Graciela Dutra Sehnem1, Giana da Rosa Beltrame1, Laís Antunes Wilhelm2, Aline Cammarano Ribeiro1, Silvana Bastos Cogo1, Márcio Rossato Badke1 Jaquiele Jaciára Kegler1, Fernanda Almeida Fettermann3, Fernanda Duarte Siqueira1, Cintia Flôres Mutti1, Amanda Peres Zubiaurre De Barros1, Francielle Morais De Paula1, Caren Da Silva Bertoldo1, Luiza Carolina Santos Malheiros1*, Silvia Tereza Nogueira Sibalde4, Richardson Augusto Rosendo Da Silva5 and Eliane Tatsch Neves1
Received Date: 29/04/2020; Accepted Date: 21/05/2020; Published Date: 28/05/2020
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Objective: The study aimed to know the experiences of young mothers of premature children about the postpartum period.
Method and methods: Qualitative research, conducted at the pediatric outpatient clinic of a university hospital in southern Brazil, in the first semester of 2019. Semi-structured interviews were conducted with 10 young mothers of premature children, respecting the ethical principles of the National Health Council. The data were submitted to thematic analysis content.
Results and Discussion: The results pointed out that, during the postpartum period, feelings of anguish and worry arose due to the specific demands of prematurity, but also moments of pleasure and happiness. Those mothers faced several changes in their routines, mainly because their babies were born prematurely. Due to the complex care that some babies required, they experienced fear that their child would need specialized support until stabilization, the long period of hospitalization and, after discharge, home adaptation, which becomes differentiated for a premature infant.
Final Considerations: Young mothers of premature children need a support network to face negative feelings and changes in daily life.
Youth, Post-partum period, Premature newborn, Nursing.
The youth can be understood as a social and cultural category, constructed from criteria covering biological, psychological, chronological and social dimensions. In this life stage, health problems are less frequent; however, some habits and behaviors, in certain situations, make young people vulnerable. This is a social group in important psychobiological changes linked to the resizing of their identity and the new social roles they assume .
At this stage, boys and girls begin to experience affective relationships and expand their bonds beyond the family. Thus, sexuality reveals itself as a plural phenomenon and one of the spheres of acquisition of individual autonomy in relation to the family, considering that representations, values and behaviors related to sexuality and gender roles begin to be constructed .
In the process of experimentation of sexuality, pregnancy sometimes occurs. However, this can be considered a serious public health problem in the world. Estimates show that approximately 21 million teenage girls from 15 to 19 years, in lowand middle-income countries, become pregnant and about 16 million give birth annually . In the Brazilian context, every 1000 girls aged between 15 and 19 years, 68 are pregnant. The perinatal mortality is 50% higher among babies born from mothers under 20 years when compared to those born from mothers from 20 to 29 years .
The motherhood, as a process of physical, emotional and social changes in women’s life, becomes even more challenging for young women . When pregnancy occurs in the youth is not necessarily considered a risk, but some factors should be monitored, such as low schooling, unsafe family and marital situations and unaccepted pregnancy . Thus, in this life stage, pregnancy may become a complex event, since, in most cases, the family is not prepared for the arrival of a new member and perinatal complications may occur .
Nevertheless, it is important to emphasize that, for some young people, there is a pre-planning of pregnancy, which may be the result of a stable emotional life, the desire to becoming a mother while still young and change of social status, among other reasons. Furthermore, the planning of pregnancy in this stage may be due to the influence of the environment and sociocultural factors, especially among girls with lower socioeconomic conditions and from urban regions, leading to increased indices in the public .
The increased indices of pregnancy in adolescence may contribute to a greater prevalence of preterm delivery . Premature birth is defined as the delivery that occurs in less than 37 complete weeks of gestation . The relationship between pregnancy in adolescence and the birth of a premature child hinders the postnatal experience for the young mother. According to the complexity of each case, there may be hospitalizations of the child in the long term and, in more serious cases, this can lead to serious consequences. A current study conducted in Turkey revealed that pregnancy in youth can lead to preeclampsia, abortion, premature delivery, low birth weight and a higher rate of cesarean section .
In the puerperal phase, the woman experiences a state of biological, psychological and social changes from pregnancy and delivery, which put her in a situation of vulnerability . The postpartum period, also called puerperium, begins immediately after delivery and has indefinite termination time, considering that its length may vary among women .
The puerperium, when experienced by adolescents and young adults, can awaken an early maturity, since the new role of being a mother modifies the routine and can awaken the responsibility. This arises from the concerns with care with the newborn and the distancing from common activities in this life stage, such as parties and fun with friends .
Such questions may be aggravated by the presence of prematurity. A research showed that young maternal age is a component of significant risk for neonatal diseases in developed countries. In this way, the adolescent’s age must be considered as a potential concern in relation to the neonatal health, which reflects the need of health professionals provide greater support and follow-up with this population .
Concerning the background that composes this study, the specific rates of fecundity in Brazil indicate a decline in all age groups, except among adolescents and young adults . Due to the high rates of pregnant women in this age range and the complications that end up increasing the occurrence of cases of prematurity, it is important to know how the young mothers of preterm infants in a hospital in the countryside of Rio Grande do Sul experience the postpartum period.
In relation to the experience of the puerperium by young women, there was a search in the national and international literature, which identified that the productions available addressed, in particular, issues such as obstetric outcomes, contraception in the postpartum and socioeconomic level related to pregnancy in this phase [9,13,14]. Additionally, it is evident that studies focusing on the experiences of young mothers of preterm infants in the postnatal period are incipient, justifying the need for greater investments in researches about the topic.
Therefore, this study sought to answer the following research question: what are the experiences of young mothers of premature children about the postpartum period? In this context, the study aimed to know the experiences of young mothers of premature children about the postpartum period.
This is a qualitative study carried out in the first half of 2019. The qualitative approach was understood as being the most appropriate for this study, because it considers the meaning of human actions, motives, aspirations, beliefs, values, attitudes and relations. The qualitative research emphasizes the understanding and analysis of the dynamics of social relations established with the experience and coexistence in everyday life, understood within structures and institutions .
The research was carried out at the pediatric outpatient clinic in a university hospital in southern Brazil. This clinic meets premature infants born at that hospital and, in 2018, there were 19,060 calls, and approximately 785 of these were intended to premature children.
The study participants were young mothers of premature children. In this research, the inclusion criteria for the participants were: being experiencing the remote puerperium, delimited after the 45th postpartum day with unexpected end, to allow better living the experiences of social support in the puerperium. There was exclusion of puerperal women who had had perinatal losses or whose newborns were hospitalized in the Intensive Care Unit (ICU), in the period of data collection, because they are different experiences of the period and could recall painful feelings .
Ten young women were included, using the concept that the sizing of the amount of participants in qualitative research follows the guidance that, when the sample is ideal, it reflects, in quantity and intensity, the multiple dimensions of certain phenomenon and seeks the quality of actions and interactions throughout the course of the process .
Data collection was performed through the semi-structured interview technique. For the participants’ identification, the list of calls at the Pediatric Outpatient Clinic and electronic records of preterm infants were used, analyzing the information from records from the year 2017, in order to select mothers according to the inclusion criteria. This period is justified because the intention was to grasp the recent memory about the experience of social support of young mothers of premature children, thus, the participants would have experienced the remote puerperium until a maximum of two years.
The data collection occurred in a room of the pediatric outpatient clinic that ensured the privacy and anonymity of the participants. In addition, it was carried out only after the consultation, i.e., the teenager’s call by that service. In this way, the research would not generate delays or interference in the schedule of consultations. The date and time of the interviews were scheduled according to the participants’ availability. The information derived from this study were recorded in digital audio upon authorization and subsequently transcribed integrally, being submitted in accordance with the selected analysis.
Data analysis adopted the operative proposal of Minayo, composed of three phases. In phase 1, called pre-analysis, following steps are developed: transcription of the data obtained through semi-structured interviews, literally, in a text editor, by the same researcher who conducted the interviews, in order to ensure the reliability; floating reading, comprising the first contact with the material obtained through interviews, emerging its initial impressions; and sequence of exhaustive readings, from which the excerpts of the participants’ speeches were highlighted in different colors, from the similar ideas contained in the content of the interviews. This allowed constituting the material subjected to a more detailed analysis. In phase 2, called material exploration, there was the clipping of common information present in the content of the statements transcribed from the enumeration of the meaning cores and the grouping of meaning units to build the thematic category. In phase 3, Treatment of the results obtained and interpretation, there were inferences and interpretations from the results of the study and discussion with the theoretical national and international references .
The research followed the precepts of Resolution n. 466/12 of the National Health Council of the Ministry of Health and was approved by the Research Ethics Committee, under the Certificate of Submission for Ethical Evaluation n. 07929119.2.0000.5346. To preserve anonymity, the participants were identified by the code P, related to puerperal, followed by Arabic numerals according to the order of the interviews. The ethical issues also comprised the knowledge and the signing of the Informed Consent Form (ICF), which was signed by the participants aged over 18 years or by the parents or legal guardians of the adolescents underage. With the ICF of parents or guardians, the Assent Form was provided to those underage .
Among the 10 puerperal women interviewed, with ages between 18 and 24 years, eight lived with their companions and two with their parents. Among the ten puerperal women, one of them resided with her companion in another city to study, far from her son, who remained under the care of her parents.
In relation to education, two mothers have complete primary education, one has incomplete primary education, three mothers have complete secondary education and two have incomplete secondary education, one has complete higher education and one, incomplete higher education.
Below, the study results will be presented in the following thematic categories: Feelings of young puerperal mothers of premature infants and Changes in routine regarding the care with the premature baby.
Feelings of young puerperal mothers of premature infants
Some of the participants reported that, during the puerperium, there arise the fatigue from sleep deprivation in the first months of the baby and feelings of anguish and concern due to the specific demands resulting from prematurity, according to the following statements:
When I first met her it was horrible, she was already eight days old. Because I got the H1N1 flu and had to stay in isolation. I had never imagined that a baby could be born that way, the first time I saw her I got sick, because she was born with 25 weeks and two days, so she was very premature and it was terrifying. (P1)
I love my son, but if I could choose, I would not have him now, because I was careless. It is exhaustive, you have to leave your life aside, the things you liked to do, to live his, and that was even harder because he was premature. (P2)
It is being very hard, I am very nervous and explosive. I was already irritated, I was a little better, but after he was born, it seems it started all over. Having to see people handling him is hard. As he has sequelae of prematurity, people are always handling him, to make tests, collect blood. (P8)
I do not choose what to do anymore, there is no life for me, only my baby’s life, everything has changed. I used to oversleep, but now I sleep very badly, because the baby cries and only wants to stay on my lap. I also think that the care with him is more intense as he is premature. I have to do everything for him, iron his clothes, tidy things for him, my life is harder. (P10)
For me, being his mother is quite different, because he used to have all the attention at the hospital when he was hospitalized and now, at home, I also have to be more careful because he was premature. (P4)
Furthermore, puerperal mothers presented ambivalent feelings, revealed by the experience of being a mother permeated by moments of pleasure and happiness, but also of sorrows and anxieties, as may be identified in the following speeches:
It is great and bad at the same time. It is quite different, our routine changes a lot, you have to be very responsible, it is quite complicated. But, it is the best thing in the world, I was so afraid of losing her, several times, because she was at risk. For me, it changed my life completely, everybody said that being a mother is the best thing in the world, I saw that it is the best thing and also the worst. I am facing many challenges. (P5)
She is my first baby and she was premature, but it is great for me, I have learned a lot. But everything changed completely, because back then I could hang out with my friends, play, oversleep. I do not have time to get dressed properly, nor to comb the hair. When she cries, I run to pick up the bottle, change the diaper. I do not sleep much. (P7)
In the beginning, it was difficult, it is harder until you get used to it, also because he was born premature, but now I am getting used to it, adapting, increasingly better. (P3)
Despite all the changes that occur with the arrival of a premature baby and an unplanned pregnancy, only one puerperal woman experienced it as positive and enjoyable, according to the following statement:
Being a mother is wonderful, the pregnancy was not planned, and she was born before the time, we knew the risks. So, we were very happy with her arrival and evolution, because the child is always a blessing. (P9)
Changes in routine regarding the care with the premature baby
Regarding the changes in their daily routines, the puerperal women revealed being more careful with hygiene, due to the premature child’s lowest immunity in relation to full-term babies. Moreover, some premature infants presented sequelae resulting from prematurity, requiring specialized care after hospital discharge, as represented in the following speeches:
I had to be more careful with her, due to bacteria, she cannot pick up this nor that, wash your hands before touching her, using alcohol gel to touch her. When we left the ICU they explained all of this, I had to take care because the immunity of a premature child is lower than that of a non-premature child. (P4)
She got home using oxygen because she has bronchopulmonary dysplasia, a prematurity-related sequela. I thought: how can I take care of her? I will not be able to take care of this child. When she got home with the oxygen tank, we had to rent it because needed it 24 hours and the it lasted a few hours. At the hospital, I learned everything, things I could ever imagine. The worst was because she took the nasal glasses off and late night I had to get up every hour to see if she was still wearing it, I had no rest in this period. (P5)
In the beginning, I had more careful with her. Only we (the parents) could put her on our laps, always using alcohol gel in our hands and always washing our hands before touching her. All her stuff were washed separately and we were more careful with hygiene. And, we also try not to go out when it is too cold outside. (P6)
My daughter used to cry and wake up all the time, I believe because she was premature and had to stay long in the ICU. I feel it was hard to adapt at home because she was already used to the ICU environment, at home, it is another routine. (P1)
According to the reports of the puerperal women, they needed to rearrange their daily activities with the arrival of a premature baby, because the specialized care that many required demanded more time and dedication, resulting, in most cases, in truancy and abandonment of their labor activities. The puerperal women revealed they wished to resume those activities as the baby's development, as demonstrated by the following statements:
I am already thinking of returning to work, but nothing certain yet. I want to wait until she can walk to start working out. As she is premature, she takes a little longer to develop. (P6)
I intend to study and work when she gets a bit older. As she is premature and has more sensitive immunity, I want to wait a bit longer. I cannot put her in daycare yet. I intend to work to be able to give her things, because I did not even finish school. I am feeling with more responsibilities because she was born early. I do not want her to lack anything. (P5)
I want to keep studying, graduate to be able to give him things. I want him to be be proud of me, I want to study to have financial stability, not to worry not go through difficulties. When he was born prematurely, I began to think so. (P8)
Only one puerperal woman reported having stopped studying before discovering pregnancy, because she was already planning a pregnancy. She reported intending to resume her activities; however, this decision depended on her baby’s development in the coming months, according to the statement:
My pregnancy was planned, so I quit school before. But I wanted to return to studies, but everything depends on her development as she is premature, how she will be. Then I will put her in kindergarten. (P7)
In relation to the negative feelings, a study carried out with mothers of premature babies in a maternity hospital in England had as a result that the premature delivery affects the lives of those mothers, triggering health problems such as anxiety. In this way, those mothers have increased susceptibility to develop negative feelings in relation to their baby, which is associated with lower use of support services available in the post-natal period .
Furthermore, the puerperal woman is aware that the baby totally depends on her, thus emerging new responsibilities and expectations in her experiences as a mother .
Additionally, in relation to the feelings experienced by the puerperal women about the perception of being a mother, some of them showed ambivalent feelings, describing that moment as positive, but with some negative aspects. The maternity in adolescence and youth can be experienced from different perspectives, because it depends on the adolescent’s social environment, in addition to the family context, which can assign different meanings to this experience .
In this sense, in relation to such feelings, a study on women’s postpartum health needs corroborates the results of the present study as it reveals, on the one hand, well-being, love, joy and affection with the birth of the child, related to the idealized experience of motherhood; on the other, an experience full of fear, anxiety, insecurity, sadness and concerns .
Only one of the deponents experienced the life changes after childbirth as a pleasant and enjoyable situation. A research on the perception of women of maternity signaled that they need to be active and reflective in their choices and with the motherhood care, considering that it is important to align their plans and expectations with their needs for satisfaction. This demonstrates a positive attitude of the mother before the motherhood .
Concerning the changes in the routine care with premature babies, mothers revealed that their care differed from that of those born at term. Moreover, a research shows that many parents of premature children are concerned with their neurodevelopment, behavior, nutrition and growth, while other parents believe that their children will have a healthy behavior and a good evolution in the development .
In the perspective of a good evolution of growth and development of premature child, there is a Model of Neonatal Development-Integrated Care, with seven neuroprotective measures directed to the care with premature children, with the focus on the family. This model guides the clinical practice in many neonatal intensive care units around the world. The seven neuroprotective measures are: healing environment, partnership with families, positioning and handling, safeguarding of sleep, minimizing stress and pain, skin protection and optimization of nutrition. The mother/child dyad represents a healing environment, being the extra-uterine physical environment .
In this sense, the hospital space suitable for the premature newborn assists in the hospitalization length, which can negatively influence the creation of the family-baby bond. Since the hospitalization length in ICU is often long and the baby requires specialized care practiced by health professionals who work at the site, the bond with the family ends up being undermined and the family feels as if the baby does not belong to them .
A study carried out with mothers of premature babies in Nigeria showed that they experience many challenges to care for their hospitalized babies, requiring emotional, financial and informational support. With this, health professionals should support these mothers in their challenges, in order to strengthen them for the care that exceeds the hospital environment .
When the baby is discharged from the hospital, the mother tends to compare the specialized care that the child received at the hospital to the care she will provide at home. Despite the baby being stabilized and more developed, it is natural for the mother feel insecure, because she is afraid that something may happen at home with the baby .
In relation to the expectations for the future, the social life of adolescents and young women went through several changes, with the need to adapt to the new phase, because the premature baby needed a range of differentiated care, requiring time and dedication. After the birth of a child, the puerperal women should receive emotional, physical and informational support, in the perspective of experiencing the puerperium healthily .
Due to the new conditions, many ended up interrupting their studies and distancing from their labor activities, however, demonstrated the intention to resume them after their baby’s growth and development. In the meantime, the changes that occur with the arrival of a premature baby imply in social and economic transformations of the family as a whole, which may trigger early school abandonment and lack of stimulus for new professional perspectives .
Faced with the effect of these changes experienced in the puerperal period, the nurse, in the context of primary healthcare, needs to support women and their family during the first postpartum days, and he/she needs to be able to give continuity to the support received in the hospital . The watchful care of professionals in the puerperium in the domestic environment, after discharge, is essential to reduce maternal and infant morbidity and mortality, and, therefore, the consequences on the quality of life of mothers, children and families .
For this reason, health professionals from primary care teams need to be able to receive early the puerperal women and her family, in order to prevent the emergence of problems and difficulties related to the experience of this period . In addition to identifying life-threatening signs and symptoms of mothers and their premature children, there is also the possibility to identify adversities experienced by the family, and the professionals may provide instrumental support and help the social support network .
Thus, in this context of peculiarities of being young, added to the challenges of being a mother of a child who needs assistance for his/her full development, health professionals need to minimize these challenges in an interdisciplinary way, and intensify care practices for a better life of this family.
The puerperal women experienced ambivalent feelings interspersed between moments of joy and happiness and others of anguish and sorrow. In addition, some experienced this period negatively, since they ceased to perform activities previously practiced to devote themselves to motherhood. Only one puerperal woman reported this period as a positive and enjoyable experience.
Regarding the changes before the care routine, these mothers faced several changes in their daily routines, mainly because their babies were born premature. Due to the more complex care required by these babies, they experienced fear because their child needed specialized support to stabilize, of the long hospitalization length and, after discharge, the adaptation at home, which can become differentiated to a premature baby. Moreover, the data revealed the need for actions that allow implementing public policies geared to women's health and, furthermore, expanding these actions to the premature child in the setting of primary health care. This recommendation is based on the fact that the care with the women in the postpartum period, in the primary care network, has not been effective and that there are difficulties to understand and plan the care with the premature child in this context. Thus, this study suggests the production of new researches related to the support of health professionals from the basic network to puerperal mothers of preterm infants.