First week of integral health for the newborn: nursing actions of the Family Health Strategy

Abstract

OBJECTIVE

To describe the nurses’ actions of the Family Health Strategy about the First Week for Integral Health regarding the care devoted to the newborn.

METHOD

It is a descriptive, exploratory research with qualitative approach carried out from October 2014 to February 2015, through a semi-structured interview, with nine nurses from the Family Health Strategy of João Pessoa-PB. Data were submitted to thematic analysis.

RESULTS

The actions identified at the first visit to the newborn child are based on maternal guidance on basic newborn care, breastfeeding, neonatal screening, immunization and childcare, as well as evaluation of the puerperal, but it was sometimes performed outside the period recommended and with incomplete and outdated guidelines.

CONCLUSION

Although there are potentialities in nurses' actions to this population, the fragilities compromise the care of the newborn and the puerperium, and it is necessary to sensitize these professionals about the importance and effectiveness of First Week for Integral Health.

Keywords:
Infant, newborn; Primary health care; Home visit; Nursing

Resumo

OBJETIVO

Descrever as ações de enfermeiros da Estratégia Saúde da Família acerca da Primeira Semana Saúde Integral no cuidado ao recém-nascido.

MÉTODO

Pesquisa descritiva, exploratória com abordagem qualitativa realizada de outubro de 2014 a fevereiro de 2015, por meio de entrevista semiestruturada, com nove enfermeiros da Estratégia Saúde da Família de João Pessoa-PB. Os dados foram submetidos à análise temática.

RESULTADOS

As ações identificadas na primeira visita ao bebê se baseiam nas orientações maternas acerca dos cuidados básicos ao recém-nascido, aleitamento materno, testes de triagem neonatal, imunização e puericultura, bem como avaliação da puérpera, no entanto, por vezes eram realizadas fora do período recomendado e com orientações incompletas e desatualizadas.

CONCLUSÃO

Embora haja potencialidades nas ações dos enfermeiros prestadas a essa população, as fragilidades comprometem a assistência ao neonato e à puérpera, sendo necessário sensibilizar esses profissionais acerca da importância e eficácia da Primeira Semana Saúde Integral.

Palavras-chave:
Recém-nascido; Atenção primária à saúde; Visita domiciliar; Enfermagem

Resumen

OBJETIVO

Describir las acciones de enfermeros de la Estrategia Salud de la Familia acerca de la Primera Semana Salud Integral en la atención al recién-nacido.

MÉTODO

Investigación descriptiva, exploratoria con abordaje calitativo, realizada de octubre de 2014 hacia febrero de 2015, por medio de entrevista semiestructurada, con nueve enfermeros de la Estrategia Salud de la Familia de João Pessoa-PB. Los datos fueron sometidos al análisis temático.

RESULTADOS

Las acciones identificadas en la primera visita al bebé se basan en las orientaciones maternas sobre los cuidados básicos al recién nacido, la lactancia materna, las pruebas de selección neonatal, la inmunización y la puericultura, así como la evaluación de la puérpera, pero a veces se realizaban fuera del período recomendado y con directrices incompletas y obsoletas.

CONCLUSIÓN

Aunque hay potencialidades en las acciones de los enfermeros prestadas a esa población, las fragilidades comprometen la asistencia al neonato y a la puérpera, siendo necesario sensibilizar a esos profesionales acerca de la importancia y eficacia de la Primera Semana Salud Integral.

Palabras clave:
Recién nacido; Atención primaria de salud; Visita domiciliaria; Enfermería

Introduction

Every year, more than 3 million newborns die before their first month of life. Three quarters of them in their first week of life, and one third in the first day¹. Considering that, the United Nations (UN) proposed the elaboration of the Millennium Development Goals (MDG), one of which was a reduction of two thirds in child mortality until 2015².

The UN indicators show that, in the period from 1990 to 2013, Brazil reduced children mortality below one year of age from 51.4 deaths per thousand born alive, to 12.3 deaths in the same number of children³, showing a clear improvement in health care. However, despite this progress, a lot more still needs to be done so that there is a greater reduction of the indicators of child mortality.

When it comes to neonatal (0 - 27 days) mortality, data from 2011 and 2012 indicate that in Brazil, on average, there are 11.1 deaths for every thousand children born alive. It also stands out that these rates are even more expressive when related to the first 24 hours of life⁴.

Neonatal deaths are generally associated to failures in the care offered to mothers and to newborns during pre- and post-delivery procedures, which are considered stable when the grievances are detected early¹. In this sense, the Ministry of Health (MH), based on the United Nations (UN) and the United Nations Children’s Fund (UNICEF), developed a training course for health professionals regarding Integrated Management of Childhood Illness (IMCI), aiming at promoting a fast and meaningful diminution in child mortality⁵. Also, due to the need for a fast start to the follow-up with the newborn and the mother, to evaluate the conditions of the binomial mother-child, the MH prescribed the “Schedule of Commitments for the Integral Health of the Child and the Reduction of Child Mortality”. It consists in recommendations for the assistance to the child, through lines of care, one of which is the First Week for Integral Health (PSSI)⁵. Still discussing the initiative taken by the government to improve the health of this population, in 2015, through Decree nº1.130, the MH instituted the National Policy for Integral Children’s Health (PNAISC), aiming to promote and protect the health of children and breastfeeding⁶. Thus, it can be noted that the authorities have been showing interest not only in reducing child mortality, but also in promoting the quality of life of these children.

The PSSI is a protocol for care that aims to make it possible to offer integral and multiprofessional care to the mother and the newborn in the first week after birth, to identify warning signs of problems which can compromise the growth and healthy development of the newborns, guide the mothers regarding the care with them, encourage breastfeeding, offer support to deal with any problems presented, verify and evaluate the vaccines and schedule consultations of childcare, contributing, thus, to minimize children morbimortality⁵.

Soon, the actions predicted by the PSSI must be a part of the routine of the professionals of Primary Health Care (PHC), as a means to offer integral and individualized attention, according to the basic tenets of primary care illness prevention, health promotion and recovery.

One of the methods indicated for the execution of this line of care are the home visits in the first week of the life of the baby⁷, which are proven to be efficient in the reduction of newborn mortality⁸. However, the daily efforts targeted at the implementation of the domiciliary visit in Brazil are still flawed, as it was found by a study conducted in Rio de Janeiro⁹, according to which only 52% of the visits to newborns happened in their first week, when this should be a practice applied to all newborns, according to the PSSI. Therefore, although there are means to effect change in the assistance model, a conservative model, whose only focus is cure, can be observed to still be present, to the detriment of integral health care.

Thus, considering that nurses are the first line of care offered to this population, and that their PSSI experience influences in newborn health prevention and promotion, and therefore, in the death rates of newborns, this study can be justified by the need to investigate how the attention to children in the first week of life is taking place, in the context of the PHC. This issue led to the following guiding question: What are the actions taken by nurses in the First Week of Integral Health in the scope of Family Health Strategy during the domiciliary visits to newborns? This study, therefore, aims at describing the actions of nurses from the ESF regarding the First Week of Integral Health in the care for newborns.

Method

This is a descriptive and exploratory study, with a quantitative approach. This method that studies the history, the relationships, the representations, the beliefs and the perceptions that the subjects have of themselves and of their own lives, feelings and thoughts¹⁰. This study was generated from a research called “First Week of Integral Health: building and validating an instrument for newborn domiciliary visits”, which was approved by the CNPq under protocol 447572/2014-8.

It was conducted from October 2014 to February 2015, in the city of João Pessoa - PB, which is divided in five Sanitary Districts, including a total of 184 Family Health Strategy (ESF) teams. There were 12,299 births in 2015, in the city. The setting for this research was the Sanitary District III, since it is under the scope of the Universidade Federal da Paraíba (UFPB - Paraíba Federal University) and is a setting for the practice of the graduation courses of this institution, counting with 53 ESF and their 53 respective nurses, responsible for the health care of 90.5% of the people in the area.

9 nurses participated in the research. They were randomly chosen according to their availability, as long as they: were nurses working in the ESF for at least a year and were active in the moment of data collection - these were the inclusion criteria.

To make data collection viable, a semi-structured questionnaire was used, with the following guiding question: What are your actions in your first domiciliary visit to a newborn?

The interviews were conducted by the researcher, recorded in digital media, and lasted for an average of 15 minutes. They were conducted in the Family Health Units (USF), in an environment that offered privacy and silence. In the results, each nurse was represented by the letter “E”, followed by an increasingly high number.

Data collection was finished when the interviews stopped generating new information that was pertinent to the objectives¹⁰. That happen in after nine interviews, when the discourses regarding the theme were theoretically saturated.

Data analysis was conducted through the technique of thematic analysis¹⁰. Initially, a floating and exhaustive reading of the answers of the interviewees was conducted, to find out their central meanings. After that, the central ideas of each line were extracted according to the questions, and grouped according to their thematic similarity. Later, the interviews were read again, to organize the material according to the topics that those interviewed highlighted, which were grouped in categories and discussed under the light of national and international literature about the subject¹⁰.

All participants signed the Free and Informed Consent form after the objectives of the study were described, according to the prescriptions and regulating norms for researches involving human beings that were established by Resolution nº 466/12, from the National Council of Health. The research was approved by the Ethics Committee of the Health Sciences Center of the Federal University of Paraíba, under protocol nº 008/15, CAAE: 39801714.2.0000.5188.

Results and Discussion

Nine nurses participated in this study, among there was only one male. Two nurses had graduated less than 10 years before the research, while 7 had done so from 20 to 35 years prior, showing that most participants were highly experienced in primary care practices, and possibly were working during the transitional periods that took place along the years in the assistance models. This can justify a great search for courses, specializations and training, as a result of which all participants stated to have at least one specialization, in the areas of Family Health, Public Health, Collective Health, in the Family Health Program (PSF), and/or through the Project for the Professionalization of Nursing Related Professionals (PROFAE).

From the analysis of empirical data, the following category was elaborated: Nursing Actions in the First Week of Integral Health.

Nursing Actions in the First Week for Integral Health

The performance of the actions of the nurse according to the PSSI is relevant, since they have the potential to diminish newborn mortality and improve the quality of life of the binomial mother-baby. The implementation of these help empowering the mother regarding self-care and caring for the newborn. In this sense, the first action of the PSSI reported by the nurses concerns the periodicity of the domiciliary visit to the newborn and the mother.

We always try to prioritize this domiciliary visit in the first week because it’s when she arrives from the maternity to receive the first guidance. (E1)

In 15 days, sure, we do the post-delivery visit to the mom. When they arrive the health agent contacts us to say that there is a baby, and we go and visit them at home. (E4)

The right thing to do is to go in the first week is what the book about children says in page 17. (E5)

The first consultation or visit post-delivery is in the first 15 days, not in the first week [...] in the first week we normally don’t visit. (E8)

It can be noticed in the reports that there is a great discrepancy in the statements, since some professionals perform the domiciliary visit in the correct time, while some do not follow the time tables prescript. Considering that performing this domiciliary visit earlier is a strategy to promote interventions regarding the primary care of newborns and promote their health, when it does not happen during the recommended period - which according to the MH is between the third and fifth day after birth - it can interrupt some actions such as aiding in the development of parenthood, improving the cognitive development of low-weight or premature children, reducing the instances of non-intentional lesions, improving the precocious detection of postpartum depression and prolonging breastfeeding⁷. Delaying this visit, thus, diminishes the potential of health vigilance and impacts the quality of life and the mortality of this population.

It should be highlighted that, among the essential actions of the PHC, family visits are a potent strategy, as they allow for a broader understanding of the health-sickness process and offer interventions related to health care and maintenance, both of individuals and their families, beyond the limits of merely curative practices¹¹.

Studies conducted in Malaysia, Nepal, Bangladesh and Uganda⁸ have found that, after a period of implementation of domiciliary visits in the first week of life of babies, their health improved and neonatal mortality diminished.

However, some nurses pointed out two reasons to justify the delaying of a domiciliary visit to the newborn and the mother: the first one was regarding the scheduling of their visits by the Community Health Agent (ACS) after the mother came back from maternity, and the second, mentioned the fact that mothers that went through cesarean sections oftentimes do not come back to their homes within the first seven days, or yet, that some mothers spend their post-delivery period in the house of their own mothers or other relatives.

For the health agent to be alert to the arrival of the mother, sometimes I don’t even know, it’s fifteen days past, twenty days past the day the mother arrived, I mean, the agents must be alert if there are so many pregnant women, when will they be delivering, having the baby, getting home, so they can tell me. (E2)

The last (mother) that gave birth I still couldn’t go and see her, I went there with exactly seven days and she wasn’t there, she had gone to do the heel prick test because the agents often schedule the visits and forget to check the scheduling done by the hospital, or the maternity itself, they go and schedule, so I had this problem. (E3)

I always tell the health agents to tell us soon when there’s a birth so we can visit in the next week. (E5)

When she (the mother) isn’t home or when she’s at the house of a relative, there’s some distance in these cases. (E1)

When they leave maternity they try to either go to the house of their mothers, or to the house of their mother-in-law, or to a relative, right? When that happens we frequently can’t find the newborn in the first week, we only manage to find them near the 45th day, when they go back home. (E3)

It was possible to identify that the ESF nurses attribute the inclusion of the mother in the post-delivery period and the scheduling of domiciliary visits to the ACS. However, the nurses must know the amount of pregnant women and the probable birth dates, so they can plan, with the team, the visits to the mother-baby binomial and their families. Also, the active search of new mothers is a responsibility of the entire ESF, and as such, the delay in domiciliary visits is not justified, nor are nurses free from responsibility regarding the ACS’s delay in finding or scheduling the visits, since it is their responsibility to coordinate these agents.

The fact that some mothers move out of the scope of the health team approached in this study is indeed a part of the local reality, and is highly concerning, as it compromises the actions of the team when it comes to offering guidance in an adequate amount of time, which can directly impact in the effectiveness of the PSSI. This also corroborates a study¹² conducted in the city of Teresina (PI), where the attention in the first days after delivery was also prevented due to the mothers not being in their homes.

It can be noticed, thus, that even though the domiciliary visit is effective to reduce child mortality as international studies show, national literature, including this study, indicates that professionals have trouble following the prescript rules, which leads, thus, to a better understanding of other factors that negatively influence the occurrence of the visits.

Aiming to guarantee that the mothers who will not come back to their houses right after birth receive the guidance necessary so they can care for the baby and guarantee breastfeeding, one of the nurses guides the pregnant women during the prenatal period, teaching them these actions of care, trying to compensate for the fact that the domiciliary visits will not happen in the recommended period.

When she tells me: “as soon as I have the baby, I’ll go to my mother’s house and stay there for so many days and I’ll only come back in that day”, I always give them the necessary information in the prenatal. (E6)

It is possible to guide the mothers regarding the care for the newborn still in the prenatal period, as to empower them to offer qualified care to their children, even considering that it is not possible to visit them in the first week. This is corroborated by studies that state the importance of educational health actions in the prenatal period, guiding mothers and empowering them regarding the care for the newborn, to help them achieve independence in the care for their children¹³.

There are, however, aspects that go beyond the scope of previous guidance, that can only be achieved through an evaluation of the newborn, especially when it comes to the signs that indicate the need for urgent visits to health services (refusal to eat, important instances of vomit, convulsions and apnea, low heartbeats (below 100 bpm), lethargy or unconsciousness, fast breathing (above 60 bpm), low activity, fever (>37.5ºC), hypothermia, subcostal retractions, beating of the wings of the nose, general cyanosis or important paleness, visible jaundice, curved fontanels, purulent ear secretion, navel hyperemia, skin pustules, irritability and pain when manipulated) and the detection of possible environmental risks that turn visits and the follow-up with a professional into essential actions during the first days of the life of the newborn^5,7.

To guarantee integral care, the participants of this study stated that their first intervention after the birth, in the residence, is focused on the offering of basic care to the newborn, and on how is it that the mothers offer such care:

I look at the umbilical cord stump, I also tell them to sunbathe the child, I see if they conducted the heel stick test, the vision screening, if they started vaccination, we also see if they have jaundice, if there’s a yellow tone to their skin, if they’re breastfeeding properly, we also guide her to always hold the baby sideways so they don’t throw up, and there’s no pulmonary aspiration. (E4)

I guide the mothers, I check the umbilical cord stump of the baby, if its fine, if it healed OK, if the mother is doing it right, putting alcohol, cleaning properly, if she is cleaning the mouth of the baby, breastfeeding, breastfeeding in a way that doesn’t hurt the nipple of the mother, I check the position they are putting the baby so the baby burps, stays up, and sleeps. (E9)

These reports show the concern of the nurses with the evaluation and guidance of the necessary care for the newborn. However, actions such as the conduction of the physical exam were not mentioned in their statements, and the guidance offered was superficial and incomplete, and even obsolete at times - for instance the information regarding the sideways positioning of the baby to avoid pulmonary aspiration, which is opposed to the current directives, that indicate dorsal or supine positions as the best options, to avoid the newborn’s sudden death⁷.

Developing countries have been showing that there is little monitoring of the care in the post-delivery period. Confronted with that, it should be highlighted that it is very important for nurses to be concerned about the basic needs of the newborn in their houses, since this period involves physical, emotional and social challenges to the mother and to the child¹⁴, in turn interfering in their quality of life.

During the visit in the first week of life of the baby, the nurse is responsible for clarifying any doubts and approaching specific newborn related care, seeking to guide the mother regarding oral hygiene, sleep and rest, caring for the umbilical cord stump, breastfeeding, bathing, diaper changes, protection from cold, rash prevention, sun bathing, conduction of neonatal triage tests (heel stick and hearing tests), family relationships, vaccine relevance, guidance regarding the follow-up of childcare consultations for the newborn, as well as family planning for the mother^5,7.

Regarding breastfeeding, a habit advocated by children’s health organizations, the participants of the study emphasized that, when the domiciliary visit is not conducted within the adequate time framework, the practice is compromised, leading, among other things, the mothers to wean the baby too early, possibly influencing the health and development of the newborn throughout his or her life.

If the child arrives in the first week and the mother can’t breastfeed, sure, she leaves the maternity breastfeeding, but the difficulty is oftentimes really big, in their house, in the residence, especially if there is a grandmother, a mother, a person who can make things more difficult, saying give the baby some porridge, or give the baby milk, or when the mother herself is insecure and buy regular milk and gives it to the baby. (E2)

We have to keep an eye out for breastfeeding habits, some mothers strictly follow exclusive breastfeeding guidance, but some others leave the maternity already thinking of giving the baby complementary foods. (E3)

If you don’t work in the first week and they start to give the child water or some compound, the child gets used to it fast [...] if you visit a mother, maybe not now, 10 days, 15 days after she gave complementary foods, it’s much more difficult for you to convince this woman to stop it. (E7)

Breastfeeding was an aspect that the nurses strongly emphasized in this study, especially when it comes to the insertion of artificial milk, partially or even completely replacing breast milk, which happens mainly when the domiciliary visit take place too late, and relatives participate in the care to the newborn. Considering that, one can clearly see the importance of offering assistance so the mother-baby binomial can follow the guidance of the MH and detect better the factors that influence in the basic care to the newborn, especially when it comes to breastfeeding by the mother - which, according to recommendations, should be the exclusive source of food to children below six months of age, and if implemented, significantly help to diminish child morbidity⁷.

The nurses demonstrated concerns regarding the care for the newborn during this period of their lives. Some important actions to prevent grievances, however, such as the detection of environmental and biological risk factors, were mentioned only by one nurse’s statement.

I check how they (the children) are being welcomed, [...] maybe there are problems with drugs, with alcohol, so we have to check under what risks a child is in her house. (E2)

The fact that this aspect was reported only by one participant shows how frail is the assistance offered by the nurses to the newborn, since a concern about the risk factors was so scarcely approached, allowing us to infer that there is a lack of knowledge and preparation in the offering of integral care to the population. Also, since this is a period of vulnerability, health actions should be more incisive and effective for a real reduction in mortality rates.

Beyond primary care to the newborn, risk factors to which they would be exposed due to family dynamics should be identified, such as domestic violence, risk of accidents, alcohol and drug users in the residence, and the way in which the newborn was welcomed⁷. A study conducted in Curitiba¹⁵ regarding the vulnerabilities to child development, highlighted chemical dependencies, especially those of the parents, as a factor that directly affects child development, since affective bonds are not created, nor are actions taken to protect the child.

There are some concerns regarding the following of recommendations of clinical practices all over the world, especially since they are based on scientific evidences that aim to improve health. In this context, the guidance offered has an important role in the reduction of morbidities, and since they are guided by theoretically based public policies, they should be followed, to guide the actions of the professionals during the first domiciliary visit, to aid the mother and the newborn in achieving integral health.

Concerning the promotion and evaluation of the health state, as well as the guidance that contemplates the health of the mother in the puerperal period, it was possible to find a contradiction in the statements of the participant, since they refer to the domiciliary visit as a “visit to the mother”, and only one nurse offered assistance to the mother, while the others focused on guidance regarding family planning.

There’s the issue of the mother, too, this is not only about the child, but about the mother too; how’s the lochia elimination in the post-delivery period; how are they doing, because there’s the issue of depression; how’s the family situation as a whole, especially her own, because we need to be careful with the mother; how is she behaving, behaving towards the baby, especially if it is her first child. (E2)

To guide her (the mother) about the contraceptive she’ll take after 42 days of rest. (E9)

It is important to highlight that, although this study refers to the actions conducted regarding the newborn, it cannot treat them as if the mother-baby binomial was not linked, since the newborn depends on it. It is, therefore, paramount to evaluate the biological, psychological and social aspects of the mother. Therefore, to achieve all the results recommended by the PSSI, it is essential for the professional to be attentive to the conditions that interfere in the state of the health of the mother, since the health of the child will be at risk if the health of the mother is not well. The mother should, thus, be one of the centers of the attention of professionals in her first days with the newborn⁵.

It is important to emphasize that the scarcity of recommendations regarding care for the mother that this study shows is corroborated by that of other studies that point out shortcomings of the assistance to the mothers of newborns during domiciliary visits, since they are not adequately evaluated, and their complaints are not always listened to by the nurses¹⁶. Another important guidance that is not made explicit by the nurses in their actions are the signs of danger about which they should be aware as they offer aid to the mother, which are: vaginal bleeding, headaches, convulsions, eyesight problems, abdominal pain, dysuria, fever, vaginal losses, difficulties to breath and tiredness⁷. This suggests that the performance of these professionals of primary care is below what the literature recommends, demonstrating the need to investigate the reasons that lead to such inconsistent practice, to subsidize posterior decisions when it comes to curative measures.

One should also highlight the role of the family in the adaptation of the woman to the new family dynamic and in the empowering of the mother, as well as their aid in the care for the newborn in daily activities in their houses. From this perspective, a study conducted in Japan with first time mothers identified that the presence of family problems and the difficulty to communicate with a partner negatively influenced the trust of the mother regarding maternity itself¹⁷.

Therefore, among the actions of the nurses, an attentive look at the detection of risk factors to newborns and their mothers must be included, considering the physical and emotional well-being of the mother and the family support for the making of decisions and the guidance of the best strategy for the care of the binomial¹⁵.

Still concerning the actions of the nurses, the importance of encouraging the mothers to take the newborns to childcare was also highlighted, as it allows for their continued care.

Another thing I think is important to report is that, when we go, we already guide the mother to come to childcare and I think that’s important also because we form this link, right, for her to come to the consultation and follow up with it. (E2)

In this context, it should be highlighted that the creation of a bond in the prenatal has an important role for the follow-up of the child, since the mother feels more confidence towards the nurse and comes to the service for childcare more often. The follow-up of assistance allows for an assessment of the growth and development of the child, for the precocious detection of problems, guidance and referral to immunization¹⁸. Furthermore, a previous study¹⁹ highlighted that the establishment of this bond is paramount for childcare consultations in the PHC, since it also allows for the strengthening of bonds of effective and affective family interaction.

The statements of the nurses also allowed for the identification of weaknesses in their actions due to lack of knowledge. On the other hand, the statement that follows also shows the lack of health educational actions for these professionals.

We don’t have these scholarly relationships [...] I think that basic attention is very precarious in this sense of training the workers, updating them you know? (E8)

This statement clearly highlights the need to offer permanent education to the professionals of PHC when it comes to the PSSI, so they can improve their work process and implement specific actions to care for maternal and child health with safety, basing their actions on health guidelines - since shortcomings were found in the knowledge of nurses regarding active health policies targeted at assistance to the mother and to the newborn. A study conducted in Cuiabá (MG) found that only half the nurses feel apt to offer aid to newborns and their mothers²⁰, corroborating the findings of this study, regarding the need to train the professionals of the ESF.

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Publication Dates

• Publication in this collection
  02 Aug 2018
• Date of issue
  2018

History

• Received
  17 Apr 2017
• Accepted
  27 July 2017