ORIGINAL ARTICLE

Pregnant women using psychoactive substances attended by nurses in Primary Health Care

Angela Aparecida Peters^I; Hugo Ramalho Cruzeiro^II; Otavia Gonçalves Paulino Bertolini^II; Giselle de Paula Assis^III; Adriana Dias Silva^IV; Maria Angélica de Almeida Peres^V

^IEscola de Enfermagem Anna Nery, NUPHEBRAS, Rio de Janeiro, RJ, Brazil
^IIFaculdade de Ciências Médicas, Suprema, Juiz de Fora, MG, Brazil
^IIIUniversidade Federal de Juiz de Fora, Juiz de Fora, MG, Brazil
^IVFundação Universidade Federal de Rondônia, Departamento de Enfermagem, Porto Velho, RO, Brazil
^VUniversidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Janeiro, RJ, Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: to discuss prenatal care performed by nurses in Primary Health Care for pregnant women who use psychoactive substances.
METHOD: a descriptive-exploratory study, with a qualitative approach, carried out in six Primary Health Care Units in a city in Minas Gerais. Data collection took place through semi-structured interviews with nine nurses who performed prenatal consultations. The content analysis technique was used for data treatment.
RESULTS: difficulties with pregnant women's adherence to prenatal care and their participation in educational groups. Nurses also identified the psychoactive substances most used by pregnant women and reported addressing the harms of substance use, to encourage the choice to reduce use.
CONCLUSION: the pregnant women's concern about treatment was poor and resulted in low adherence to the programs offered in Primary Care, which proved to be a public health problem, which requires reoriented care practices for this clientele.

Descriptors: Pregnant Women; Alcohol Drinking; Street Drugs; Nursing Care; Primary Health Care.

Introduction

The relationship between pregnancy and psychoactive substance (PAS) is a worldwide public health problem. In some countries such as New Zealand and England, the prevalence of alcohol use is 56% and 75%, respectively⁽¹⁾, while in Brazil it is 34.4%⁽²⁾ and this use was associated with gestational diabetes, suicidal ideation and tobacco use⁽³⁾. In a review study, the prevalence of other PASs, such as crack-cocaine, was also found in different parts of the world⁽⁴⁾.

The use of PAS and pregnancy is complex, requires assistance aimed at reducing and discontinuing it. The performance of Primary Health Care (PHC) is essential for the better development of the pregnancy-puerperal cycle^(5-6).

During the prenatal consultation in the PHC, a careful investigation of the family history and habits of the pregnant woman should be done. In the case of history for PAS, there must be a detailed assessment to detect chronic use or risk situations, such as acute intoxications, risk of suicide, self-harm and psychiatric comorbidities⁽⁵⁾. Also, the harms caused by the use of PAS in the development of the fetus must be reminded, to make the pregnant woman aware of her co-responsibility in the success of the pregnancy^(5-7).

The work with pregnant women who use PAS is done through periodic monitoring and their inclusion in specific support groups, including family members. Such guidance is extremely important to capture the pregnant woman and her family for prenatal care, and the nurse is one of the professionals responsible for interfering directly or indirectly with adequate care in PHC⁽⁵⁾.

The care of pregnant women addicted on PAS is challenging and requires special preparation by PHC nurses to guide and encourage complete and lasting abstinence from all substances, and offer support for this transition to occur in a safe and tolerable way for pregnant women, given the difficulty of keeping abstinence in cases of chemical addiction^(6,8). In addition to clinical examinations, nurses must set aside time for subjective listening and offering guidance, creating a greater bond with pregnant women and their families, of build a relationship of trust⁽⁵⁾.

The use of PAS during pregnancy is a constant concern of the PHC teams, regarding their assistance and prevention. Once detected during prenatal consultations, the problem may not be resolved during pregnancy, leaving the doctor or nurse to refer the user for follow-up in specialized services, which does not dissociate PHC's role in coordinating care⁽⁵⁾.

However, a referral can cause a disconnection in the bond between the PHC and the pregnant woman, which is already fragile in itself. Without such a link, little will be possible if PHC, as a representation of affective and geographic territory, loses its co-responsibility in this monitoring, as it ceases singular actions to guarantee integrality in interinstitutional actions, such as harm reduction and health education and those aimed at optimizing health professionals, both low and medium complexity, in preventing pregnancy problems⁽⁹⁾.

This study aims to discuss prenatal care for pregnant women who use psychoactive substances performed by nurses in Primary Health Care Units-UAPS. We expect to contribute to the construction of theoretical bases to reorient the practices developed at UAPS in assisting pregnant women and to the creation of intervention, monitoring and health education strategies, avoiding risks and aggravations and enabling a better quality of life for the population assisted.

Method

This is a descriptive-exploratory study with a qualitative approach. Qualitative research methodologies incorporate the issue of meaning and intentionality as inherent to acts, human relationships and social structures as significant human constructions^(10-11).

The field stage was conducted in February and March 2016, in six Primary Health Care Units (UAPS) which are part of the Integrator Project (PI) of teaching-research between the Faculty of Medical and Health Sciences - Suprema and the Municipal Health Department of the Municipality of Juiz de Fora. These integrate one of the central components of teaching-learning, established in the curricular structure of courses in the ​​health field at this institution. The PI plays an important role in the teaching-research and extension triad, as it incorporates the academic community into the local and regional social environment, intending to contribute to the integrated training of health professionals through the inclusion of students in different communities. The six UAPS had approximately three Family Health Strategy teams. As the students of the 8^th curriculum stage of the Nursing program were under a supervised internship at the respective UAPS, which were the PI practice scenarios, the nurses selected for the study were the accredited supervisors, who followed these students in the field of practice in carrying out prenatal care.

Data collection was carried out by using a semi-structured interview script and a form with questions for the participants' characterization, including sex, training time and specialization. Guiding questions comprised the script with questions about how the first prenatal care for pregnant women using PAS in the UAPS occurred; types of drugs most used by them; strategies and behaviors adopted by nurses; and educational practices created about the use of PAS.

The inclusion criteria included nurses from the UAPS who performed the prenatal consultation and supervised students of the PI. Exclusion criteria were all nurses on vacation or sick leave during the data collection period. The interviews were carried out by the researchers themselves with nine nurses at the UAPS, in a room appropriated for this purpose, in non-working hours and after prior telephone appointment. The participants were informed about the theme and objectives of the research, and it was requested authorization to record the interview. The average duration of each interview was approximately 30 minutes. The anonymity of the participants was guaranteed through the use of alphanumeric codes (N1, N2...).

Data analysis according to the guidelines of Laurence Bardin⁽¹²⁾ was composed of three major stages: pre-analysis; exploration of the material and treatment of results. The Pre-analysis was an organization phase, with float reading and elaboration of indicators that supported the interpretation. In the Exploration of the material, the registration units identified in the previous step were organized into categorization. The treatment of results included inference and interpretation.

After data collection, interviews recorded on MP3 media were transcribed in full. For data organization, Microsoft Excel software was used. From the objectives of the study and the float reading performed, analytical questions were elaborated. For the analysis and interpretation of the content, the speeches were explored and used as answers to the essential and problematic questions contained in the interviews. Based on that, the registration units were highlighted, which enabled the creation of categories.

Following all legal procedures, this study was assessed and approved by the Research Ethics Committee of the Faculty of Medical and Health Sciences-Supreme under Consubstantiated Opinion no. 1,373,578 and CAAE 51602815.0.0000.5103.

Results

Of the nine study participants, two were male and seven were female, aged between 31 and 54 years and mean age of 44.2. The training time of these participants was from two to 28 years. All professionals had a specialty: one in Obstetric Nursing; four in Family Health Nursing; three in Nursing in the Intensive and Neonatal Care Center; and one in Occupational Nursing.

Through the participants' speeches, it was possible to establish three thematic categories: A) Prenatal care in the UAPS with pregnant women who use alcohol, crack and other drugs; B) Drugs most used by pregnant women and the associated risks; and C) Conduct adopted by nurses with pregnant women who use drugs and alcohol in the UAPS.

A) Prenatal care in Primary Health Care Units with pregnant women who use alcohol, crack and other drugs:

During prenatal care, when one or more risk factors were identified, pregnant women were referred to high-risk outpatient clinics for appropriate prenatal follow-up and follow-up evaluations, attending a flow of multiprofessional care in consultations interspersed at the outpatient risk clinic and UAPS: ... We also refer to a social worker, who makes this referral to CAPS. After the first consultation, she (the pregnant woman) is referred for risky prenatal care; after that, she returns going to interspersed consultations with nurses, doctors and secondary care... (N4); ...They are referenced for high-risk; the secondary care service itself requests the follow-up of primary care, that is, she makes an appointment with the doctor there and intersperses with a doctor here... (N8); ...Pregnant drug users, we refer them to high risk; but we follow both at high risk and here; not only with drug users, but like any high-risk pregnant woman, we continue to follow-up here; It is a high-risk consultation and a consultation at the Unit... (N3).

B) Drugs most used by pregnant women and the associated risks

For prenatal care for pregnant women who use psychoactive substances, the nurse needed to be aware of the specifics of each substance and thus draw up a care plan with preventive action, so that the risks were reduced and the pregnant woman was more likely to safe pregnancy. The drugs used by pregnant women treated at the UAPS surveyed were: marijuana, tobacco, crack and cocaine.

According to the care area of each UAPS, nurses highlighted the most used drugs, as pointed in the sentences: I usually attended users of marijuana, crack and alcohol; nowadays, it is marijuana and crack ... (N2); Alcohol, cigarettes (nicotine) and marijuana; some use cocaine as well, but lately there is the crack, which is a devastating, very cheap and easily accessible drug; so, unfortunately, the crack has ruled nowadays ... (N5); ... Officially, I heard that crack, marijuana and tobacco were used; tobacco is very common; but alcohol is more seldomly ... (N7); ... The types of drugs most used by them here are either cigarettes (nicotine) or crack; alcohol not so much because it is common; they don't even consider it like a drug; so, tobacco, marijuana and crack are the most used ... (N8).

C) Conduct adopted by nurses with pregnant women who use drugs and alcohol in the UAPS.

The results presented in this category sought to translate the conducts adopted and the difficulties found by nurses to create educational practices with pregnant women who use psychoactive substances, as observed:

Here at UAPS, we have groups for smokers, and when we see that there is no adherence, that the pregnant women are not attending, we refer them to the CAPS, where the professionals will give the guidance ... (N1); ... We have a group for smokers; there is the CAPS for alcohol and drug, which we also refer to, and we give guidance during prenatal care, in which we talk to pregnant women at all times; although some are very inflexible ... (N3); Most of these pregnant women (users of alcohol and other drugs) do not attend prenatal care appropriately; so it turns out that we have to do an active search and try to sensitize the family to bring them in ... (N7); Here at the unit, we still do not do this type of work with these pregnant women; we work with these impairments regularly during consultations; we have a certain hard time even with normal pregnant women to keep this type of educational work in the unit here because they are not consistent ... (N8).

The study showed that the care provided by nurses in the UAPS existed in prenatal care, and there were difficulties with keeping the frequency of pregnant women in consultations and educational groups.

The data showed that the educational actions carried out by nurses occurred more at the individual level, aimed at pregnant women who were users of some type of PAS. In the nurses' view, the pregnant women had a lot of resistance and difficulties to join the educational groups: ... Normally, pregnant women do not report the use of alcohol and drugs in the first consultation; they report in the third and fourth months after a lot of professional insistence; there is a great difficulty for them to admit the use of a drug or any other substance ... (N2); We took the opportunity during the consultation to do the education approach; they do not come to participate in a group of pregnant women; they are short of patience and not attracted in doing it; so, we do all prenatal education: the needs, the risks and the care they should have during prenatal consultations ... (N4).

Still, in this perspective, nurses' difficulties in keeping direct and continuous connection with pregnant women were noticed, because when they identified the use of PAS, they referred the pregnant woman to high risk, and some of them did not return to PHC, hindering the follow-up bond that provided educational practices. The following speeches illustrate this issue: This bond (nurse-pregnant woman) is difficult, because we even try, but in most cases, they abandon prenatal care; but when they do the follow-up here, we can keep them around ... (N7); ...unfortunately, the reality is that when she is referred to as high risk, then she has nothing to do with us anymore ... (N8).

In these cases, the difficulty in keeping care follow-up to these pregnant women was identified; by them, who omitted the use of PAS, and by the UAPS team, because they feel insecure about assistance to this population, choosing the referral to the Center for Psychosocial Care for Alcohol and Other Drugs (CAPS-AD) and high-risk prenatal clinics. In both cases, an obstacle was created to carry out the appropriate interventions and follow-up on the cases.

Discussion

Observation of the data presented showed that the care provided to pregnant women using PAS was performed in PHC and specialized services, through referral to CAPS-AD and consultations interspersed between outpatient clinics. This information corroborates with studies that aim at the quality of care, intersectoriality, and integrality as an ethical framework^(5,13).

PHC fulfills its role of articulating the Health Care Network (RAS) when sharing care with other specialized health services. Integrality stands out as a guiding thread and guiding the monitoring of pregnant women classified as high risk. When using PAS, care will require specialized professional attention to the pregnant woman's health needs, which need to be identified during prenatal care. Thus, comprehensive care will guarantee the identification of demands at different levels of care⁽⁹⁾.

From the moment that the services make use of the RAS to attend with quality care pregnant women who use PAS, health teams find challenges to overcome, such as those highlighted in the data, with frequent referrals and loss of bond. The proposal to share assistance at different levels, discussed here between primary and secondary care, demands that communication between them be much more than referral and counter-referral assistance forms. In this context, the Family Health Strategy (FHS) model has the greatest chance of early capture for prenatal care and shared monitoring at high risk⁽¹⁴⁾.

The intercommunication between the regular risk prenatal, high-risk pregnancies, and the CAPS-AD outpatient services will function as a support network to avoid complications in pregnancy during follow-up. It will also provide the creation of care flows to users, benefiting everyone, since prenatal care must be intensified and it should involve several health professionals such as nutritionists, psychologists, doctors, and nurses⁽¹⁵⁾.

The FHS team at the UAPS where the pregnant woman started prenatal care needs to keep the bond with this woman and her family to encourage adherence to the follow-up/treatment, as the PHC should not lose the crucial role of a care coordinator^(5,16). This team must be kept informed about the evolution of pregnancy and treatments adopted with the pregnant woman, through contact between the teams, active search, and home visit⁽¹⁵⁾. However, the data showed some challenges, such as when nurses mentioned the loss of connection with pregnant women and lack of knowledge on how to proceed.

In addition to the high-risk outpatient clinic, pregnant women served at UAPS were also referred to specialized mental health services, the CAPS-AD, as stated by some nurses. These services are responsible for the creation, with the pregnant woman and her family, of strategies to face the abstinence from the PAS or harm reduction measures, in the perspective of autonomy and co-responsibility of care^(17-19).

This communication between specialized mental health services and UAPS is called matrix support, an articulation tool in which CAPS-AD reference teams can subsidize actions with PHC teams, in a process of shared construction for monitoring pregnant women and their families⁽²⁰⁾.

As for the use of PAS, according to nurses, the most frequent among pregnant women were marijuana, tobacco, cocaine, and crack; alcohol was less frequent. These data reinforced the importance of the early identification of risk factors, their follow-up to improve the quality of life of the mother and the fetus, as well as the probable obstetric complications and cognitive problems for the child, in case this information is omitted during the prenatal care^(21-22). Pregnant women should be instructed not to use any type of drug during pregnancy and breastfeeding, and make that moment an opportunity to quit the PAS^(23-24).

The data also showed that the actions on prenatal care and educational activities developed by nurses with pregnant women and their families in the UAPS respect the diversity of actions proposed by the Ministry of Health, which created the Comprehensive Assistance Program for Women's Health (PAISM). Educational actions were proposed, with the nurse being the main responsible for these activities, since this is the closest professional to the pregnant women and the possibility of positive responses on them^(25-26).

PAISM is aimed at promoting the health of pregnant women to favor the pregnancy-puerperal cycle. For good management, it is central that the pregnant woman, companions and family members participate in educational and support groups, as they are the main focus of the learning process. Also, these groups are moments of expanding the knowledge of pregnant women about their bodies, health conditions, preventive practices, rights and duties. Thus, it is possible to avoid maternal and fetal complications, so that prenatal care, childbirth and the puerperium occur more smoothly and safely, and promote the participation of pregnant women in decisions about their health and reproductive process⁽²⁷⁾.

According to the results found, some pregnant women had a hard time admitting or reporting that they used alcohol or other drugs. This omission may be driven by fear and distrust^(28-29) and makes it difficult to professionally manage the real risks during prenatal care, reducing the chances of approach and treatment proposals⁽²⁷⁾.

Therefore, the moment of the prenatal nursing consultation is convenient to discuss the harmful effects of the use of PAS and the repercussions of each disease on the maternal, fetal and newborn organisms that may occur as a result. Prenatal care is the time to clarify doubts and review and reinforce guidelines related to pregnancy for women and their families. The nurse, when developing educational actions in dynamic groups, involves the participants in a discussion that allows them to expose their doubts in a welcoming and preventive environment⁽³⁰⁾.

Based on the difficulties presented by nurses, the development of therapeutic care abilities for the risks of using psychoactive substances during pregnancy and to promote health and prevent diseases constitutes a challenge for health professionals. The work with these pregnant women requires a process of growth and acquisition of new skills, such as knowledge, skills and attitudes for the two protagonists of the process: nurses and pregnant women^(27,30).

To know the behavior towards health and illness, professionals must educate about health and be open to choose and listen⁽⁴⁾. The problem of adherence to treatment and the factors related to pregnant women using PAS are complex, as they involve sex, age, education, socioeconomic level, chronicity and the symptoms of the disease, beliefs, cultural and life habits, costs, undesirable effects and complex treatment schemes, relationships with the health team and a great effort by professionals to ensure that pregnant women are assiduous in any kind of care⁽³⁰⁾.

These findings highlighted the need for training for nurses working in women's health care, given the wide range of actions that may be aligned with a dialogical perspective and guided towards the recognition of the other and their uniqueness⁽¹³⁾.

Education for the health of pregnant women is essential to prevent and control complications during pregnancy, childbirth and the puerperium. A RAS focused on actions and services articulated at increasing levels of complexity is of notable importance. The network must act according to their specificities and emphasize community-based services that are adequate to the needs of the user and their family members, since isolated and fragmented attitudes do not meet the demands. In this sphere, nursing contributions are to educate pregnant women and strengthen their awareness of the value of health, as well as promoting care, implementing interventions, evaluating results and considering needs and desires⁽³¹⁾.

The performance of this action by the nurse professional is supported by the law of professional practice (law no. 7498/86) and supported by municipal regulations. These recommend carrying out prenatal nursing consultation, to guarantee nursing care for pregnant women, parturient and women who have recently given birth, as well as health education to promote the improvement of the population's health. In this sense, nurses will be able to make use of comprehensive assistance to pregnant women and address educational health actions, aiming at improving the health of this clientele⁽³⁰⁾.

Study limitations

A limiting factor of the study was that the population was composed only of nurses from the six UAPS belonging to the Integrative Teaching and Research Project of the Faculdade Suprema-Sociedade Universitária for Medical Teaching. This fact made it impossible to know all the strategies and behaviors of nurses with pregnant women using PAS from all UAPS. Not giving a voice to pregnant women and their families was also a limitation.

Conclusion

In this study, it was observed that the PAS/pregnancy theme is still an obstacle and professionals must develop a critical view of the problem in their daily lives. At the same time, they must not be moralistic about the problems and challenges to be faced with this demand, which is gradually increasing in the country.

The nurse is the health professional who stays in contact with this clientele for a longer time and the opportunity and the challenge to minimize and diagnose the use of PAS are up to them.

Through this study, it was easy to notice the littlest interest and participation of pregnant women. Their poor participation in specific programs shows the problem of this issue. The reports of low adherence to pregnant women using PAS in follow-up also show serious public health problems, which in most cases are trivialized.

Having a bond with the pregnant women is extremely important, and the PHC must be close and available to do so, so that they feel welcomed and want to be part of educational groups to exchange experiences and interaction, establishing a bond with the UAPS and favoring adherence to prenatal care.

This study achieved the proposed objective, but the importance of multidisciplinary teamwork is emphasized, as the perception of each member is an aggregator for the management, monitoring and direction for each situation that arises. The results of this study may assist in future research regarding the strengthening of actions developed by nurses and other professionals in PHC.

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Corresponding Author:
Adriana Dias Silva
E-mail: adriana.dias@unir.br

Received: Feb 7^th 2020
Accepted: Apr 14^th 2020

Authors' Contributions: Research conception and design: Angela Aparecida Peters, Giselle de Paula Assis, Hugo Ramalho Cruzeiro, Otávia Gonçalves Paulino Bertolini, Adriana Dias Silva, Maria Angélica de Almeida Peres. Data collection: Angela Aparecida Peters, Otávia Gonçalves Paulino, Hugo Ramalho Coelho, Maria Angélica de Almeida Peres. Data analysis and interpretation: Angela Aparecida Peters, Hugo Ramalho Coelho, Otávia Gonçalves Paulino, Giselle de Paula Assis, Adriana Dias Silva, Maria Angélica de Almeida Peres. Manuscript writing: Angela Aparecida Peters, Giselle de Paula Assis, Adriana Dias Silva, Maria Angélica de Almeida Peres, Hugo Ramalho Coelho, Otávia Gonçalves Paulino. Critical revision of the manuscript: Angela Aparecida Peters, Adriana Dias Silva, Maria Angélica de Almeida Peres, Giselle de Paula Assis.
All authors approved the final version of the text.
Conflict of interest: The authors have stated that there are no conflicts of interest.