Participants

The participants in this study were 12 professionals from different specialties, members of a multidisciplinary team from a UBS in a city in the state of Mato Grosso, and 11 pregnant women aged 18-34 years in different gestational periods, multiparous and primiparous. Pregnant women aged 18 years or older with normal-risk or high-risk pregnancy classifications, who were attending follow-up care visits at the same UBS and willing to voluntarily talk to the researcher in person in a group dialogical encounter with other pregnant women were included as participants. Among pregnant women participating in the study, five had complete secondary education, three had complete higher education, one had incomplete higher education and one had incomplete primary education. As for professionals, three physicians, three nurses, one dentist, one pharmacy attendant and four community health agents participated. This team did not include psychologists. The professionals had between six months and 24 years of experience in the SUS, and had been relocated to the UBS between 11 months and three years earlier. Most professionals were female and the team had only two male members: a physician and a community health agent.

The sample for this study was obtained intentionally, as inclusion criteria were specifically defined to select professionals from different specialties and pregnant women with different gestational ages, both linked to the same UBS. The choice for this type of sampling is justified, since we sought participants who had experience with the phenomenon investigated in order to allow a significant understanding of the experience lived in the process of monitoring the pregnancy period in prenatal care. Thus, intentional sampling allowed the recruitment of participants who were motivated to share their experiences with the researchers in a dialogical encounter, which is fundamental in phenomenological research.

Instruments

Dialogical encounters were held in group. The dialogic encounter consists of a conversation stimulated by the researcher based on a guiding question of a propositional nature that seeks to provide participants with an opportunity to share their personal experiences in their own way. It is a methodological strategy developed in the context of the research group (information suppressed to prevent identification of the authors).

The dialogical encounter is a methodological strategy developed in the context of an Institutional Research Group linked to the Postgraduate Program (master’s and PhD) in Psychology of the (information suppressed to prevent identification of the authors). It is a methodological innovation in the sense of proposing that the researcher maintains a clinical attitude while being with participants, aiming to apprehend and understand the meanings that emerge as the conversation evolves from a guiding question posed at the beginning of the meeting. There is an intentional effort by the researcher to get closer to the experiences lived by participants through attitudes of empathic understanding, congruence and unconditional acceptance in order to contribute to the development of a climate of human warmth and embracement, conducive to the updating of symbolizations and the sharing of ideas, feelings and perceptions.

In the dialogical encounter, the researcher is not interested in aprehending the participants’ experience of the phenomenon under investigation in an objective and neutral way. On the contrary, he is willing to be affected by the interpersonal relationship experienced with participants, constituting himself an instrument of this understanding. Thus, the researcher does not record written statements during the meetings, nor does he record the participants’ speeches. He writes a comprehensive narrative after each encounter, using his own perceptions, ideas and feelings as material, based on what was experienced during the encounter in a hermeneutic movement.

Procedures

Data collection. It was performed through three face-to-face group encounters with pregnant women and three with health professionals. The encounters with groups of pregnant women and professionals were held separately with the aim to ensure privacy for both groups of participants and avoid causing any type of conflict regarding the shared content. The pregnant women were invited by the researcher at the UBS waiting room, and the professionals at their offices. All meetings took place at the UBS during the year 2023 and lasted an average of one hour and 20 minutes. The UBS is located in a peripheral region and 90 pregnant women were in follow-up care, including those at high-risk and normal-risk. The researcher began each encounter with the following guiding question: “I would like you to share with me what has been your experience with the prenatal follow-up program been like?”

Data analysis. Initially, it was performed by constructing a comprehensive narrative immediately after each dialogical encounter, and a synthesis narrative containing the significant elements that the researcher aprehended during the three encounters with each group of participants. The narratives are a methodological strategy adopted for the operationalization of the phenomenological reduction carried out in three stages: epoché - eidetic reduction - transcendental reduction. The epoché is the suspension of natural theses and constitutes the first stage of the eidetic reduction and its operationalization starts during the dialogical encounter. The second stage of the eidetic reduction is the construction of comprehensive narratives, which are the researcher’s description and understanding of the experiences lived by participants and communicated during each dialogical encounter. The transcendental reduction is carried out through the synthesis narrative that consists of the reconstruction of the lived experience based on the elaboration of the structuring elements of the phenomenon.

The comprehensive narratives were written in the first person by the researcher immediately after each dialogical encounter, containing her impressions, ideas, and perceptions about the participants’ experience regarding the phenomenon under investigation. Then, saturation of the extraction of the intersubjective experiences lived in the encounter was reached after editing and rereading the six comprehensive narratives. Subsequently, two summary narratives that allowed the elaboration of the structuring elements of the experience lived by participants in the prenatal follow-up program were written.

The experiences were understood in light of the psychological perspective of the PCA. All names referred to in the text are codenames.

Ethical Considerations

The study was approved by the Research Ethics Committee of the Pontifícia Universidade Católica de Campinas (PUC-Campinas) under Opinion No. 5.920.954 - CAAE No. 67120623.0.0000.5481.

Professionals: “it would be different in the ideal SUS”

Five professionals gathered in the first encounter: Odair (physician), Kelly (nurse), Emerson (community health agent), Larissa (dentist) and Alana (community health agent). Emerson has been a community health agent for three years, feels frustrated with the lack of agents to cover a large area and described the need for more hiring more staff as urgent. Odair has been a physician in the SUS for six years and enjoys the tranquility of caring for pregnant women, but feels overwhelmed by the high demand. He explained that often prescribed psychiatric medication himself, recognizing the need for psychologists on the team and stating that “it would be different in the ideal SUS”. Alana has 24 years of experience and explained that the members of the UBS team experienced difficulty in establishing deeper contact with pregnant women due to the work overload.

Pregnant women: “See me, listen to me!”

Three multiparous pregnant women participated in the second encounter: Adriely, Adriana and Kênia. Adriely, in her third pregnancy, felt uncomfortable due to the lack of privacy during consultations, where interns took on a predominant role. Kênia, after three miscarriages, also faced consultations with little privacy and interaction with the physician. Adriana, in her second pregnancy, praised the technical assistance, but disliked the rigidity of protocols that did not address the emotional issues of pregnancy.

Professionals: “We have managed to put out the fires”

The third encounter involved five professionals: Aracira and Thaylline (community health agents), Aline (physician), Francisca (nurse) and Marina (pharmacy attendant). Aline has been a general practitioner for six months at the UBS, and highlighted the lack of regular psychological follow-up and the need for urgent referrals to polyclinics. Francisca has been a nurse in the SUS for 17 years, mentioned that both the team and pregnant women faced the lack of support from the Family Health Support Center (Portuguese acronym: NASF- Núcleo de Apoio a Saúde da Família). Aracira highlighted the prioritization of emergencies given the difficulties in performing basic tasks.

Pregnant women: “Every pregnancy will be unwanted at some point for the woman, even if it has been planned”

The encounter was held with four pregnant women, Elifia-multiparous, Mariane-primiparous, Fernanda-primiparous and Jéssica-primiparous. Elifia is 29 years old, single, came from São Paulo to Mato Grosso. She is already the mother of two children. Right at the beginning of the encounter, she made a point of showing how sad she was about being pregnant. She did not accept the pregnancy, decided to stop attending prenatal care, and talking about the pregnancy became unbearable. Elifia had recently separated, was in an abusive relationship and reported suffering domestic violence.

Fernanda, 16 weeks pregnant, is expecting her first child. She said that like Elifia’s, her pregnancy was not planned. At only 18 years old, she felt too young to be a mother and was feeling frustrated about getting pregnant without being married.

Jéssica is 19 years old, married and 38 weeks and three days pregnant. She reported a lot of difficulty with accepting the pregnancy at the beginning. She had started a job and just began using birth control, because she did not want to get pregnant. However, she ended up getting pregnant, which made her feel guilty in some way. She felt so bad and sad that she considered seeking psychological help. From observing the women in her family, Jéssica noticed that none of them went through pregnancy without having moments when it was not unwanted.

Mariane has had a miscarriage and is pregnant again. She said that although professionals in the team are attentive and treat her well, they are practical. She had already had a miscarriage, but had not been asked how she felt about being pregnant again.

Pregnant women: “they are attentive and helpful, but they are focused on the ‘fetus’”, “they are concerned with the child”

In the last encounter with pregnant women, Clara, Pâmela, Jordana and Neuzeli participated. Jordana emphasized the need for psychological support in addition to physiological support. Clara mentioned the lack of emotional support during the follow-up. Neuzeli, in her first pregnancy, evaluated the care provided by the SUS as better than that offered at the private network, where she felt neglected. Pâmela, fearful after a miscarriage, did not discuss her concerns with the physician.

Professionals: “I listen, sometimes silently, they start crying and I offer my duty here, which is what I have”

The encounter took place with the physician Gaia and Têmis, a nurse. Têmis is 42 years old, married, has worked in the SUS for eight years and been a member of the multidisciplinary team at the UBS for three years, since its inauguration. Têmis said she felt safe providing follow-up care to pregnant women because she always had a physician in her team. She explained that it is not common that the UBS constantly has a physician in the team. Many nurses end up having to provide follow-up care to pregnant women alone given the lack of a physician in the minimum team. She noticed an increase in pregnant women who did not want to get pregnant and this has worried her. She does not feel capable of dealing with emotional issues and understands that pregnant women need psychological support and the UBS does not offer this service.

Gaia is 28 years old, a physician specialized in family and community health, and has also been in the team since the UBS opened. She noticed that some women openly express their sadness and frustrations, while others do not. In these cases, it is necessary to wait for pregnant women to bond with her and feel safe.

Establishing interactions that facilitate the expression of pregnant women’s emotional experiences is not part of the professionals’ conduct.

The unique emotional experiences of pregnant women are challenging for professionals, who consider themselves technically qualified to deal with the physiological issues of pregnancy, but lacking the skills to offer embracement to pregnant women’s emotions.

Similar results were found by ^{Gazotti and Cury (2019}), who conducted a study with psychologists of a multidisciplinary team at a General Hospital. The authors identified that professionals in the team face difficulties in dealing with patients’ emotional experiences, as they often experience feelings similar to those of the people they care for, which makes them feel vulnerable to embrace patients’ feelings.

The professionals who participated in this study realize that the emotions and subjective experiences of pregnant women are elements that exert impact on communication during consultations and the healthy development of pregnancy as a whole. However, the attention and care that they are able to provide to pregnant women are limited to prioritizing the health of the fetus. In the UBS itself, the professionals did not mention activities they perform with the aim to address the psychological aspects of pregnant women. When they feel this need, they refer the pregnant woman for external psychological care.

A survey was conducted by ^{Dias and Silva (2021}) with 12 professionals from different specialties: physician, nurse, community health agent and nursing technician in a UBS in Piauí. The results indicated a reductionist nature in the training of professionals who work in health teams. Since care is individually provided, the perspective of care at the UBS is close to that of the outpatient practice.

A finding in our study was that although most professionals of the multidisciplinary team at the UBS have years of practical experience and two out of the three physicians were specialized in family and community health, the training has been generalist, not preparing them to comprehensively deal with the complexity and uniqueness of people. They have cognitive and theoretical skills and abilities, but this has not been enough to achieve the objective of humanizing care as recommended by the SUS guidelines. Professionals need to be able to go beyond the techniques that equip them. Then, as advised by ^{Rosito and Loterio (2012}), they will be able to sustain a meaningful interpersonal relationship, since, “Objectivity in care transforms into a mechanical act what should be human, full of life” (p. 126).

Faced with such a challenge, attitudes of empathetic understanding and positive consideration present as facilitators by means of suspending judgments of causes and effects a priori. This enables professionals to have a comprehensive human understanding and an openness to the reality experienced by patients, which calls them to open up to others and broaden their self-perception and their own feelings towards the people they care for.

The experiences of the participating professionals reveal that the essence of humanized care lies in the possibility of a dialogical conduct and posture experienced in the intersubjective encounter between them and pregnant women. However, professionals experience a state of rigidity and impoverishment of the capacity to establish genuine interpersonal relationships and end up protecting themselves from the unpredictability of this type of contact through theories, techniques and protocols.

The intersubjective relationships between professionals in the team constitute a shield that protects them from threatening situations.

The professionals participating in this study consider the relationship with their colleagues in the multidisciplinary team to be very good and important, experienced as a type of emotional support. A study conducted by ^{Silva and Moreira (2015}) in a public neonatal intensive care unit concluded that horizontal interpersonal relationships experienced between team members are fundamental in consolidating multidisciplinary practices and those of the team itself.

We are relational beings and become humanized through contact with other people, with shared cultural experiences and the social contexts we live in. We have significant experiences with the community we belong to, and the recognition of others is made possible by the intentional direction that we consciously make towards them: “an intersubjective coexistence that is built by the encounter of consciousnesses” (^{Rus, 2017}, p. 124). In this directional movement, empathy constitutes a way of understanding the other and is the condition and possibility of knowledge about the external world (^{Tassinari & Durange, 2019}).

Regarding the functioning of groups, ^{Rogers (1978/2002}) highlights they can be formed for different purposes and when people are participating in a group, they can experience personal and intersubjective development based on interpersonal relationships. The participating professionals talked about how they relate to each other through integrated actions within the team on a daily basis, highlighting the importance of helping each other in order to obtain better results in the prenatal follow-up program.

Although the results of our study indicate enriching experiences permeated by the intersubjective relationships that professionals experience with one another, this factor alone cannot enable the achievement of comprehensive care by professionals. On the other hand, professionals share a collective sense of responsibility that guides all the actions they develop individually in the follow-up of pregnant women.

Professionals also revealed that they experience a sense of belonging to the team, which is shared by those who have been there since the inauguration of the UBS as well as by newly arrived professionals. There is an attitude of embracement and openness to new team members. For ^{Gazotti and Cury (2019}), interpersonal relationships based on mutual trust and acceptance among team members are fundamental. The authors emphasize that a positive and reciprocal interpersonal relationship can promote changes in the professionals’ understanding of their role in the team. In a group context where attitudes of empathy and openness prevail, procedures and intervention methods are positively impacted, promoting a sense of safety among team members, which benefits the comprehensiveness of actions (^{Barbalho & Magalhães, 2024}).

Helplessness and frustration are experienced by professionals due to a mismatch between proposals contained in the SUS documents and daily experiences at the UBS.

The professionals’ experiences highlight the difficulties faced in relation to the public health network and the lack of basic resources necessary to perform care actions. Professionals feel mobilized by the situation of the people they serve and end up using their own resources, e.g., their own vehicles for home visits, to avoid leaving them unassisted. There is also a lack of human resources, as the multidisciplinary team is understaffed. They are experiencing a drastic reduction in community health agents, which is reflected in the low coverage of the area of the population served, and impacts on the follow-up performed by the other professionals of the multidisciplinary team in the UBS.

Community health agents are essential in the multidisciplinary team, as they represent a bridge between the population and the public health service offered at the UBS. ^{Fernandez et al. (2021}) conducted a study with community health agents and concluded they are essential in the composition of the minimum team provided for in the policy recommended by the Family Health Strategy. According to the authors, it is possible to understand the weaknesses of Primary Care by analyzing the challenges and difficulties experienced by these professionals with negative impacts on the organization of health services.

There is a significant shortage of professionals in UBS teams in the state of Mato Grosso. Not even the presence of physicians is guaranteed in some units, as reported by the professionals themselves. Nursing professionals often need to provide follow-up care to pregnant women and users in general without the support of a physician. Professionals also feel the need to include other specialties in the team, such as a psychologist, who would meet the emotional demands of pregnant women and team members.

Although they want a psychologist in the multidisciplinary team, they do not clearly distinguish the role of this professional. The psychologist is recognized as the professional responsible for providing emotional support to pregnant women from a traditional clinical perspective. Physicians, nurses, community health agents and dentists have never worked with a psychologist at the UBS. Thus, they refer to the psychologist’s actions as being linked to traditional care practices in the health-mental illness binomial through individual consultations.

Participants in our study also do not associate the psychologist’s practice with actions aimed at health promotion, since referral for psychological care is directly related to mental illness that can harm the physiological development of the fetus during pregnancy.

The subjective experiences of pregnant women impact the process of adherence to the prenatal follow-up program.

Pregnant participants consider pregnancy as a unique experience lived by the condition of being women. However, this premise does not imply that all of them expressed the desire to be mothers during the prenatal follow-up program. They do not think the pregnancy corresponds to a process in which they experience only positive feelings, even if it has been planned.

Participants included women of different ages, educational levels and gestational experiences - multiparous and primiparous. They expressed that feelings of sadness, fear, anguish and despair manifest in different ways and they are not always able to verbalize them to the team. They understand these feelings impact on their adherence to the prenatal follow up program.

According to ^{Benincasa et al. (2019}), feelings of fear, anxiety, and guilt are inherent to the pregnancy process. A study conducted by ^{Nunes et al. (2018}) with first-time pregnant women indicated that they experience significant anxiety, especially when the pregnancy has not been planned. The results indicated that more intense anxiety may be related to the fact that some women undergoing prenatal care do not receive appropriate information, guidance, and embracement from the multidisciplinary team.

Most participants in this study did not plan to become pregnant and highlighted that pregnancy causes changes in the personal, social, and economic spheres. Many women, upon discovering the pregnancy, have to stop working and postpone plans and dreams, which makes them feel frustrated, in addition to the difficulty in dealing with the pregnancy and accepting it. Such feelings emanate from biological factors, as well as from subjective and intersubjective conditions and values of the social context in which they live. According to ^{Maldonado (2017}), pregnancy not only entails biochemical and psychological changes; the arrival of a child impacts a woman’s life in the social and economic spheres, causing significant impacts for many women.

The participants who planned to become pregnant also highlighted experiencing profound changes and ambivalent feelings: sadness and joy, insecurity and hope, uncertainty and expectations. For ^{Maldonado (2017}), the pregnancy corresponds to a transitional experience in the process of human development and enables healthy maturation when experienced with appropriate support and assistance.

^{Piccinini et al. (2012}) conducted a survey with 39 primiparous pregnant women with the aim to understand their feelings. The results indicated that women experience bodily, relational and interpersonal changes, and intense ambivalent feelings throughout the process of becoming a mother.

The experiences of participants in this study revealed pregnancy as an event involving all dimensions of the human structure: body, psyche and spirit. Bodily experiences occur through changes and sensations experienced by the woman in her body. There is an awareness that she is harboring another body within her body, touching and being touched by this other body. They also experience a bodily reorganization and changes in their life plans (^{Ales Bello, 2019}).

The psyche experiences the emotional manifestations of pregnancy through the vital force. Psychic acts are experienced when reflecting on being pregnant. They imagine what the child will be like and what life as a mother will be like and make decisions in the spiritual dimension. They choose whether or not to undergo prenatal care or may even decide to have an abortion. According to ^{Ales Bello (2019}), human activities that belong to the spiritual dimension are those that enable critical assessments of the experience lived, leading to decision-making based on values and beliefs. These dimensions are subjectively interconnected and fluid, constantly moving between each other, so that the gestational process is experienced in a complex and unique way.

When relationships with health professionals are guided by attitudes of consideration and empathetic understanding, pregnant women feel valued as people and this facilitates the emergence of positive experiences during pregnancy.

Pregnant women highlighted their perception that professionals in the team are unable to understand them emotionally. As these women cannot stimulate the emergence of a relationship that facilitates experiencing significant intersubjective contact, for them, professionals fail to provide a supportive environment that makes them feel safe to share their feelings.

^{Nahsan and Magalhães (2023}) emphasize that a healthy bond is achieved through dialogic communication and through a relationship of help constituted by significant interpersonal relationships. For these authors, the bond between pregnant women and professionals is what allows pregnant women to feel safe.

According to ^{Rogers (1977/1986}) the establishment of relationships of power and control in helping professions is trivial. However, the construction of meaning and the resumption of personal autonomy are necessary for pregnant women to be able to deal with current and future problems. The PCA proposed that professionals who occupy a specialist position in health professions must be able to relinquish control and power in order to establish a genuine and congruent relationship with the people they serve through attitudes of unconditional positive regard and empathic understanding. In other words, they must recognize that the people they serve have the capacity to develop psychologically towards greater autonomy and self-understanding.

Participants reported that feelings of non-acceptance of pregnancy, desire to abort, sadness and frustration are experienced by them alone and when verbalized to professionals, they naturalize such feelings as being normal, transitory manifestations typical of a certain period of the pregnancy process. Thus, they are advised to be patient because these feelings will disappear as the pregnancy progresses. A study was conducted by ^{Batista et al. (2021}) in a UBS with the aim to understand how women perceive the care and embracement offered by professionals. They found that pregnant women were unhappy because professionals were not offering empathy and embracement.

The experience of pregnant women shows the importance of professionals creating an atmosphere of consideration and unconditional appreciation for women’s experiences during the period of the prenatal follow-up program. According to ^{Rogers (1977/1986}, p. 19), the creation of an environment aimed at psychological growth requires “a positive and considerate attitude in relation to whatever the client is feeling at that moment. It involves the therapist’s willingness to allow the client to experience any feeling - confusion, resentment, fear, anger, courage, love or pride”.

The professionals use technical protocol procedures as instruments in their relationship with pregnant women, avoiding personal contact with them.

The participants narrated their experiences and expressed a sensitive and authentic understanding that the care offered during the prenatal follow-up program is aimed at ensuring the healthy development of the fetus. They emphasize that although the follow-up is well performed in clinical aspects, there is a predominance of biomedical care.

A study conducted by ^{Batista et al. (2021}) showed similar results to those found in our study; women were satisfied with the care received in relation to the technical procedures performed during the prenatal period. However, the care did not include user embracement and psychological care, and biopsychosocial care was not achieved.

The women participating in our study identified that prenatal follow-up needs to offer care that embraces psychological demands and this care should not be limited to the healthy development of the fetus. They emphasized that psychological care is only possible in contexts including the presence of a psychologist in the multidisciplinary team.

The experiences of pregnant participants demonstrate the relevance of including a psychologist in the multidisciplinary team of the UBS. In the study by ^{Abreu et al. (2021}) on the provision of individual follow-up care, group interventions and psychological support to pregnant women, was reached the conclusion that psychological follow-up during pregnancy promotes the strengthening of subjective resources and autonomy, broadens self-perception and provides women with subjective and emotional tools for decision-making.

In conclusion, our study corroborated the results of other studies on the need for rewarding intersubjective relationships between professionals in multidisciplinary teams and pregnant women during the prenatal follow-up program, with an emphasis on considering the emotional aspects of the pregnancy process. On the other hand, it made it possible to understand that even with the challenges faced on a daily basis, professionals who make up UBS teams take responsibility and strive to provide quality care to pregnant women, who recognize that and are grateful for this type of follow-up received in the public health network.

A limitation of this study is that it was carried out in a single UBS located in a municipality in the state of Mato Grosso, making it impossible to extend the conclusions to other social contexts and other regions of Brazil. Furthermore, it is also necessary to reflect on what it means to “be a woman” in the Brazilian culture under different historical and social understandings. Some transgender men experience pregnancy, and it is essential to understand these experiences in the context of the prenatal follow-up program. In this study, we did not delve into the analysis of the SUS system and the impacts this may have on the daily lives of professionals and the prenatal follow-up given the thematic focus chosen. Thus, it is important that new studies contemplate these aspects and perspectives to enrich knowledge about the diversity of experiences in pregnancy follow-up.