PRENATAL QUALIFICATION COURSE: INTERPROFESSIONAL CONSTRUCTIONS AND RECONSTRUCTIONS

CURSO DE CALIFICACIÓN PRENATAL: CONSTRUCCIONES Y RECONSTRUCCIONES INTERPROFESIONALES

ABSTRACT

Objective:

to understand the perception of health professionals regarding the implementation of a prenatal qualification course from an interprofessional perspective.

Method:

action research conducted from August to November 2022, with the participation of 47 professionals from Primary Health Care and hospital institutions from 33 cities that make up a Regional Health Coordination in southern Brazil.

Results:

data analysis allowed the delimitation of two thematic categories: Training: professional constructions and reconstructions; and Network articulation: weaknesses and perspectives. The prenatal course, with an interprofessional focus, was a driving tool for integration, dialogue and enhancement of initiatives aimed at qualifying prenatal care.

Conclusion:

the implementation of the prenatal qualification course enabled the expansion of knowledge and the (re)construction of interprofessional practices capable of inferring in the maternal and child health care network.

DESCRIPTORS:
Prenatal care; Postpartum period; Maternal and child health; Primary health care; Continuing education

RESUMEN

Objetivo:

comprender la percepción de los profesionales de la salud sobre la implementación de un curso de capacitación prenatal desde una perspectiva interprofesional.

Método:

investigación-acción realizada entre agosto y noviembre de 2022, con la participación de 47 profesionales de la Atención Primaria de Salud e instituciones hospitalarias de los 33 municipios que integran una Coordinación Regional de Salud en el sur de Brasil.

Resultados:

el análisis de los datos permitió delimitar dos categorías temáticas: Formación: construcciones y reconstrucciones profesionales; y Articulación de redes: debilidades y perspectivas. El curso prenatal, con enfoque interprofesional, fue una herramienta impulsora de integración, diálogo y potenciación de iniciativas encaminadas a calificar la atención prenatal.

Conclusión:

la implementación del curso de calificación prenatal permitió la ampliación de conocimientos y la (re)construcción de prácticas interprofesionales capaces de inferir en la red de atención a la salud maternoinfantil.

DESCRIPTORES:
Atención prenatal; Período posparto; Salud maternal e infantil; Primeros auxilios; Educación contínua

RESUMO

Objetivo:

conhecer a percepção de profissionais de saúde acerca da implementação de um curso de qualificação pré-natal na perspectiva interprofissional.

Método:

pesquisa-ação conduzida entre agosto e novembro de 2022, com a participação de 47 profissionais da Atenção Primária à Saúde e de instituições hospitalares dos 33 municípios que integram uma Coordenadoria Regional de Saúde do sul do Brasil.

Resultados:

a análise dos dados possibilitou a delimitação de duas categorias temáticas: Formação: construções e reconstruções profissionais; e Articulação em rede: fragilidades e perspectivas. O curso pré-natal, com enfoque interprofissional, constituiu-se em ferramenta propulsora de integração, interlocução e potencialização de iniciativas voltadas à qualificação da assistência pré-natal.

Conclusão:

a implementação do curso de qualificação pré-natal possibilitou a ampliação de saberes e a (re)construção de práticas interprofissionais capazes de inferir na rede de atenção em saúde materno-infantil.

DESCRITORES:
Cuidado pré-natal; Período pós-parto; Saúde materno-infantil; Atenção primária à saúde; Educação continuada

INTRODUCTION

Indicators associated with maternal and child health are closely related to the quality of prenatal care, which includes a set of intersectoral and interprofessional actions that involve aspects of both management and care. Brazil has presented prenatal indicators below the targets recommended by the Ministry of Health. The late and discontinuous start of pregnant women at appointments, Gestational Hypertensive Syndrome and other problems are among the main causes of maternal mortality1^-3.

Several strategies have been implemented within the scope of the Unified Health System (SUS), with a view to reducing maternal and child morbidity and mortality. Among the inducing strategies, the Comprehensive Women's Health Care Policy (CWHCP)4 and the “Stork Network”, established by the Ministry of Health in 2011, stand out with the aim of reordering the model of primary care for both women’s and children health, from prenatal care, childbirth, postpartum, birth and development of the child up to 24 months old5.

In addition to the “Stork Nework” project, which led to important advances in the pregnancy-puerperal cycle, the Ministry of Health has recently launched the Maternal and Child Care Network (MCCN), under Ordinance no. 715 of 2022. This new Network aims to guarantee women the right to family planning and access to safe, quality, and humanized care in prenatal, childbirth and the postpartum period, as well as the child the right to a safe birth, to healthy growth and development6.

Prenatal care is, however, a complex process, influenced by multidimensional factors. This perception has traditionally been conceived in a very specific, disciplinary and verticalized manner by managers and health professionals. If, on the one hand, doctors are presented as supporters of the biomedical model, on the other hand, nurses are recognized as defenders of integrated and horizontal approaches. These representations, generally polarized and dichotomous, simplifying and reducing the complexity and completeness of the journey and, at the same time, underestimating the relevance of interprofessional work in health7^-9.

Studies have shown across Brazil persistent gaps related to low coverage, late initiation and the discontinuity of pregnant women attending prenatal consultations, access to diagnosis and treatment centers, in addition to the unpreparedness of health professionals to conduct of quality prenatal care10^-11. Other studies show, in the same direction, that the quality of prenatal care is directly associated with theoretical-practical intervention approaches, that is, with the expanded and contextualized understanding of biological, psychological and sociocultural aspects by the interprofessional health team12^-13.

Therefore, in addition to inductive quality prenatal care programs, we require initiatives aimed at interprofessional qualification associated with Continuing Health Education. It is essential that health professionals see themselves as protagonists of innovative and transformative processes in their professional practice. In this sense, our research question is: what is the perception of health professionals regarding the implementation of a prenatal qualification courses from an interprofessional perspective? The objective, based on the above, was to understand the perception of health professionals regarding the implementation of a prenatal qualification course from an interprofessional perspective.

METHOD

This is an action research that took into account the consolidated criteria for reporting qualitative research (COREQ)14. Action research15 comprises a constructive and inductive process of knowledge and experiences, from understanding and identifying the problem in a given context, to interventions in the practice scenario, in order to promote the desired improvements.

The study included professionals and multidisciplinary residents from Primary Health Care (PHC) and hospital institutions from 33 cities that are part of a Regional Health Coordination in southern Brazil. These professionals had already participated in a prenatal qualification course. Although we initially had a total of 104 registrations for the course, only 47 professionals actually took part in all meetings, including 16 nurses, 2 nursing technicians, 9 physicians, 4 dentists and 16 multidisciplinary health residents. The inclusion criteria for this study were professionals who had participated in all meetings related to the prenatal course. Participants who, for some justified reason, did not attend any of the scheduled meetings were excluded from the study.

The prenatal qualification course was systematized in 40 hours/class, in face-to-face and asynchronous virtual activities, alternately, held from August to November 2022. Themes suggested by the participants were discussed in the face-to-face meetings, under mediation of experts in the area of maternal and child health. And, in the asynchronous virtual modality, video classes created by regional and national experts were available. The following themes were considered throughout the process: quality of prenatal care; Interprofessionality in prenatal care; Birth plan and female empowerment; Partner's prenatal care; Chronic and acute illnesses during pregnancy; Infections during pregnancy; Congenital anomalies; Breastfeeding in the first hour of life; Virtual visit to maternity wards, among other discussions.

The path was systematized into four procedural steps illustrated in the Flowchart below - Figure 1. In the first phase, the survey of demands was listed, from the perspective of managers and health professionals. In the second phase, the prenatal course schedule was systematized. In the third phase, the prenatal course itself was implemented. And, in the fourth and final phase, post-course procedures related to the analysis of the implementation process, return of results to participants and the construction of the final report were carried out.

Figure 1 -
Flowchart for systematizing the prenatal qualification course. Santa Maria, RS, Brazil, 2022.

The data for this study were collected at the end of the prenatal qualification course, in December 2022, using a form available on Google forms, which contained open questions related to the repercussions of the prenatal course on professional practice, which were: what was it like for you to participate in the prenatal course? Which aspects of the course did you find most relevant? How did this course resonate with the other professionals on your work team? In what aspects did the course contribute to the qualification of your professional practice? What are your suggestions for improvement for a new edition of the course? And, finally, an open space for each professional to describe their impressions and experiences.

We sent them, through email, the form link, together with the Free and Informed Consent Form and the invitation for the individual interview to all 47 professionals who had participated in the prenatal course. Of these, however, only 13 professionals responded affirmatively to the invitation to participate in individual interviews. Thus, the sample of this study consisted of 13 participants. The interviews were carried out by a researcher-author with expertise around the field of investigation, on a day, time and place indicated by the participant. The interviews were audio-recorded using a cell phone and transcribed in full by the main researcher immediately after completion. The duration of the interviews varied from 21 to 39 minutes.

The data were analyzed, in sequential phases, based on the content analysis technique16, which made it possible to discover the cores of meaning that make up a given communication, whose presence or frequency is relevant in the set of information. In the pre-analysis (1^st phase), which consisted of exploring the material, processing and interpreting the results obtained, a floating reading of the data collected through the questionnaire and interviews was carried out, in order to identify the main themes of meaning. The exploration of the material (2^nd phase) consisted of coding the raw data, so that we could reach the core understanding of the text. An in-depth reading of the previously organized material was carried out, and the registration and context units were identified and grouped by similarity. To this end, the texts were highlighted in different colors and in registration units. For the context units, excerpts from the interviews were highlighted and those most representative of achieving the proposed objectives were selected. When interpreting the results (3^rd phase), the raw data were subjected to statistical operations, in order to make them representative and valid in the set of data investigated.

Research ethics recommendations were considered throughout the research process and the project was approved by the Research Ethics Committee. Participants signed, in duplicate, the Free and Informed Consent Form and, to guarantee confidentiality, each participant was identified by a letter “HP” (Health Professional), followed by a numerical figure, according to the order of the lines HP1... HP13.

RESULTS

Among the 47 participants who had participated in the prenatal course, according to previous details, 38 worked in Primary Health Care and the rest of them in the hospital network. All of them, with the exception of the residents, had already worked for more than two years in the same workplace. The age of the participants, in general, ranged between 25 and 45 years old.

The present study describes, however, only the 4^th phase of the action research flowchart related to the evaluation and analysis of the implementation of the prenatal course. From this qualitative analysis of the data, two thematic axes emerged: Training: professional constructions and reconstructions and Network articulation: weaknesses and perspectives, as illustrated in Figure 2.

Figure 2 -
Central ideas of the coding process. Santa Maria, RS, Brazil, 2022.

Training: professional constructions and reconstructions

The professional training process was highlighted as relevant in participants' statements. Professionals mentioned the need for greater investment in professional training in different undergraduate health courses, residencies and stricto sensu health programs, with regard to prenatal care. In general, everyone mentioned that prenatal care is approached in a superficial, narrow and disciplinary way in the different courses. [...] I’ve never had this subject in my undergraduate course or graduate courses. Prenatal care is little discussed during training (HP2).

[...] I signed up for this prenatal course because I saw, in practice, that there are many weaknesses. As professionals, we feel very much limited in relation to our tasks and all professionals lack this broader perspective on the subject (HP7).

The prenatal course was highlighted as relevant in the process of (re)construction of knowledge and professional practices to achieve the Sustainable Development Goals. It was noticed, in the speeches of several participants, that the course constituted a new approach to intervention and qualification of health professionals, mainly due to its horizontal and interprofessional nature. [...] this way of learning, discussing and exchanging experiences was very good. Permanent education here was different, because all professionals participated and shared ideas and professional experiences (HP7).

[...] it was important. Everyone discussed and suggested new ideas to improve prenatal care. I really enjoyed participating (HP9).

Participants recognized that permanent health education needs to be taken by managers and professionals as a priority goal in different areas of professional activity. Professionals have also emphasized that in healthcare scientific evidence is constantly updated and that care, in turn, demands renewed responses that are consistent with the specificities of each patient.

[...] things evolve. Every day we have new health evidence. Therefore, we cannot stand still and think we are ready and doing our best (HP8).

The prenatal course was considered, from this perspective, a strategy that induces interprofessional qualification through the participation of professionals from different areas and health services. This collaborative construction process enabled the expansion of knowledge and the sharing of professional practices, although one of the participants reinforced the validity of vertical and fragmented practices.

[...] we have everything we need to be a reference in prenatal care, but I’ve noticed that we have been working in a very fragmented and isolated manner in the network. The service there understands its weaknesses and works on them internally. The other services are not aware of these problems, and everything continues as it was. And the course is a space that provided this expanded look at the role of each of the health professionals and services (HP9).

In the understanding of the participants, the prenatal qualification course gave new meaning to the work process, expanded associative possibilities and renewed the desire for content renovation among health professionals. In addition to the topics discussed, the course enabled effective exchanges and the sharing of concrete experiences, which transcend institutionalized routines, recipes, protocols or flowcharts.

[...] I realized that I always need to study more. It's not the diploma that makes the difference, but the ability to always seek new learning (HP11).

I realize that we were able to give a new meaning to our work after taking the prenatal course. Today we talked and talked more, we tried to learn together and also discuss routines and protocols (HP13).

Initial and ongoing training was translated by the participants as prospective learning that takes place throughout life. A path, therefore, that needs to be learned, shared and (re)signified among managers and health professionals, in a horizontal, participatory and networked way.

Network articulation: weaknesses and perspectives

Participants recognized the need to transcend specific perceptions and encompass participatory, dialogic, and integrative approaches through the inclusion of different services, professional areas and users. In this sense, they mentioned the need to create mechanisms for interaction and dialogue among professionals and users, including the companion. [...] based on what was covered in the course, we discussed the need to create a WhatsApp group where everyone can interact, including managers. Where everyone knows everything and can interact to jointly find the best solution for the continuity and quality of prenatal care (HP9).

Networking and communication between managers and health professionals from different services and levels of care is an important strategy to guarantee early access and continuity of pregnant women to prenatal consultations. However, weaknesses related to prenatal care persist. Several participants mentioned that, in professional practice, professionals and services do not talk to each other and do not understand health care as integrality and continuity. It was noted that specific, fragmented, and misaligned professional practices persist in the care network.

[...] when we refer pregnant women to high-risk prenatal care, we reinforce the importance of continuing prenatal care while still in Primary Care, so that we can also monitor her pregnancy. However, we do not have access to the exams and conduct requested in the high-risk service. That’s why we see the importance of the integrated service here we can have access to the pregnant woman’s medical records (HP4).

[...] all professionals must know what happens at different points in the network. How can we work in a network if we don't know it? (HP10).

Prenatal care, as evidenced by some participants, focuses on specific professionals, that is, generally on the doctor or nurse, which is justified by the absence of other health professionals in the units or through the validity of the technocratic model, strongly centered on the doctor. In other statements, work overload and the prospective impulse of professionals to contemplate and encompass knowledge from other areas were also noted.

[...] in the health unit esid I work, I do everything. I need to understand nutrition, physical care, pharmacy, everything. We esi have one doctor and one esidente doctor here. And the course provides this knowledge for more and values the importance of each of the professionals (HP9).

[...] in the unit where I work, I do everything. The prenatal course convinced me that we need to work together, talk more and create strategic mechanisms (HP13).

In one of the statements, more specifically, it was noted that there is a strong desire to improve prenatal care, but sometimes this process is hampered by high demand, work routines and misalignments in the network, as follows: [...] I want to do better, but I have limited time to help the patient. Sometimes I would need to dedicate more time to them, but you know there is a line waiting and you need to forward them. If there was greater integration, many cases would not need to come here (HP7).

In the speech of two multi-professional health residents, friction and a certain competition between health services professionals were noticed. In this sense, they mentioned that the essence of prenatal care is often distorted and care for the pregnant woman/companion ends up being relegated to a secondary level. [...] I have already highlighted friction in communication between service professionals. Sometimes the focus is on the professionals and they forget that there is a user and a companion (PS12).

In short, health professionals have recognized that the prenatal qualification courses, with an interprofessional focus, constitutes a driving strategy for articulation and integration of the different actors in the health network, as well as the possibility of rethinking approaches to learning throughout of life.

DISCUSSION

National and international studies are increasingly directing discussions in relation to consultations and prenatal care as a strategic and sensitive path towards encouraging the role of women and their companions. In addition to diagnosis, treatment, and routine consultations, it is essential that professionals enhance initiatives aimed at promoting and protecting maternal and child health. This thinking involves expanded and interprofessional approaches on the part of the healthcare team, as well as personal and collective commitment to lifelong learning17^-20.

Lifelong learning comprises a set of elements that value the diversity of knowledge and professional experiences and that lead to collegial and coordinated decision-making with the different actors in the health network. In this logic, professionals acquire knowledge and experiences that enable them to understand the relationships specific to the world of work and to make choices with autonomy, critical awareness, and responsibility21^-22.

The study participants highlighted the need to discover new teaching and learning methods and approaches, mentioning that all professionals must know and talk to the different points of the network. In this sense, they recognize that an autonomous, conscious, and responsible decision demands knowledge from each part and the whole of the network, in order to avoid new reductions and discontinuities in the pregnancy-puerperal cycle.

A study shows that intersectorality and interprofessionality are tools that promote better health practices23. Under this approach, networks/lines of care in maternal and child health were established within the Brazilian Unified Health System (SUS) with the purpose of overcoming the fragmentation of care and management and guaranteeing health solutions24. Reflecting and discussing interprofessional strategies, under this prospective impulse, implies initiating processes, allowing ruptures, and transcending the disciplinary and dichotomous thinking of health promotion.

Although a scenario of fragmentation and disarticulation between management and care in maternal and child health persists, one participant has mentioned advances associated with the qualification of professional relationships and interactions. This thinking is in line with the findings of a study that highlighted the need to qualify the health work process, based on collaborative, interactive and interprofessional approaches. The same study also emphasizes the relevance of intersectoral coordination through initiatives that enable integration among professionals, services and healthcare users25.

Health professionals also recognize that quality prenatal care is the result of early recruitment of pregnant women, the ability to promote effective bonds between professional-patient, with a view to the continuity of prenatal care, in addition to the ability to work in a collegiate. It is recognized, therefore, that interprofessional action is essential in the face of growing demands and complexities, as well as the need for intersectoral and systemic theoretical-practical learning.

Interprofessional action greatly requires teamwork, that is, a collaborative and participatory way of producing knowledge and practices. Teamwork focuses on the uniqueness of each user and, consequently, enables the continuity and resolution of health care. Interprofessional work must be increased by exercising empathy, dialogue, conflict resolution, cooperation, and valuing unity in diversity26. Interprofessional action leads, in parallel, to the enhancement of initiatives, the optimization of human and material resources, in addition to integrated practices that contribute to favorable outcomes in the pregnancy-pueperal cycle27.

Quality prenatal care is, therefore, directly related to the qualification process of health professionals. The more appropriate, engaged and integrated into the lines of maternal and child care, the greater the possibilities for health professionals to see themselves as protagonists in promoting quality prenatal care with a multidimensional character. From this perspective, each health professional plays a determining role in achieving favorable outcomes in the pregnancy-puerperal cycle28.

The contributions of this study to the advancement of nursing science are related to the induction of new professional - interprofessional thinking and acting in the context of prenatal care. Nurses should, as leaders and mediators of processes, lead spaces for dialogue and integration in order to enable collegial and interprofessional solutions.

The limitations of this study are related to the non-effective participation of all those enrolled in the course, low adherence of professionals from other cities that comprise the macro-region and the non-inclusion of healthcare users. Furthermore, it is considered that the study constitutes a specific action with a possible limited impact on other professional practice scenarios.

CONCLUSION

The implementation of the prenatal qualification course enabled the expansion of knowledge and the (re)construction of interprofessional practices capable of inferring the maternal and child health care network. The course constituted a driving tool for collaborative and integrative work, mediated by effective communication between different professionals and points in the network.

The quality of prenatal care is related to the quality of the work carried out by health professionals at different levels of care. Based on the study carried out, new interprofessional qualification courses are suggested that enhance different professional initiatives and expand the exchange of experiences, based on successful strategies in different areas and health contexts.

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NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the Research Project “"Qualification of Pre-Natal Care in the central region of Rio Grande do Sul" approved by CNPq/MCTI/FNDCT Call No. 18/2021 - Track A - Emerging Groups. Process: 402157/2021-4. Santa Maria, 2022.

• FUNDING INFORMATION

  CAPES/COFEN - Edital nº 08/2021. Ordinance number: 88887.690076/2022-00 Ordinance CNPq/MCTI/FNDCT Nº 18/2021. Ordinance number: 402157/2021-4.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Research ethics commitee from Universidade Franciscana, under the CAAE number: 53319116.5.0000.5306 and report n. 4.253.922.

• TRANSLATED BY

  Jaqueline Claudino da Silva

Edited by

EDITORS

Associated Editors: Melissa Orlandi Honório Locks, Ana Izabel Jatobá de Souza. Editor-in-chief: Elisiane Lorenzini.

Publication Dates

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

History

• Received
  24 Mar 2023
• Accepted
  23 Aug 2023