Occupational therapy practice with puerperal women in the actions of the family health support center

Abstract

Introduction

Occupational Therapy works in Primary Care through the Family Health Support Center, collaborating to promote comprehensive health monitoring for the population served by SUS. Among the people assisted are women in the puerperium, the period between childbirth until the next six and eight weeks is marked by several changes for those who experience it.

Objective

To investigate the role of occupational therapists with postpartum women in Primary Care actions at Family Health Support Center in Recife-PE.

Method

A qualitative exploratory study, carried out between April and May 2022, with eight occupational therapists working in Recife-PE. As a research instrument, a semi-structured interview script was produced. For analysis, the Collective Subject Discourse technique was used.

Results

The professionals report difficulties to work as a team with postpartum women due to the lack of knowledge of the possibilities of assistance on the part of the Family Health Teams. Despite this, they carry out several actions aimed at the field of action and the core of knowledge of Occupational Therapy. Among the actions carried out are home visits, individual and shared care, group care, breastfeeding support, guidance to postpartum women and support network, mental health care, guidance and resumption of occupational roles, routine structuring and guidance or support for daily activities.

Conclusion

Based on the understanding of occupation and occupational performance, the practice of occupational therapists at team represents benefits to the health of women assisted during the puerperium.

Keywords:
Primary Health Care; Daily Activities; Postpartum Period; Woman’s Health; Occupational Therapy

Resumo

Introdução

A Terapia Ocupacional atua na Atenção Básica em saúde e por meio do Núcleo de Apoio à Saúde da Família (Nasf), contribuindo com a integralidade no acompanhamento à saúde da população atendida pelo SUS (Sistema Único de Saúde). Entre as pessoas atendidas, encontram-se as mulheres no puerpério, período entre o parto e até seis e oito semanas seguintes, marcado por diversas mudanças para quem o vivencia.

Objetivo

Investigar a atuação das terapeutas ocupacionais com puérperas nas ações da Atenção Básica em Saúde no Nasf do Recife-PE.

Método

Estudo qualitativo de natureza exploratória, realizado entre abril e maio/2022, com oito terapeutas ocupacionais que trabalham no Nasf do Recife-PE. Como instrumento da pesquisa, utilizou-se um roteiro de entrevista semiestruturada e para análise a técnica do Discurso do Sujeito Coletivo.

Resultados

As profissionais relatam que a equipe Nasf apresenta defasagem na atuação com as puérperas por desconhecimento das possibilidades desta assistência por parte das Equipes de Saúde da Família. Apesar disso, realizam ações voltadas ao campo de atuação e ao núcleo de conhecimento da Terapia Ocupacional. Entre essas ações, estão as visitas domiciliares, atendimento individual e compartilhado, atendimento em grupos, apoio à amamentação, orientações às puérperas e à rede de apoio, atenção à saúde mental, orientações e retomada de papéis ocupacionais, estruturação de rotina e orientação ou apoio às atividades diárias.

Conclusão

A partir da compreensão da ocupação e desempenho ocupacional, a atuação da terapia ocupacional no Nasf representa benefícios à saúde de mulheres no puerpério.

Palavras-chave:
Atenção Primária à Saúde; Atividades Cotidianas; Puerpério; Saúde da Mulher; Terapia Ocupacional

Introduction

From 2010 onwards, the Unified Health System (SUS) has the Health Care Networks (RAS) as its organizational model, with the purpose of overcoming fragmentation and hierarchization and ensuring principles such as integrality and coordination of care, from Primary Care, thematic networks, diagnostic and specialized support services. Since then, the implementation of RAS has faced design challenges, in internal and external articulation, underfunding, insufficient services and others that reflect on the recognition of the centrality of the coordination of Primary Health Care (PHC) and the model itself (Tofani et al., 2021).

Primary Health Care (APS), or Basic Care, is the preferred gateway and contact for users with the health network, providing integrated care, communication between points/services and qualified management. The actions are aimed at “the population in a defined territory, for which the teams assume health responsibility” (Brasil, 2017, p. 60). The Primary Care network responds to individual, family, and collective actions, for “promotion, prevention, protection, diagnosis, treatment, rehabilitation, harm reduction, palliative care and health surveillance” (Brasil, 2017, p. 68).

In this model, the Family Health Team (EqSF) monitors the population in a defined territory, being its main reference. To support this team, expand the comprehensiveness and quality of care, the Family Health Support Center (Nasf) was created as a strategic device. Multidisciplinary in nature, it acts as a back-up of support and sharing of knowledge between teams, with the purpose of offering greater resolution to Primary Care (Brasil, 2008).

At this initial moment, Nasf's work process was guided by the National Primary Care Policy (PNAB) and specific guidelines, with responsibilities and tools for action (Brasil, 2010, p. 8). However, with the changes in the PNAB (Brasil, 2017) and others that affected the financing and organization of networks (Brasil, 2019), the Nasf began to lose its character. The change of name, in 2017, to Expanded Centers for Family Health and Primary Care (Nasf-AB) (Brasil, 2017) and, in 2019, to Expanded Center for Family Health and Primary Care (eNASF-AP) (Brasil, 2019), it is not just a semantic issue. This replacement implies changes in work parameters for Nasf and APS, loss of matrix support reference and forms of team linking, suspension of federal funding, among others. In this sense, the loss of financial incentive and the classification of the three types of Nasf, with suspension of team registration from January/2020 (Brasil, 2020), characterizes the extinction of the Nasf, called by Mattos et al. (2022) as a dismantling period.

In addition to reducing the number of teams, the priority in APS is the care dimension, with an outpatient and individual model. A setback from what had been built with work between teams in Primary Care, loss of coordinated action between multidisciplinary teams, which is structuring at this level of care (Mattos et al., 2022; Mendes et al., 2022; Paulino et al., 2021).

Although the present study was carried out in the current scenario until 2022, it is worth highlighting that there are new changes underway. The financial incentive from the federal government was reestablished and the Nasf name and guidelines were definitively replaced. What was Nasf is now called multidisciplinary teams in APS (eMulti). New modalities and parameters for the work of eMulti with “co-responsible action for the population and territory, in intersectoral coordination with the RAS” are under construction (Brasil, 2022, p. 12). This contextualization is to situate this study, still within the logic of the Nasf teams, in which, in Recife, occupational therapists have been included since its implementation in 2010, and the teams continue to be maintained. Nasf is recognized in the network as part of “a successful model for qualifying Primary Care in the municipality and expanding the range of services offered to users in the territory” (Recife, 2020, p. 1).

This same municipal document, still in force, defines that the work process at Nasf continues to be guided by matrix support in the clinical-care and technical-pedagogical dimensions, as recommended in the initial creation guidelines. In this way, we continue referring to the work of occupational therapists, shared between Nasf and family health teams, with actions in the territory and directed to one of the defined strategic areas of Nasf, which are “Child and Adolescent Health; Women's Health; Mental health; Social service; Pharmaceutical care; Physical Activity/Bodily Practices; Integrative and Complementary Practices; Rehabilitation/Comprehensive Health of the Elderly; Food and Nutrition” (Brasil, 2010, p. 8).

At Nasf, occupational therapists are often required to care for people with disabilities, those in mental distress, children with developmental disabilities, the older adults, and bedridden people, among other priorities in the territory. In general, they seek to favor the conditions for social participation of individuals and families, respecting their uniqueness, linking them in life projects and meaningful occupations, prioritizing community contexts. Thus, the occupational therapist adds interdisciplinary actions shared with multidisciplinary teams, those specific to their core of knowledge, carrying out case discussions, team meetings, home visits, health education and promotion activities, waiting room, groups and workshops, individual and shared care, adaptation of utensils and environments, matrix support and guidance for families and caregivers, among others (Lobato et al., 2020; Chagas & Andrade, 2019; Andrade & Falcão, 2017; Cabral & Bregalda, 2017).

The role of occupational therapy at Nasf, aimed at women's health and especially postpartum women, is the interest of this study. However, the participation of this professional in assisting this population, although recognized as important, is more studied in hospital environments and health units, with few records in Primary Care (Lourenço et al., 2022; Oliveira & Oliveira, 2019; Fraga et al., 2019; Nascimento et al., 2017).

Assistance to women in the pregnancy-puerperal cycle has a priority space at this level of care, due to its proximity to needs, longitudinal, humanized, and comprehensive care, which can be provided by Nasf's family and multidisciplinary health teams. This care is defined as Rede Cegonha, the first of the five thematic networks agreed for implementation and whose components include prenatal care; labor and birth; puerperium and comprehensive care for children up to two years of age. Its conception was, at the same time, a response to the demands of women's movements for a change in the delivery care model, the reduction of maternal and neonatal mortality, as well as a break in actions, considering only the biological and reproductive aspect (Vilela et al., 2021; Baratieri & Natal, 2019; Brasil, 2011).

This assistance in Primary Care includes both prenatal care, with an established number of consultations and screening for infectious diseases, such as HIV, syphilis and hepatitis, chronic diseases, such as diabetes and hypertension, which harm women and children, as well as home visit in the first week postpartum, offering family planning, encouraging breastfeeding and tracking the mental health of the postpartum woman (Rodrigues et al., 2021; Baratieri & Natal, 2019). Studies that investigated the quality of care, adherence to consultations, and meeting the needs of pregnant and postpartum women in Primary Care highlight the role of multidisciplinary teams in preventing, detecting problems, and improving indicators related to these periods (Baratieri et al., 2022; Rodrigues et al., 2021).

The first Nasf guidelines (Brasil, 2010) establish support for family health teams in caring for women's sexual and reproductive health, with education and health promotion actions, aimed at reproductive and family planning, assistance during the pre-natal, childbirth and postpartum period. The actions are aimed at couples regardless of gender and age. Groups of women, pregnant women, and work in the School Health Program (PSE) are strategies planned to operationalize these guidelines. And, in this sense, a dialogue is identified with objectives and dimensions from the perspective of Occupational Therapy, due to the potential for transformations in women's routine and roles during pregnancy and the postpartum period.

The puerperium, the period after childbirth, with variable duration, brings intense biopsychosocial changes related to the end of pregnancy and recovery of body structures, sociocultural and emotional aspects involved in this experience. Sleep deprivation, isolation, or less social participation, restructuring of body image, sexuality and female identity, together with the tension and pain experienced during childbirth, responsibility and care in the face of the baby's fragility can generate ambiguous feelings and health problems, such as anxiety, depression and postpartum psychosis. The postpartum period is a phase that involves risks and the need for assistance for women and their babies (Assef et al., 2021; Silva & Krebs, 2021; Castro et al., 2019; Baratieri & Natal, 2019).

There are those who identify exterogestation in the postpartum period – “gestation outside the uterus” – for another nine months, due to the dependence on care that human babies are born with. The mother's total dedication to the baby, in theory, will provide future gains in the baby's autonomy in adult life. However, when dealing with a relationship (mother-baby), it is also necessary to take into account the conditions to exercise this role, considering the needs of the baby and those of those who provide motherhood (Hernandez & Víctora, 2021). However, these aspects are often neglected, and the newborn receives priority and attention from the health system (Castro et al., 2019; Baratieri & Natal, 2019).

The idea of playing another social role, adapting to the new routine and responsibilities as a mother, nursing mother and caregiver, require adjustments to the identity of the pregnant woman, now also as a mother. This highlights the need to provide comprehensive care to women in order to reduce stress, tiredness, frustrations and feelings of overload (Lourenço et al., 2022; Oliveira & Oliveira, 2019). In this context, of influences on routine, the occupational therapist can contribute to the care provided to this population within the scope of Primary Care. Thus, the objective is to investigate the role of occupational therapists with postpartum women in Primary Care actions at Nasf in Recife.

Method

The study, characterized as qualitative and exploratory in nature, complied with the provisions of Resolution No. 466/12 of the National Health Council (CNS), observing ethical care with obtaining the Free and Informed Consent Form, guaranteeing anonymity with participant numbers and exclusion of all data that could identify them, such as references to teams and capacity Health Districts.

The estimated population for the study was 20 occupational therapists, linked to the Nasf of Recife City Hall, who were recruited with the support of the Coordination of the municipal Health Department, also by individual invitation from the researchers and publicity on their social networks. As exclusion criteria, professionals in management positions and those who were training as residents were defined.

The interview used a semi-structured script, developed by the researchers, which enabled dialogue based on guiding questions, aiming to obtain data to understand the topic. It was held in April and May 2022, being scheduled according to the possibilities of the participants. The interview was recorded individually on the free online platform Google Meeting, which allows video calls. The recordings and notes were only accessed by the research team, ensuring confidentiality and protection of the participants' identities.

The recordings were transcribed for analysis following the organization and tabulation of the Collective Subject Discourse (DSC), a methodology developed by Lefévre & Lefévre (2005), which is based on the Theory of Social Representation, for which individual thought regarding a fact represents and communicates a collective construction of understanding of a given group and context. More than a thought, “representation is used to act in the world and in others” (Costa-Marinho, 2015, p. 93).

For Lefévre & Lefévre (2005), in the statements collected, the Key Expressions (ECH), Central Idea (IC) and Anchorage (AC) for the construction of the DSC are identified, which express the idea of a collective – in this case, the occupational therapists linked to Nasf in Recife. The summary speech is prepared with significant excerpts from the central ideas, written in the first person singular and which results from the combination of key expressions with the same meaning (Monteiro et al., 2021).

Results and Discussion

With the invitation, 14 of 20 occupational therapists showed interest in participating in the research. Of these, eight were interviewed; two were excluded because they held a management position; two were excluded because they were undergoing training as residents. Another two represent a loss among the eligible population, because, after three attempts to schedule, they did not indicate an available time within the collection period to carry out the interview.

Participants are women, aged between 35 and 49 years old. Half report having training, through courses related to women's/postpartum health, not specific to occupational therapy. Among those interviewed, six have been part of the Nasf team for 11-13 years, having been there since the service was implemented in the city, and two other professionals have worked at Nasf for between seven and nine full years. The professionals are linked to teams that are distributed across seven of the eight Health Districts, as a territorial division of the city and coverage of health actions. The results and discussion are presented based on the speeches related to the work of occupational therapists at Nasf in Recife shared with the Family Health teams and others specific to this professional.

When seeking to understand how occupational therapy at Nasf is part of actions aimed at postpartum women, there is a consensus among interviewees that postpartum home visits are carried out, as the responsibility of the family health team, which occasionally includes the Nasf team. Generally, care is provided by nursing, between 30 and 45 days after birth. The postpartum home visit is recommended for the first week, and at least in the first month of birth. The purpose of this early approach is to identify the mother-baby health status, encourage breastfeeding, offer appropriate guidance, and track risks for immediate intervention (Baratieri & Natal, 2019; Corrêa et al., 2017; Brasil, 2016). In the study by Canario and collaborators (2021), home visits were scarce, focused on the baby and clinical aspects, not meeting the minimum expected for that moment. In the evaluation, women felt little guidance regarding breastfeeding, family planning and self-care, therefore, visits and attention were unsatisfactory in these women's expectations. The home visit is, “due to the cycle, [...] the responsibility of the family health team”, as highlighted in the following DCS:

Generally, in the first month of life they already done it (home visits), nurses, which are more common, right [...], but not as an activity for postpartum women [...] specifically about postpartum women, I don’t remember, I don’t think so.

The literature states that the conditions for care in the postpartum period are programmatic and part of the work agenda of the family health team (EqSF) (Brasil, 2016). Monitoring is expected to occur prenatally and postpartum, ensuring the completeness of actions and continuity of care, prioritizing the family in its territory, reception, bonding, prevention, and health promotion actions. Being predicted, however, does not guarantee that it will be carried out or that it will meet needs (Canario et al., 2021; Corrêa et al., 2017).

The Nasf team was sporadically included in home visits for shared postpartum monitoring. For almost all interviewees, the Nasf team is rarely requested by EqSF for visits, which only occurs if there are problems with the woman or the baby. Nasf's occupational therapists recognize that there are needs of postpartum women that could be met, however, there is no routine, systematized work for them, other than that aimed at meeting the problems identified by the EqSF.

It is important to remember that Nasf is not a gateway with free access for users. Therefore, access for pregnant women (and other users) is mediated by the EqSF, which will discuss the case and the necessary interventions together with the Nasf teams (Brasil, 2010).

Table 1 presents the central ideas and speeches for the demands made to the Nasf team.

Table 1
IC and DSC regarding the performance of occupational therapy with postpartum women.

IC 1	DSC 1
EqSF does not request Nasf.	[...] we have a lot to contribute, but it is not required [...] the teams don't always know what we can do [...] they (Nasf professionals) have tried a few times to integrate themselves better, at least less so during the first postpartum visit, but it is a little difficult [...] as the Nasf team we assist those women in the postpartum period who the ESF signals to us that they need assistance [...] they see the need [...] then if they have any complications we provide support [...] we only have access to this postpartum woman if by chance the baby needs some type of intervention from the Nasf.
IC 2	DSC 2
Nasf to meet baby’s difficulties	Generally the Nasf team is requested [...] when there is any difficulty in breastfeeding [...] sometimes the speech therapist, the OT, but it is more related to the child's issue and not for them (the postpartum women) specifically [...].
IC 3	DSC 3
Nasf for problems with postpartum women.	[...] difficulty breastfeeding [...] when there is this issue of postpartum depression [...] some postpartum women who were unable to establish a mother-baby bond

Occupational therapists highlight that providing care to women who have recently given birth is not routine, due to the absence of a request from the EqSF. In the speeches, the lack of knowledge of the contribution of the Nasf team as health promoters for this population was identified as an anchor.

This thought corroborates the role generally attributed to occupational therapy in the rehabilitation stage, which has as its general objective the reduction of disabilities and adaptation to deficiencies, given already established conditions (Andrade & Falcão, 2017). The speeches thus demonstrate the valorization of work in the presence of postpartum difficulties, to the detriment of health education work, without necessarily the presence of any comorbidity.

The interviewees reported that, when requested, they carry out shared actions with the EqSF, as presented in the central ideas (IC) and DSC grouped in Table 2.

Table 2
IC and DSC referring to the actions of occupational therapists shared with the Nasf team.

IC 4	DSC 4
Individual and shared services	They are usually individual care [...] we do shared care with the doctor or nurse [...] we also do home visits [...]
IC 5	DSC 5
Breastfeeding support	[...] they talk to us a lot about breastfeeding [...] reinforcement of exclusive breastfeeding and baby latching issues [...].
IC 6	DSC 6
Guidance for postpartum women and support network	[...] provide guidance [...] talk about care at home [...] work on the birth process [...] carry out listening and guidance [...] guidance for those who share this moment with them (postpartum women), the family members who are the team, right, who are the support point. [...] there is a lot of activating the support network.
IC 7	DSC 7
Attention to mental health	It is important to work on mother-baby relationships [...] the issue of postpartum depression [...] we don't just bring a romantic vision (motherhood), we bring the care, the fears, the problems that can occur, the body issue that happens, self-image, self-esteem [...].
IC 8	DSC 8
Group service	There are groups [...] they ended up staying in the same group and then we formed the group of pregnant and postpartum women [...] The intervention is much more focused while she is pregnant, preparing herself [...] in the groups of pregnant women sometimes topics arose that they didn't know about, but are part of the postpartum period [...].

The actions carried out in the field of Primary Care are guided by the Protocols, Policies and Guides of the Ministry of Health. From the DCS, in Table 2, we identified that the actions follow the provided guidelines, the most common for Nasf being the assistance provided for breastfeeding maternal; baby care; postpartum mental health care. According to the interviewees, services provided by the Nasf team occur in four main modalities: individual service; shared individual care; home care and group care.

The groups demonstrate their power in monitoring pregnant and postpartum women, because they provide guidance such as sharing knowledge and educational practices on topics about prenatal care, development of pregnancy, signs and symptoms of childbirth and postpartum care during the gestational period (Canario et al., 2021; Luz et al., 2019). As mentioned in DSC 8, group situations address aspects that will be experienced after birth and the exchange of experiences between them also serves as guidance for the health teams. This sharing can even promote a strengthening of the support network among women in the territory (Silva et al., 2018).

Guidelines regarding breastfeeding are one of the fundamental factors for maternal and child health, with benefits for both mother and baby (Brasil, 2016). The advantages of breastfeeding include strengthening the emotional bond between mother and baby, benefits for women's reproductive health, promoting uterine involution and reducing the risk of hemorrhage. In addition to being a complete food for children, in most cases requiring additional food up to six months of age, it offers protection against infections and reduces the chances of developing allergies (Martins, 2013).

Mental health care is another topic emphasized by the interviewees and highlighted in the literature as one of the vulnerabilities of the postpartum period. The physiological changes of the body and the new routine of care, responsibilities and changes in social roles influence the experiences that result in women's mental illness and influence the care and development of the baby (Assef et al., 2021; Arrais et al., 2018). Among the demands of postpartum women monitored by Nasf occupational therapists in Recife, postpartum depression emerged more clearly; feeling of abandonment or lack of support network; changes in self-image and self-esteem.

The interviewees also presented the difficulties in monitoring the postpartum period, which are grouped in Table 3.

Table 3
IC and DSC regarding difficulties in monitoring the postpartum period.

IC 9	DSC 9
Unstructured work process at Nasf for the postpartum period	All teams provide postpartum follow-up, but this specific action is not usually in our routine [...] we have a form of care, but it is not systematized [...] there are many other demands that we have [...] the Nasf team is lacking [...] it could do more.
IC 10	DSC 10
Deficient professional training for work in the postpartum period	[...] I think that occupational therapy is important in all areas, but when I was in college I didn't have much of it [...] I discovered that I didn't have training for it [...] we study this issue of the postpartum period little, there are few things offered to us [...] in my graduation I don't think I saw anything even about pregnancy [...] I don't remember seeing a moment in my training that was aimed at women who has a baby and will be a mother for the rest of her life [...] I think we also have a structural difficulty, which is not understanding what the postpartum period is.
IC 11	DSC 11
Prioritize the child	What we do is follow-up even with the children, with the woman only when they come to us [...] OT is more related to the child's issue and not for them (the postpartum women) specifically [...] because sometimes the attention is very focused on the baby and they become kind of neglected [...].

When analyzing the difficulties presented in postpartum follow-up, the common work process was found to be little or not systematized and not aimed at women. This fact can be associated with the lack of training of professionals, as contained in the speeches (DSC 9) that address this absence in graduation. Furthermore, practice tends to be fragmented, as interventions take place punctually.

The lack of professionals prepared to approach the user comprehensively proves to be a complicating factor in actions in APS and Nasf. Furthermore, the work process requires professionals to have knowledge about public health policies, in addition to specific technical knowledge (Canario et al., 2021; Moreira et al., 2020). Therefore, it is necessary to adapt academic training to the SUS proposals, serving the population – including women in the postpartum period (Oliveira & Oliveira, 2019; Santos et al., 2017).

We can identify, in the work of Lourenço et al. (2022) and Santos & Fornereto (2020), evidence of the work of occupational therapists in pre-delivery, labor, postpartum and other gynecological and obstetric situations aimed at caring for women's health and exerting an additional protective factor for maternal-children’s health. Focusing on occupational performance, they help pregnant or postpartum women and their families to carry out their occupations, respecting their completeness as a biopsychosocial subject and contributing to the performance of occupational roles in everyday life in a satisfactory manner, as described below.

When asked about the actions carried out by occupational therapy as part of the Nasf team, the participants brought in their reports the routine, social role, and relationship with the occupations of women in the postpartum period, as presented in the following DSC:

It is always important to remember that the postpartum period is not an illness [...] it is a moment in life when the relationship with your occupations becomes completely different, you become another person, a new occupational role with new tasks for life [...] it's a completely different routine than any other audience.

Roles and occupations are social constructs and are correlated with the activities in which individuals engage (Associação Americana de Terapia Ocupacional, 2021). In the case of the role of mother, social factors linked to the idealization of gender attributed to women influence the way in which this role will be experienced. These influences have repercussions on the idealization of motherhood, causing mothers constructed under the idealization of gender to shape themselves to achieve the culturally suggested representation. These difficult reconciliations interfere with women's occupational performance, as, to manage their roles as women-mothers, concessions, abdications, and restructuring are necessary within their daily lives (Lourenço et al., 2022; Behar, 2018).

In his work, Gomes (2021) argues that gender is a question of Occupational Therapy as it is based on the development of care that occurs in relationships and encounters with others, in the analysis and understanding of daily life, life trajectories, affections and of desires. It also reinforces respect for the commitment that must exist as a profession and field of knowledge to construct epistemologies aligned with diversity, existence and singular and plural expressions of life and belonging.

We understand that the changes for women and their occupations with motherhood are perceived by the interviewees as part of the condition of being a woman, although they do not refer to this, as permeated by the gender condition. This possible naturalization of roles manifests itself in other conditions and professional approaches, often causing difficulties in the experience of those receiving care. When referring to gender, the social representation of mother and woman are strongly linked, since performing the role of being a mother involving mothering and care is part of what is perceived as part of being a woman (Lourenço et al., 2022).

The burden on women in caring for the baby can be alleviated through care provided by professionals. Understanding comprehensiveness in health care involves going far beyond the physiological aspect, it also represents an understanding of the spheres of the woman's relationship with her baby and the entire environment in which she lives; create a space to listen and welcome their anxieties and sensitive topics, such as body image, sexual activity, and discomforts of their new role (Lourenço et al., 2022; Corrêa et al., 2017).

The approach to gender in professional discourse and practice is portrayed as incipient in Brazilian Occupational Therapy, as evidenced in other studies, including those by Andrade (2017) which point to a worrying scenario regarding the mainstreaming of gender in the training of occupational therspists, with an absence of content, disciplines and teachers with training or production of knowledge in this area (Ferreira & Almeida, 2022).

On the other hand, it is worth highlighting that one of the interviewees brought up a point in her speech that differed from the others, when talking about monitoring women in the postpartum period, including the possibility of pregnant men, which refers to an issue that is also contemporary and related to discussions of gender.

[...] I say women because we have never had a situation with a pregnant man, so my reality is that of a pregnant woman with a baby (Participant 8).

The history of public policies aimed at comprehensive health care for the LGBTQIA+ population is short, lasting just over a decade. The experience of the gestational process by this population, specifically by trans men, is little known or invisible (Angonese & Lago, 2017). Even if the action does not occur directly with this public, the fact that they are mentioned portrays a change in the perspective of comprehensive care for human health. This statement validates the existence of this population and recognizes the possibility of support from Nasf occupational therapists.

Another peculiar aspect brought up by an occupational therapist (Participant 8) is that “there is a postpartum period without a baby”. In this discourse, it is also possible to perceive death and mourning for a baby as a reality not planned by the woman, whose expectations and idealizations are interrupted. In this condition, the biological, psychological, and social adaptations and changes of the postpartum period can be intensified by grief. Therefore, it is up to the health professionals who accompany this woman, regardless of the level of care, to welcome and offer adequate support to face this difficult time (Medeiros et al., 2022).

It is important to highlight that postpartum care in Brazil, even in areas covered by Primary Care, is low and marked by regional and social inequalities. Women who usually attend health units have a greater bond with health professionals and those who are covered by income transfer programs are more likely to undergo this monitoring. Thus, for longitudinal assistance appropriate to physical, psychological, emotional, and social health needs, it is essential to consider the family and community context of these postpartum women, which normally add to economic issues, racial structural difficulties, and support network difficulties (Baratieri et al., 2022).

With this understanding of the postpartum period, some actions and strategies are promoted by occupational therapists in the Nasf teams at Recife and can be highlighted based on the DCS in Table 4.

Table 4
IC and DSC regarding occupational therapeutic activities with postpartum women.

IC 12	DSC 12
Guidelines and resumption of occupational roles	[...] we are doing well in this life process [...] showing her that she continues to be a woman regardless of being a mother [...] this moment of sitting down and talking to the person to understand who they are, who they want to be and where they want to get [...]
IC 13	DSC 13
Routine structuring	[...] help her organize this routine [...] with the demands of care [...] know and fit this new daily life for her [...] into the accumulation of occupations that she will have upon arrival of child [...] exercises that she can do on a daily basis.
IC 14	DSC 14
Guidance or support with daily activities	[...] how can we really advise on the utensils she will need, the space she will have [...] organization of devices and day-to-day adaptations [...] train with them this return home and the care that must be taken [...]

With the acquisition of the maternal role, new demands arise for the woman's routine that can be challenging. Occupational roles are related to the daily routine and human behaviors, regulating, and organizing them according to the subject's personal skills, the context, the people involved and the frequency with which it is performed (Lourenço et al., 2022; Behar, 2018). In the case of postpartum women, attention to adapting to the new role of mother and her new responsibilities related to caring for herself and her baby proved to be a priority in the occupational therapeutic intervention at Nasf.

According to Lourenço et al. (2022) and Fraga et al. (2019), playing the role of mother is a social construction linked to gender, linked to the care and monitoring of the child's health. It can be influenced by the woman's previous experiences as a daughter and through the relationships she establishes with the baby after birth. The maternal role takes place through a construction process in which the woman experiences and can count on the contribution of the occupational therapist in all processes of the mother-baby binomial.

The process of maternal care, based on the dyad between the mother and child's occupations, can be understood as co-occupation. This terminology refers to the involvement of two or more individuals in an occupation, so that each person influences the other. Sometimes, involvement in these co-occupations can lead to women distancing themselves from their other social roles. In this way, based on knowledge of expectations, the occupational therapist can facilitate women's involvement in co-occupations and in their social roles and occupations of interest (Fraga et al., 2019).

Occupational therapists report their work with postpartum women, aimed at developing strategies to improve the performance of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). According to Nascimento et al. (2017), the practices carried out by the occupational therapist in relation to ADL and IADL contribute to occupational performance in the daily routine, reduction of health problems, promotion of autonomy, functional independence and well-being of the women assisted.

The Recife Health Department (Recife, 2022) also guides, through the Basic Care Protocol: Prenatal, childbirth and postpartum care, the specific competencies of occupational therapy in the Nasf team for care for women with Habitual Risk pregnancies. The competencies include: “intervening individually with the postpartum woman and/or caregivers aiming to (re)construct a routine in their daily life activities (eating, bathing, dressing and self-care/hygiene), professional and leisure life” (Recife, 2022, p. 28).

Both pregnancy and the postpartum period are perceived differently by each woman. Depending on their experience and personal history, some may need the help of an occupational therapist to facilitate their passage through this stage in their lives. Whether this is direct facilitation, with specific actions that may have occurred and caused occupational harm, or with general actions for health promotion.

Final Considerations

The research made it possible to understand, based on the collective construction of Occupational Therapy activities with postpartum women at Nasf, the actions they perform in this context. Furthermore, it also highlighted the understanding of occupational therapy in the area of Women's Health, which presents itself as a field of action that is still little explored in its intervention possibilities.

Occupational therapists from the Nasf teams demonstrate difficulties in carrying out postpartum follow-up due to a poorly or unsystematized work process, due to less knowledge of their possibilities of action in promoting women's health in the postpartum period. Another complicating aspect is the lack of undergraduate training for a comprehensive approach to postpartum women, as reported by professionals.

The study identified several activities with postpartum women promoted by occupational therapists in the Nasf teams, compatible with the foundation of the profession and with the teamwork process they carry out with other populations. With regard to occupational therapy activities at Nasf, guidelines for resuming occupational roles, routine structuring and guidance or support for daily activities were highlighted, which demonstrates the transversal look at the person in their uniqueness and the context in which who play their roles.

• How to cite: Vidal, C. C., Marques, A. L. M., Jucá, A. L., Silva, E. V., Gomes, S. O. L., Alves, C. K. A., & Falcão, I. V. (2023). Occupational therapy practice with puerperal women in the actions of the family health support center. Cadernos Brasileiros de Terapia Ocupacional, 31, e3504. https://doi.org/10.1590/2526-8910.ctoAO268935042

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Edited by

Section editor

Prof. Dr. Marta Carvalho de Almeida

Publication Dates

• Publication in this collection
  08 Dec 2023
• Date of issue
  2023

History

• Received
  22 Jan 2023
• Reviewed
  30 May 2023
• Reviewed
  12 July 2023
• Reviewed
  15 Aug 2023
• Accepted
  26 Sept 2023