Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 1 - Jan/Mar - 2017

Article Update Imprimir 

Páginas 107 a 111


Integrality in the care for pregnant adolescents

Integridad en el cuidado a las gestantes adolescentes

Integralidade no cuidado às gestantes adolescentes

Autores: Silvana Januario Jorge1; Marinês Finco2; Adriana Lobo Muller3; Monica Helen Winnikow4; Sarita Martins Camina Reinicke5

1. Master's Degree in Collective Health , Blumenau Regional University (FURB). Blumenau, Santa Catarina State, Brazil. Nurse, Blumenau Municipal Health Bureau. Blumenau, Santa Catarina State, Brazil
2. Master's Degree in Collective Health , Blumenau Regional University (FURB). Blumenau, Santa Catarina State, Brazil. Nurse, Blumenau Municipal Health Bureau. Blumenau, Santa Catarina State, Brazil
3. Master's Degree in Collective Health. Lecturer, Blumenau Regional University (FURB). Blumenau, Santa Catarina State, Brazil
4. Master's Degree in Collective Health , Blumenau Regional University (FURB). Blumenau, Santa Catarina State, Brazil. Physician, Santa Catarina State Health Bureau. Blumenau, Santa Catarina State, Brazil
5. Master's Degree student in Collective Health , Blumenau Regional University (FURB). Blumenau, Santa Catarina State, Brazil. Nutritionist, Instituto Federal Catarinense (IFC). Rio do Sul, Santa Catarina State, Brazil

Silvana Januario Jorge
Rua José Ricardo Hersing, Nº 42, Warnow
Indaial, SC, Brasil. CEP: 89130-000
januariojorge@bol.com.br

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Keywords: Adolescent, pregnant women, integrated delivery of health care.
Palabra Clave: Adolescente, gestantes, prestación integrada de cuidados de salud.
Descritores: Adolescente, gestantes, prestação integrada de cuidados de saúde.

Abstract:
Adolescence is a time when are experienced many changes in the body and mind. Questions about identity, changes in the relationship with parents and the necessity to live together with a group, all of these happens at the same time. Once a teenager is pregnant, she needs a lot of attention from the health team because the complications due to the pregnancy for the mother and the newborn are a big risk. Furthermore, it may cause social and economic problems. The healthcare center should be the preferential option in the system for the pregnant teenager, which is a strategic place that best supplies their necessities, including providing a longitudinal and continuous monitoring. Health professionals play an important role in listening to health requirements and should allow the expression of feelings that emerge from the pregnancy experience in order to establish a relationship of trust. The primary care welcoming implies in the responsibility of the team for comprehensive care with qualified listening, favoring the bond and vulnerability assessment in accordance with their social context. In this way, it is clear that when a pregnant adolescent comes to the healthcare center, it is not enough that each adolesprofessional only develops a care proposal, but it is essential that each one looks beyond their academic formation because the transdisciplinarity concerns with an interaction between subjects, where each of them looks for something beyond themselves, their purpose is the understanding of this world.

Resumen:
La adolescencia es un período donde son vividas diversas modificaciones corporales y mentales, cuestionamientos sobre su identidad, cambio en la relación con los padres y necesidad de convivir en grupos. La adolescente gestante necesita mucha atención del equipo de salud, pues las complicaciones obstétricas para la madre y el recién nacido son de alto riesgo, además de acarrear problemas sociales y económicos. La unidad básica de salud debe ser la puerta de entrada preferente de la gestante adolescente en el sistema, lugar estratégico para acoger mejor sus necesidades, incluso proporcionando un acompañamiento longitudinal y continuo. Los profesionales de salud tienen importante papel en la recepción de necesidades de salud, debiendo permitir la expresión de sentimientos que emergen en la vivencia del embarazo, de modo de establecerse una relación de confianza. La acogida en la atención básica implica a responsabilidad del equipo por la integralidad del cuidado con atención calificada y favorecimiento del vínculo y evaluación de vulnerabilidades de acuerdo con su contexto social. Se entiende entonces que cuando una adolescente gestante llega a la unidad básica no basta que cada profesional la atienda y elabore una propuesta de cuidado, es imprescindible que cada profesional amplíe suyo mirada más allá de su formación académica, pues la transdisciplina se preocupa por una interacción entre las disciplinas, donde cada una de ellas busca una más allá de sí, siendo su finalidad la comprensión del mundo presente.

Resumo:
A adolescência é um período onde são vivenciadas diversas modificações corporais e mentais, questionamentos sobre sua identidade, mudança no relacionamento com os pais e necessidade de conviver em grupos. A adolescente gestante necessita de muita atenção da equipe de saúde, pois às complicações obstétricas para a mãe e o recém-nascido são de alto risco, além de acarretar problemas sociais e econômicos. A unidade básica de saúde deve ser a porta de entrada preferencial da gestante adolescente no sistema, local estratégico para melhor acolher suas necessidades, inclusive proporcionando um acompanhamento longitudinal e continuado. Os profissionais de saúde têm importante papel na escuta de necessidades de saúde, devendo permitir a expressão de sentimentos que emergem na vivência da gravidez de modo a se estabelecer uma relação de confiança. O acolhimento na atenção básica implica a responsabilização da equipe pela integralidade do cuidado com escuta qualificada e do favorecimento do vínculo e da avaliação de vulnerabilidades de acordo com o seu contexto social. Entende-se então que quando uma adolescente gestante chega à unidade básica não basta que cada profissional a atenda e elabore uma proposta de cuidado, é imprescindível que cada profissional amplie seu olhar para além de sua formação acadêmica, pois, a transdisciplinaridade preocupa-se com uma interação entre as disciplinas, onde cada uma delas busca um além de si, sua finalidade é a compreensão do mundo presente.

This project is an update paper on public policies addressing healthcare available in Brazil for pregnant adolescents. Initially, public policies already in place will be described, in addition to practices already implemented and their challenges. This will be followed by critical reflections on setting up the work teams, their historically-constructed conceptions of healthcare, and the possibilities of actions that could pave the way to moving beyond fragmented healthcare models.

A time of transition between childhood and adulthood, adolescence1, extends between 10 and 19 years of age2, characterized by many physical modifications, particularly rapid growth and the appearance of secondary sexual characteristics, in addition to doubts about individual identities, shifting relationships with parents and the need to live in groups3,4,5. Other characteristics of this period are increased interest in romantic relationships, together with the discovery of sexuality and consequently sexual intercourse6.

According to the World Health Organization, out of the total adolescent population worldwide, 16 million girls give birth every year7. The phenomenon of teen motherhood is rated as high-risk, due to obstetric complications for these mothers and their newborns4, in addition to social and economic problems2.

During the past decade, the number of births to girls between 15 and 19 years of age dropped by 30% in Brazil. However, this figure remained unchanged for the group between 10 and 14 years old, at 27,000 births each year, accounting for 1% of the total number of births7.

As there are references to higher frequencies of several problems for pregnant girls, including anemia, high blood pressure, and urinary infections, among others2, pregnancy must be assessed in a broad-ranging manner, with early diagnosis vital for risk assessment and control, right from the start1.

Monitoring these girls must ensure that their pregnancies progress smoothly, necessarily preparing them for birth and motherhood. The care model rated as ideal consists of ongoing oversight of these adolescents, either individually or in groups, by multi-disciplinary teams1 (page 28).


Among the principles and guidelines established for Brazil's Unified National Health System (SUS) through the Basic Healthcare Act (Law Nº 8,080) promulgated in 1990, comprehensive healthcare is rated as one of the guiding principles for steering related practices and the organization of these facilities for the population in general. Comprehensive care acknowledges that the users of this system are complete beings who can and must play active roles in their own health, disease and self-care processes 8. Comprehensive care was included as an SUS guideline in order to surmount long-established dichotomies between the individual and the collective, as well as prevention and cure9.

The practices adopted by healthcare practitioners are rated as extremely important in the quest for comprehensive care10. This is why programs and policies deployed by the Ministry of Health have encouraged the inclusion of these practices by healthcare facilities11, thus striving to reorganize the national health model. A good example is the National Humane Care Policy, with another proposal being the Stork Network (Rede Cegonha), included in discussions of the Healthcare Network in order to promote the integration of health-related actions and facilities that underpin efficient and good-quality care for all points requiring attention, focused on user satisfaction and improving the mother-and-child morbidity and mortality indicators12.

It is vital to stress the idea of care, rather than merely diagnosis or cure. Providing comprehensive care means offering support for social, biological, psychological, spiritual and environmental matters. Colliére13 stresses the difference between treating and caring, with the former focused on disease-related aspects and technologies used to avoid death, while care is related to everything stimulating life forces.

Women´s healthcare is extremely susceptible to difficulties, as women are addressed in a fragmented manner by a wide assortment of vertical government programs that are largely disjointed, resulting in poor compliance and with minimal effects on health indicators14.

The Basic Healthcare Unit must be the preferred gateway to the system for pregnant girls15, as a strategic venue for meeting their needs effectively, including ongoing longitudinal monitoring, particularly when pregnant16.

In order for basic care facilities to offer comprehensive care, interaction is needed between providers and users. Healthcare practitioners play an important role in listening to healthcare requirements, and must allow their patients to express feelings that emerge as their pregnancies progress, thus establishing relationships of trust16.

In this context, the Ministry of Health recommends that teams organize their work processes in ways that assist pregnant girls, with the activities performed by each team member tailored to their needs for care16.

The team must be open to these demands, as girls may not even know that they are pregnant on arrival at Basic Care Units, instead mentioning an assortment of specific and non-specific complaints, with the most common being late menstruation, which is common at this age. Confirmation of pregnancy may trigger a crisis for these girls, and at this time it is vital to strengthen links with the team who must advise and guide them on seeking support from their families, friends and partners, as this will help them through this new phase in their lives16.

Consequently, ensuring that these girls feel comfortable at Basic Care facilities requires the team to accept responsibility for providing comprehensive care from their arrival onwards, listening carefully to them while building up links and assessing vulnerable aspects reflecting the social contexts within which they live16.

It is important to clear up all doubts mentioned by these pregnant teens and anyone accompanying them. If necessary, they must be referred to other facilities available in the care network, including obstetricians, nutritionists, psychologists and social workers, among others16.

Providing educational activities is an excellent strategy for addressing important topics during pregnancy, such as breastfeeding, birth types, the importance of vaccinations for mothers and their babies, visit to maternity clinics which will help these young mothers-to-be to feel more confident and protected by the team. Particularly noteworthy is the importance of the team allowing and encouraging the participation of a companion during appointments and educational activities, either a common-law husband or someone else selected by the pregnant teen16.

Healthcare practitioners must strive to provide appropriate, safe and humane care for pregnant teens, who must be the protagonists in their own pregnancy and birth processes, thus strengthening supportive links and collective participation in healthcare practices8.


"BEYOND SELF" FOR COMPREHENSIVE CARE

Nowadays, a paradigmatic shift is becoming apparent in ways of dealing with human complexity, necessarily moving beyond a fragmented attitude towards a comprehensive approach that addresses people and their surroundings, taking into consideration aspects related to culture, art and philosophy. It is thus necessary to shed the reductionist disease-centered concept of healthcare17.

Along these lines, the multi-disciplinary team compositions are proving inadequate, as the basic concept for this team model consists of a set of specialties studying the same problems simultaneously, without explicitly defining the links among them 18, resulting in a cluster of approaches without a common project. This configuration reflects the historic fragmentation of knowledge permeated by professional training, as well as corporate culture and power structures that are characteristic of the sectorization of work that upholds the gap between theory and practice, knowing and doing, managing and executing17.

The difficulties faced by these teams also encompass a lack of understanding of the potential and skills of each practitioner, problems in communication due to intolerance of different ideological and technical approaches, and work conditions fettered by tangled paperwork and low pay, "prompting practitioners to absorb feelings of powerlessness and dissatisfaction either individually or in small groups, with low visibility for institutional dynamics, unable to identify the extent to which their own relationships at and with work are institutionalized"17 (page 190).

The absence of reflection and dialogue in multi-professional teams fosters the repetition of logics grounded on the separation of specialties and their different subjects of study and intervention. This triggers feelings of dissociation and segregation among workers and consequently users as well, as the discourse calls for a comprehensive approach, while the practice is fragmented and also fragments processes and subjects. [...]19 (page 1687).


It is thus understood that the paradigmatic shift that is currently under way, calling for comprehensive care through a new conceptualization of health also requires the appearance of a new configuration for institutional, personal and professional relationships, steered by changes in "[...] theoretical, philosophical, technical, political, managerial and ethical aspects [...]"17 (page 185).

Consequently, transdisciplinarity arises as an option for dialogue between scientific expertise and other fields of human knowledge such as religion, culture and art, challenging the neutrality and objectivity of traditional science by "acknowledging the importance of human subjectivity in the production of knowledge"17(page 186).

Through transdisciplinary logic, the conceptualization of healthcare is associated with "multiple human dimensions [...] individual, emotional, subjective, cultural and social. In these relationships, users, administrators and workers may be producers for themselves and for health in the collectivity"19 (page 1687).

It is thus understood that when a pregnant teen walks into a Basic Healthcare Unit, it is not enough for each practitioner to see her and draw up a care plan. Instead, it is vital that all these practitioners extend their fields of view beyond their own academic training as "transdisciplinarity is grounded on interactions among specialties, with each of them transposing their own boundaries in order to understanding today´s world and thus ensuring that there is a plural unity of knowledge"20 (page 485).


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