Prenatal care satisfaction: perception of caregivers with diabetes mellitusNicolosi, Bianca FioravantiI Lima, Silvana Andréa MolinaI Rodrigues, Meline Rossetto KronI Juliani, Carmen Maria Casquel MontiI Spiri, Wilza CarlaI Calderon, Iracema de Mattos ParanhosI Rudge, Marilza Vieira CunhaI
- IUniversidade Estadual Paulista Júlio de Mesquita Filho. Botucatu, São Paulo, Brazil.
to understand the satisfaction of pregnant women with diabetes who took insulin during pregnancy and prenatal care performed through outpatient and inpatient follow-up.
a qualitative approach with analysis of 30 pregnant women who underwent prenatal care and participated in a clinical trial study carried out by the research group of the Perinatal Diabetes Research Center of the Hospital das Clínicas, of the Faculdade de Medicina de Botucatu. The data were collected through interviews and analyzed from content analysis.
from the category Satisfaction, the following subcategories emerged: facilities and difficulties faced in prenatal care performed through outpatient or inpatient follow-up, demonstrating that the pregnant women were satisfied with the prenatal care offered regardless of the type of follow-up.
there was satisfaction in both care, but in outpatient care some structural, technical and administrative difficulties were identified, requiring reassessment, in order to guarantee service agility.
Patient Satisfaction, Prenatal Care, Diabetes, Gestational, Pregnant Women, Diabetes Mellitus
Health services are increasingly concerned with the quality of care provided and, consequently, it becomes relevant to know the satisfaction of clients, since this is one of the dimensions of quality. The concern with satisfaction began in the 70’s and was based on technical and structural aspects of quality of care (1).
In Brazil, care satisfaction assessment is relatively recent (2). However, since 1990, with the application of the principles of the Brazilian Unified Health System (SUS – Sistema Único de Saúde), there is a concern with the structuring of a new healthcare model focused on the health needs of the population and, consequently, on the pursuit of user satisfaction (1).
Considering the health needs of the population, numerous actions must be performed to obtain quality care and user satisfaction, as well as to solve the health problem.
Among the different health needs, prenatal care stands out. In Brazil, it is guaranteed by the health policy, which must be offered and organized in order to guarantee the basic needs of pregnant women, so that, at the end of gestation, a labor without complications, without any harm to the mother’s health and a healthy newborn can occur (5).
In pregnancy, innumerable changes occur in this period that, in addition to the biological dimension, involve individual aspects of the woman, her partner, family and health services (6).
In addition to physiological changes, gestation may be associated with several pathologies, such as Diabetes Mellitus (DM) and maternal and fetal complications. DM is a chronic pathology that has been studied worldwide, since it affects all socioeconomic classes, without distinction of subject vulnerable to glycemic instabilities. The cost to public networks and the fall in the quality of life are impact factors for funding organs (7-8).
In pregnancies complicated by DM, hyperglycemia and changes in lipid metabolism are associated with complications in the maternal and fetal organism (10-11). DM is related to comorbidities, such as macrosomia, hyperbilirubinemia, hypokalemia and hypoglycemia, as well as morbidity and mortality (12). It is also associated with the incidence of miscarriages and first-trimester malformations (13-14).
Considering the severity and importance of rigid glycemic control of diabetic pregnant women, studies have been carried out by the Research Group of the CIDP - HCFMB. One of these studies was a randomized clinical trial that aimed to assess the cost-effectiveness of outpatient and inpatient treatment during the prenatal period of pregnant women with diabetes using insulin. In this study, the reduction of costs for outpatient treatment and similar maternal-fetal outcomes between the groups (15).
Considering the scarcity of studies in literature, it was necessary to understand the satisfaction of pregnant women with diabetes in prenatal care offered in outpatient and inpatient treatment, thus justifying the performmance of this study that had the following question: are the pregnant women with DM under treatment satisfied with care received in inpatient and in outpatient clinic?
To understand the satisfaction of pregnant women with DM who used insulin during pregnancy, with prenatal care performed through outpatient and inpatient follow-up.
The research was developed in accordance with Resolution 466/2012 of the Brazilian National Health Board (Conselho Nacional de Saúde)/MoH, and approved by the Research Ethics Committee of the Faculdade de Medicina de Botucatu - UNESP. It obtained Opinion 606,987, and all participants signed the Free and Informed Consent Term.
Theoretical-methodological framework and type of study
This is a descriptive and exploratory study, with a qualitative approach, that used Bardin’s content analysis (16) as methodological framework. The qualitative approach, in this study, allowed the expansion of the scope of social reality, preoccupying with meanings, and identifying issues that could go unnoticed.
The research was carried out at the Perinatal Diabetes Research Center of the Hospital das Clínicas of the Faculdade de Medicina de Botucatu (CIDP - HCFMB), which includes care in Technical Section Inpatient and hospital care in the Technical Section of Obstetrics and Obstetric Center. The Technical Section Inpatient serves high-risk pregnant women, which includes those with DM. The Technical Section of Obstetrics and Obstetric Center has 29 beds intended for prenatal monitoring of pregnant women with diabetes and for hospitalization of pregnant women with gestational complications, for delivery and obstetric procedures.
Participants in the study were pregnant women who underwent prenatal follow-up and participated in a clinical trial study conducted by the research group of the CIDP - HCFMB. This clinical trial was performed by Kron et al. (15) who randomized diabetic pregnant women into two groups: 1) intervention group, with a new proposal for outpatient care (pre-natal outpatient follow-up and home glycemic control, with nursing and medical staff guidance); and 2) comparator group, who followed the protocol of the institution (hospitalization of diabetic pregnant women during prenatal follow-up for hospital glycemic control).
The research universe consisted of 15 pregnant women attending outpatient clinic and 15 pregnant women hospitalized during prenatal care. It was adopted an intentional sample constituted by pregnant users. The data collection was closed when there was saturation of the data, presenting repetitions and having responded to the research objectives.
The survey was based on inclusion criteria: pregnant, with prior or gestational diabetes, using insulin, during the gestational period, hospitalized or in outpatient care during prenatal care at HCFMB, and performed the HCFMB, once the interview was scheduled after delivery.
Collection and organization of data
The study adhered to the recommended protocol for qualitative research - Consolidated Criteria for Reporting Qualitative Studies (COREQ) (17).
Data collection was performed between May and October 2014, through a semi-structured interview script, applied individually, based on the guiding questions: what is satisfaction/opinion about prenatal care performed by outpatient/inpatient clinic follow-up? What facilities did you have to perform prenatal care at the outpatient clinic? What difficulties did you have in getting prenatal care at the outpatient/inpatient clinic?
The itinerary consisted of two parts, the first of which was the identification and sociodemographic characterization of the participants and the second of three questions related to the satisfaction with the prenatal care received by the outpatient clinic or hospitalization, and the facilities and difficulties found in the two types of follow-ups.
The interviews were recorded and then transcribed in full for further analysis of the data. Transcripts of the interviews were ordered and the study participants were named P for pregnant women, O1....O15 for prenatal outpatient follow-up and I1.....I15 for prenatal inpatient follow-up.
The data were analyzed according to the content analysis, respecting the three phases: pre-analysis, material exploration and data processing (data analysis and interpretation) (16,18-19). The analysis of the data was performed by coding the speeches of the participants (used the letter O for outpatient and I for inpatient), and the codes were grouped by the similarities of meanings in analytical categories. The units of meanings were grouped into three categories: Satisfaction with prenatal care performed through outpatient or inpatient follow-up; Facilities found with prenatal care performed through outpatient or inpatient follow-up; Difficulties faced in prenatal care performed through outpatient or inpatient follow-up; with the subcategories: Safety with hospital care. Living away from health care; Problems with outpatient care; and Concern with other children.
Identification and characterization of study participants
Of the pregnant women participating in the study, the age range varied from 18 to 42 years of age, and schooling level that prevailed was Elementary School. Most of the pregnant women had companions and children before the current gestation, and the desire to have more children ranged from 13% to 22%. Only 30% of pregnant women had an employment relationship, and the predominant type of DM in outpatient follow-up was gestational, and inpatient follow-up was DM2.
Satisfaction with prenatal care performed through outpatient or inpatient follow-up
When questioned about prenatal care, the pregnant women interviewed showed satisfaction with care provided by outpatient and inpatient follow-up, as indicated in the following statements:
Oh, it was great, I’ve been being followed up there for a long time, right?! (PO5)
I found the service excellent, we can trust in this hospital. (PO4)
Very, very good, really. (PO6)
I thought it was good, I was very well taken care of there. (PI7)
Oh, I liked it a lot, see? I have nothing to complain about. (PI12)
Very good, everyone treated me very well, I only had a problem with a woman there, but otherwise it was great. (PI13)
Facilities found with prenatal care performed through outpatient or inpatient follow-up
Tranquility with outpatient care. The pregnant women in the outpatient clinic interviewed expressed that they would be worried and anxious if they needed hospitalization for prenatal care, as stated in the statements below.
It was good, because if I were hospitalized I would be nervous and I would be more uncontrolled. It is a dangerous disease so the doctor said “hey, take care”. (PO2)
Good news was that I did not have to be hospitalized because if I had to, I would be worried. (PO5)
Being hospitalized makes a bad impression, you know? It is bad. (PO9)
Worry and anxiety are affective states developed during hospitalization. These feelings are reflections of the concern with the health and the fear of the unknown or of what could happen with the pregnant woman and the fetus. In this case, the participants demonstrated greater tranquility with outpatient care.
In addition to the absence of concern about hospitalization, the pregnant women also demonstrated that outpatient care is a simpler, faster process, allows home glycemic control and allows greater flexibility of the activities performed at home, according to the statements presented below.
Ah, I think it’s much better, I come already I do it and just leave. (PO10)
Oh, I think it’s better because it’s complicated to admit it, at home you can do the things you want to do, there you go measure. (PO2)
I found it very simple, it became part of the routine to go to prenatal care and take the exams. (PO6)
According to the speech below, another positive point that guarantees the tranquility of outpatient care is the ease of the pregnant woman staying close to her relatives, including the children, who end up being the mothers’ biggest concern.
Oh, it’s good, because I already have a son there I was close to him, right?! (PO4)
Safety with hospital care
The pregnant women who received inpatient follow-up to perform the prenatal care showed positive points of hospital care, such as frequent monitoring of the health team and strict control of feeding by the nutritionist, as stated below.
I thought it was good, because they are monitoring us all the time, it was very good. (PI13)
Oh, because there was a nutritionist who controlled and said that we could eat everything, right? (PI14)
Difficulties faced in prenatal care performed through outpatient or inpatient follow-up
Living away from health care
One aspect reported by the majority of pregnant women attending in the outpatient and hospitalized setting was the difficulty of performing prenatal care because they lived away from the hospital, according to the statements below.
I have no problem with food, because they give it, the only problem is that I live very far away and I do not live in the city, I live in the farm. (PO7)
So, since I live far away, it’s already difficult for me. (PO8)
My biggest problem is transportation. (PO9)
Oh, what I find difficult is that I live far away and have to come every Tuesday, right? (PO10)
The most difficult thing is to come at dawn in the morning. I leave one hour in the morning, because I do not live in the city, I live in the farm. (PI8)
Problems with outpatient care
Problems with outpatient care were identified, such as the delay in care for insulin-dependent pregnant women, multidisciplinary schedules on different dates, home glycemic control at the time of leaving the home for appointment, and the high number of visits in the same week, according to the statements below.
The only thing that bothers me is when the nutritionist schedules in one day and the doctor in the other, it is complicated. (PO10)
I just find it a little time consuming because of insulin-dependent women. (PO11)
Oh, it’s more the exam because I leave the house at 4:30 in the morning, and on those days I came on Wednesday, Thursday and Friday. (PO09)
Concern with other children
In addition to changes in gestation and the need for treatment in a specialized service with rigid glycemic control, pregnant women need to reorganize their family routine.
In this context, another difficulty presented by the pregnant women during their stay in the treatment service was the concern with the other children, according to the statements below.
I have to leave the two children, they are not mine, but I raise and I have to leave them with my mother. (PO8)
It’s difficult, because I have a 12-year-old girl who stays there, right? (PO10)
It’s more having to stay hospitalized, because I have a younger son and have to stay with his father. (PI15)
The study evidenced that the interviewed women showed satisfaction regarding care performed by outpatient and inpatient follow-up. In a review of Weiss’s (20) literature on satisfaction in care, it was identified that the professionals who follow the patient’s role play a key role in the quality of care and user satisfaction.
According to Marinho et al. (21), satisfaction encompasses many factors besides the professional’s relationship with the patient, such as the quality of care, access to the service provided, structure and organization made available by the service.
Ramirez et al. (22) also affirm that care goes beyond appointment, it is carried out in a holistic way, and satisfaction is present from the moment the user is received in the unit, hygiene and lighting of the place, care conditions, waiting time to be served to the way they are welcomed, diagnosed and followed-up. For the authors, the environment in which the user is exposed has a total influence on their degree of satisfaction.
In this sense, by the speeches presented, participants were satisfied with the treatment received, regardless of the type of outpatient or inpatient follow-up pregnancy. The pregnant women did not refer specifically to care of a professional category. However, there were feelings about the health service, such as trust and excellence in care. These feelings also indicate that the service has a concern with care humanization, taking into account the fulfillment of the user’s need.
A qualitative study (23), with the objective of identifying access, satisfaction and embracement of pregnant women about the nursing appointment in prenatal care, showed that good care is based on the reception, active listening and communication, since they allow a linkage of the binomial user and health service and, consequently, greater user autonomy and satisfaction.
In one of the statements above, it was also demonstrated the frequent use of the service, which, in addition to the aspects discussed previously, probably stems from being a reference center for the region and treating participants of the study with chronic disease (DM).
Regarding facilities with prenatal care performed by outpatient or inpatient follow-up, among positive points, which guarantees tranquility of outpatient care, is the facility for the pregnant woman to remain close to her family, including the children, who end up being the greater concern of mothers.
A study carried out by Nachum et al. (24) also showed that the outpatient treatment allows the patient to perform home glycemic control in order to avoid distancing between the pregnant woman and her family, in addition to reducing trauma psychological, mental and social consequences of hospitalization. Moreover, authors such as Cavassini et al. (25) have demonstrated that outpatient care is more economically advantageous than hospitalization during prenatal care.
Regarding safety with hospital care, this study allowed us to identify that hospitalization brings to the patient a sense of security and greater control of his illness.
A qualitative study, performed by Araujo et al. (26), with diabetic pregnant women corroborates the findings, evidencing that the pregnant women had easy access to hospitalization, which allowed a strict control of DMG due to care of the health professionals’ team. According to these authors, for these pregnant women, hospitalization raised the hope of healing the disease after birth, which strengthened security and self-care motivation.
Another aspect identified by the study by Araujo et al. (26) was that the pregnant women expressed support for hospitalization due to their concern about the birth of a healthy baby.
Among the difficulties encountered with prenatal care performed through outpatient or inpatient follow-up, living away from the health service can be explained by the service’s breadth of service, constituting a reference center for 68 municipalities of DRS VI. Consequently, it does not only serve the population of the city where it is located, generating physical exhaustion due to the displacement, besides those already caused by gestation and DM.
Another fact is that, since pregnant women depend mostly on public transport, they must leave during the night for appointment or hospitalization, being sure that the return only occurs when the available vehicle is ready, that is, with all patients from the same city already served. This makes the service even more exhausting for the diabetic pregnant woman, causing a situation that generates complications for long periods without food and stress. A study by Costa et al. (27) identified that the greatest difficulty regarding access to the health service was geographical, especially for pregnant women living in rural area. Furthermore, 42% of the pregnant women interviewed resided in rural area and presented complaints mainly related to the lack of transportation and difficulties in accessing appointments during rainy periods.
The delay in care for insulin-dependent pregnant women occurs for several reasons. The service is a reference for high-risk pregnant women, which generates a high number of cases to follow up these pregnant women and, consequently, an overload in care. In addition, it is a university and teaching hospital, where students from boarding schools, residents, professionals and professors participate in the service, which may justify the extension of the time of care of pregnant women. In particular, diabetic pregnant women attending the outpatient clinic, who use insulin, receive guidance from nurses on glycemic control at home and participate in groups to discuss pregnancy and DM. These activities were carried out on the same day of the medical appointment and the nutritionist’s attendance, which also favors the greater permanence of the pregnant woman in the service.
The appointments of medical, nursing and other professionals should be organized in such a way that the pregnant woman moves as little as possible to the service. This study brings the difficulty of attending the pregnant woman to appointments on different days (medical and nutritionist), which means that the service needs to readjust the multidisciplinary schedule.
Home glycemic control, with a glucose meter, occurs the day before medical and nursing appointment, and the following hours are standardized: 8 a.m., 10 a.m., midday, 2 p.m., 4 p.m., 5:30 p.m., 7 p.m., midnight, 4:30 p.m. and 6:00 p.m. The pregnant women record the results in the control cards, bringing them completed for medical and nursing appointment. One of their difficulties is examination at the time of leaving home for appointment, which causes discomfort or not in its accomplishment. This evidences the need to reassess the standardized schedules for home glycemic control by medical staff.
The high number of appointments in the same week may occur for several reasons, such as lack of glycemic control, need for adjustment of insulin dose, complications of pregnancy, among others, which justifies a more intense follow-up of the pregnant woman by medical staff.
In this context, in addition to other studies, there are maternal-fetal and economic benefits for outpatient care (19,24), there are some difficulties manifested by the pregnant women who deserve attention on the part of the teams (medical, nursing, nutritionist, among others) and need reassessment of this type of follow-up, guaranteeing greater service agility, reducing physical wear out, and complications and adoption of practices of humanization of care for pregnant women.
The present study also showed that the concern about having to leave the other children occurs in outpatient and inpatient follow-up. This is due to the fact that the pregnant woman accompanied in an outpatient clinic arrives to the service in the morning and returns to its house in the afternoon. The hospitalized pregnant woman remains at least 24 hours in the service, which generates a need to rearrange her household chores and take care of her children.
Araujo et al. (26) observed that daily life disruption and distance from family and home causes, initially, the non-acceptance of the critical situation experienced, especially when involving small children, who depend on care for the mother. The authors also mention that, in some cases, participants have family support (sisters, grandmothers and husbands) and in others, this does not happen and the concern about who does not leave the children generates greater insecurity.
The limitation of this study is related to the context where the patients enrolled in the study used insulin, a fact that contributes to increase the gestational risk and, thus, require specialized prenatal care, which may differ from other less specific DM in pregnancy.
Contributions to Nursing, Health or Public Policy
Although the prenatal care performed by outpatient follow-up presents numerous advantages, as already reported by other studies found in the literature and described in this research, there are some structural, technical and administrative difficulties of the institution, such as the delay in care of insulin-multidisciplinary schedules on different dates, home glycemic control at the time of leaving home for appointment and the high number of visits in the same week. Therefore, it is necessary to reassess this type of follow-up, in order to guarantee greater service agility, reduction of physical exhaustion and complications, in addition to the adoption of humanization practices of care for pregnant women.
As an easy prenatal care performed by outpatient follow-up, it was pointed out the tranquility of care, because it is a simpler, faster process, allowing the accomplishment of home glycemic control, which generates greater flexibility for the development of work and domestic activities and proximity with relatives, including children. On the other hand, pregnant women who received prenatal care through inpatient follow-up reported feelings of safety and increased disease control.
Despite the satisfaction with the offered service, some difficulties were identified with outpatient and inpatient care. The pregnant women presented difficulties in performing prenatal care due to living away from the hospital and problems with transportation, elements that contributed to physical exhaustion and risk situations, which could lead to complications for pregnant women. Another difficulty was the concern with the children at home because, often, the pregnant women did not have with whom to leave them generating feelings of concern and anxiety.
It is hoped that this study encourages reflection for managers and professionals of the service and also of the units that refer patients to hospitals, in order to seek and adopt new organizational strategies in the services to improve the quality of prenatal care services.
The present research comprised the satisfaction of pregnant women with DM who used insulin during the gestational period during prenatal care performed by outpatient and inpatient follow-up.
User satisfaction is referred according to what he expected of the service and the return he had in relation to his expectations. In this study, the pregnant women were satisfied with the prenatal care offered, regardless of the type of follow-up (outpatient or inpatient).
This service satisfaction was followed up by positive feelings of the pregnant women towards the health service as trust, frequent use of the service (treatment continuity), excellence in service and concern with the overall service humanization.