versão On-line ISSN 1518-8345
Rev. Latino-Am. Enfermagem v.15 n.5 Ribeirão Preto set./out. 2007
Care needs of pregnant women with a private health insurance: a comprehensive social phenomenology approach
Miriam Aparecida Barbosa MerighiI; Renata Tavares Franco RodriguesII; Selisvane Ribeiro da Fonseca DomingosIII
IPhD in Nursing, Associate Professor; e-mail: firstname.lastname@example.org
IIUndergraduate student, e-mail: email@example.com. University of São Paulo, School of Nursing, Brazil
IIINursing Master student; Assistant Professor, School of Nursing, University Center of Caratinga, Minas Gerais, Brazil, e-mail: firstname.lastname@example.org
This study aimed to understand the meanings women who possess health plans hold regarding pregnancy and get to know their care needs in this phase of the vital cycle. It was based on the qualitative research of phenomenological inspiration. The discourses analysis was based on the sociologist and fenomenologist Alfred Schutz's thought. Having health plans and being attended in private institutions were defined as inclusion criteria. The following categories emerged from the discourses: having new responsibilities; experiencing a special situation; experiencing insecurity, anxiety and expectations; feeling limited; trusting the health professional. It was found, through the analysis of categories, that the experience of the pregnant women who participated in the study is similar to those who do not possess health plans. However, in the category "trusting the health professional" it was possible to perceive the importance of possessing health plan, which allows the intersubjectivity between the woman and the health professional.
Descriptors: qualitative research; women's health; pregnancy
JUSTIFICATION AND OBJECTIVES
A review of literature about the subjectivity of women who experience pregnancy reveals that these studies mainly focus on women who use the Single Health System (SUS) and are attended in public hospitals. These women are conditioned to see and act in the health and disease area from the perspective of their social insertion, characterized by their living condition itself and by the experience of many economic difficulties(1-5). Therefore, initially, some considerations are needed about the results of studies about pregnancy and prenatal care, after which the experience of pregnancy will be addressed from the perspective of women with a private health insurance, who are focused on in this study.
In a research carried out in Duque de Caxias/RJ, aimed at getting to know health professionals' and clients' opinions about prenatal care, it was observed that, in general, the pregnant women who used the services under study did not mention a significant contribution by primary care to facilitate their understanding of the pregnancy and birth process. Exceptions were related to nursing consultations, which took longer and contained more information, opening up a space where the women's affective questions, doubts, anxieties and curiosity can be brought up, permitting the establishment of a relation between health professionals and clients(1).
The results of an ethnographic study about the care offered to pregnant women at a philanthropic institution reflects these women's actual anxiety about prenatal care, besides proving their difficulties to get access to prenatal services, the discontinuity of care and the women's negative assessment about the prenatal care offered by the public network and in agreement with the social security service(6). The author comments that, when the pregnant women manage to get attended by the prenatal service, they are confronted with the professionals' lack of preparation and commitment, who do not give them attention, are always in a hurry and, therefore, do not manage to establish interaction with the women who, in turn, consider the service too fast and superficial. Some of them, dissatisfied, move on to seek attention to their needs elsewhere. Others get discouraged and, in a subsequent pregnancy, no longer attend prenatal services or do it at a late stage, merely attempting to guarantee a place to give birth.
Another study about the pregnancy experience of women in a low-income community aimed to understand and describe how these women and their husbands experience the pregnancy. The analysis of their reports showed that, essentially, the pregnant women are: "Living an uncertain future, attempting to adapt to the new situations emerging from the pregnancy and asking God to show them the right way". The author considered that there exists a large distance between the health service users' needs and what they are offered by the institutions and their professionals(3).
A study carried out in Ribeirão Preto about access to prenatal care in the basic health network identified that 54.6% of the women started prenatal care in the second term of their pregnancy, 40% attended less than six prenatal appointments and 77.1% did not have any paid work. The analysis of the care this group of women received evidenced that, in prenatal care, the women defined the sociocultural access as biological and individual care, centered on the doctor's appointment. Organizational access displayed obstacles related to waiting time for the appointment, lack of places and difficulty to do exams. Geographical/economic access was related to distance from the maternity hospital, as well as financial difficulties for transportation(5).
Hence, we believe it is important to research on women who have a private health insurance and are attended at private institutions as well. We depart from the premise that they may get easier access to health care. In public hospitals, the woman's isolation, during prenatal care as well as in the delivery room and in the puerperal phase, the indifference, carelessness, lack of efficient care and prohibition of the partner's or relative's presence are factors that contribute to the feeling of solitude, helplessness and panic, making these women feel that they are in the hands of fate(7).
We also depart from the premise that women with a private health insurance have easier access to prenatal services, continue receiving care during labor, delivery and postpartum, have a guaranteed place at an institution when they are going to give birth and do not experience the apprehension of not knowing who will do the delivery.
We believe that knowledge about other persons in their totality can be obtained if we attempt to understand them as individuals belonging to a social group with peculiar characteristics, which are collectively constructed and accepted and influence the way their perceive their health problems and treatment. Thus, in this study, we attempt to display the experiences of pregnancy in a comprehensive way, mainly in terms of the meanings attributed to the experiences and to the acknowledgement of these women's needs based on their experiences during pregnancy.
With a view to unveiling the phenomenon of the experience of pregnant women with a private health insurance, this study had the following objectives:
- general: Identify if the feelings and care needs of women with a private health insurance, who are attended in private institutions and experience pregnancy, differ from users of the Single Health System.
- specific: Understand the meaning women with a private health insurance attribute to the pregnancy process; get to know these women's care needs in this phase of the life span.
We believe that this knowledge can offer significant contributions in care delivery to this clientele and add to teaching in the women's health area.
The theoretical-methodological framework of this research is based on the principles of qualitative research, which favors a deeper knowledge of the meanings, beliefs and values of people, who attribute specific meanings to their actions and human relations. The phenomenological perspective was adopted, as we consider that this allows for a better understanding as women who are capable of thinking, acting and reflecting on their life world and who need to be understood and helped by their caregivers.
We used the reference framework of social phenomenology, based on Alfred Schutz' conception. This framework studies the phenomenon on the basis of what people experience in their daily life, considering them as elements that act, interact and understand one another within the so-called social world; it allows for the replacement of the objectives of thinking by common sense, exemplified by the typified activities for the study questions(8).
Alfred Schutz' social phenomenology aims to understand the world with the others in its intersubjective meaning. Its proposal is to analyze social relations, considered as mutual relations involving people. It is structured on the meanings of the intersubjective experience of the social relation and seeks to attend to social actions, which have a contextualized meaning, configured in the social and not purely individual sense. It is the focus of interest that can be contributed as a typical characteristic of a social group that is experiencing a certain situation(9).
This research aimed to get to know the reality of a group of pregnant women at the end of the second term of their pregnancy, situating them in the natural attitude and, therefore, in their life-world, to understand the different interpretative practices through which reality is constructed in the personal and social perspective.
Social action is a conduct directed at the achievement of a certain goal and this action, called motive for can only be interpreted by the actor's subjectivity, as it is only the person him-/herself who can define his/her action project, his/her social performance. In this sense, the understanding of the social is oriented towards the social behavior in relation to the motives, to the intentions that guide the action and to its meanings for the actor performing the action(8).
Motive is considered as: "a state of things, the objective one intends to reach through the action". Hence, motive for is the orientation towards the future action. It is, therefore, a context of meeting that is constructed or constructs itself on the context of experiences available at the moment of the projection. This category is essentially subjective. On the other hand, the motive why refers to a project in function of past experiences and is an objective category, accessible to researchers. The context of meaning of the true reason why is always an explanation after the event(8).
Schutz developed his studies out of interest in understanding the subjective meaning of actions, which will make it possible to construct the experienced type. The experienced type is the expression of a structure lived in the social dimension, a characteristic of a social group, a concept expressed by intelligence, whose experienced nature is essential, unvarying. The experienced type is reached through the analysis of social relations(8).
In this study, we used the methodological resource of typology because we attempted to learn and apprehend from the "social things" as significant, thanks to the pregnant women's action in the social scene, in their typical function and not as unique and singular, but as an experienced type. In the action of getting pregnant, women often have something in mind, that is, motives for the action as an intentional project to be accomplished.
With a view to unveiling the phenomenon of "being a woman who is experiencing pregnancy", the subjects' selection was based on criteria established in function of our concerns. Thus, to participate in this research, we chose the following criteria: pregnant women, over 18, attended at private institutions, who had a health insurance and agreed to participate in the study.
The pregnant women who served as research subjects should also have reached the end of the second term of pregnancy and, therefore, be experiencing pregnancy and prenatal care. This phase in the course of women's life is appropriate to collect the descriptions as, at the end of the second term of pregnancy, their feelings are closer to the reality they experience and, hence, they will be able to express its meaning in richer discourse.
There is no need to define a place for data collection in this study, which was carried out from November 2004 to March 2005. The region under analysis was the situation itself where the phenomenon occurs, the life world, the pre-reflexive of women who live and suffer the influences of pregnancy. The contact with the pregnant women depended on the researchers' knowledge and information from third parties about the existence of these subjects. The interviews were scheduled according to the women's preferred date, time and place. Thus, some took place at their homes and others at their workplace.
The number of subjects was defined as soon as we perceived that the testimonies unveiled the research phenomenon, that is, when our inquiries were sufficiently answered. We decided to stop including new women who were experiencing the pregnancy period on the basis of the set of collected data, which evidenced both the wealth and range of meanings contained in the testimonies. Thus, ten statements were analyzed and considered sufficient to unveil the phenomenon.
Data were obtained through interviews, which were recorded with the participants' authorization, and guided by a script with the following questions: Tell me about your daily life after you got pregnant. How do you feel? What do you expect from the care-giving professional during pregnancy, delivery and birth?
The women received further information about the study objective, as well as about secrecy, anonymity and their right to participate or not. After these clarifications, the participants were asked to sign the Free and Informed Consent Term to participate in the study. With a view to preserving anonymity, the women were identified with fictitious names.
CONCRETE CATEGORIES EMERGED FROM THE EXPERIENCE
To analyze the testimonies, we attempted to attentively limit ourselves to what appeared in common, that is, seeking the reasons for in the interviews, which identified the convergences in the pregnant women's desire for the health professionals' actions. The women's feelings and experiences were understood through the analysis of the five categories identified after the organization of the statements, which were: Having new responsibilities; Experiencing a special situation; Living insecurity, anxiety and expectations; Feeling limited and Trusting the health professional.
The concrete categories that emerged from the experience, which were constituted on the basis of the meaning of the subjective action, allowed us to describe the experienced type "woman experiencing pregnancy, with health insurance and attended at a private institution" as women who, through pregnancy, starts new projects and acquires new responsibilities, who experiences special situations, such as insecurity, anxiety and expectation, with respect to pregnancy, delivery and birth, who expects attention, availability and technical-scientific competence from the professional and who, due to the fact that they had the opportunity to choose the care-giving professional during pregnancy, birth and puerperal period, feel secure and confident.
COMPREHENSIVE ANALYSIS OF THE EXPERIENCED TYPE: WOMAN EXPERIENCING PREGNANCY, WITH HEALTH INSURANCE AND ATTENDED AT A PRIVATE INSTITUTION
This study allowed us to apprehend, through the communicative act, the reciprocity and intersubjectivity that permeated the pregnant women's testimonies about the motives for and the motives why of the pregnant women's daily experiences, and of their expectations related to the actions of the care professionals during prenatal care, pre-birth and birth. The collected data allowed us to get to know and understand what is typical about the experience of these women, who are pregnant and have a private health insurance.
The motives forextracted from the daily experiences of these pregnant women, who were the subjects of this study and had a private health insurance, appeared in a relevant way in the following categories: Having new responsibilities; Experiencing a special situation; Living insecurity, anxiety and expectations and Trusting the health professional. The motives why were revealed through the category "Feeling limited".
In the category Having new responsibilities, some pregnant women's statements show a behavioral change in terms of care with their movements, body, food, care that not only relates to them, but also to their babies. In this sense, they have new projects, showing greater responsibility:
... It's a feeling of greater responsibility. We think more about the future and in the first place about the child. So we no longer think alone like, for example, I'm going to accept another job because I need to make more money. We start to think about what's gonna be safer for the baby. So that changes, because we know that there's a child who depends on us... (Luciana)
...Everything has changed. My life project has changed. Now, I program my day, my night and my weekend. The financial side has changed, the private, intimacy, the family. Everything has changed. It's completely different. Each day, there are changes and adaptations. You start to make new plans... (Bianca)
...quite a lot has changed in my life, even your future perspective changes, you know, if you were only concerned with yourself before, or with your family, it changes, you are much more concerned with the baby...(Carolina)
In the category Experiencing a special situation, the reports show how the pregnant women define their feelings of happiness, accomplishment, projection of family construction, in short, they experience a special situation. The pregnancy is influenced by several factors. This process provokes both internal and external modifications and, therefore, becomes a moment loaded with feelings and sensations, as demonstrated by the following statements:
...everybody is experiencing a pregnancy that was wanted. Oh dear! It's totally different. Everybody is enjoying it a lot. Everybody is very happy... (Bianca)
... The pregnancy is wonderful for me... I'm very happy. It's such a great happiness... Everything is wonderful... It's being a divine blessing from heaven... (Kelly)
... It was such a great happiness that I can't describe it. That idea that there was a human being in my belly, that is, that thing of carrying a new life inside you made me feel blessed. When I found out I was thinking, I thought that God had remembered me... (Giovana)
... it is very special when you manage to carry a little being inside your belly... (Carolina)
In the category Living insecurity, anxiety and expectations, we could perceive that each pregnant woman refers to her insecurity and concern according to the experiences and transformations that occur during the pregnancy. The statements unveiled the motives for this insecurity:
... we get like, how will it be and what's gonna happen? Another concern we have at the beginning is with spontaneous abortion. So, we get concerned. There is some care... we feel insecure and are afraid of abortion . (Luciana)
... I was afraid of feeling contractions and not having time for anesthesia... (Lílian)
... They told me that the doctor does not stay there the whole time. A nurse stays and she does the assessment. Then, I got concerned if she would do the vaginal exam or the doctor... people are going to see me and how many are going to touch me. In view of this situation, I got very concerned because, if it's like that here, can you imagine in other places. After all, this is a private hospital offering this differentiated care. Now, imagine the other places. (Camila)
... The emotional part that is most affected really is anxiety. We get kind of anxious to know if everything's alright... I anxiously waited for the day of the ultrasound to know how she was doing... (Giovana)
The category Feeling limited shows fatigue as a limitation. Everything that used to be done with certain ability can no longer be done naturally. The motives why of feeling limited appear. Some changes can be clearly perceived. Increased sleep needs are common, as if a new, slower rhythm were imprinted in the organism, including calmness, serenity, tranquility, it is as if they became more vulnerable and sensitive(9).
... I do not manage to do everything I used to all at once, I have to lie down sometimes, put my legs up... (Gabriela)
... Ah I feel bad..., it's not nice when you're going through a series of hormonal changes that turn your organism totally unprepared, at least in my pregnancy right, I don't know, I don't know if all pregnancies are like that, at least mine is, so I get very sad because I don't have the energy used to have before, to do things, I get sad... (Natália)
... It seems that everything gets a bit more difficult, more tiresome, so I have to rest a bit more... in the physical sense it's only the fatigue, I feel more tired, right, I feel a bit of lack of air, swelling... (Adriana)
In the category Trusting the health professional, we could perceive the importance of professional-client interaction. This bond offers tranquility, trust and security. The acknowledgement of the feelings, expectations, insecurities and anguish lived by the pregnant women can definitely be minimized through professional-client interaction, as this grants the woman freedom and provides for an important channel of expression. Being well informed substantially contributes to solve doubts, anguish and anxiety:
... she charged to do a C-section and I didn't think that was fair. So I changed to another doctor. This doctor now is much more humane. I can be much freer with her. The other doctor was much more distant. I hope and think that what we always expect in pregnancy is greater approximation with the doctor (Luciana)
... Look, I had a first appointment that was like this... I opened up the book and looked at a name. I had no reference and did not know the person. Then I went to an appointment with her, I didn't like her. She wasn't the kind of professional I wanted to follow me for nine months. She was a very distant person, of little words. Kind of, you're gonna do this, that and then you come back. You know that empty thing. She didn't offer me any room for questions either. I felt inhibited. She was not the kind of Professional I wanted...so, then I thought, oh dear, am I gonna have to make appointments with everyone and screen until I find someone good. Then they ended up indicating some highly demanded people. Then I made another appointment...(Bianca).
... and she's a very kind person and companion. If I need her, I call her and she's always there and available, she transmits great tranquility to me...she makes me feel very secure, which I find fundamental, she is always ready to attend me and always very present, and she's gonna be my obstetrician, she'll be there on the day of birth, when it's time. That is excellent for me, as the person who accompanied you the whole time, I believe she has to be inside the room... She's a person I trust. I think this is a very delicate moment and it's not good for you to have many surprises... (Giovana)
It should be highlighted that we verified through literature that the presented categories, that is, what is typical about the experience of pregnant women with a private health insurance, showed to take the same form as for women without this insurance(3-4,10). However, in the category: "Trusting the health professional", the importance of having a health insurance and bonding with the professional is perceived, as there exists intersubjectivity and mutual intentions between the woman and the health professional. The result of this study does not reveal difficulties to attend to the search for professional care, as the client-health professional interaction allows for a positive experience of the pregnancy period. This is different from other studies about the experience of pregnant women who do not have a health insurance, who were attended in the context of a prenatal care service and show the discontinuity of care and their negative assessment of the care they were offered(1,3,5,10).
The work overload in health professionals' daily reality can often result in a mechanic, technicist and non-reflexive care. The mixture of science and art is what distinguishes a good professional from a mere competent technician. Good care only becomes possible when the professional acts not only with technical preparation, but also with intuition and empathy(11).
... Mainly, I think that it's the attention... Being listened to... A bit of kindness...We really want to be listened to... (Adriana)
... All I expect from the professional is attention, because we need attention, it is a moment of great fragility... (Carolina)
Taking care of a pregnant woman does not mean taking care of a "belly" but of a pregnant woman. Dialogue is the most important act in prenatal care. It is essential that all professionals active in women's health have a profound knowledge of pregnancy as a human development phase(2).
The role of professionals who attend women in prenatal care is broader, should go beyond the biological. The subjective aspects should be valued, and the socioeconomic and cultural context needs to be systematically known with a view to offering a better quality care to pregnant women(4).
For pregnant women who have a health insurance and are attended at private institutions, analyzed in this study, we perceive the possibility of being able to count on and sometimes even choose the health professional who will deliver care to them during their pregnancy, be present and strongly contribute to their security, tranquility and well-being. The statement below show that, after making this choice, the woman feels secure because she can count on the professional in case of doubts and problems. The motives why appear in their discourse.
... she's a very kind person and companion. If I need her, I call her and she's always there and available, she transmits great tranquility to me... (Giovana)
We believe that the women's concern with the baby's well-being, or the type of delivery, or the care received at this moment can be cured, partially through professional-client interaction, which will definitely greatly contribute to promote tranquility during this phase of the pregnancy-puerperal period.
It should be reminded that the way the woman experiences pregnancy, the way this experience is perceived, the information she receives about pregnancy throughout her life, can directly affect her perception and belief with respect to the experienced events, in combination with other factors. The available knowledge baggage is "a deposited structure of the individual's previous subjective experiences, acquired throughout his life, through experiences he lived or that were communicated to him by other people"(11).
The use of Alfred Schutz' social Phenomenology allowed us to reveal the experiences of pregnant women with a health insurance, which explanatory research and casual relations had not unveiled yet.
The way they live the pregnancy and the reasons and motives for each experience are based on their values and beliefs, which are socially acquired.
The pregnant women's statements revealed what pregnancy means to them as knowledge of social origins and socially approved. It is socially approved because it is being accepted as the truth not only by these women, but also by their contemporaries. Based on this premise, we understand the importance of knowledge acquired about pregnancy. Even if it is passed from generation to generation of women, with modifications over time, this knowledge maintains the structure of earlier generations.
The pregnant women depart from typical actions to solve typified problems in their daily social relations, using the knowledge inventory to understand and project their delivery and birth actions and expectations about care.
In this sense, we consider that this study looked for answers based on a methodology that allowed to reflect the care to pregnant women who cannot afford a health insurance, developing a critical attitude towards the care delivered to attend these clients' needs, including the possibility to turn the knowledge learned into actions.
The categories Living insecurity, anxiety and expectations and Trusting the health professional were shown in their context, allowing us to reflect on their content when we perform our actions.
Using the comprehensive approach, we believe that the obtained answers can contribute to a dignified care, which included information and the capacity to make the Best of it, the improvement of work conditions at health services and of the user population's living conditions. A right that we, health professionals and users, should conquer little by little.
The dimension that values interpersonal relations takes us to the ethical dimension, in which value, freedom, respect and dignity are essential. Thus, the human experience contains elements like relationship, sharing of ideas, emotions and feelings in the world of life. People are worth more than things; they have a value in themselves and not because of their position, as they have an inherent dignity, due to the fact that they are human beings(12).
If pregnant women were considered as agents instead of patients, prenatal care could positively affect epidemiological indicators in the maternal and perinatal health areas.
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Recebido em: 8.6.2006
Aprovado em: 4.6.2007