syphilis treatment during pregnancy; d) adapting to the diagnosis of congenital syphilis in view of the possibility of a cure by treating the newborn, considering the negative result of congenital neurosyphilis; e) indignation at the diagnosis of congenital syphilis and hospitalization of the newborn; f) denial of congenital syphilis as the reason for hospitalization of the child.

Guilt regarding vertical transmission of syphilis also emerged during the narratives:

[...] I feel guilty that I did not have the prenatal care, I could have avoided it if I had done the exams. He wouldn´t need to go through this [...] (M10).

[...] knowing that it was syphilis that caused my daughter to be born prematurely was enough for me to learn [...] now she has to do the treatment, she will suffer because of me because I did not take care [...] if I had known before, I would not have let this happen, stubbornness and now there is no use regretting if I’m already wrong [...] (M5).

As it is a disease with an attached stigma, two mothers, in agreement with their partners, omitted to tell their family and friends about the child´s true diagnosis:

[...] it’s not easy because everybody asks why your child is taking antibiotics, I do not like to talk about it, I make up another reason [...] it’s annoying, because, even nowadays, people can be prejudiced about syphilis... people think that syphilis is a disease that you can catch not only through sexual relations, they think if they put her child beside you that she’ll get it too, you know? [...] (M12).

[...] even explaining that we treated it, we used a condom, they will not believe it, they will think that we have been irresponsible all the time ... we are trying to delay as much as possible because I am very ashamed [. ..] what happened was my fault, it was both of them, but the blame will fall more on me because I am a woman and I am a mother. I feel guilty, I try to hide from them, I am so shameful, and every day is a headache [...] (M13).

Experiences of transitions to parenthood when faced with the hospitalization of the child due to congenital syphilis

Becoming a mother and a father was an experience filled with happiness and resilience.

[...] When I’m with my daughter, it´s just happiness and attention, a lot of things, I do not know how to explain it [...] I really like this period of being a father again [...] (P2).

[...] the experience of being a mother is great, I’m finding that I’m doing well, I was afraid I wouldn´t be able to do anything [...] (M13).

Hospitalization was perceived as something positive, necessary for the well-being, and treatment and cure of the child with congenital syphilis:

[...] it is for the good of my daughter, it is for our good and not for the worst, the important thing is to be better to leave here well and stay well [...] (P2).

However, for the majority of the interviewees (12) the hospitalization of the child has caused suffering, stress, worry and anxiety. These feelings were related to the multiple injections needed to receive crystalline penicillin and blood samples for laboratory tests; to the risk of imminent death of the child; and waiting for the results of the laboratory and imaging tests that caused fear and stress.

[...] the experience that I have is that I do not like it because I see him suffer, getting needle stings, taking him all the time to receive medication [...] (M3).

[...] I feel terrified, afraid of the results of the examination [...] I already have the news about syphilis and HIV and there still may be other malformations, these things make me nervous [...] (M12).

The principal changes reported by the participants were: change in the routine and daily activities, absence of daily contact with family and caring for other children.

[...] I have other children, I have been away from home for ten days but it’s like ten months, I haven´t seen my other children, my life is at a standstill [...] (M11).

All mothers were worried about needing to stay in the hospital for ten days, but they realized that the hospitalization was necessary and, therefore, they connected their hospital discharge with the cure and well-being of the child.

The fathers demonstrated their desire and commitment by accompanying the child and his companion during hospitalization:

[...] I want to participate in all his examinations [...] to see how he’s doing, how he’s responding. I want to be with him like this when we go home too. I always want to be with him [...] (P6).

[...] I’ve been here since Wednesday, I just left here Sunday and Monday, I went home a little late to get some clothes and some things, and I came back to stay every day and I’m going to stay until he’s discharged, [...] (P13).

Regarding the support received from the family members, the participants expressed the complicity and mutual care between the couple. Two deponents reported receiving support from other family members: the maternal grandmother and maternal aunt of the child.

The narratives showed that the nursing care they received helped to feel connected and comfortable to interact with the rooming-in and neonatal unit team.

Informs, clarifies doubts and encourages doubts [...] they show everything they are doing. We do tests and want to know the result, if the treatment is developing, or if it is not, then they [health professionals] tell us. They let us go together to see how the child is [...] they are always willing to clear up our doubts, give us all the information we need [...] (M1).

Provides care, assistance and promotes safety [...] the nurses are very good, they treat us very well. At night, they take our blood pressure, check if we have a fever, if we are in pain, gives us medicine, asks us how we are, if our feet are swollen, if our bowels moved, they are always around [...] there is no chance that you could feel bad here ... we are cared for all night and all day, no one is left out here, we feel safe [...] (M7).

Provides emotional support [...] for sure you [as a nurse and researcher] were a psychologist for a moment, I needed to cry [...] (M7).

Shows love in their care for the newborns [...] the people who work in the nursery seems like they were made for that job. They have love for the child, they treat the children well, we can see it. It’s not even when they are in front of us, we see it all the time. Sometimes I go there and I see the nurses talking to the boys, it seems that they are their own children, it’s amazing! It´s a lot of love [...] (M7).

Regarding the crystalline penicillin treatment and the follow-up of the newborn with congenital syphilis, the participants of the present study showed to be settled in the routine of the institution.

However, two mothers had their experience and practice of parenthood affected due to the separation from their child for the purpose of the intensive treatments related to congenital syphilis. M5 was separated from her child due to its premature birth and was referred to the neonatal unit, whereas M10 was deprived of prolonged contact with the child, due to the difficulty of adapting the newborn to extrauterine life. Both were discharged from hospital, but they were waiting in the rooming-in accommodation for the clinical improvement of their children, and thus they accompanied them for as long as they thought necessary.

Although the narratives were obtained during the hospitalization of the newborn, it can be affirmed that experiencing syphilis in the gestational period, transmitting it vertically and consequently, the hospitalization of the child, caused the participants to reformulate their identities, in the terms of : personal growth; becoming more responsible and careful with themselves and their child; adopting a preventive approach regarding STIs and unplanned pregnancy; awareness of the importance of syphilis treatment; learning; serious consideration regarding syphilis and congenital syphilis; refrain from drug addiction for the benefit of her daughter; the desire to experience the functions of parenthood with the daughter.

DISCUSSION

By knowing the nature of transitions (types, patterns and properties), facilitators and inhibitors of transition (personal, community and society) and response patterns (process indicators and outcome indicators) it is necessary to promote competent care to individuals who experience transitions in their lives. Awareness is one of the transitional properties for parenthood and consists in the perception of a new condition, resulting from a change in the life of the individual, which causes them to activate mechanisms that enable them to experience the transition.¹⁰

Upon receiving the diagnosis of syphilis in pregnancy, women present fear, disappointment, embarrassment, sadness, feelings that are caused by the rudimentary knowledge about syphilis or lack of knowledge of the disease.¹³ Theses feeling emerged when faced with the health consequences that congenital syphilis can cause the newborn, such as malformations, physical and mental deficiency, despite the parents being aware about the vertical transmission of syphilis.

During the transition to parenthood, the moment in which the parent receives the diagnosis of a congenital disease may interfere with their parental role. If the diagnosis is made during gestation, experiencing the loss of the previously imagined baby could confer greater readiness to adapt to the new situation, and contact between the father, mother and baby in the first moments of life, favoring parenthood. However, early diagnosis may have a greater impact on the life of the parents because they did not experience parenthood in the presence of the baby.¹⁴

Faced with the diagnosis of a congenital disease, parents presented defense mechanisms, denial of the problem and of its severity. The fear, sadness, rebellion and guilt experienced due to the hospitalization of a child inhibited the transition of parenthood.¹⁵

The parents blame themselves for the child’s clinical condition, suffering, and the need for hospitalization. The mothers, who hold themselves responsible for the child, blame themselves for not having a normal gestation and a healthy birth.^13,16

It is emphasized that the mother´s choice to omit the child´s congenital syphilis diagnosis is developed as a strategy to avoid the moral judgment of society. Cultural prejudice related to STIs may interfere with treatment, and professional action is essential to demystify it.¹³

The stigma of contracting an STI began with the emergence of the HIV virus, which causes individuals to feel shame and rejection and it is possible for them to feel as though their social identity is tainted. It can be accidentally imposed by carelessness, lack of sensitivity or deliberately to punish behaviour considered harmful. Professionals who are ethically committed to upholding human dignity and equality, especially for vulnerable women, should protect, neutralize, and alleviate the stigmatization of users and health staff.¹⁷

Society is one of the determinants of the Transition Theory, which acts as an inhibitor or facilitator of the transition process.¹⁰ The stereotypes of society related to syphilis hindered the parenting transition and increased the fear of mothers and fathers which led them to experience prejudice and blame for having a child with congenital syphilis.

All transitions are responsible for changes in the lives of individuals, but as well as being permanent becoming a parent is a critical transition that causes instability. The arrival of a baby entails a modification in the psychological organization of the woman and the man, individually, and as a couple, resulting in a new organization: the addition of the third (when it is their first child); the change of the status of the parents, who pass from the position of children to parents; the projections of their infantile aspects about the child and the demands that the baby makes on the mother.¹⁸ The pregnancy period allows the parents to become familiar with the new position that awaits them.

However, the participants had a sudden and intense reorganization of their parental identities with the hospitalization of the child causing them to assign different meanings to this event. According to Meleis’s Transition Theory, the meanings attributed to events may facilitate or hinder transitions.¹⁰

Authors say that negative feelings are experienced more intensely at the beginning of the child’s hospitalization, when parents do not accept the situation, because it is a time of adjustment to parenthood. After this phase, positive meanings begin to emerge, together with the possibility of the survival of the newborn and recovery and stabilization of the child´s clinical status.¹⁹

Hospitalization provokes ambiguous emotions, with a predominance of negative feelings, because parents feel powerless and insecure to care for the sick child, who is inserted in an unknown environment and exposed to the observation of others, like other parents and health professionals. The hospitalization of the newborn interferes in the adaptation of the parenting and in the relationship and mother/father and son bond.¹⁵

The experience of the child´s hospitalization impacts emotions and in the daily life of the family. The daily life of the parents is marked by sudden changes, in addition to the changes that would already occur with the birth of a healthy child.¹⁹

Change is one of the properties of the transition process that leads to changes in ideas, perceptions, identities, relationships, and routines.¹⁰ The main changes experienced were changes in routine and daily activities, family disruption, and caring for other children. The latter is a difficult aspect of this transition.¹⁵

Mothers are the most affected by the hospitalization of the newborn, because they give up taking care of themselves to dedicate themselves to their children, and are inserted in an unknown environment away from the home. These factors culminate in a situation of physical and psychological exhaustion.¹⁹

However, the birth and hospitalization of a child is a family experience. The family is embedded in the constraints of the transition theory, as a facilitator or an inhibitor, and also in the process indicators, as part of the support network of the individual who experiencing the transition.¹⁰ In this case, this is an important resource for mothers and parents to fully develop their parenting roles.

The family is the primary source of support for mothers and fathers who are faced with the hospitalization of a newborn child. The husband/partner in the first place and the grandmothers are the family members who are most involved in supporting the mother and the hospitalized child and can be facilitators in the parenting transition. However, the family can also make motherhood difficult, when they are unable to deal with the new experience, and express themselves negatively.^15,19

When the family is exclusively composed of the couple, the father of the child may be the only or the main emotional and social reference of the woman. The father´s involvement can help with to bonding with the child and strengthening family ties. The presence of the father transmits more affection to the baby.²⁰ The effects of the hospitalization of the newborn for the fathers are complex, however the man usually attends to the woman at that moment.²¹

The practice of parenting a hospitalized child has an impact on both parents, with renegotiation of roles and affective connections between family members. The care of this child is sometimes centered on the mother, so the collaboration of the fathers in the care with the other children and in the household tasks is fundamental. It is also important to encourage the participation of the sibling (s) in the care of the hospitalized baby, by means of visits, in order to promote the family bond and a secure affective relationship.^9,15

The commitment and proactivity of the individual act as facilitators of the transition process.¹⁰ In this sense, the nurse, when considering the particularities of each family, can empower the parents to act as the primary caregivers of their children.²²

However, the fact that the parents accompany their hospitalized children and interrupt their work activities can lead to losses for the family. It is stressful for parents to manage the demands of employment, housework, other children, the wife and still get involved in the care of the hospitalized newborn. Paternity license or a job that allows parents to be present facilitates parenting.²¹ Support from the extended family is also essential for the parent’s stay in the hospital.¹⁵

Grandparents also participate in out-of-hospital activities, caring for the rest of the family and the children left at home, as well as caring for the newborn. Support from the grandparents is of fundamental importance during the hospitalization process of a child. Support may also be provided by friends and other mothers and fathers who are experiencing similar situations.¹⁹

The support of family members and health professionals allows the bond between parents and children and enables parents to care for their children after hospital discharge.¹⁵ The support received by professionals regarding the care of the baby is considered important for post-partum women, who emphasize that without the guidance of the health team would find it difficult to practice parenting.²⁰

In the hospital environment, health professionals are part of the support network of individuals. In turn, they are able to ease the parenting transition when the mothers and fathers of hospitalized children feel connected and interact with the care team.

“Feeling connected” and “interacting” are embedded in the individual’s response patterns as indicators of the transition process. Feeling connected to health professionals promotes a positive transition experience, as the care team can bring comfort by asking questions and answering the questions of those who experience the transition. The interaction between professionals and clients can also allow care or self-care to occur in an effective and harmonious way.¹⁰

Relationships of proximity and trust between the subjects are also present in the availability of professionals to meet the information needs of the health service users. It is important that the health professional encourages parents to verbalize their concerns, doubts and fears and, above all, to listen to them, in order to establish a relationship of trust and understanding, essential for the child´s treatment.¹⁹

The nursing team needs to communicate comprehensibly and implement health education actions to promote parental care. It is important to recognize parents who undergo a parenting transition due to the hospitalization of a child as vulnerable and provide safety, affectivity, humanized care and accurate information about the child’s health status and general routines, constantly seeking to open dialogue.^15,23

As for the care received, the parents developed a bond with the team and confidence in the therapy given to the children with congenital syphilis. The focus of neonatal nursing care must be on the creation of a supportive environment for the care of the baby, alleviating noxious stimuli, enabling development and reducing the negative consequences of the illness and hospitalization.²³

Nurses become role models for parents, who, by observing the care provided, learn to give care in the same way. It is worth emphasizing the nursing interventions that can facilitate the parenting process: welcoming the parents/baby/family trinomial; favor the acceptance of the hospitalized child; promote the bond in this trinomial; orientate, encourage and enable parents to care for their children.^15,21 With regards to the specificities of syphilis, information exchange, communication and continuing education are essential.⁷

Another aspect of great relevance is affective support, in which the parents of hospitalized newborns feel supported by nurses when they provide positive words, even if they are not intended to be informative.^16,19 Knowing what and how to talk about such adverse situations is of fundamental importance, since it can contribute to the establishment of a relationship of trust between client and professional.

Thus, care that goes beyond biological issues and includes social, emotional and psychological demands, involving the whole network of relationships of those who experience a parenting transition is needed. The nurse’s approach should be family-centered, in which mothers, fathers, siblings, and the extended family are considered as recipients of care.¹⁵

Locating and being situated is also an important factor for most transitional experiences. The understanding of a new life situation and the “situation” in terms of time, space and relationships allows individuals to understand their transition process.¹⁰ By understanding the treatment and the hospital environment, the parents are able to exercise parental care more confidently.

The development of trust and coping, which are indicators of the transition process, are manifested in the level of understanding of the different processes inherent in diagnosis, treatment, recovery and/or living with limitations; in the level of resource utilization; and in developing strategies for adapting to the new condition of life.¹⁰ By becoming an integral part of the team, parents have more confidence in the performance of parental care during their child’s hospitalization.

Another factor that interferes with parenting is the separation imposed by the need for intensive care of some newborns. Separation from the child is a difficult aspect of the parenthood transition.¹⁰ This interferes in the mother-baby bond, hampering the mothers’ confidence and coping in the care of their children.

Although the hospitalization of a child with congenital syphilis is a transitory event, it has caused changes in the perception of life and parenthood of the parents, as well as the acquisition of new knowledge about the disease and the child´s development.

The recognition of the individual’s response patterns to the transition process can be based on process indicators and outcome indicators. The latter are the mastery and the fluid integration of identity; i.e., the domain of new competences and the reformulation of identity. In all transitions, there is a subjective element to achieve a sense of balance in one’s life. Mastering new skills and behaviors which are needed to manage their new life situation, as well as a new identity, is reflected in the healthy outcome of the transition.¹⁰

Caregivers who care for hospitalized newborns and their families need to create strategies to optimize hospitalization time and resources to empower parents to care for their child. They must also be effective in the care given to these families.¹⁹

In Meleis’s Theory of Transitions, nurses are often the primary caregivers of clients and families who are in a transition phase. They see the changes and demands that transitions bring to the daily lives of clients/users and their families, and prepare them for imminent transitions.⁹ Thus, it is these professionals who can facilitate the process of learning new skills related to experiences, health and illness.

The limitations of the present study were related to the difficulty of interviewing the fathers due to their work commitments, as well as to the fact that this research mapped the transitional experiences in parenthood during hospitalization and not after the hospital discharge of the newborn; therefore, the transition outcome indicators are not fully established in the lives of the participants.

It was found that the hospitalization of the child allowed the parents to learn and acquire new knowledge and skills regarding illness and parenthood with the child, as well as more responsibility regarding the performance of self-care and parental care.

CONCLUSION

The life narratives revealed important aspects for the construction of parenthood from the diagnosis of syphilis in the prenatal, to the birth and to the hospitalization of the newborn by congenital syphilis. Hospitalization has been perceived as a complex situation, which can lead to a crisis, especially when parents feel they have failed in their parental role. As they feel incapable, they cannot perform parenthood functions or support the suffering of the newborn.

It is understood that nurses have an essential role in caring for mothers and fathers who experience two simultaneous transitions - such as the transition to parenthood and in parenthood - triggered by the critical events, birth and hospitalization of the child with congenital syphilis, since the mother-father-newborn bond is not fully constituted and requires the help of the health professionals to strengthen it.

Transitional care allows the parents to learn new skills and helps them to reformulate their identities, which are indicators of the outcome of a successful transition. This intervention enables them to perform self-care and care for their children, as well as empowering them to prevent syphilis reinfection and, consequently, to reduce the recurrence of congenital syphilis cases.

• 1
  Article extracted from the thesis - Vulnerability and parenting in the hospitalization of a child with congenital syphilis in light of the theory of transitions, presented to the Postgraduate Program in Nursing e (PPGENF), Universidade Federal do Estado do Rio de Janeiro (UNIRIO), in 2015. The article received financial support from the Research Support Foundation of State of Rio de Janeiro (FAPERJ).

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Publication Dates

• Publication in this collection
  31 Jan 2019
• Date of issue
  2018

History

• Received
  07 Apr 2017
• Accepted
  18 Dec 2017