Centrality of family bonds in the experience of middle-aged women*

* Extracted from the thesis: “Demandas de saúde na experiência de mulheres de meia idade”, Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem, Universidade Federal da Bahia, 2018. 1 Universidade do Estado da Bahia, Departamento de Educação, Guanambi, BA, Brazil. 2 Universidade Federal da Bahia, Programa de Pós-Graduação em Enfermagem e Saúde, Salvador, BA, Brazil. 3 Universidad Complutense de Madrid, Madrid, Spain. 4 Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. ABSTRACT Objective: To analyze meanings attributed to middle-aged women from their experience in their family relationships. Method: Qualitative study of the Convergent Care Research method. Gender was used as an analytical category, developed with a total of thirteen middle-aged women from the coverage area of the Family Health Strategy program in a city in the southwest of Bahia state, through reflection workshops and interviews. Data were analyzed using discourse analysis. Results: They express the affective relationship with children and grandchildren as the greatest highlight of middle age in overlap with the relationship with partners and other bonds, which makes their uniqueness and identification of demands for health care unfeasible. Conclusion: Female middle-aged are marked by conceptions of femininity that emerge from their condition as a woman-mother, from her complete donation. The research points to an urgent need to add gender as a reference for the care of middle-aged women, in order to consider the biopsychic and social interlaces in their life experience and that outline demands for care.


INTRODUCTION
Middle adulthood is understood as a period of life within the so-called adult age, inserted in the aging process (1) . Several studies define it as a period from 45 to 59 years old (2)(3)(4)(5) . The experience of middle-aged women is configured, in part, by the way in which each culture conceives the aging process and the social roles of women. Thus, deconstructing discourses that favor the stigma associated with female middle age is essential and, at the same time, open possibilities for understanding the plurality of being a middle-aged woman, in view of bodily, family, work and social changes, historically and socially situated, that extrapolate the occurrence of menopause or the empty nest, caused by children leaving their homes.
During this period, there are changes in the scope of life, work and family relationships, such as widowhood, divorce, children leave their homes and/or grandchildren are born. In addition, many women have been marrying and having children "later" outlining new configurations and arrangements: middle-aged women with kids and adolescents at home, and who may also be responsible for the their parents' care, which can affect the experience of this transition period (6) . Despite the complexity of biopsychosocial and cultural issues that permeate female middle age, health actions directed at middle-aged women in Brazil and other countries have been insufficient, even in the context of primary care (7)(8) .
The National Policy for Integral Care to Women's Health (Política Nacional de Atenção Integral à Saúde da Mulher -PNAISM) addresses women's health in middle age as a climacteric, presenting action plans to implant and implement care for this population group at the national level (9)(10) . A study carried out at a Family Health Unit in São Paulo, SP indicates that there is no organized demand for the development of actions with women and that the existing services occur due to spontaneous demand or are guided by protocol actions, such as prevention programs for cervical and breast cancers, hypertension and diabetes control, which seem to focus on diseases and fragment care (11) .
In contexts of medicalization of health, gender issues are almost always absent from the health service and also from the demands most valued by users, not due to their inexistence, but due to acculturation towards medicalization. From this perspective, it is necessary to have a critical view on the implications of gender in the field of health and on the contradictions and limitations of the biomedical logic that hinder this perception (12) .
Thus, considering it necessary to add knowledge that goes beyond the strictly medical view of middle adulthood, seeking to raise subsidies for care proposals for these women, one has the following objective: to analyze meanings attributed to middle-aged women from their experience of this stage in their family relationships.

Study deSign
This study is characterized as qualitative of a Convergent Care Research (CCR) method, which consists of a research method in which there is a commitment to the construction of knowledge and juxtaposition to the care processes and practices (13) . This is part of a larger research named Health demands from the experience of middle-aged women which involved health professionals and middleaged women. In this article, one presents the results referring to the empirical category called Centrality of family bond in middle adulthood, composed entirely of speeches by middle-aged women.
Gender was used as an analytical category. It constitutes a socio-historical-cultural construct, which delimits hierarchical social roles for women and men. As an analysis category, it favors the recognition of asymmetries of a relational character related to women and men, and their implications in the daily relationships and in the configuration of women's health demands (14) .

Selection criteria
The inclusion criteria were: being in the 45 to 59 age group, being enrolled at the Family Health Strategy (FHS) program in a city in the southwest of Bahia and the exclusion criterion was: being pregnant. One defined the number of two or three women per micro-area, which totaled sixteen invitations made by the researcher through a home visit, accompanied by the community health agent from the micro-area, scheduling the first meeting. Days and times for subsequent meetings were agreed at the end of each workshop provided.

PoPulation
A total of ten women attended the first workshop, another one attended only the second one and two were inserted later, participating in the third and fourth meetings. Thus, thirteen middle-aged women from a family health unit in a city in the southwest of Bahia, where the researcher develops regular activities as a university professor, took part in this research.

Production of emPirical material
The production of empirical material took place through two reflection workshops and interviews in May and June 2017. The reflection workshops offer space for discussion and educational intervention on issues related to women's daily lives and on gender relations, enabling horizontality of power (15) . Each workshop was carried out by the researcher with two or three collaborators and started once participants had filled out an identification form and socioeconomic data. The operation took place following the steps: Presentation/Relaxation; theme development; socialization of Experiences; synthesis, performed by the coordinator and, assessment, performed by the whole group (16) .
The first workshop sought to sensitize women to care from the perspective of valuing subjective aspects, problematizing reality with sensitive listening, welcoming and identifying demands, while the second one sought women's opinion on raised demands. The average meeting time was three hours, with a break in between. The process was photographed, the speeches recorded and transcribed in full and the observations recorded in a field diary. The speeches were organized in the form of a narrative and examined in order to identify relevant aspects directed to the research objectives, which generated a synthesis.
Once the speeches were transcribed and examined according to the research objectives, one identified five women who were further interviewed in order to deepen themes of their discourse, due to the greater need to listen, considering the demands presented. Beyond verbal speeches, one observed periods of silence and expressions of restlessness/anxiety. These participants had demands related to the involvement of children with drugs, domestic violence, housework overload, children who still demand financial support and care, anxiety and difficulties to sleep. Thus, five women were selected and invited to participate in the interview, with its date and time agreed for. Only one interview was conducted at the participant's home by choice.
Reflection workshops and interviews, as well as methodological strategies for the production of empirical material made possible the convergence of research and care, in compliance with the principles of the CCR. The workshops favored an exchange of experiences and a reflective approach to middle-aged women from a problematizing perspective. In the interaction, the participants recovered emotions, experiences and exchanged knowledge and strategies to deal with their demands. In the interviews, women showed to be in a trusting relationship with the interviewer and made reports of the intimacy of their life that, although not necessary as empirical data for research, they proved to be important for them, due to the need for listening and welcoming.

data analySiS and treatment
Data analysis was performed using the discourse analysis technique according to Fiorin, for whom discourses are social positions, whose ideological formation is materialized in verbal language (17) . One carried out the following steps: 1) Comprehensive reading of the entire text to identify concrete (figures) and abstract (themes) semantic elements which lead to the same plan of meaning; 2) Grouping of data according to the significant elements that make up the same meaning plan; 3) Apprehension of central themes; and 4) Formation of empirical categories (18) .

ethical aSPectS
The research was conducted in accordance with the ethical standards required in Resolution 466/2012 of the National Health Council, and was approved by the Research Ethics Committee from the Universidade do Estado da Bahia (UNEB) in 2017, under number 2,063. 533. To ensure anonymity, the participants were identified with the letter P, followed by an Arabic number. The abbreviations corresponding to the technique that enabled the recording of women's speech, workshops (WS) and interview (I) are included at the end of each speech.

RESULTS
The study included women aged 45 to 58 years old. Five of them could not read, four had completed or incomplete elementary school, three had completed high school and one of them finished higher education. Ten declared themselves brown, two black and one declared herself white. Seven women were married or in a stable relationship, five were divorced and separated and one was single. Ten reported being Catholic and three reported being evangelical.
As for occupations, they reported being a vegetable seller, laundry washing, housewife (five), baker, seamstress, nursing technician, household assistant (two), one was retired and the other was receiving sickness aid. Two received social benefits from the Bolsa Familia Program. As for family income, it ranged from less than one minimum wage to three minimum wages.
The central empirical category, which gives the article a title, is analyzed from the following empirical subcategories:

What marks my life is my children, I am proud of all four children I have and my four grandchildren (P6, 51 years old, WS).
When women talk about motherhood as power, at times, they refer to the fullness of having given birth, having raised and seeing children building independence, creating new families and starting a new generation: The only woman who was not a mother considers it possible to be happy without having children, but she is questioned by one of the participants, according to the following dialogue: The woman who has no child has no joy in life (P4, 46 years old, WS).

I have no children, but I am happy (P8, 45 years old, WS).
Yes, but it is empty. Isn't it? It is empty. I have never seen a woman who did not have a child and did not want to (P4, 46 years old, WS).
When affirming that the dream of becoming a mother was not fulfilled, seeking to care for nephews to exercise motherhood, as shown below, participant P8 expresses ambivalence towards the existence of this void, although other achievements stand out: Performing professionally, having my family close by, having a job, being a mother (...) I managed to go to college and have a profession with a lot of sacrifice (...) I couldn't do it as a mother, which was my dream too, but I have no problem with that. I take great care of my nephews as if they were my children (P8, 45 years old, WS).
The independence of children is limited in unfavorable social and economic contexts. In the reality of some women in the study, children still demand financial support and grandchildren demand care: I am still raising my children today. When we finish raising our children, the grandchildren come home. So, it's the same. Even today I'm raising kids (P13, 52 years old, WS).
I have a son who is a drug addict. He doesn't hit me, but I help his wife and his kids. When he is not with his wife, he is at my house (P10, 52 years old, I).
One of the participants, when referring to the reasons why middle-aged women take care of grandchildren, renewing their maternal role states: Life goes on as if it started all over again, giving birth. That's why they don't have time to take care of themselves. After their children, the grandchildren come (…) Everyone inside the house (…) (P8, 45 years old, WS).
The involvement of children with drugs causes concern, insecurity and fear in middle adulthood, when these women are facing problems, whose overcoming goes beyond the condition of mothers, as shown in the following statements: My concern is my son What I have is a lot of concern about the youngest boy. He lived in the world of these drug people (…) He is dealing with drugs again (P7, 50 years old, I).
middle adulthood aS a SPace to give meaning to exPerienceS with PartnerS The participants in this study recovered their experiences with a focus also on the relationship with the partner, highlighting it as a contractual relationship, of provision and family protection, without highlighting more intimate issues, related to romantic love and sexuality.
Some refer to domestic violence as a mark that remains in middle age, being submitted under the argument of still dependent children, in an unfavorable socioeconomic context: Simultaneously with the domestic violence that affects the well-being of women, there are situations in which unemployed and alcoholic partners, when carrying out occasional jobs, ignore the responsibilities for family provision: When he [husband] is drunk, I don't sleep. I am afraid of falling asleep because he may do something to me (…) What bothers me the most today is that he stays at home without getting a job. This is too bad (P4, 46 years old, I).
In the experience of women, there are also break ups of marriage after children are grown, restructuring the nuclear family in a new relationship. This new bond is expressed as a need for protection, security of family provision, respectful relationships that meet a family demand without the conflicts of violence, in a financial partnership, allowing an improvement in living conditions. However, affective detachment is demonstrated under references to romantic love referred to by the woman as the result of an agreement.
I met this man (...) he is not rude with me, he is neither brute, nor ignorant. He gets along with my children (...). But he is a person that I am with and I don't even know why. Because there is no longer that great love (...) There is that partner that when the weekend comes, he gives me R$100.00 to buy meat and vegetable. He buys cereal (…) Like, a livelihood that I have when I'm not working (P11, 58 years old, I).
Having grown-up children is an opportunity for women to break free from violent relationships, and this condition is also a mark of middle age for women in this study:

If it was my time now, I wouldn't be married. I would go to a good college. I would have a son by myself. And I wouldn't want any men in my life (P1, 49 years old, WS).
care of otherS in SuPerPoSition with the care of themSelveS Some women, when referring to self-care, attribute to their children the way they see themselves, as an old woman, and without the requirements to be admired, transforming the care of self-image and self-esteem unnecessary. Thus, the time lived is represented as devoid of the condition of a woman with a body that expresses sexuality/sensuality: Sometimes the children could be supportive for us to be more beautiful, for us to go out. Instead, they say: "Why do you want this?"; " You are old"; "Why buy clothes"; "Why go to the salon?"; "What is all this for?" (P5, 56 years old, WS).
This social position coexists with another one in which children stimulate the mother to take care of the body and appearance under the framework of youth, in the perspective of distancing signs of aging, while valuing it. However, the sense of aging remains negative and as something to be avoided:  Women who said they care about themselves and seek to take care of themselves, breaking the logic of subjection to what another person demands, redo a movement that dislocates them and positions them in a constant disposition to the other. Thus, they can hardly express their demands: I worry about myself because we also have our children, we have a husband for us to take care of. I worry about myself, you know, we have to be well to serve our people, our family (P3, 58 years old, WS).

DISCUSSION
In this study, women express the power of motherhood as a major highlight of middle adulthood and the centrality of the bond between mother and children as a strengthening of subjectivities. The analysis of the discourses reveals an identity construction strongly marked by cultural values that naturalize motherhood and that, once introjected and experienced, is considered a requirement for well-being, attributing incompleteness to those who did not go through this experience.
Children appeared as one of the few reasons for the pride of middle-aged women participating in this study, and it is precisely the success of children that gives meaning to the perception of their own vital achievement. A study draws attention to the notion of achievement as a result of the socialization processes of men and women, due to gender issues, highlighting the discourse of women who take the achievements of their children as an achievement of themselves (19) . Thus, when children leave home to go on with their own lives and personal projects, some studies have shown the possibility of women experiencing what is called an empty nest (20)(21) .
However, this is not a reality of the participants in this research, since they reveal in their speeches that children continue to demand attention and care for social and economic issues. The level of financial independence of children defines limits on the lives of women in this age group, in addition, some women feel as if they were reconducted to their role of mothers in the care of grandchildren. Others do not reach a sense of fulfillment when children are grown when their behaviors diverge from family and social expectations, such as when they become drug addicts, imposing the potential to enhance maternal function.
As their children are raised, the research participants maintain their maternal role and extend it to their grandchildren. Moreover, these women are usually in financial vulnerability, creating conditions for the woman to become a selfless wife.
Regarding the bond with partners, domestic violence was highlighted in this study. Even in the face of relationships in which the partner did not contribute to the financial provision and/or direct care in the domestic and family environment, the maintenance of a violent marital relationship is credited to the need to raise little kids, lasting for years, www.scielo.br/reeusp Centrality of family bonds in the experience of middle-aged women Rev Esc Enferm USP · 2021;55:e03734 which portrays the place of authority and dependence of the male figure in the nuclear family.
Domestic violence is complex regarding the bonds that support relationships. Thus, an emotional bond may not be broken due to violent relationships. Financial issues, family pressures and care for children contribute to this, reproducing religious and common sense discourses as the basis for maintaining the imbalance of power in relationships and the naturalization of male violence against their partners (22) .
However, in middle adulthood, as their children have already been raised, it is possible to break violent relationships. Thus, possibilities are opened for a period of greater self-realization and female autonomy, which is presented as a finding in this study.
Research on conjugality in middle adulthood has shown that aspects such as companionship and tranquility are valued as factors of marital satisfaction. Furthermore, it demonstrates that the theme needs further study, with difficulties in finding more targeted studies (23) .
Despite accumulated dissatisfactions in the marital relationship, some participants do not see possibilities of making decisions in the sense of ruptures and, in this perspective, are resigned, managing to subvert social norms only based on wishful thinking. From the gender point of view, they tie their subjectivity to the role of women as mothers, as selfless women, leading them to remain trapped in male submission, even after "fulfilling the duties of motherhood".
In family relationships, the middle-aged women participating in the research care for and respond to the needs of others, demonstrating how striking the socialization of women is for childcare and domestic care. Thus, they move to a place of resignation and little care for themselves where children, grandchildren and husbands are the signifiers for longings and self-care.
The care of oneself is linked to an external point of view, of another person, revealing an evaluative approach beyond their control, their needs and desires. In addition, they have a negative mirror, since the valued beauty has the young body as a standard. Thus, they pursue an acceptance taking as a reference the young body which contributes to the woman's distancing from the valorization and legitimization of their own body.
This observation can be understood in the light of the "el yo espejo" theory, according to which the "I" constitutes an idea or a set of ideas extracted from the communicative life that the mind holds as if it were its own and seems to be integrated by three central elements: the imagination of our appearance to the other person; the imagination of their judgment about this appearance and some kind of feeling, such as pride or mortification (24)(25) .
The participants define themselves in relation to the other, in a very subject condition, as an eccentric subject (26) . They show that they assume a familiarly feminine position in family relationships, in the light of gender, "relational yo" (26) . In this place, they tend to prioritize the relationship and give prominence to their presence and availability, often becoming the maintainers and caregivers of their bonds. On the other hand, the "yo fortaleza", male position, tends to establish a series of limits on what can be expected from them in affective bonds (27) . It should be noted that, as the authors themselves recall, it does not mean that the former are assumed only by women and the latter by men, although it is the most frequent situation.
Thus, in this study, gender presented itself as a lens to problematize and deconstruct essentialist and naturalizing readings of the female universe, through their experiences, demands and health care. It allowed us to look critically at its implications in the field of health, signaling the importance of transposing the biomedical logic towards a type of care that could be more congruent with the demands of middleaged women and their life contexts.

CONCLUSION
The findings of this study show that middle-aged women are marked by conceptions of femininity that emerge from their condition as woman-mother, from complete donation to their children and family. In addition, this period of life enables women to look back and see themselves as a mother who took care of children and who went through and succeeded in life and today, they express a social position of accomplished mission, even if new demands are presented as an unfolding matter.
The role of mother and grandmother takes a central position in the lives of those who participated in the research. Thus, they reaffirm themselves as people who take responsibility for the demands of children and grandchildren, taking into account the response given to the needs of another person for their appreciation, becoming invisible to themselves. Without their own projects as a woman, they almost entirely restrict their existence to their maternal function. They deny themselves the assumption of the role of subject in their history, which makes it difficult and even impossible to identify their own demands for health care.
The research points to an urgent need of gender approaches to better understand the life contexts and demands of these women, obtaining subsidies for the care of middle-aged women. Thus, one should consider aspects related to the biopsychic and social entanglements, gender problems, social class and race/color in the generation of health demands of middle-aged women.
The conduction of this research, through the adoption of the CCR method, made it possible to know meanings attributed to middle adulthood from the experience of women in their family relationships, while allowing care, based on their narrated experiences as a justification for this care. Its results offer subsidies for future projects in the scope of Teaching, Research and Extension. It also offered immediate compensation to the participants favored by the problematizing methodology adopted, in addition to listening sensibly to their demands.
Although a common characteristic of qualitative researches, the sample size may represent a limitation. Even though the generalization of the results or information presented is not intended, one highlights that the experience of these women, from a specific context of economic and social vulnerability, may be common to a large number of women.

RESUMEN
Objetivo: Analizar los significados adjudicados a la mediana edad desde la experiencia de mujeres que la viven en sus relaciones familiares. Método: Se trata de un estudio cualitativo de la clase Investigación de Cuidados Convergentes en el que se utilizó el género como categoría analítica. Se llevó a cabo mediante talleres de reflexión y entrevistas entre trece mujeres de mediana edad que estaban bajo la Estrategia de Salud Familiar de un municipio del suroeste de Bahía. Los datos se analizaron a través del análisis del discurso. Resultados: Se identificó la relación afectiva con hijos/as y nietos/as como una marca importante de la mediana edad que se superpone a la relación con la pareja y otros vínculos, lo que restringe la identificación de su singularidad y las demandas para el cuidado de la salud. Conclusión: La mediana edad femenina está marcada por concepciones de feminidad que surgen de su condición de mujer-madre, de entrega total. La investigación señala la necesidad urgente de añadir el género como referencia para el cuidado de las mujeres de mediana edad, con el fin de considerar el entramado biopsicosocial en su experiencia de vida que perfila las demandas del cuidado.