Group of high-risk pregnant women as a health education strategy

Abstract

OBJECTIVE

To understand the importance of group strategy in the process of nursing care to high-risk pregnant women.

METHODS

Qualitative and descriptive study conducted at Assis Chateaubriand Teaching Maternity Hospital in February-March 2017, through focus groups with 24 hospitalized pregnant women. Data was submitted to content analysis and the relevant ideas of the discourses were extracted, forming categories.

RESULTS

Three thematic categories were constructed: Interactive groups as a space of bond and coexistence, Educational strategy as an approach to good delivery and birthcare practices, Impact of group experience in strengthening the connection between the health team and the pregnant woman. The group of pregnant women is a space of coexistence and bonding that stimulates them to share knowledge and experiences, re-signifying links. The groups promote sharing of experiences, learning and reflection on the possibilities and limitations of the health-disease process, reducing anxiety and contributing to empowerment in decision making.

CONCLUSION

The considerations and suggestions of the pregnant women guided the nurses in the development of the groups, which became strategic spaces of care, acquisition of knowledge and establishment of trust relationships with the nurses, with a consequent impact on the quality of care.

Keywords:
Pregnancy; high-risk; Nursing care; Health education; Women's health

Resumo

OBJETIVO

Compreender a importância do grupo no processo de cuidado de enfermagem as gestantes de risco.

MÉTODOS

Estudo qualitativo, descritivo realizado na Maternidade Escola Assis Chateaubriand, de fevereiro a março/2017, através de grupos focais com 24 gestantes internadas. Dados submetidos à análise de conteúdo e as ideias relevantes dos discursos foram extraídas, formando categorias.

RESULTADOS

Construíram três categorias: Grupos interativos como espaço de vínculo e convivência, Estratégia educativa como abordagem das boas práticas do parto/nascimento, Repercussão da experiência do grupo no fortalecimento do vínculo entre equipe de saúde e gestante. Os grupos promovem partilha de experiência, aprendizado e reflexão sobre as possibilidades e limitações do processo saúde-doença, reduzindo a ansiedade e contribuindo para o empoderamento na tomada de decisões.

CONCLUSÃO

As considerações das gestantes nortearam a equipe no desenvolvimento do grupo e efetivá-lo como espaço estratégico de cuidados, ampliação do conhecimento e relação de confiança, impactando na qualidade da assistência.

Palavras-chave:
Gravidez de alto risco; Cuidados de enfermagem; Educação em saúde; Saúde da mulher

Resumen

OBJETIVO

Comprender la importancia del grupo en el proceso de cuidado de enfermería las gestantes de riesgo.

MÉTODO

Estudio cualitativo y descriptivo realizado en la Maternidad Escuela Asis Chateaubriand, de febrero a marzo/2017, a través de grupos focales con 24 gestantes internadas. Los datos sometidos al análisis de contenido y las ideas relevantes de los discursos fueron extraídas, formando categorías.

RESULTADOS

Se construyeron tres categorías temáticas: Grupos interactivos como espacio de vínculo y convivencia, Estrategia educativa como abordaje de las buenas prácticas del parto/nacimiento, Repercusión de la experiencia del grupo en el fortalecimiento del vínculo entre equipo de salud y gestante. El grupo de gestantes es un espacio de convivencia y vínculo que las estimulan a compartir conocimientos y experiencias, resignificando vínculos. Se comprendió que los grupos promueven compartir experiencia, aprendizaje y reflexión sobre las posibilidades y limitaciones del proceso salud-enfermedad, reduciendo la ansiedad y contribuyendo al empoderamiento en la toma de decisiones.

CONCLUSIÓN

Las consideraciones y sugerencias de las gestantes contribuyeron a orientar a la enfermera en el desarrollo del grupo y realizarlo como espacio estratégico de cuidados y ampliación del conocimiento y relación de confianza con el enfermero, impactando en la calidad de la asistencia.

Palavras clave:
Embarazo de alto riesgo; Atención de enfermería; Educación en salud; Salud de la mujer

Introduction

The gestational process involves physiological, psychological, economic, educational and family changes that, in most cases, do not result in complications¹. However, some women may have complications associated with pregnancy, and thus are classified as “high risk”, compared to other pregnant women, since these complications threaten the health or life of the mother or her fetus².

Thus, care to women's health during pregnancy is very important, even for pregnant women classified as "low risk", in order to detect the onset or worsening of complications. The classification of pregnancy risk takes into consideration both the clinical and obstetric conditions and psychological/emotional aspects, in order to gain a broad understanding of the potential risk. This requires physical and psychological adaptations and specialized care³. Nurses play a crucial role in this care process, being able to identify the factors that interfere in the educational process.

In order to improve the care to pregnant women, the Ministry of Health developed policies on women's care, such as the National Program for Humanization of Prenatal and Childbirth Care and the National Program for Integrated Women’s Health Care as measures aimed to prevent the high maternal morbidity and mortality rates^{2-4) .} The Ministry of Health has recently established the Rede Cegonha strategy, a network of care aimed at ensuring women's right to reproductive planning and humanized in pregnancy, childbirth, in the postpartum period, and in abortion, as well as the child’s right to safe birth and healthy growth and development⁵.

Nurses play a crucial role in care, as these health professionals establish closer relationships with the patients in their daily routine, in a holistic and comprehensive way, through the use of multidisciplinary practices to ensure the delivery of appropriate care⁶.

In this regard, nurses are supposed to guide, assist and support the patients, through the use of plain language. The recognition of alternative forms of nursing care production in the health-disease process can be due to the adoption of work technologies perceived as creative and innovative strategies^7-8.

Thus, health education groups consist of a therapeutic tool that facilitates in-depth discussions, broader knowledge and the process of health education. They also favor trust in patient-nurse relationships, providing a welcoming and safe environment⁹.

These considerations shed light on the care delivered to pregnant women, drawing attention to the need to ensure, as best as possible, a humanized and high-quality care practice, through the delivery of systematic and individualized care, adapted to the peculiarities of each patient, which requires effective communication. In view of the aforementioned, the following questions arise: Does the implementation of the group of pregnant women contribute to the process of care of the nursing team with high-risk pregnant women?

It is hoped that the results obtained by this study are shared and provide guidance to nursing professionals regarding the construction of special and personalized care for high risk pregnant women. Therefore, the present study aimed to gain knowledge on the importance of groups of pregnant women in the nursing care process and in the adaptation and coping with the hospitalization of pregnant women classified as having high-risk pregnancies.

Method

Descriptive study with a qualitative approach. Qualitative research allows us to approach the deeper levels of social relations by gaining a more accurate and deeper understanding on the social relations^10-11.

The study was conducted from February to March 2017 and the sample was composed of pregnant women admitted to the Obstetric Clinic of the teaching maternity hospital Assis Chateaubriand, a tertiary public hospital in Fortaleza, Ceará. The hospital is a reference center in the Brazilian Northeastern region in maternal-fetal care and counts on the following medical specialties: obstetrics, gynecology, mastology and neonatology services. The institution has been actively involved in the Rede Cegonha” strategy of the Ministry of Health and was chosen to be a support center for good practices in Obstetric and Neonatal Care of Rede Cegonha.

The focus group technique was used to obtain knowledge on the experiences of the participants, as pregnant women, when among their peers, feel more comfortable to express their views. This technique provided interaction, facilitated the verbalization of doubts, taboos and prejudices, and the participants also shared opinions, made inferences and sought for solutions to common problems¹².

The group sessions were held in the Obstetric Center of the referred institution, to encourage the pregnant women to discuss topics related to the good practices of labor and care recommended by the Ministry of Health/Rede Cegonha strategy⁵, besides stimulating them to identify labor signs.

The study sample consisted of twenty-four pregnant women randomly distributed in four groups of six women who met the inclusion criteria to participate in the study, namely: high-risk pregnant women over 18 years of age without restriction of mobility who agreed to participate in the study. The exclusion criteria were: adolescents under 18 years old and pregnant women who did not agree to participate in the study.

Given the nature of the study, and in order to comply with the proposed objectives, three focus groups (each one with an average length of one hour) were held. The groups were composed of a moderator (main researcher), an observer (researcher responsible for recordings and notes) and the six participants in each group.

In the first focus meeting, the participants were invited to expose their knowledge of good obstetrical practices based on some of the approaches made by the researcher: Recognition of signs of labor and knowledge of good practices adopted during labor. Subsequently, the researcher guided the discussion by addressing the good obstetrical practices recommended by the Ministry of Health.

In the second focus meeting, a critical-reflexive analysis was made following the discussions about the knowledge acquired on good obstetrical practices based on scientific evidence.

The third focus meeting consisted in the assessment of the educational intervention according to the patients' perceptions, in order to contribute to the implementation of these groups as part of routine actions through the following approaches: Contributions of groups of pregnant women to their treatment during hospitalization; Setting (environment) of these groups, and Motivation to participate in the group and suggestions for improvement. In each one of these sessions, the participants' statements were recorded by the observer, and the main ideas were written down.

The data were treated using Bardin’s thematic content analysis¹³. Three thematic categories were identified and a descriptive plan composed of the expressions, feelings, perceptions and knowledge of the women was elaborated. The peculiarities of each high-risk pregnant woman hospitalized in the institution were considered. According to this plan, the most relevant statements related to the theme of each category were extracted, and the main ideas for discussion of the results and basis of the conclusions were obtained from these statements.

Following the invitation to participate in the study, the women were informed on the objectives of the study, type of participation, risks, benefits and the guarantee of anonymity and freedom to accept or refuse to participate in the study, without incurring any penalty. The pregnant women signed the free informed consent form. To ensure the anonymity of the participants, their names were replaced by letter G (pregnant), followed by an ordinal number ranging from 1 to 13 (Ex. G1).

The present study complied with the regulations governing research with human subjects established by Resolution 466/12 of the Brazilian Ministry of Health¹⁰, and was approved by the Research Ethics Committee of Universidade Federal do Ceará, under protocol no 1.899.089 on January 26, 2017.

Results and Discussion

Characterization of the sample

The twenty-four participants were pregnant women with gestational age of 26 to 39 weeks and age group between 19 to 31 years. Eight of them were single, six married and ten lived in stable union. Regarding their educational level, the participants ranged from illiteracy to complete high education, with most participants having completed secondary education. Regarding occupation, three were students, twelve were housewives, three were unemployed, two were teachers, two were civil servants and two were self-employed persons. Five reported being primigravidae, and the others had one to six children. Of these, six reported previous abortions. Of the pregnant women admitted for obstetric complications, the most frequent diagnoses of hospitalizations were: hypertensive pregnancy diseases, pyelonephritis, type 1 and 2 diabetes mellitus, premature rupture of the membranes and placenta previa.

Interactive groups as spaces of bond and coexistence

In general, the pregnant women that participated in the study perceived the educational strategy adopted in the groups as something positive, as it contributes to discussion and learning, allowing them to express their fears and anxieties. They felt comfortable to express their views and make comments, as it can be seen in the following statements:

[....] I liked it a lot ... I could exchange experiences with patients from other wards. I heard many things that I did not even think about.. (G1)

[....] It was good to know that I’m not the only one to feel afraid. (G5)

[....]I've always been told that caesarean delivery was easier, but after the reports I've heard, I feel more confident about choosing normal delivery. (G6)

There are many advantages here. I can be alone in the bedroom with my husband, and that's great. (G4)

Most participants, especially the primigravidae, perceive the group strategy as a space of coexistence that brings them closer to the nursing staff and other pregnant women in a similar situation, and thus recognize the importance of participation in these groups to clarify doubts through dialogue, as shown in the following statements:

It’s good to be here and know the place where the baby will be born ... I was relieved because I realized that although my pregnancy is complicated, I can have a vaginal delivery. (G2)

I've been hospitalized for more than 20 days now [...] I miss home, I worry about my work, I do not know if my employer will still want me to continue working for her. (G3)

I'm relieved to know that I can eat during labor... I hate the feeling of being hungry. I get stressed! (G8)

When we get information, when we become aware of what is going to happen, e.g. birth ball exercises, warm aspersion bath, etc… and it’s much easier to accept vaginal delivery. (G6)

Many pregnant women were experiencing adverse situations, which were expressed by sadness, discouragement, guilt, insecurity, as well as complaints of lack of affection and support, which prevented them from meeting their needs. As the participants felt relaxed and safe, they tended to interact more easily with one another in the group.

Group work is the means by which pregnant women socialize and experience opportunities for better coping with new situations^14-15. The educational intervention also allows people to establish effective communication, express concepts and emotions, minimize stress and fears, modify behaviors, and better understand the routine of hospitalization^16-17.

The interactions experienced produced transformations that occurred in a dynamic process, influenced by the group. They made it possible for the participants to reflect on their gestational process and on the adaptation to hospital routine. Thus, the educational process is not a simple task, because it is not restricted to the transmission of information to pregnant women¹⁸. On the contrary, it is a shared practice that involves exchange of knowledge, through the establishment of bonds and must be constantly improved.

Educational strategy as an approach to good practices in childbirth/birth

Care and delivery guidelines, when provided through an educational strategy, are more effective compared to the mere delivery of routine care. This led to the Good Delivery and Birth Care Practices, of the Ministry of Health, that recommend humanized normal vagina delivery, non-pharmacological measures for pain relief and the presence of a companion of the woman’s choice to turn this event into a physiological process⁵.

The reports of most pregnant women reveal that they were unable to recognize the signs of labor. Moreover, some pregnant women had no prior knowledge of good delivery and birth care practices, as shown in the following statements:

I know it begins with a pain in the lower abdomen that irradiates to the back. The doctor said that there is discharge of clear liquid [...] this pain seems to suggest the baby is on its way. (G5)

I’m afraid of this sharp pain everyone talks about [...] I’m alone. (G6)

I did not know that pregnant women could walk during labor [...] I didn’t know I could do birth ball exercises and use a stool that favors vertical position. (G7)

I didn’t want to have a normal vaginal delivery because of the things my sister told me about her delivery… the excruciating pain. [...] The doctors make an incision to allow the baby’s head to pass through more easily down, and there is this painful injection used by doctors to strengthen labor contractions. I’m afraid and worried (G8)

That’s great! I want to have a vaginal delivery here [...] I’ll talk to my doctor about it [...] These exercise balls will help a lot [...]And we can stay in this room [...]My husband can be with me here. (G9)

The attitudes and the behavior of women during labor depend on their previous knowledge about the parturition process. Pregnant women should obtain as much information as possible about pregnancy, adequate nutrition, labor, delivery, breastfeeding and care of newborns prior to the delivery. Information on adequate physical preparation, positions, non-pharmacological interventions, right to have a companion of their choice is necessary for active delivery⁵.

Moreover, during the group intervention, the participants suggested that their relatives got involved in the parturition process, because they get very anxious about it due to lack of proper information and may contribute to turn labor into something stressful and unpleasant.

I want my sister-in-law to watch my delivery because I'm scared of all the things she tells me about deliveries. (G10)

As it was reported by the participants, ensuring the women’s right to a companion of their choice during labor, delivery and in the immediate postpartum period is a practice that has proven to be useful and should be encouraged in accordance with the good practices of labor and birth care adopted by the Ministry of Health in accordance with Administrative Measure No. 1459 of June 24, 2011⁵ and the institution's routine practices. Pregnant women are generally unaware of their rights during the parturition process. Counting on a companion of their choice during this process reduces the need for analgesia, the incidence of cesarean sections and low Apgar scores of the newborn in the fifth minute of life. Moreover, such support makes these women calmer, confident and secure¹⁷. It is understood that health promotion actions should be essentially participatory and transformative.

Impact of group's experience on the strengthening of the bonds between the health team and the pregnant women

The use of nursing care technologies aims to provide women with an environment conducive to labor. Studies report that obstetric nursing care should be targeted to women perceived as individuals who demand care and not control, respecting their privacy and safety in the parturition process. In addition, the potential benefit of collaborative work among obstetrical physicians and nurses in labor and delivery, ensured by adopting good practices of labor and birth care, can be the first step towards more effective obstetric care^14-15.

Describing and understanding the particularities, concerns and fears related to the gestational period and hospitalization will result in greater involvement and will contribute to the establishment of a more effective bond between the pregnant women and the healthcare team. Also, the women were now able to perceive pregnancy from a different perspective, feeling closer to their babies.

One aspect mentioned by the participants concerned the way the nurse mediated the groups, asking them about the meaning of pregnancy and motherhood. She also stimulated reflections about the situations experienced by the women and the new reality facing them:

Participating in the group made me feel more confident...I now pay closer attention to what the nurse says about my treatment (G11)

I’m not angry anymore when nurses come in my room to monitor my pressure at 05:00 a.m. I know it's important for my treatment. (G12)

The use of new educational approaches is gradually changing the type of care provided by nurses. These approaches are mechanisms aimed to strengthen health intervention actions for the empowerment of pregnant women. Such empowerment will allow them to actively participate in their therapeutic plan and develop their autonomy and co-responsibility throughout the process. Thus, active listening by health professionals aware of the specificities of pregnant women is necessary for the establishment of a bond and for ensuring a strong collaboration of these women and their families who are coping with high risk pregnancy⁷.

The recommendations of the Ministry of Health on humanized care to women include the creation of support groups to meet the real needs of pregnant women and their families⁴. During these interventions, nurses act as facilitators in the formation of the groups, and the participants expose their doubts¹⁰, and interact with other pregnant women who are experiencing a similar situation, to better cope with high-risk pregnancy-related problems ¹¹.

The participants began to perceive health in a different way. They said they now understand the process through which they develop proper care practices consciously. Their broader perceptions are related to the re-evaluation of their beliefs, their values and knowledge about the health-disease process¹².

In the statement below, one participant reported the difficulty in establishing ties with health professionals and the lack of understanding of care routines during hospitalization, and said that group activities could minimize such problems:

Sometimes doctors make very short visits to our rooms... These visits are so short that we forget to ask them to clarify our doubts. In the group we can expose all our doubts. (G13)

This study provides support for the implementation of participatory strategies for the development of groups of pregnant women, because of the aforementioned benefits of this strategy. Therefore, the purpose of the study is to contribute to the delivery of an ever more integral healthcare that meets the specific needs of the groups.

Conclusion

The findings of this study gave insight on how the dynamics of groups with pregnant women favor greater contact with nurses, resulting in moments of action-reflection to identify the needs of care, collaborating in the planning and implementation of care.

The healthcare practice targeted to pregnant women based on a dialogical approach through interactive groups attempted to stimulate interaction, support and exchange of experiences among participants, as well as strategies for learning and coping with the difficulties during hospitalization.

One limitation of this study is the fact that more in-depth studies on the impact of the group activities on obstetric outcomes are needed. However, the key contribution of this study is that the group strategy has proved to be a valuable resource for pregnant women, providing a space to share experiences, feelings and socialization of technical-scientific and popular knowledge. The study also identified a sense of belonging on the part of women in their reflections on personal autonomy and empowerment in decision making. This had a positive impact on the quality of obstetric nursing care. In addition, it contributed to the nursing practice, minimizing gaps in the care to these pregnant women.

Also, the results obtained demonstrated that good practices, associated with the involvement of the multidisciplinary team, can contribute to a paradigm shift in the obstetric scenario. Therefore, this study may provide support for other studies in the obstetric nursing field, in order to qualify obstetric care. To that end, references that support the practices in this area, as well as the promotion of a network of care are necessary in order to ensure the right of women to humanized care in pregnancy, childbirth and the postpartum period.

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• Errata

  In the article "Group of high-risk pregnant women as a health education strategy", with elocation e20180023 and number DOI: 10.1590/1983-1447.2019.20180023, published in journal Revista Gaúcha de Enfermagem, from the year 2019, volume 40, in the authors:
  Where it was written:
  Francisca Leonilda Rodrigues Sampaio
  Should read:
  Francisca Leonilda Sampaio Rodrigues

Publication Dates

• Publication in this collection
  18 Feb 2019
• Date of issue
  2019

History

• Received
  09 Mar 2018
• Accepted
  28 Sept 2018