Maternal decision on obtaining prenatal care: a study in Brazil

Abstract

Objective

to address the social aspects of pregnancy and the views of pregnant women regarding prenatal assistance in Brazil.

Design

this qualitative study was focused on describing the Social Representations of prenatal care held by pregnant women. The discourse of the collective subject (DCS) framework was used to analyse the data collected, within the theoretical background of social representations, as proposed and developed by Serge Moscovici.

Participants and setting

21 pregnant women who were users of the publicly funded Brazilian unified health-care system and resided in the area served by its family health programme in a low- to middle-income neighbourhood on the outskirts of Campo Grande, the capital of the state of Mato Grosso do Sul, in southwestern Brazil. Data were collected by conducting in-depth, face-to-face interviews from January to October 2006.

Findings

all participants were married. Formal education of the participants was less than five years in four cases, between five and eight years in six cases, and greater than 11 years in 10 cases. Nine participants had informal jobs and earned up to US$ 200 per month, four paricipants had administrative jobs and earned over US$ 500 per month, and eight participants did not work. No specific racial/ethnic background predominated. Lack of adherence to prenatal care allowed for the identification of two DCS themes: ‘organisation of prenatal care services’ and ‘lifestyle features’.

Key conclusions

the respondents were found to have negative feelings about pregnancy which manifest as many fears, including the fear of harming their children's health, of being punished during labour, and of being reprimanded by health-care professionals for overlooking their prenatal care, in addition to the insecurity felt towards the infant and self.

Implications for practice

the findings reveal that communication between pregnant women and health-care professionals has been ineffective and that prenatal care has not been effective for the group interviewed—features that are likely to be found among other low- to middle-income groups living elsewhere in Brazil.

Introduction

In Brazil, women's health policies and related guidelines are defined by the Health Ministry, a national government body that, along with 27 statewide health offices and an additional five thousand local health offices, develops and implements actions aimed at reducing maternal and infant mortality. Mortality rates in these population segments are still particularly high, as shown by 1620 maternal deaths out of 3,035,094 deliveries in 2005 (Ministry of Health, Brazil, 2007).

In the Brazilian health-care system, primary care is provided through publicly funded health-care programmes whose focus on women's health is based on the overall goal of providing comprehensive assistance to women throughout the life cycle. Prenatal care teams consist of doctors, nurses, dentists, dental assistants nursing assistants and community health agents (these agents can be described as public health assistants who live in the district they serve and have undergone training in order to make visits to residences to provide instruction in health care and identify cases requiring social or medical attention). The activities of prenatal care teams are overseen by the nursing staff and include outpatient nursing appointments, maternal and fetal health education, control of attendance and recall appointments, weight and nutritional status control of pregnant women, collection of samples for laboratory tests, prescription of drugs such as ferrous sulphate and folic acid, and monitoring of tetanus immunisation status (Duarte and Andrade, 2008).

Data from the Ministry of Health, Brazil (2007) provide evidence that women are the group that places the highest demands on health services. This suggests that women's health-care requirements have not been satisfactorily met and that policies must be implemented to address the real needs of this population segment. Despite the availability of a program for comprehensive attention to women's health (Programa de Atenção Integral à Saúde da Mulher), which began in the 1980s in response to sanitarist and feminist movements, its scope still falls short of the overall purpose of providing comprehensive care in relation to women's health since it is primarily focused on reproduction.

Although in Brazil, assistance for women has centred on obstetrics, many still fail to seek health-care services during pregnancy, thus being deprived of the benefits of prenatal care.

Psychosocial aspects should not be viewed as hierarchically inferior to those valued in biomedical models. Instead, feelings associated with the experience of pregnancy and motherhood, in their multiple dimensions, should be taken into consideration, as pregnancy is a unique period in a woman's life (Brasil, 2004). Therefore, the set of actions carried out as part of prenatal assistance should have a comprehensive reach and should address the real needs of pregnant women, while also encouraging receptivity and retention in prenatal care, particularly when aided by effective communication and a humane approach (Smith et al., 2009).

This study was motivated by the authors’ professional experience in the field of women's health care, particularly in prenatal attention. The study was focused on investigating the reasons why large numbers of women residing in the study area fail to adhere to prenatal care, which is a key process for reducing infant and maternal mortality. The authors hypothesised that the rapport established between users and health-care professionals might interfere with the adherence of pregnant women to prenatal care.