Percepções maternas sobre a assistência nutricional no

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Percepções maternas sobre a assistência nutricional no acompanhamento interdisciplinar do pré-natal e puerpério.

Maternal perceptions on nutritional assistance in the interdisciplinary accompaniment of prenatal and postpartum.

Percepciones maternas sobre la asistencia nutrición en el seguimiento interdisciplinario de la atención prenatal y puerperio.

Andreia Marinho Barbosa1

Linda Susan de Almeida Araújo2 Virginia Matias de Oliveira Barbosa3

Flavia Alessandra de Melo Guerra4

RESUMO: Os Programas de Residência Multiprofissionais em Saúde (RMS) possibilitam o aumento do escopo de profissões na Estratégia de Saúde da Família (ESF), permitindo um acompanhamento pré-natal integral e interdisciplinar. Nesta perspectiva, o estudo visa descrever as percepções maternas sobre a assistência nutricional fornecida através do acompanhamento interdisciplinar do pré-natal e puerpério em uma Unidade de Saúde da Família (USF) campo da RMS. O estudo foi de campo descritivo-exploratório de abordagem qualitativa, o qual foi realizado nos meses de novembro e dezembro de 2016, na USF São José II, em João Pessoa-PB, com 15 mães que foram acompanhadas, no mínimo, em três interconsultas de pré-natal entre março/2015 e março/2016. O material empírico foi obtido mediante a técnica de entrevista semiestruturada com

1 Nutricionista Residente no Programa de Pós-Graduação em Residência Multiprofissional em Saúde da Família e Comunidade – RMSFC, Faculdade de Ciências Médicas da Paraíba (FCM-PB), João Pessoa, Paraíba, Brasil.2 Nutricionista. Coordenadora do Curso de Bacharelado em Nutrição da Faculdade de Ciências Médicas da Paraíba (FCM-PB), João Pessoa, Paraíba, Brasil.3 Nutricionista. Preceptora do núcleo de nutrição da Residência Multiprofissional em Saúde da Família e Comunidade – RMSFC, Faculdade de Ciências Médicas da Paraíba (FCM-PB), João Pessoa, Paraíba, Brasil.4 Enfermeira. Preceptora de campo e do núcleo de enfermagem da Residência Multiprofissional em Saúde da Família e Comunidade – RMSFC, Faculdade de Ciências Médicas da Paraíba (FCM-PB), João Pessoa, Paraíba, Brasil.

ISSN 1982-8829 Tempus, actas de saúde colet, Brasília, 11(2), 09-24, jan, 2018

DOI: http://dx.doi.org/10.18569/tempus.v10i4.2047

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base em um roteiro contendo questões relacionadas ao objetivo do estudo, utilizando-se o sistema de gravação. Os dados foram analisados mediante a técnica de análise de conteúdo. Ao analisar, emergiram as categorias: “influência da assistência nutricional no controle de ganho de peso e sinais/sintomas relacionados à gravidez”; “mudanças de hábitos alimentares a partir de orientações nutricionais fornecidas durante o acompanhamento pré-natal”; e “importância do acompanhamento interdisciplinar na prevalência de aleitamento materno e na alimentação complementar saudável”. As percepções maternas revelaram as potencialidades do acompanhamento pré-natal e puerpério de maneira interdisciplinar e a importância da assistência nutricional para a saúde materno-infantil.Palavras-chave: Saúde Materno-Infantil; Estratégia Saúde da Família; Nutrição na Gravidez.

ABSTRACT: The Multiprofessional Health Residency Programs (MHRP) makes possible to increase the scope of professions in the Family Health Strategy (ESF), allowing integral and interdisciplinary prenatal care. In this perspective, the study aims to describe how maternal perceptions about nutritional care provided through interdisciplinary prenatal and postpartum follow-up in a Family Health Unit (USF), which is field of the MHRP. The study was a descriptive-exploratory field of qualitative approach, developed in November and December 2016, at USF São José II, in João Pessoa-PB, with 15 mothers who were followed at least three prenatal inter-appointment between March/2015 and March/2016. The empirical material was obtained through semi-structured interview technique; based on a script with questions related to the purpose of the study, using the recording system. The data were analysed through a technique of content analysis. From the analysis emerged as categories: “influence of nutritional assistance in the control of weight gain and signs/symptoms related to pregnancy”; “changes in eating habits based on nutritional guidelines provided during prenatal care”; and “importance of interdisciplinary follow-up on the prevalence of breastfeeding and healthy complementary feeding”. The maternal perceptions exposed the potential of prenatal and postpartum monitoring in an interdisciplinary way and the importance of nutritional assistance for maternal and child health.Key words: Maternal and Child Health; Family Health Strategy; Nutrition in Pregnancy.

RESUMEN:Los programas de residencia multidisciplinares en Salud (RMS) permitir un mayor alcance profesiones en la Estrategia Salud de la Familia (ESF), lo que permite prenatal integral e interdisciplinario. En esta perspectiva, el estudio tiene como objetivo describir las percepciones maternas de la ayuda proporcionada a través nutricional prenatal y puerperio interdisciplinario de seguimiento en una Unidad de Salud de la Familia (USF) campo de RMS. El estudio fue de campo descriptivo-exploratorio de enfoque cualitativo, desarrollado en noviembre y diciembre el año 2016, en USF San José II en João Pessoa-PB, con 15 madres que fueron acompañadas sin mínimo en tres interconsultas de prenatal entre marzo/2015 y marzo/2016. Se obtuvo el material empírico través de la técnica de entrevista semi-estructurada, basado en una secuencia de comandos que contiene preguntas relacionadas con el propósito del estudio, usando el sistema de grabación. Los

Tempus, actas de saúde colet, Brasília, 11(2), 09-24, jan, 2018. ISSN 1982-8829

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datos se analizaron utilizando la técnica de análisis de contenido. A partir del análisis, las categorías surgieron: “influencia del soporte nutricional en el control del peso y el aumento de los signos/síntomas relacionados con el embarazo”; “los hábitos alimenticios cambia de orientación nutricional proporcionada durante la atención prenatal”; y “la importancia de la interdisciplinario seguimiento de la prevalencia de la lactancia materna y la alimentación complementaria sana”. percepciones maternas revelaron el potencial de la atención prenatal y puerperio en forma interdisciplinaria y la importancia de la asistencia nutricional para la salud materna e infantil.Palabras clave: Salud Materno-Infantil; Estrategia de Salud Familiar; Nutrición Prenatal.

INTRODUCTION

The attention to maternal and child health is considered historical in the field of public health, especially when it regards to care during the pregnancy-puerperal cycle. In this way, to provide health quality and reduce the mortality rate, it still is a priority in the area of health and reproductive rights, where necessary and effective strategies are developed to achieve this goal1.

In Brazil, since 1988, health has become everyone’s right, guaranteed by a Unified Health System (SUS) integrated by a regionalized and hierarchical network, which has Primary Health Care (APS) as the main gateway, through the Family Health Strategy (ESF). With the increase of this assistance coverage, there were positive effects on the improvement of maternal and infant mortality rates, which in 1997 were 61.2 and 23.5, and in 2013, reached the levels of 58.0 and 13.4, respectively2, although these results are not considered satisfactory according to parameters established by the Pan American Health Organization (OPAS)3.

In the field of health services, adequate prenatal care stands out as a potential, with the objective to ensure the proper development of pregnancy, ensuring at the end of the gestation, a safe delivery and a healthy new-born, with no implications on maternal health and also addressing psychosocial aspects and the promotion and prevention of health activities4. The first prenatal appointment should take place up to 120o day of gestation, and should be at least six visits in total; preferably, one in the first, two in the second and three in the last trimester of gestation5.

The pregnant woman’s health assistance must be performed by a multiprofessional team. Many reports reinforce that the specificity of the professions, when linked in an extensive context of health, contemplates the integrity in the production of care 6-9.

However, there are several casualties in the health system and local realities that come up against this proposal, for example, the minimum family health team does have a nutritionist, what is an essential regard to ensure the axis of follow-up and monitoring gestational weight and nutritional


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orientations in the period from pregnancy to breastfeeding, and complementary feeding4.

Suggesting the integration of different professions in the different health scenarios, including APS, the Ministry of Health (MS) and the Ministry of Education (ME) established a Multiprofessional Health Residency (MHRP) through Interministerial Ordinance No. 1,077/2009, as a modality of lato sensu10 postgraduate education, with a minimum duration of two years and a total workload of 5760 hours, with 80% of activities, practices and 20% theoretical or theoretical-practical activities11.

The objective of the MHRP is to promote a transformation of the health services where it is inserted stimulating a critical reflection on the interdisciplinary practice and the possibilities and limits to modify it12, through an in-service learning that prioritizes activities carried out in a multiprofessional way, where the professional practice is developed with excellence in the areas of integral health care, involving individuals, communities, work management and organization, as well as health education13.

The interdisciplinarity confers this innovative character to MHRP’s, demonstrated mainly by the coverage of fourteen professionals categories of health10. “This way of operate in an “intercategory” training aims a collective formation within the same ‘field of work but still prioritize and respect the specific knowledge centres of each profession” 14:13.

Thus, the program of Multiprofessional Residency in Family and Community Health (RMSFC) of the city of João Pessoa, in partnership with the Faculty of Medical Sciences of Paraíba (FCM-PB), approved in 2014 and covering the following professions: nursing, physiotherapy, psychology and nutrition, develops its actions primarily in the ESF and allows an expansion of the possibilities of the multiprofessional health teams of the respective city.

Previously the RMSFC, the low-risk prenatal service was performed predominantly by medical and nursing attendance. The interdisciplinary experience, characteristic of the Program, is a way to seek a comprehensive care and attention to the health of users assisted by staff, including pregnant-puerperal women, allowing an expanded look at their bio-psychosocial status.

Bearing in mind the increment of the scope of professionals‘ nuclei directed to the prenatal and puerperium assistance performed at the Family Health Units (USF), RMSFC fields, in the city of João Pessoa-PB, this respective work describes maternal perceptions about nutritional assistance that was provided by the interdisciplinary monitoring.


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METHODS

This is an exploratory descriptive field study of a qualitative approach, developed in the city of João Pessoa-PB, specifically at USF São José II, V Sanitary District, one of the RMSFC fields of action since 2015.

During the first year of work at this Unit, ware conducted prenatal and childcare inter-appointments assistances, which consists in an appointment with nutritionist, pharmacist and nurse at the same time, beyond activities in the promotion and prevention in any area of USF itself, and in the regions of its territory.

Focusing on prenatal care, the population of the study had 15 mothers who were followed during the period from March 2015 to March 2016. As criteria for inclusion, the mothers should have been followed during this period, participating in at least 3 inter-appointments of prenatal. The exclusion criteria were mothers under the age of 18 years. As it was a qualitative approach, the sample was defined when the recidivism of information15 started, wherefore, was used criterion of repetition and saturation of the data to determine the number of interviews16.

A retrospective survey of the mothers who were followed up at the above mentioned period was performed and subsequently called by phone or straight by the Health Community Agent (ACS) responsible for their micro-area; in both cases the mothers were invited to go to the ESF on specific days and pre-scheduled times to talk to the responsible of the research and if she accepted, to be interviewed at that time. The choice of the location of the interviews was made through the bond established between the mother and the ESF, so that the same person felt confortable to talk with an interviewer without influences from the external environment.

The data collection was made between November and December 2016, where the empirical material was obtained through the semi-structured interview technique, based on a script with questions related to the purpose of the study, using a recording system. It should be mentioned that, in order to maintain the anonymity of the participants, the statements were identified by the initials ‘M’, followed by cardinal numbers, according to the order of interviews.

The recorded testimonies were later heard by the researcher and transcribed in full through the Microsoft Word® program. For interpretation and analysis of content, the one proposed by Bardin17 was used, following the subsequent steps: pre-analysis, which consisted in organizing the data collected on the basis of the forms; material exploration, identifying the central themes of each question, with their respective convergent points, according to their common focus; and grouping into categories and treatment of results, at which point inferences and interpretations were addressed.


14 // The project was submitted to analysis by the Research Ethics Committee (CEP) of the Faculty

of Medical Sciences of Paraíba (FCM-PB), and approved in accordance with the certificate number 044/2016 and CAAE 56525216.1.0000.5178. The research procedures were carried out in accordance with Resolution 466/12 of the National Health Council that regulates researches involving human beings. All participants received information about the nature of the research, its objectives, methods, expected benefits, potential risks and the annoyance it might involve, and accepted to participate in it by signing the Free and Informed Consent Form (TCLE).

RESULTS AND DISCUSSION

From the analysis of the data, the following categories emerged: “influence of nutritional assistance on the control of weight gain and signs/symptoms related to pregnancy”; “changes in eating habits based on nutritional recommendations provided during prenatal care”; and “importance of interdisciplinary follow-up on the prevalence of breastfeeding and healthy complementary feeding”.

Influence of nutritional assistance on the control of weight gain and signs/symptoms related to pregnancy

Prenatal follow-up performed by the ESF in basic health care aims to verify women’s blood pressure, weight and height4. However, in an interappointment, it goes beyond evaluating only the evolution of these questions. Residents in an interdisciplinary way seek to carry out an integral follow-up, so each one interacts with the other in what concerns to his/her area, resulting in complete and simple delivered orientations, contemplating different levels of knowledge. Thus, the category most cited by the mothers consisted in how these interdisplinary orientations, especially nutritional ones, could influence their gestational weight gain:

“I was gaining to much weight, [...] after I received some tips, the information, it got

better” (M1).

“I was able to control my weight [...]” (M8).

For Padilha et al.18 it is important to observe the weight evolution during the prenatal period, in order to get obstetric improvements. As goals, priority should be given to pregnant women who present nutritional risk by proposing that they undergo nutritional counselling.

The prenatal care evaluation from the perspective of puerperal women, Libera et al.19 identified that they have the habit of praising doctors, even considering other professionals in the team also agents of knowledge and practices that should be shared during prenatal care, such as the nutritionist.


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In this study, the mothers showed dissatisfaction about the medical attention and complained about the delay to schedule appointments and exams, but regarding the interappointment, there were no lines that revealed negative points. Related to the nutritionist, they considered that their presence in prenatal care was important in future choices related to feeding.

One of the points reported by the mothers was the difference of the current pregnancy weight gain, related to the previous pregnancies, although they were also accompanied by ESF, they were not able to carry out the control of the weight in an efficient way:

“In the last gestation I put on weight, I ate everything [...], especially what I could not,

was what I ate the most, so I gained a lot of weight, but now I gained just the normal, fed

me right, avoided many foods that was not supposed to eat; mainly fried, fat, for me it

made a big difference” (M8).

“[...] The last gestation I reached 102kg, and in that I got up to 96kg” (M6).

“I only gained 13kg, in the other one I gained 25, so it was great for me ... as I didn’t have

a nutritionist’s follow-up in the other gestation, the other gestation I didn’t have, in the

first” (M1).

Many women had pre-gestational deviation of weight, which enhance the importance of being established actions to promote the healthy lifestyle, where the nutritional orientation is highlighted in this sense, favouring the adequate nutritional condition and minimizing the risks of maternal and infant intercurrences18.

Nutritional assistance given during the interdisciplinary prenatal also helped to improve some pregnancy-related symptoms that influence weight gain/loss, as observed in one of the mothers’ speech:

“In the beginning I lost a lot of weight, because I felt very sick, and she taught me what I

had to eat, [...] then I was able to keep my weight and without affecting the baby too. Thus,

during all the pregnancy, she told me what I could, and I could not eat, it helped me a lot

to regain my weight and another thing, when I had the baby I got my normal weight, I did

not exceed it, I liked because of it”(M11).

“Since I was skinny, I thought I was going to get a lot of fat, and I went to the clinic, they

explained that I should eat a little of everything, but not too much. Sometimes I ate a lot of

pasta, then I had a lot of heartburning, and I did not know why it was happening, when I

went to my prenatal appointment, the nutritionist explained to me that it is because I had


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not to eat too much biscuit, bread; That I had too much heartburn when I was pregnant, as

even feeling bad, then I went there to know why I felt it, so much, and it was very strong,

so she explained to me that it was because I had to stop eating a lot of bullshit, a lot of

biscuit, sweets, which was what I ate” (M14).

The physiological changes that occur during gestation mark its complex and singular nature, and it is up to the health professionals to be alert, so with their knowledge they can develop interventions that will help women to overcome the difficulties imposed by this condition20, such as group activities and educational groups, as well as interdisciplinary appointment with horizontal dialogue. This last one was the main strategy used in this study, and their contribution was perceived from the moment that the women felt the willingness to report the presence of these scenarios and the improvement after the inter-appointment implementation.

Blood pressure may also change during gestation and cause intercurrences during this period as well as parturition, being a healthy diet one of the foundation to maintain it within the acceptable limits4. Mothers who are hypertensive or who have already undergone gestational hypertension also reported the importance of nutritional assistance in controlling blood pressure:

“About the blood pressure, this last one was better, at the other, my pressure was higher,

because I had no nutritionist monitoring, I ate everything, salt, salty, I ate a lot of salty

food, a lot of cake, chocolate cake, then the pressure went up a lot, and at this time it

did not rise, it was normal, 13 to 14, but in the maternity it lowered to 11, when I went

to delivery. It did not go up there at all. In the other, the pressure went up at the time of

delivery, it was 17” (M6).

“During this gestation my pressure is controlled, at the first one it was not [...]” (M1).

It is very important the participation of a multi-professional team that is active in relation to hypertensive diseases during pregnancy, capable of seeking strategies to guide the pregnant woman in maintaining weight, dietary re-education, and control of the tensional levels and the usage of medications21.

In an analysis of the maternal experience of a pregnancy with preeclampsia performed in a reference maternity for risk pregnancies in Rio Grande do Norte, the authors were able to identify that the difficulties faced by these women were intensified by the absence or inadequacy of information, as well as in the hospital unit, pointing out the needing to reorganize perinatal care in these spaces in order to promote actions for the entire women’s health in the pregnant and puerperal cycle22.


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Through this study, could be noticed that the information provided at the prenatal appointments also contributed to clarify mother’s knowledge related to the increase of blood pressure, which with nutritional recommendations, could influence their food choices, so mothers knew “why” and “what for” choose the correct food, and through co-responsibility they contributed to their own great gestation and delivery.

Health education carried out in prenatal care covers these aspects, since it can be done individually or in a group way, assuming a combination of opportunities that improves health promotion and maintenance and, above all, it is not just a transmission of content, but also a way to seek for the autonomy of the subjects in the conduction of their lives23.

Changes in eating habits based on nutritional recommendations provided during prenatal care

The evaluation of the dietary intake of pregnant women and their weight gain serves to subsidize the development of dynamic action plans to control the feeding quality and adequate weight gain at this stage of life24. The provision of nutritional recommendations that lead to the promotion of a healthy nutritional status for the mother-child binomial are also specific actions instituted in the monitoring of low-risk prenatal care4.

Through the MHRP, there is openness to the possibility of providing nutritional and dietary recommendations, in addition to the elaboration of dietary prescriptions for the pregnant women who will be followed at the USF during prenatal care and puerperium period, allowing more effective changes in the field of food and nutrition for maternal and child health.

At the interdisciplinary prenatal care, the nucleus of nutrition is especially responsible for nutritional recommendations, although it is not the exclusive activity of this professional as it is the dietary prescription, but by the own training, these recommendations become more complete, since they cover eating habits which influence both weight gain and the importance of nutrition in the treatment of certain clinical conditions related to pregnancy, such as increased blood pressure, anaemia, nausea and vomiting, intestinal constipation, oedema, etc.

According to some interviewed mothers, such nutritional and dietary recommendations were especially important during the gestational period:

“It’s always good to be oriented, right?! Receiving like a little push… it’s good... I reduced

salt, fat, these type of things”(M9).

“I used to drink a lot of soda, [...] I used to eat many coxinhas (deep-fried chicken filled


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croquette), I was used to eat all those salty foods every day, [...] that’s when I got the

information I decided to change” (M1).

“The part of nutrition, that she directs the person to make a good diet, especially for me,

that it was very difficult to drink water, to feed right at work, I was used to took a lot time

without eating, she explained to me a lot of that” (M2).

“It was good because I stopped eating many things that I was used to eat and caused me

heartburn. I was used to eat a lot of bullshit. I did not eat at the right time, but I started

eating, it was good, I also enjoyed being accompanied by the nutritionist” (M15).

Increase consumption of healthy foods like fruits and vegetables; avoid foods high in fats and sodium; and eating at the correct times are strategies usually well accepted by pregnant women as healthy practices, despite the difficulty of adherence to this new eating behavior25.

An experience with nutritionists at the Unit is able to provide a better communication and relationship with the users and, consequently, the consolidation of the adhesion of the pregnant women to the proposal of nutritional assistance19. It is also necessary to transmit new knowledge, to value the knowledge of the served population, such as tradition and food culture25, thus inserting it in the concept of health as a determining part of the results.

Dietary prescription was also cited as a strategy to obtain greater usage of all dietary and nutritional recommendations:

“I liked it because as I eat a lot of bullshit, well, but mainly because of my diet, that I think

it was well elaborated, very detailed, perfect, full of examples of what I could and could

not eat and had some things that I actually removed from diet during prenatal care” (M4).

The satisfaction found during nutritional assistance can also contribute to a greater adherence of the women to the guidelines and recommendations articulated during the appointment with the nutritionist. The incorporation of healthier dietary practices results in a change in diet that, in turn, can be maintained beyond the gestational period19.

Importance of interdisciplinary follow-up on the prevalence of breastfeeding and healthy complementary feeding

It is well known that exclusive breastfeeding up to six months of age and supplementing up to two years constitutes a strong strategy for reducing infant morbidity and mortality, also providing a child right supply of necessary nutrients for healthy growth and development. Such breastfeeding


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is also very important for maternal health, since some diseases can be avoided as the mother breastfeeds26.

Brazil is already a worldwide reference in the prevalence of breastfeeding 27; however, this is still low in comparison to its positive effects on maternal and child health28. Therefore, prenatal follow-up also aims to provide necessary information to stimulate mothers to breastfeed, as well as offer good complementary feeding at the right time29.

Breastfeeding was one of the points that as mothers reported as positive when guided by the interdisciplinary team, where each member of the team shows, according to their emphasis and through the exchange of knowledge, the health benefits of the mother and child with this action:

“It gave me more encouragement to breastfeed until 2 years old, because milk is essential

in their lives” (M12).

“It helped, because it is better to breastfeed until 6 months, eat well, a lot of fruit, and

things that improve the milk production to breastfeed” (M13).

Interdisciplinary performance with pregnant women enables work with their demands, which results in favourable effects on maternal and child health care. The integration of the different knowledge of the different professionals in a team favours interventions that consider other relevant dimensions of health to pregnancy-puerperal care30.

Some mothers who were followed without interdisciplinary prenatal care had some difficulties in breastfeeding but found in the multi-professional team refuge and assistance in how to proceed facing such a situation:

“They taught me everything, but since I was almost depressed, I cried a lot, [...] they

talked to me, said that I could not sacrifice myself. If I would not breastfeed, it would be

normal. They taught me and gave me advices how to breastfeed, but I could not, then they

told me what to do with her, they gave me the milk to give her, and all the attention that

I needed. That time I finally got calm, and they told me that my baby was healthy and I

might not worry anyway, it was good if she got her breastfeed until 6 months, but since I

could not I may not worry about that, because she was healthy, and they kept following me

straight, me and the baby to see if everything was going right” (M11).

“At the beginning when I had him I did not have milk in my breast, then I got desperate

thinking that it would not be produced, if it was something I ate when I was pregnant, or

if it was not right [...] the girls explained that I should be calm, and do not think the milk


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would not come, that it would, and from that day I could breastfeed him, thanks God, and

he is well until today” (M14).

Through the dialogue between mother-professionals, the woman is guided on the importance of other professional nuclei for her prenatal follow-up. Such approach establishes a bond, assigning confidence to the woman and reducing her anxiety, in order to make her feel valued21.

The resident is a health professional in specialization. Despite this, they are still often seen as students, who according to Libera et al.19, when prenatal care was performed by these, the women saw them as capable of perceiving and dealing with issues related to technical knowledge and interpersonal relationships in a more relaxed and welcoming way. “It is believed that students, when using their experiences and knowledge acquired in health practices, take a position that goes beyond professional training and end up contaminating those who work in the same environment” 31:1125.

There were also reports of mothers who considered the importance of nutritional and dietary recommendations when offering complementary food to the child:

“We think that we have to give food for the child soon, so the child becomes chubby soon,

many mothers think that’s right, and in fact, it is not [...]” (M8).

“It changes so much! I was giving things that it was not right to give to my son and during

the follow up they taught me what I should give and what I should not. What was healthy

and was not for my son. I learned a lot from it” (M10).

The satisfaction of the mothers in relation to the assistance provided is often associated to the explanation of their doubts by the professionals, and how clear the information is gave19. In this study, the women showed satisfied because could be heard and informed, instead of being just a collector of information, but a thoughtful subject who is able to express opinions and collaborate for their own well being and their child.

The valuation of subjectivities and relational practices in women’s care during pregnancy and puerperal period constitutes a powerful device capable of lead to a higher quality of care and health services more welcoming and resolutive, as well. For this, it is required that the follow-up by qualified professionals, which go beyond clinical knowledge, dedicating themselves to the process of caring for health and appropriating technologies, such as listening, bonding and receiving, and being mutually responsible for promoting care32.


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CONCLUSION

From the study it was possible to conclude that maternal perceptions about prenatal and puerperium care by an interdisciplinary team are capable to reveal the potential of this follow-up, as influencing on weight gain and postpartum weight restriction; nutritional recommendations for the pregnancy-puerperal period; encouraging breastfeeding, as well as offer good complementary feeding at the right time; establishment of a link with users in order to make them feel supported; elucidation of doubts; and knowledge exchange of professional-professional and professional-user.

The nutritional assistance provided has been shown effective to its destination, and this service when performed during an interappointment, makes maternal and child health better, and changes the strategy of the process to act in an integral and integrated way, making the mother also a participant of the process, who collaborated in her own future actions.

This study intends to collaborate with other researches in the health area that also take into account users’ opinions, and provide subsidies for the elaboration of health policies directed to primary care. After all, in order for these to be effective, it is necessary to listen first those who are supported, since in one horizontal talk they can explain better the fragilities and as potentialities in health care, mainly about nutritional and preventive actions in health, making them more effective and satisfying for supporters and those who are supported.

REFERENCES

1. Souza JP. Mortalidade materna e desenvolvimento: a transição obstétrica no Brasil. Rev Bras Ginecol Obstet. 2013; 35(12):533-5.

2. Brasil. Sistema de Informações sobre Mortalidade – SIM [Internet]. Brasil: SIM; 2016 [acesso em 2016 mar 15]. Disponível em: http://www2.datasus.gov.br/.

3. Carvalho ML, Almeida CAL, Marques AKL, Lima FF, Amorim LMM, Souza JML. Prevenção da mortalidade materna no pré-natal: uma revisão integrativa. R. Interd. 2015; 8(2):178-184.

4. Ministério da Saúde (BR). Atenção ao pré-natal de baixo risco. Brasília: Ministério da Saúde; 2012. 318p.

5. Ministério da Saúde (BR). Pré-natal e Puerpério: atenção qualificada e humanizada – manual técnico. Brasília: Ministério da Saúde; 2005. 163p.


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6. Maia DB, Sousa ETG, Gama RM, Lima JC, Rocha PCF, Sassaki Y. Atuação interdisciplinar na Atenção Básica de Saúde: a inserção da Residência Multiprofissional. Sau. & Transf. Soc. 2013; 4:103-10.

7. Ceron MI, Barbieri A, Fonseca LM, Fedosse E.. Assistência pré-natal na percepção de puérperas provenientes de diferentes serviços de saúde. Rev. CEFAC. 2013; 15(3):653-62.

8. Trevisan ML, Lewgoy AMB. Atuação interdisciplinar em grupo de puérperas: percepção das mulheres e seus familiares. Rev Textos Contextos. 2009; 8(2):255-73.

9. Matos E, Pires DEP, Campos GWS. Relações de trabalho em equipes interdisciplinares: contribuições para a constituição de novas formas de organização do trabalho em saúde. Rev. Bras. Enferm. 2009; 62(6):863-9.

10. Ministério da Educação; Ministério da Saúde (BR). Portaria Interministerial n. 1.077, de 12 de novembro de 2009. Dispõe sobre a Residência Multiprofissional em Saúde e a Residência em Área Profissional da Saúde e institui o Programa Nacional de Bolsas para Residências Multiprofissionais e em Área Profissional da Saúde e a Comissão Nacional de Residência Multiprofissional em Saúde. Diário Oficial da União. 2009 nov. 13; Seção I. p 7.

11. Comissão Nacional de Residência Multiprofissional em Saúde (BR). Resolução CNRMS nº 3, de 4 de maio de 2010. Dispõe sobre a duração e a carga horária dos programas de Residência Multiprofissional em Saúde e de Residência em Área Profissional da Saúde e sobre a avaliação e a frequência dos profissionais da saúde residentes. Diário Oficial da União. 2010 maio 5; Seção I. p 14-15.

12. Nascimento DDG, Oliveira MAC. Competências profissionais e o processo de formação na residência multiprofissional em Saúde da Família. Saúde Soc. 2010; 19(4):814-27.

13. Silva JC, Contim D, Ohl RIB, Chavaglia SRR, Amaral EME. Percepção dos residentes sobre sua atuação no programa de residência multiprofissional. Acta Paul Enferm. 2015; 28(2):132-8.

14. Brasil. Residência multiprofissional em saúde: experiências, avanços e desafios. Brasília: Ministério da Saúde; 2006. 414p.

15. Minayo MCS, Assis SG, Souza ER. Avaliação por triangulação de métodos: abordagem de programas sociais. 4. ed. Rio de Janeiro: Fiocruz; 2014. 244p.


23 //

16. Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad. Saúde Pública. 2008; 24(1):17-27.

17. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2011. 229p.

18. Padilha PC, Saunders C, Machado RCM, Silva CL, Bull A, Sally EOF, Accioly E. Associação entre o estado nutricional pré-gestacional e a predição do risco de intercorrências gestacionais. Rev Bras Ginecol Obstet. 2007; 29(10):511-8.

19. Libera BD, Saunders C, Santos MMAS, Rimes KA, Brito FRSS, Baião MR. Avaliação da assistência pré-natal na perspectiva de puérperas e profissionais de saúde. Ciência & Saúde Coletiva. 2011; 16(12):4855-4864.

20. Queroz AA. Conhecendo as alterações da gestação para um melhor cuidar no pré-natal. [Trabalho de Conclusão de Curso]. Brumadinho – MG: Universidade Federal de Minas Gerais; 2012. 33p.

21. Vieira SM, Bock LF, Zocche DA, Pessota CU. Percepção das puérperas sobre a assistência prestada pela equipe de saúde no pré-natal. Texto Contexto Enferm. 2011; 20:255-62.

22. Souza NL, Araújo ACPF, Azevedo GD, Jerônimo SMB, Barbosa LM, Sousa NML. Percepção materna com o nascimento prematuro e vivência da gravidez com pré-eclampsia. Rev Saúde Pública. 2007; 41(5):704-10.

23. Santos, AL, Radovanovic CAT, Marcon SS. Assistência pré-natal: satisfação e expectativas. Rev. Rene. 2010; 11(nº Espec):61-71.

24. Fazio ES, Nomura RMY, Dias MCG, Zugab M. Consumo dietético de gestantes e ganho ponderal materno após aconselhamento nutricional. Rev Bras Ginecol Obstet. 2011; 33(2):87-92

25. Junges AF, Ressel LB, Monticelli M. Entre desejos e possibilidades: práticas alimentares de gestantes em uma comunidade urbana no sul do Brasil. Texto Contexto Enferm. 2014; 23(2):382-90.

26. Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, et al. Amamentação no século 21: epidemiologia, mecanismos, e efeitos ao longo da vida. Epidemiol serv saúde. No prelo 2016.

27. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Por que


24 //

investir e o que será necessário para melhorar as práticas de amamentação? Epidemiol serv saude. No prelo 2016.

28. Venancio SI, Escuder MML, Saldiva SRDM, Giugliani ERJ, Breastfeeding practice in the Brazilian capital cities and the Federal District: current status and advances. J Pediatr. 2010; 86(4):317-24.

29. Frota MA, Aderaldo NNS, Silveira VG, Rolim KMC, Martins MC. O reflexo da orientação na prática do aleitamento materno. Cogitare Enferm. 2008; 13(3):403-9.

30. Barbieri A, Fonseca LM, Ceron MI, Fedosse E. Análise da atenção pré-natal na percepção de puérperas. Distúrb Comum. 2012; 24(1):29-39.

31. Adolpho CVT, Dias IMAV, Aveiro MC, Vasconcelos ACF. A percepção do usuário sobre a abordagem de uma equipe de residentes multiprofissionais. Saúde Debate. 2015; 40(107):1117-1126.

32. Cabral FB, Hirt LM, Van der Sand ICP. Atendimento pré-natal na ótica de puérperas: da medicalização à fragmentação do cuidado. Rev Esc Enferm USP. 2013; 47(2):281-7.

Article submitted on 30/01/2017Article approved on 16/10/2017

Article posted in the system on /03/2018


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