Perception of women on the care in the childbirth : contributions to nursing

This study aimed to understand the perception of women regarding the care received during delivery/birth, and discuss the precepts of integrality according to humanization of care. This was a qualitative research study, performed at a tertiary care public hospital in Fortaleza, Ceará State, Brazil. The research subjects were 13 women whose deliveries were made in that unit, and invited to take part in the focal group featuring the following themes: women’s perception about the care received; the relationship with the professionals of the obstetrics and neonatal units; satisfaction with the assistance provided by the hospital at the time of delivery and birth. The data were subjected to thematic category content analysis. The women emphasized the good assistance received, consisting of care and dedication by the professionals. They showed the importance of correct and detailed information, but observed miscommunication and lack of a user-professional bond, due to the large number of professionals working in the unit. Nevertheless, they were satisfied with the assistance received. Positive aspects of the assistance were evidenced, but it is essential that the professional-user relationship be improved, in order to meet the humanization perspectives of care, which are also anchored on integrality.


Introduction
The purpose of perinatal care is to reduce the high index of mortality and morbidity of children and women due to complications likely to be avoided in the pregnancy and childbirth, crucial moments for a healthy birth.In this way, the integral attention to women and baby health can be improved with the rational and humanized application of obstetrics and neonatal technologies available, in order to achieve lower levels of maternal and perinatal mortality (BRASIL, 2006).
For Guinsburg (2005), the most prevalent causes of death worldwide during the perinatal stage are the intrauterine and intrapartum asphyxia, low birth weight, respiratory diseases of the newborn, maternal and newborn infections, and prematurity.
These diseases and disorders that can affect maternal and newborn health require preventive and rehabilitation action with participation of multidisciplinary staff able to promote humane care, as recommended by health policies aimed at the general population and specifically to perinatal and neonatal phase.
These perspectives are associated with integrity principle that aims to provide a quality care that assists the individual as a whole, respecting their rights and values, making it capable to contribute to a more human reality (PINHO et al., 2006).
For integrity be performed in professional practice, it is necessary that professionals and managers act in an interdisciplinary way, meeting the needs of users and promoting a quality care in its multiple dimensions, including relational and accountability moments involved in the care to the users.
The user embracement consists of humanization of relationships between users and health professional, contributing to create links between them.The user embracement intends to ensure the universality with qualified hearing of all who come to clinic (CAVALCANTE FILHO et al., 2006).
The bond implies responsibility, which means the health worker to assume the conduct of clinical and therapeutic care within a possibility of intervention, but not bureaucratic nor impersonal (CAMARGO JR. et al., 2008).
According to Solla (2005), the accountability to the health issue goes beyond the service itself, it also refers to the needed link between the service and clientele.Thus it is possible to build relationships of trust and support between worker and user through access and adequate care.
In this way, the production of care in health services should focus on interpersonal relationships.These express the humanization and development of the precepts of integrity.In recent years, issues such as the quality and integrity of care, teamwork, user embracement, and humanization of health practices have been occupying space in discussion and formulation of policies, which point out to the importance of the interpersonal dimension of health services and their processes of work.
The humanization issue had received an increasing attention by the Ministry of Health, standing out the initiative in 2001 of the National Program for Humanization of Hospital Care (PNHAH), and especially the current National Policy of Humanization (PNH), which was expanded for the entire health system in 2004 (SÁ, 2009).
Before this, the Ministry of Health had created the Program for Humanization of Prenatal and Childbirth Care (PHPN) in 2000, which ensured the right to a quality care and the humanization of the care during pregnancy and delivery (SERRUYA et al., 2004).
The 'Humaniza SUS' intends to have crosssectional feature, aiming to reach all assistance levels, by understanding the humanization as a cultural transformation of the care to the users and of the management of work processes, which should pervade all actions and health services (FORTES, 2004).
In this way, the implementation of this policy requires the involvement of professionals and management, which should act upon the needs of the users, and interactions in the process of work in order to optimize the care and attention, meeting the assumptions of humanization and integrity.In the assistance to woman and newborn, these actions should permeate the nursing practice that assumes permanently the direct contact and the care with these users, allowing an integral care.
This research comes from the Project 'Assessment of perinatal care: analysis of the determinants of quality'.Therefore, this study focuses the women view on the care received during the delivery/birth.
It had paramount importance to know the perceptions of women about the care provided by health professional during perinatal stage by giving them opportunities to talk soon after the childbirth, in other words, with recent experiences.Thus, it was possible to understand their needs, the aspects of received attention with focus on humanization and integrity of care.
This information brings reflections about the mode of action of professionals and the possible difficulties exhibited by these mothers, which will support to guide professional conduct and service organization.
In this context, we sought to respond the following questions: How postpartum women perceive the care received at a tertiary care public hospital of SUS? How does it occur the user embracement and the bond during labor/birth?What is the satisfaction regarding the received care?We intend to understand the situations perceived by women as regard with user embracement and bond, and other issues experienced in perinatal care as precepts of integrity according to humanization of care.
In this way, it is highlighted the importance of the study, once it will point ways to support the improvement of care during delivery/birth, promoting consequently the welfare of the mother and infant.
Given the above, this study aimed to understand the perception of women about the care received during delivery/birth, and discuss the precepts of integrality according to humanization of care in the childbirth process.

Material and methods
This is a study with qualitative approach by studying particularities of subjects with a specific experience.This approach permits to understand the experiences, with their subjective aspects involved in reactions and behaviors of the investigated subjects (POPE; MAYS, 2009).
The research was conducted in a tertiary care public hospital belonging to Brazilian Health System (SUS), located in Fortaleza city, Ceará State, in October 2008.The hospital provides prenatal care to high-risk pregnancies and obstetric emergencies, with assistance to the mother and newborn.The Neonatal Sector, at the time of the study, had 25 beds distributed into Medium Risk Units and Neonatal Intensive Care Unit (NICU).Currently, the Unit has 33 beds and the service maintains the monitoring of newborns after discharge in the Center for Breastfeeding and Specialized Outpatient Services, for all infants born in the unit, and those that need follow-up due to some morbid process, respectively.
Thirteen women participated in the study, among them, mothers admitted to the rooming-in of the study hospital, in addition to the mothers that visited daily the children to the NICU.They were randomly chosen regarding the inclusion criteria: be in the rooming-in after childbirth, or mother visiting a child admitted to neonatal unit; have physical and psychological conditions to participate.
The information was gathered from the focus group with qualitative/participatory strategy.The discussion was guided by an agenda of issues: perception of women about the care received including the bond and user embracement; the relationship with professionals; satisfaction with the service provided by the hospital on the occasion of delivery and birth.The list of topics served to trigger the discussion, but the moderator let the participants to discuss the idea with freedom and detailing.The agenda is an important tool that has a list of concepts to be explored during the meetings, in order to facilitate the opening, expansion and deepening of communication in a group (POPE; MAYS, 2009).
There were two focal groups in different days, lasting on average 80 minutes, in the first group participated seven women, and the second, only six.Some of them had no difficult to concentrate into the group because their children were in neonatal unit.It is worth emphasizing that when inviting the women to participate, it was necessary a previous contact, when we provided information about the study and the mode of participation, ensuring the freedom to participate or not, and the anonymity of each one.Then, it was presented the Consent Form.
The data collected were organized and interpreted from the content analysis method proposed by Bardin (1977), of the type thematic category content analysis.For the author, the analysis is organized around three moments: preanalysis that consists of transcription of recorded conversations, floating reading of contents, and resumption of the study goals; exploration of the material that consists of encoding operation, with the formation of corpus from the transformation of raw data; and the treatment of results (inference and interpretation), when the researcher makes logical deductions, and assigns traces of meaning supported by the reference and/or literature.
According to recommendation of the above cited author, we proceeded with the cutting of the text into record units, whereby it was chosen the sentence extracted from the context units (the paragraph).Then, it was highlighted the subcategories that were pooled, resulting in two categories: attention and communication generated between professionals and women users of obstetrics service and, satisfaction of women with the received assistance.
The last stage, presentation and discussion of results, was based on understanding the phenomenon, considering the theoretical framework, allowing to capture the perceptions of women and keeping a dialogue with theoretical references relevant to the study.
The project was approved by the Ethics Committee of the Federal University of Ceará (CEP-UECE), opinion number 04252522-5.All the women that agreed to participate in this research have signed the Consent Form.In this way, the study followed the ethical and legal procedures of the Resolution number 196/96 of the National Health Council / Ministry of Health about studies involving human beings, which ensures ethical conduct and protection of research subjects.

Results and discussion
Among the list of topics discussed with women in the interactive group, stands out the care received in the hospital on occasion of delivery and birth, considering that they have experienced it recently.

Attention and communication between professional and users of the obstetrics service
This emerging focus on women speech was expected, because when talking about the care received consequently we refer to communication, which is imperative for users to feel like a worthy human being, which is heard on their needs.As a parturient, the interactional aspects and the communication bring welfare, feeling of being cared with attention and care.For Waldow (2006), the humane care is undoubtedly embedded on values that regardless of focus prioritize the peace, freedom, respect, love, among other aspects.
The women commented situations experienced in the service that focus the communication and the form of care guided by professionals at various moments of care: There is professional that gives you full attention, affection, true assistance, solve doubts, explains how your baby is, but there is professional that turns away, doesn't talk, and doesn't give details [...].There are people that don't give the attention that we need (P1).
There is professional who treat us well because gives us attention.They explain all about the baby all we want to know, the name of the drugs, this kind of thing, they explain everything to us.They say everything, don't hide anything.They are good professionals you know, they are very cool (P9).
The participants reported the importance of attention provided in form of communication, when they passed the information about the infant, the proper way to approach, to provide care and explanations about health.This attitude is essential for women to get the information and participate in self-care and childcare.
The confidence of users in relation to the team is essential, both for the effectiveness of procedures and for the feeling of security conveyed by these professionals, with information, attention, care, and daily contact (TRONCHIN et al., 2006).
The communication and interaction are important tools of the work, through which the worker will introduce changes in the relationship of existing power, both between professional categories and professional and user (SILVA;SENA, 2008).
In this speech, it stands out the interaction of professional and user: [...] several times one of them had come and measured my blood pressure and it was high.I did not feel anything, but just the way she came to check the pressure, it rose suddenly, and then just due to the cool way of the other professional, the pressure was regular, then it was nice (P2).
It was stressed the importance of nonverbal communication, gestures, body language and expressions.
In the speech of some women it was noticed the disagreements between information provided by the professionals, causing indignation and hindering the understanding of self-care and learning about how take better care of the child at home.This is relevant to the care provided to women in postpartum period, which can develop into an exchange of knowledge with the staff and favor more and more the care to the child, minimizing the anxiety and fear, promoting thus security to mother and child.I've asked to the doctor and she told me that my son was the worst of all.(…) other doctors have said that when he gain weight he could go home, other doctor said that he would stay until Friday, and others have said he would spend eternity there (P2).
One doctor says: We will operate today!Then another one comes and says: If I were you, I wouldn't permit this operation.I have 35 years of experience, I am a doctor.Then besides being traumatized by having a premature child and knowing the things that are going to happen with him, the doctor says something like this, we never know what to do on this time (P3).
You ask: how my baby is?They answer that your baby is stable.This is not an answer for us.We want to know about that monitoring, how was it, what was made today, how is his weight, what he is taking, what he has evolved.We want to know this (P1).
The reports stress out the importance of information to the women, i.e., an effective communication that enable to understand the message, once it is of great interest for the child monitoring.The narratives still show the need of mothers to receive information about procedures and happenings related to health status of the child, in other words, the participants were aware of the right to information about the health of them and of their children.This can be a way to strengthen the bond of users with the service and with the professionals, emphasizing the continuity of care on an outpatient basis.
The process of giving birth creates moments of great vulnerability and loneliness, and often the women have no support from professionals.These frequently due to their professional training, show insensitivity rather than empathy (HOTIMSKY et al., 2002).
The humanization includes also the use of interpersonal communication, i.e., the interactive communication that occurs between professionals and users, the guidance on the procedures to be performed with the postpartum woman and child, in order to make her feel safer during the hospitalization, which contributes even more to create a bond between health professionals and users, beyond promoting the right in decision-making, stimulating the independence and involvement of women during child care (OLIVEIRA; KRUSE, 2006).
Acta Scientiarum.Health Sciences Maringá, v. 35, n. 2, p. 195-200, July-Dec., 2013 Satisfaction of women about received care Despite some difficulties faced during the course of delivery and other passages in the hospital, women commented on the satisfaction with the service and highlighted mainly the 'good treatment' provided by the professionals.
Up here in the delivery room I was treated very well [...].At the time of the delivery, they talked to me, played, hugged and took my hand.I was well treated.(P5) It is great the assistance of here, the girls are very nice, the doctors, nurses, auxiliaries that monitor us, all of them are very nice, there are our friends, we come together (P9).I'm rather pleased.It would be good if there were more hospitals providing this assistance in Fortaleza.Because if you came from Maracanaú, Sobral, you came from locations that are big cities, with conditions to hold a neonatal ICU like this, but don't have.The state government should take a look; deploy more hospitals with this kind of resource.But I'm rather satisfied (P6).
Nursing plays a key role in assisting women in delivery conditions.It was evidenced in the speeches, the multiple roles of nursing, how much it is required under several conditions for meeting the needs of women that have just had a child.It should be noted that this professional category should be aware and reflect continuously on their attitudes on care in order to be able to meet these demands and play the diverse functions, extending the qualified hearing that will also promote a differentiated care.
Also, we could observe aspects of humanization of childbirth, including the approach of patient by providing a receptive attitude, showing respect to the woman and as a single person also responsible for her welfare.Therefore, health professionals should also have in addition to technique, the empathy and abilities to communicate with the users to improve the assistance and promote a humane care (QUEIROZ et al., 2003).
In one speech it was also evidenced the issue of the reference for delivery service by the lack of technical support and material in maternity wards of the State.All this issue focuses many difficulties and fear faced by these women during labor and delivery.
Health professional are supporting this experience, they play important role in the service provided, putting their knowledge to serve the wellbeing of mother and child, recognizing the critical moments whereby their interventions are necessary to ensure the health of both.With this they can try to mitigate pain, stand by, give comfort, enlighten, guide, help to give birth and birth.They must remember that they are the first to touch every child that born and be aware of this responsibility, not permitting the routine and the daily stress to influence this care (WROBEL; RIBEIRO, 2006).
This study highlighted 'some satisfaction' at crucial points of the care, such as in the delivery room and other units, evidenced by the attention received, the respect and the quality care with the child.Mothers unsatisfied have referred to the way of relationship of professional when they have treated them rudely, when they do not listen or have a miscommunication.Women emphatically have referred the mismatches of information by the professionals and the lack of bond caused by the large number of professionals that care for and decide differently.

Conclusion
The study proposal was also to discuss the aspects of humanization according to the precepts of integrity of attention that have been presented in the form of user embracement, bond, generated during the assistance.
Nevertheless, the aspects unveiled showed the experiences full of meaning, which bring the ambiguity: satisfaction by the great opportunity to be promptly attended.This already had a great meaning for them, as if it was not a right, the access to maternity with all favorable conditions to a healthy childbirth.The dissatisfaction was generated much more due to the difficult in communication and relationship than by the assistance referring to technique and operational dimensions of the service.
The perception of service users leads the caregivers and managers to reflect about the way of care where it is more valued the technical aspect at the expense of the interpersonal relationship.