NUTRITIONAL GUIDANCE DURING PRENATAL CARE IN PUBLIC HEALTH SERVICES IN RIBEIRÃO PRETO : DISCOURSE AND CARE PRACTICE 1 Luzia

This study aimed to verify if pregnant women attended in prenatal care services at Basic Health Units in Ribeirão Preto-SP, Brazil, received nutritional guidance and if this guidance was pertinent to their nutritional status. Ninety-one pregnant women participated. The pregnant women were classified according to their nutritional condition, using a weight, height and pregnancy stage table established by the Brazilian Health Ministry’s technical prenatal care manual. We found pregnant women with weight under (13.19%) and exceeding normal levels (37.36%). Independently of their nutritional condition, most of them (60.43%) declared they did not receive nutrition guidance. The mean number of prenatal visits did not influence the nutritional status. The results reveal deficiencies in the contents and quality of nutritional care. This suggests the need for care changes so as to turn discourse into practice.


INTRODUCTION
Adequate nutrition is fundamental in any stage of the lifecycle to promote, prevent, maintain and recover health (1) .During pregnancy, nutritional needs change to permit the development of the fetus, as well as to supply women's nutritional needs.
Among pregnant women with nutritional alterations, the following appear more frequently: infections, parasitoses, hemopathies (anemia), hypertensive syndromes, placental insufficiency, obesity; greater chances of hemorrhage during delivery and puerperal infection; as well as the possibility of premature infants, with intrauterine growth restriction (IUGR), presenting greater possibilities of neonatal infections, respiratory diseases and increasing perinatal death statistics (2) .
Assessing body weight and surveying eating habits during prenatal care are important strategies to identify pregnant women's nutritional conditions and permit individualized nutritional guidance with a view to optimizing the mothers' nutritional status, improving maternal conditions for delivery and adapting the infant's weight (3) .
The Brazilian Health Ministry (MS) determines the understanding of the multiple meanings of pregnancy for these women and of the context they are inserted in.This makes prenatal care a privileged moment to discuss and clarify each woman's unique questions (3) .Thus, nutritional guidance should be offered in accordance with each patient's economic, social and cultural possibilities (4) , which implies the need to adequately prepare health professions about this subject (1) .
Health professionals in this care context can assume an important role in guidance, in encouraging pregnant women about healthy living and nutritional aspects, in identifying pregnant women at nutritional risk by assessing their nutritional condition, as well as in referring pregnant women to social assistance programs when situations of need are diagnosed.
During care delivery to pregnant women taking part in the Nascer ("Birth") Project maintained by the Ribeirão Preto Municipal Health Secretary (SMSRP), we identified a considerable number of women who mentioned they had not received any nutritional guidance until that stage in their pregnancy; as well as the absence of nutritional status records on the prenatal cards.
The mother's nutritional condition is determinant for fetus growth and the infant's (RN) weight.There is concrete evidence that weight gain during pregnancy serves as a prognosis for the RN's weight at birth, which can be affected by the mother's nutritional status and size before pregnancy.
This is important from a public health perspective, since birth weight is one of the parameters that is most associated with RN survival, growth and mental development.
We departed from the premise that the pregnant women who were receiving prenatal care in the Ribeirão Preto public health services, were neither being assessed nor adequately advised about nutritional aspects.Our initiative to realize this study was motivated by the need to intensify nutritional actions and care with a view to high-quality prenatal care.

OBJECTIVE
This  (5)(6) .The nutritional status was assessed after surveying the pregnant woman's size and weight during the first prenatal visit at the maternity hospital, consulting her pregnancy card, and after determining the gestational age (from the 13th week of pregnancy onwards), observing weight (10 th and 90 th percentiles) on the intersection of maternal height and gestational week (5)(6) .
The pregnant women were divided in three groups, depending on their weight/height index, following the weight-height table according to gestational age, as follows: Group 1: pregnant women whose weight was below normal levels for their gestational age (below 10 th percentile); Group 2: pregnant women whose weight was within standard levels for their gestational age (within the 10 th to 90 th percentile); Group 3: pregnant women whose weight exceeded normal levels for their gestational age (above 90 th percentile).
Data related to nutritional status assessment and the pregnant women's characteristics were analyzed using frequencies.We also analyzed means and standard deviations for the number of prenatal visits which these women attended.

RESULTS
The results are related to the assessment of the women's nutritional condition, to their characterization according to age and obstetric history and, finally, to the nutritional guidance they received in prenatal care.

Nutritional Condition of the Pregnant Women
The study participants were divided in the groups described above (Groups 1, 2 and 3), depending on their weight/height index according to the table of weight-height for gestational age (Table 1).

Characterization of pregnant women according to age and obstetric history
The sample included more adult (74.72%) than adolescent pregnant women (23.07%).In the group of adolescents, 14.28% belonged to Group l, 38.09% to Group 2 and 47.61% to Group 3.Among adult participants, 13.23% belonged to Group l, 57.47% to Group 2 and 35.29% to Group 3.
In the total group of participants, 41.75% started prenatal care in the first, 50.54% in the second and 5.49% in the third trimester.Their nutritional condition varied according to the trimester when they started prenatal visits.(Table 2

Nutritional Guidance
We identified that 37.36% of the pregnant women we interviewed had received nutritional guidance, whereas 60.43% had not.When looking at the groups, 75% of women in Group 1 had not received any guidance, against 58.13% in Group 2 and 61.78% in Group 3.
Pregnant women in Group 1 received the following advice: "Do not eat fried food or light products*", "Eat vegetables" and "Consume a healthy diet".Tables 3 and 4 show the advice received in the other groups.In the study group, 83.51% denied unhealthy life habits, 12.08% indicated smoking and 2.19% alcoholism.We did not identify any illegal drug consumption.In Group 1, 41.66% mentioned smoking, 58.33% denied unhealthy habits and we did not find any cases of alcoholism.In Group 2, 88.37% of the pregnant women denied unhealthy habits, 11.62% were smokers and no alcoholics were found.In Group 3, 91.17% denied unhealthy habits, 2.94% mentioned smoking and 5.88% alcoholism.

DISCUSSION
The urge to verify if pregnant women attended in public health services receive nutritional guidance during prenatal care and if this guidance is pertinent Other suggestions include: the elaboration of prenatal health education programs about nutritional assessment and guidance, to the example of the pregnancy course, waiting room, and recycling for the nursing and medical team active in prenatal care.We also highlight the need to demand health policies in favor of food and supplement distribution to pregnant women in need.This can contribute to the improvement of women's nutritional health in the gravid-puerperal cycle, as well as to newborn health, and collaborate to put the systemization of nutritional assessment and guidance of pregnant women into practice.

Table 1 -
Distribution of pregnant women according

Table 2 -
Nutritional Condition and Start of Prenatal Care, Public Health Services, Ribeirão Preto, 2002

Table 3 -
Nutritional guidance received by pregnant women in Group 2, Public Health Services, Ribeirão Light Foods: are food products with a minimum reduction of 25% in calories or another component (fat, carbohydrate, protein, etc.), in comparison with the normal version *