Introduction

Pregnancy is a period of biopsychosocial change that occurs in the woman's life, as it involves the creation and development of a new being, being marked by intrinsic bodily changes characteristic of this phase.¹ Such an experience can cause feelings and perceptions ranging from the joy of the arrival of a new member to discomfort and fear through life changes.^2-3

In view of the concept, it is necessary to have adequate monitoring, preferably from the beginning of pregnancy, as recommended by the Ministry of Health.⁴ Such assistance provided to pregnant women during the puerperal pregnancy cycle is guaranteed through prenatal care. This, in turn, is characterized as a set of procedures whose purpose is to promote the monitoring of the binomial and their family, in an integral and humanized way, by health professionals, resulting in healthy pregnancy and childbirth without complications for the mother and her child.⁵In view of this, it is guaranteed through public policies to monitor risk factors and minimize the effect of possible complications.⁶

Prenatal care has been stimulated in the scope of health services since 1979, with the creation of the Comprehensive Women's Health Care Program (CWHCP), in an attempt to reduce the high rates of morbidity and mortality of pregnant women and the fetus. CWHCP then promoted important changes in the sector, culminating in direct influences on the construction of the Unified Health System (UHS) in the 1980s.^6-7

From the year 2000, Ordinance 569 of the Ministry of Health instituted the Program for Humanization in Prenatal Care and Birth (PHPB), in an attempt to ensure access, improved coverage and quality of maternal health care. However, even though Brazil has shown advances in coverage of care and the number of consultations by pregnant women during the pregnancy cycle, the number of deaths of women and children due to complications of pregnancy and childbirth remains high.⁷

In view of this scenario, in 2011, the implementation of the Cegonha Network took place. This aims to promote the implementation of a new model of health care for women and children, covering prenatal care (PN) and care for children up to 24 months, in addition to structuring the care network and reducing maternal and child mortality, with emphasis on the neonatal component.⁸

According to recommendations from the Ministry of Health, prenatal care should be performed in Primary Care by the Family Health Strategy (FHS), composed of a multidisciplinary team that works in a defined area. Such assistance must occur through welcoming conducts; with the increase in educational and preventive actions; in the early detection of pathologies and conditions of gestational risk; in the formation of bonds with the place of delivery and access to quality health services, from primary care as well as at more complex levels, with the participation of a multidisciplinary team.⁴

Adequate prenatal care should occur with at least six consultations, starting in the first trimester, with two in the second and three in the third trimester of pregnancy. During the entire follow-up by the nurse, physical examinations are carried out and others are requested in a complementary way. These actions make it possible to observe fetal growth and its development, reducing the risk of complications during pregnancy. ^6-8

In addition, regarding the nursing consultation, its importance in assisting pregnant women is notorious. The exchange of information between the nurse, the user and their family enables the systematization of assistance aimed at health promotion and prevention of diseases and injuries, promoted through health education, as well as actions that focus on knowledge and action, understanding the care of human beings and their particularities. Thus, the nurse contributes to good health practices and changes in behaviors that are unfavorable to the well-being of the pregnant woman.⁹

However, studies show that minimum care for quality care is not being performed satisfactorily. This may indicate a failure in health services, resulting in undesirable results, such as prematurity, even contributing to the maintenance of high rates of maternal and neonatal mortality.^7,10

In order for this peculiar monitoring to be better understood, it is necessary to consider the social representations of pregnant women before the prenatal nursing consultation, since subjective factors are contained in the relationship between the individual who receives care and the system that produces it. This is possible through the Theory of Social Representations (TSR).¹¹

The use of TSR in Brazil encouraged research in the health area, especially in nursing. When applying it in studies in this area, it contributes considerably to the understanding of representations built about care, also helping to understand how people act and behave in their daily lives, making it possible to conduct care according to the needs of others, which is the “Target” to whom it is intended.¹²

The pregnant woman's perspective on prenatal care can provide adjustments and protocols from the users' perceptions, since the needs perceived by them directly reflect on the way they adhere to preventive and therapeutic activities. Studies that discuss the social representations of pregnant women about PN assistance showed aspects related to access, participation in care, adherence to consultations, well-being, importance in health and discussion of the supply of material and human resources.^10,13-14

Thus, this study is relevant to public health due to difficulties in coverage and monitoring of pregnant women attended, also denoting the importance of early prenatal care for favorable outcomes. Therefore, it answers the following research question: how is nursing consultation in prenatal care seen by pregnant women monitored in Family Health Units? It aimed, then, to analyze the social representations of pregnant women about the nursing consultation in prenatal care.

Method

Descriptive and exploratory study, with a qualitative approach, carried out in Family Health Units (FHU) in the city of Petrolina, Pernambuco, Brazil. Participating in this empirical investigation were pregnant women registered in the FHU who met the following inclusion criteria: being pregnant; being 18 years of age or older; having performed at least three prenatal consultations, regardless of the length of pregnancy, number of previous pregnancies and obstetric past.

The municipality has 45 Family Health Units, which house 90 health teams distributed in urban areas (31 teams) and rural areas (22 teams). The selection of the FHU was made by convenience through the insertion of researchers in these as a practical field of curricular internship. The determination of the number of participants followed the criterion of saturation of the information.¹⁵ At the end of data collection, there were 30 pregnant women registered in four FHU of that city.

Data collection took place between the months of June and October 2017, in a direct approach in the waiting room of the FHU, according to their demand. Accepting the invitation, participant and researcher went to a reserved room. In order to guarantee the participants' privacy, the interviews took place individually.

A semi-structured interview script was applied with each participant, divided into two parts: the first, with a sociodemographic questionnaire to characterize the pregnant women and data related to reproductive health; the second had guiding questions based on the objective of this research, which are: What do you think about the prenatal nursing consultation? What does this service represent to you? How do you think the monitoring contributes to your pregnancy? All interviews were recorded on an audio device, with subsequent transcription, with the consent and after signing the Free and Informed Consent Term (FICT). The average duration of each of them was twenty minutes.

The study was approved by the Research Ethics Committee and followed the precepts of Resolution 466/12, of the National Health Council (CAAE 66333617.6.0000.5196). The participants are identified by the letter G for the pregnant woman and the cardinal number and according to the sequence of the interviewees, in order to guarantee anonymity.

The questionnaire data were grouped in tables to characterize the sample. The material produced during the interviews gave rise to the corpus, treated by the Iramuteq software. Based on this test, the program groups the words with the highest occurrence and organizes them graphically according to their frequency, being presented in this study by the word cloud.¹⁶Thus, through lexicographic analysis, it displays contexts characterized by the vocabulary shared by the participants, identifying their common field and translating the message, since the program also presents excerpts from speeches in which the grouped words were said.

The report generated by Iramuteq classified 77.64% of the material as relevant. Researchers say that to guarantee the stability of the results, it is acceptable to classify at least 70% of the text units. Then, the corpus analysis was continued, which made it possible to infer and understand the results generated by the software.^17-18

Results and discussion

The data referring to the sociodemographic and gynecological-obstetric profile are presented in tables. And then, the terms that portray the social representations about the prenatal nursing consultation: Prenatal care; The importance of nursing in prenatal care; The care provided by nurses and Challenges faced. The discussion will be held concurrently with the presentation of the results.

The age range of the participants was between 18 and 38 years old, with an average of 24 years old. The majority declared themselves brown and with low education; married or in a stable relationship (Table 1). These findings corroborate with similar results found in other studies, showing the prevalence of young, brown women, with a partner, with no fixed income and little schooling followed up in the prenatal care offered in the Basic Health Units.^19-21

Table 1 - Sociodemographic data of the research participants. Petrolina/PE, Brazil, 2018.

VARIABLES	No.	%
Age
18 – 20 years	11	36.7
21 - 30 years	12	40
31 - 40 years	7	23.3
Color
White	4	13.3
Yellow	3	10
Brown	18	60
Black	5	16.7
Marital Status
Married	11	36.66
Stable Union	12	40
Single	7	23.33
Religion
Catholic	14	46.7
Evangelical	12	40
Other/Non religious	4	13.3
Education
Incomplete Elementary School	6	20
Complete Elementary School	4	13.3
Incomplete Highschool	7	23.3
Complete Highschool	10	33.3
Incomplete Higher Education	2	6.7
Complete Higher Education	1	3.3
Profession
Housewife	16	53.3
Student	3	10
Teacher	2	6.7
Other	9	30

Source: Field research.

With regard to obstetric data (Table 2), it was found that a large part was in the third trimester of pregnancy, with an average gestational age (GA) of 30 weeks; 46.7% said they had performed 6 or more PN consultations, as recommended by the Ministry of Health.⁴ The GA at the first consultation ranged between six and 20 weeks, with an average of ten weeks.

Table 2 - Gynecological-obstetric data of the research participants. Petrolina, PE, Brazil, 2018.

VARIABLES	No.	%
Number of gestations
First pregnancy	11	36.6
Second pregnancy	8	26.6
Multiple pregnancies	11	36.7
Parity
Nulliparous	11	36.6
Primiparous	8	26.6
Multiparous	11	36.6
1st Consultation
1st trimester	28	93.3
2nd trimester	2	6.6
Number of consultations
< 6 consultations	16	53.3
≥ 6 consultations	14	46.7
Type of delivery from previous pregnancy
Vaginal	12	40
Cesarean	4	13.3
Vaginal and Cesarean	3	10
No previous deliveries	11	36.7

Source: Field research.

The exposed data confirm the results found in other studies, revealing the predominance of prenatal care starting in the first trimester of pregnancy. The average gestational age around ten weeks, multiple pregnancy women and women with a history of previous pregnancy and vaginal delivery also corroborate with the data described in the literature.^{19, 22- 23}

Regarding the number of prenatal consultations, a recent study found that those newborns whose mothers underwent adequate follow-up, with at least six consultations, had fewer complications at birth. In addition, the quality of care and early diagnosis are important factors for reducing maternal and perinatal mortality rates.^24-25

Figure 1 groups the corpus of the interviews, presenting the data in the word cloud generated by the software IRAMUTEQ. It is noticed that the terms are positioned in a random way, so that the bigger ones present a higher frequency of citation, thus demonstrating their prominence. Thus, prenatal care was the most frequent (131 times), in addition to nurses (78 times) and care (65 times).

Figure 1 - Word cloud on prenatal nursing consultation for research participants. Petrolina/PE, Brazil, 2018.

Prenatal care follow-up

For the purposes of this study, after processing the data, the meanings of the words were analyzed in the statements of the participants. Thus, the word “prenatal” shows that this monitoring represents an important moment in the pregnant woman's life, connecting her with the child in her womb. The following clippings express such findings:

Prenatal care represents a lot because that is the first step I am taking in my pregnancy, and through prenatal care I know what is happening to my child. (G23)

Prenatal care is something important because I am in the final stretch of my pregnancy and I cannot help coming because if something happens to my baby, I can know. (G8)

Prenatal care aims to welcome the woman at the beginning of her pregnancy, to guarantee quality and humanized care until her delivery and puerperium, so that the well-being of the mother-child binomial is assured.⁴ In this context, the nurse must be trained to carry out these actions, with the purpose of promoting comprehensive, resolving and qualified assistance to pregnant women, parturients and women who have recently given birth, in addition to playing an important role in health promotion.¹⁴

The nurse's duties during prenatal care were also recognized in the testimonies of some pregnant women, marking their representations. They mentioned that the service of this professional is a differential for them to seek to carry out past orientations, assisting in the regularity of consultations.

What motivated me to come for prenatal care was mine and my baby's health. (G12)

What I like most about the service is the concern he has with us. He speaks what can and cannot. I like his sincerity. (G11)

It is noticed that the interviewees recognize nursing care as a tool for a better delivery outcome. The way care is developed during consultations has become an instrument that strengthens the relationship between the user and the nurse. Thus, it is essential that the patient acts as a health educating agent and bears technical and scientific knowledge for the performance of the nursing consultation in prenatal care, differentiating himself from the others by active listening. Thus, it contributes to the quality of care and favorable outcomes.

Quality care and establishing a bond between professional and pregnant women contribute to changing practices and attitudes, making this moment as natural and less medicalized as possible. However, failures are still found in this assistance, especially in rural areas and low income, showing gaps in adequate coverage for those who need care and guidance for having a unique experience with each pregnancy.⁷

The importance of Nursing in prenatal care

Regarding the term “nurse”, it is seen as essential in prenatal care since most participants showed satisfaction with the professional who assisted them, as can be seen below.

If we didn't have the knowledge we have during prenatal care, I think we could have something that could bring harm to the baby's health. (G29)

The nurse contributes because she teaches you how to breastfeed, the care you have to have, especially for first-time pregnant women, because she takes our doubts. (G20)

I suggest that the consultations are every 15 days and not every month. They are very important! (G30)

The nurse has an essential role in the PN, operating as a simplifier and pluralizer of knowledge. The nursing consultation works as an occasion to cultivate the bond with the pregnant woman. In addition, the nurse must instruct the pregnant woman and her family about the importance of prenatal care, breastfeeding, vaccination and the frequency of consultations; request complementary exams according to established protocols; do quick tests; perform a syndromic approach to sexually transmitted infections (STIs); prescribe standardized medications for the prenatal program; promote educational activities; perform clinical breast exams and Pap smears, among other activities.^24-25

Some of the participants also suggested that the interval between consultations should be reduced so that they could have more of them, even in low-risk prenatal care. The fact of expressing interest in more consultations and in a short space of time can demonstrate the indispensability of care geared to your needs. Given this, the nursing consultation can contribute positively in these situations, when there is a lack of prior information about pregnancy and care that must be taken, enabling security.

The care provided by nurses

Regarding the term “attendance”, its meaning was especially focused on the interpersonal relationship of the pregnant woman with the professional during prenatal care, this being a time when dialogues are established and allow, more than a professional, the nurse be seen as someone they trust.

What I like most about the nurse's care is the dialogue, because she talks well, likes to listen and is concerned. (G23)

I like it because she doesn't put herself as a professional; it's like a friend. I like her more than the doctor because I feel more comfortable. (G14)

It is noticed that the interaction with the nurse through dialogue, reception and concern with the health of the pregnant woman makes the user feel more secure. Conducts such as welcoming and qualified listening are the activities that pregnant women expect from the team that attends prenatal care. Such means, known as light technologies, improve care and enable the being to be seen integrally in their needs.¹⁰

In the perception of pregnant women, quality care is more linked to the attention turned at the time of the consultation, to the dialogue and guidance that the professional provides than to the technical procedures. Thus, they are concerned with the information received during care and tend to attend more consultations and other activities offered by the health team.¹³

Therefore, it is clear that the social representations of pregnant women about the prenatal nursing consultation indicate that, for them, this service is seen as essential for favorable outcomes in childbirth and postpartum. It is through this monitoring that doubts are clarified and actions are taken to prevent possible injuries, especially for those who do not have practical experience in the subject. Therefore, it is important that these professionals recognize the dimension of the care they perform, seeking more and more to work in a humanized and welcoming way.

Challenges faced

Despite the positions attributed to the prenatal / nurse / pregnant woman context, a term that appears relatively mentioned in the interviews appears in the word cloud and is relevant to the results found. The element is "problem", the frequency of which was 44 repetitions. Regarding this term, its meaning was attributed to the difficulties and conflicts faced in prenatal care.

One of the problems I see is the delay! Because he takes too long to see a pregnant woman. So, we have to wait a lot if we don't arrive early. (G21)

One thing that could be improved is the structure of the rooms and the appliances, which are old. Could be more modern. (G17)

I see it as a problem that doctors and nurses could be more attentive so that the care is even better, because there is little attention and also the [Basic Health Unit], which is very crowded. (G3)

It is perceived in their testimonies that one of the challenges faced for care in the health unit is the great demand and structure of the service. This leads to longer waiting times than necessary and, in most cases, professionals need to be agile to attend on time, which often hinders the establishment of bonds and the possibility of dialogue. Some findings were found in other studies, in which part they reported an increase in waiting time and lack of reception, by the nurse of the health team, to qualified listening. ^5,10,23

Another study explores the perspective of nurses regarding the challenges faced in prenatal care, a daily reality of nursing, which receives many requests from pregnant women for a short time of care. It is worth mentioning the fact that this monitoring requires individual consultation, with care and attention to the pregnant woman. To cope, professionals end up making appointments faster, losing the quality of care.^5,10-,23

There are countless challenges and efforts to ensure quality prenatal care. Therefore, Social Representations become important elements in the evaluation of this according to each social reality. What, for some, is a pleasant moment of clarification, for others it ends up being just a consultation that does not cover comprehensiveness due to the lack of connection with the professional who assists her. It is worth mentioning that the welcoming offered by nurses is essential for the relationship between the latter and the community to be established.

Final considerations

Knowing the social representations of pregnant women attended at Family Health Units allowed us to understand how much they value the prenatal care provided by nurses, especially for the possibility of reaching the end of the pregnancy feeling prepared. The data found reaffirm that this is an important tool, being indispensable due to the orientations passed by, active listening - which allows more than just listening: exchanging information - and monitoring the evolution of pregnancy, demonstrating that they feel cared for.

It is known that prenatal care is not based only on consultations and requests for exams. Carrying out strategies that involve welcoming and recognizing health needs contributes to establishing a bond between pregnant women, health staff and family.

In this study, the participants aimed at the figure of the nurse as someone who gives them security, anchoring on the idea that by putting into practice what they are told, the culmination will be with the birth of a healthy baby. Even so, it highlights the need for improvements in care management due to issues intrinsic to the health team and managers, such as the availability of time and quality structure.

Thus, the findings of this study may contribute to a better understanding of the importance attributed to nurses, in addition to their image being linked to health education. For these and other reasons, nurses must seek more theoretical and practical knowledge every day to better assist their audience, culminating in the valorization of assistance and the transformation of their practices.

This study contributes to the discussion among health teams, insofar as it explores the complexity of the care offered to pregnant women in Primary Care, demonstrating the need to reassess attitudes towards their clientele. However, it has as limiting factors the fact that it was carried out only from the perspective of users, in addition to the investigation having occurred in a single Brazilian municipality, making generalizations difficult. It is suggested to carry out further studies on the subject from the perspective of different contexts and social subjects.

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Autor correspondente

Danyella Evans Barros Melo

E-mail: danyella.evans@gmail.com

Endereço: Rua Santa Inês, n 10, Vila Eulália, Petrolina, Pernambuco, Brasil.

CEP: 56.331-100.

Authorship contributions

Danyella Evans Barros Melo

Conception and planning of the research project; obtaining, analyzing and interpreting the data; critical writing and review.

Susanne Pinheiro Costa e Silva

Conception and planning of the research project; analysis and interpretation of data; critical writing and review.

Khesia Kelly Cardoso Matos

Conception and planning of the research project; analysis and interpretation of data; critical writing and review.

Victor Hugo Silva Martins

Analysis and interpretation of data; critical writing and review; final approval of the version to be published.

How to cite this article

Melo DEB, Costa e Silva SP, Matos KKC, Martins VHS. Prenatal nursing consultation: social representations of pregnant women. J Nurs. UFSM. 2020 [Acess in: Year Month Day]; vol.10 e18: 1-18. DOI: https://doi.org/10.5902/2179769237235