Maternal difficulties in home care for newborns

Objective: to analyze the association between maternal difficulties in home care for newborns and parity. Methods: cross-sectional study, carried out in Primary Health Care in a Brazilian municipality. The sample consisted of 247 puerperal women, whose data collection took place by using two questionnaires, applied in home visits. The data were analyzed using Pearson’s chi-square test. Results: it was observed that both primiparous and multiparous women had a very high percentage of difficulties related to care, however, primigravid women showed greater obstacles in the care related to bathing and belching while multiparous women reported greater obstacles during breastfeeding. The worry with the choice of clothes and the umbilical stump was statistically significant, regardless of the number of gestations. Conclusion: there were difficulties, regardless of the woman’s previous obstetric experience, being mainly associated with insecurity, concern, and helplessness. Descriptors: Postpartum Period; Infant Care; Infant, Newborn; Perinatal Care. RESUMO Objetivo: analisar a associação entre dificuldades maternas no cuidado domiciliar a recém-nascidos e paridade. Métodos: estudo transversal, realizado na Atenção Primária em Saúde de um município brasileiro. A amostra foi constituída por 247 puérperas, cujos dados foram coletados por meio de dois questionários, aplicados mediante visitas domiciliares. Os dados foram analisados pelo teste qui-quadrado de Pearson. Resultados: observou-se que tanto as primíparas como multíparas apresentaram porcentagem muito elevada de dificuldades relacionadas ao cuidado, entretanto, as primigestas manifestaram maiores contratempos nos cuidados referentes à realização do banho e arroto, enquanto as multigestas relataram maiores obstáculos durante a amamentação. Os cuidados com as escolhas das roupas e o coto umbilical obtiveram significância estatística, independe da paridade. Conclusão: as dificuldades estiveram presentes, independente da experiência obstétrica anterior da mulher, estando principalmente associadas à insegurança, à preocupação e ao desamparo. Descritores: Período Pós-Parto; Cuidado do Lactente; Recém-Nascido; Assistência Perinatal. 1Universidade Paranaense. Francisco Beltrão, PR, Brazil. Corresponding author: Lediana Dalla Costa Av. Júlio Assis Cavalheiro, 2000 Industrial. CEP: 85601-000. Francisco Beltrão, PR, Brazil. E-mail: lediana@prof.unipar.br EDITOR IN CHIEF: Ana Fatima Carvalho Fernandes ASSOCIATE EDITOR: Renan Alves Silva Lediana Dalla Costa1 Kelly Dalorsoletta1 Ketlin Margarida Warmling1 Marcela Gonçalves Trevisan1 Géssica Tuani Teixeira1 Jolana Cristina Cavalheiri1 Alessandro Rodrigues Perondi1 How to cite this article: Costa LD, Dalorsoletta K, Warmling KM, Trevisan MG, Teixeira GT, Cavalheiri JC, et al. Maternal difficulties in home care for newborns. Rev Rene. 2020;21:e44194. DOI: https://doi.org/10.15253/2175-6783.20202144194 Special Call 1 Maternal and Obstetric Health Costa LD, Dalorsoletta K, Warmling KM, Trevisan MG, Teixeira GT, Cavalheiri JC, et al Rev Rene. 2020;21:e44194. 2 Introduction The puerperium is characterized as an active stage of the pregnancy-puerperal cycle, after Greenberg’s fourth period, when the expulsion of the placenta happens, relating to the first four hours of postpartum. In this stage, the woman goes through several physical, emotional, and physiological changes that introduce a phase that may last for six weeks(1). After birth, the family’s daily routine is changed, especially for the puerperal woman, who acquires, as a new duty, the care for the newborn. Thus, the puerperium may be linked to changes in sleep patterns, feelings of frustration, irritation, and feelings of leaving the previous life behind(2). Indeed, qualified care and care for newborns are crucial to reducing child mortality. The number of deaths per thousand live births in Brazil in 2019 was 12.4%, while in the state of Paraná it was 10.4% in 2017(3), with a high rate of neonatal death. Thus actions aimed at promoting, preventing and providing comprehensive health care to pregnant women and children are essential to reduce these rates(4). The difficulties that women face in the postpartum period are related to cultural aspects, family, and health professionals’ support, as well as the knowledge about the changes that happen in this period. In primigravid, the transition to the maternal role brings with it a restructuring of the family environment, feelings, expectations, doubts, and uncertainties(5). Besides, the main difficulties experienced by women in the first pregnancy relate to breastfeeding and the interpretation and understanding of the signs expressed by the baby(6). Multiparous women, despite previous experiences, have greater troubles regarding family support in this period and, also, with self-care and breastfeeding(5). It is also pointed out that women may experience similar feelings in the experience of taking care of a child, since each maternity experience is unique, having experienced this moment in a particular way, regardless of the number of children they have had(2). Therefore, the training of parents and other family members in postpartum care is essential, as well as the clarification of doubts, fears, and insecurities, making them independent, responsible and empowered to provide the best care for the baby(7). Identifying the difficulties that mothers experience in the puerperium allows the development of health actions, not only to assist them in qualified care, but also to provide that they go through this phase occurs with confidence(8). In this context, the guiding question of the research was: what are the difficulties found by puerperal women in caring for newborns at home? Thus, the objective was to analyze the association between maternal difficulties in home care for newborns and parity.


Introduction
The puerperium is characterized as an active stage of the pregnancy-puerperal cycle, after Greenberg's fourth period, when the expulsion of the placenta happens, relating to the first four hours of postpartum. In this stage, the woman goes through several physical, emotional, and physiological changes that introduce a phase that may last for six weeks (1) .
After birth, the family's daily routine is changed, especially for the puerperal woman, who acquires, as a new duty, the care for the newborn. Thus, the puerperium may be linked to changes in sleep patterns, feelings of frustration, irritation, and feelings of leaving the previous life behind (2) .
Indeed, qualified care and care for newborns are crucial to reducing child mortality. The number of deaths per thousand live births in Brazil in 2019 was 12.4%, while in the state of Paraná it was 10.4% in 2017 (3) , with a high rate of neonatal death. Thus actions aimed at promoting, preventing and providing comprehensive health care to pregnant women and children are essential to reduce these rates (4) .
The difficulties that women face in the postpartum period are related to cultural aspects, family, and health professionals' support, as well as the knowledge about the changes that happen in this period. In primigravid, the transition to the maternal role brings with it a restructuring of the family environment, feelings, expectations, doubts, and uncertainties (5) . Besides, the main difficulties experienced by women in the first pregnancy relate to breastfeeding and the interpretation and understanding of the signs expressed by the baby (6) .
Multiparous women, despite previous experiences, have greater troubles regarding family support in this period and, also, with self-care and breastfeeding (5) . It is also pointed out that women may experience similar feelings in the experience of taking care of a child, since each maternity experience is unique, having experienced this moment in a particular way, regardless of the number of children they have had (2) . Therefore, the training of parents and other family members in postpartum care is essential, as well as the clarification of doubts, fears, and insecurities, making them independent, responsible and empowered to provide the best care for the baby (7) . Identifying the difficulties that mothers experience in the puerperium allows the development of health actions, not only to assist them in qualified care, but also to provide that they go through this phase occurs with confidence (8) .
In this context, the guiding question of the research was: what are the difficulties found by puerperal women in caring for newborns at home? Thus, the objective was to analyze the association between maternal difficulties in home care for newborns and parity.

Methods
Cross-sectional research carried out in a city in the Southwest of Paraná, Brazil, which has a total population of 88,465 people. The municipality had, at the time of the research, 20 Family Health Strategies, of these, sixteen were in the urban area and four, in the interior. It also had two Basic Units and a Health Center.
The study population consisted of pregnant women enrolled in the Rede Mãe Paranaense System, with active registration in 2018, making up a population of 689 women, with delivery outcomes during the data collection period. For sample selection, a sample calculation was performed with stratification proportional to the number of enrolled pregnant women, with a 95% confidence interval and a sampling error of 5%, totaling 247 puerperal women. As an inclusion criterion, primiparous and multiparous women who were up to three months postpartum were considered. Those with fetal or neonatal death were excluded.
The sample cut selection considered the puerperal women who first had delivery outcome, until reaching the intended sample. For identification and control, the monthly list of puerperal women discharged from the hospital provided by the Municipal Heal-th Department was used.
Based on this relationship, the community health workers helped to identify their addresses. Data collection took place using questionnaires, applied between April and September 2018, through home visits by researchers, always accompanied by community workers, according to prior telephone scheduling with families. The questionnaires were filled out in the presence of the researchers. None of the selected puerperal women refused to participate in the study.
The first instrument was formulated by the authors, following national and international literature, encompassing the following variables: sociodemographic characteristics (maternal age, skin color, education, family income, marital status), obstetric history (number of children, beginning of pre-natal, number of consultations, type of delivery, gestational age), as well as difficulties and feelings experienced in caring for the newborn. The second refers to a validated instrument that was formulated by the Brazilian Association of Research Companies, in 2015, used to assess economic classification -the Brazilian Criteria of Economic Classification.
After data collection, the information was inserted in the Microsoft Excel program and submitted to statistical analysis, using Software Statistical Package for Social Science, version 25.0. Categorical variables were presented in absolute and relative frequencies.
Also, an association test (Pearson's chi-square) was performed between the dominant variables (primigravid and multigravid) and the difficulties experienced and maternal feelings, adopting a 95% confidence interval and a p≤0.05 significance level.
The study took place after the approval of the project by the Research

Results
A total of 247 puerperal women participated in the study, in which 76.5% were aged from 20 to 34 years, 68.8% were white, 38.5% had completed high school, and 19.8% had completed higher education. As for the marital status, 88.7% were in a domestic relationship, 61.5% were employed and 38.5% had a family income of one to two minimum wages. Concerning the economic classification, 32.0% belonged to class C1, with an income of up to R$ 2,705.00 per month.
Regarding obstetric data, 43.3% were in the late puerperium, 84.2% started prenatal care in the first trimester of pregnancy, 93.1% attended more than six consultations and 50.2% planned the pregnancy. Related to parity, 62.8% were multiparous and 37.2% were primigravid. As for the number of children, 59.9% had two or more. Cesarean delivery prevailed over vaginal delivery, with 64.8% of births and, of these, 84.6% occurred between 37 and 42 gestational weeks, classified as full term.
Regarding the care provided to the puerperal women by the health team, 93.5% received prenatal guidance, 78.5% of which were referred by doctors and 73.3% by nurses. Regarding the home visit, 70.4% reported having received it, of which 61.1% were carried out by community health workers. Family help in caring for the newborn was reported by 86.6%, mainly from the husband, in 61.5% of the sample. Table 1 shows the difficulties reported by the puerperal women and the statistical concerning parity variable, in which it was observed that the primigravid presented higher percentages, with 57.6% reporting insecurity for being small (p=0.000), 35.9% had trouble holding the baby in the bathtub (p=0.000), 30.4% to wash the back and genitals (p=0.000), 21.7% to wash the head and face (p=0.002), 12.0% to dry the baby (p=0.003). Besides, it was evidenced that the difficulties of the puerperal women expressed significance concerning parity, when associated with the difficulties with bathing and whoever performs it, as well as in the choice of clothes and care for the umbilical stump. Regarding the difficulties related to breastfeeding, it was observed that 56.5% of the primigravid women presented obstacles regarding the correct latch (p=0.003), 48.9% in knowing if the baby is being breastfed sufficiently (p=0.038), 34, 8% if is milking excessively (p=0.020), and 41.3% with belching (p=0.001), showing no association with the other variables (Table 2).  Table 3 shows the feelings reported by the mothers concerning the newborns, in which it is observed that 54.3% of the primigravid women had a feeling of insecurity (p=0.000) and 88.0%, concern (p=0.013), on the other hand, 18.1% of the multigravid women highlighted helplessness (p=0.023).

Discussion
As a limitation of this research, it is highlighted that the puerperal women were in distinct postpartum phases. When considering the learning curve, with the amount of experience they acquire in the postpartum phase, some difficulties tend to be reduced. Also, it is noteworthy that the study was conducted in a single medium-sized municipality, and that home care for the newborn and the knowledge of new mothers can be influenced by sociocultural conditions and popular beliefs, making it impossible to generalize the data.
On the other hand, the study enabled to identify the difficulties experienced by the puerperal women in home care for the newborn, and to associate them with parity. The need to verify the correlation of these variables allowed to highlight the vulnerabilities in the assistance to the mother-baby binomial, as well as the adoption of strategies, to humanize and qualify the assistance. Maternal difficulties should be explored by health professionals in Primary Care, especially by nurses, who can associate popular knowledge with scientific knowledge and enable care practice, besides empowering postpartum and family members in child home care. It is noteworthy that the results of the present study corroborate with other investigations that emphasize the obstacles experienced in this period, especially with breastfeeding and, also, the feelings experienced by the mothers, which reveals the need for health education for women during prenatal care, and follow-up in the puerperal phase and through the child's growth.
It was observed that the difficulties in the bathing were prevalent among the primigravid women, corroborating with research carried out in Piauí, Brazil, in which 52.0% of the participants had obstacles in bathing, especially in holding the baby, for 96.2% (6) . A study conducted with puerperal women in Rio Grande do Norte, a Brazilian state, also found insecurity and fear in bathing because of the child's size (9) , as well as a study developed in a private obstetric clinic (2) .
Similarly, a study carried out in a health unit in Fortaleza, Ceará, Brazil, with primigravid women, revealed bathing as the most complex procedure, causing doubts and insecurity when performing it (10) . It is believed that the main reason for this difficulty is the fear that the baby may slip and fall into the bathtub, with the risk of drowning, fracturing a limb, as the baby is small and fragile (1,4) .
Moreover, the main responsible for the bath was the mother, regardless of parity, which is contrary to a study carried out in the Northeast Region of Brazil, in which the primiparous women, for lacking any practice and feeling insecure, assigned this task to another family member (9) or performed the activity under their supervision (6) . It is believed that these findings may be related to the guidelines given in prenatal care, due to the absence of family support, as well as the empowerment of parturients to perform the activity.
Also, it was observed that the primigravid assigned the activity to the parents, which is in line with a study developed in Londrina, Paraná, in which, after discharge, the companions helped in the diaper change, in the dressing and in bathing the newborn, because of the mothers' insecurity regarding the performance of the technique, as well as the sharing of activities (11) . In contrast, a study with primigravid mothers in Ceará found that this procedure was performed by maternal grandmothers, due to the mothers' fear and their inexperience (10) .
Identifying whether the baby is hot or cold and the adequate clothes for heat and cold were also reported as a difficulty, regardless of the previous maternal experience, as in a research carried out in a health unit, in which 46.0% had doubts, considering that the temperature, types and quantity of clothes can cause discomfort and pruritus in newborns (8) . A study carried out with parturients, found that 69.7% of the participants had difficulties in identifying the ideal temperature to bathe the newborn (2) . Another study pointed out, in addition to these dressing difficulties, the choice of suitable products for hygiene, dressing and undressing, referring to fear of breaking a body limb, when handling the child (7) .
Regarding the cleaning of the umbilical stump, a research carried out in a public hospital corroborates the findings of this study, in which 62.0% of the puerperal women, both primigravid and multigravid, had a lack of knowledge about cleaning the stump and were afraid of hurting the baby (6) . Also, a study with first and second pregnancies showed that the knowledge about the proper care of the umbilical stump, the use of 70.0% ethyl alcohol as a recommendation for hygiene and the time of mummification were the difficulties evidenced in the participants' speeches (12) , corroborating the data presented.
The correct latching, especially for multigravid women, was the main difficulty found, confirming a study carried out in Portugal (13) , in which 82.4% of the participants had the same doubts. Research developed in Acre, one of the 27 federative units in Brazil, found the incorrect latching as an important element that negatively influences breastfeeding (73.3%) and the positioning of the baby (66.7%) (14) . It is emphasized that breastfeeding is one of the main difficulties evidenced in the puerperal phase, especially regarding the correct latching of the breast (1)(2)(6)(7)15) .
Besides the difficulty with the handling, a study in Piauí found 83.7% of those surveyed with doubts in recognizing the baby's satiety during breastfeeding (6) , which was also evidenced in a study carried out in an obstetric clinic with multigravid, in which 89.4% of the participants had this king of trouble (2) , reinforcing the results of the present study.
Excessive milking was prevalent among the multigravid, similar to a study carried out in Campo Grande, Mato Grosso do Sul, with multigravid and primigravid, in which 13.3% were found to have difficulties with the technique, without statistical significance with parity (16) . It is suggested that this practice be performed by multigravid participants, due to the excess of milk produced and the improvement in breast discomfort.
Regarding the baby's belching, a study carried out in an obstetric clinic found that 8.3% of the participants had this difficulty, being prevalent in the multiparous (2) , which is different from the present study, in which the primigravid presented greater obstacles. It is believed that this difficulty is related to the mothers' lack of knowledge about the belching position and insecurity regarding the possibility of choking the newborn.
The feelings experienced at this moment are mainly related to the postpartum phase, in which it was found that insecurity was prevalent in the primigravid women, which may be associated with fear of performing care and the unknown. Besides, it is important to be aware of the women's expectations in this period, as fear and anguish may affect the mother-child bond, which may show difficulties that the puerperal woman and the family may be experiencing, impacting the family relationship and consequently, on the child's health (5) .
In contrast, the multigravid women showed concern and helplessness, associated with the understanding of family members and even professionals, that she would be free from difficulties and would not need guidance, for having previous obstetric experiences. Also, a study found that puerperal women may feel helpless, due to the restrictions resulting from cesarean delivery, the increase of chores, the difficulty of getting organized in the daily routine and lack of family support (5) .
A study carried out in the seaside region of Rio de Janeiro observed that some women reported the feeling of loneliness in the puerperium, which was related to the responsibility of taking care of a child that depends on care, the absence of a support network by family members and partners (17) .
The phase of life that the puerperal woman begins to experience is a process of incorporating the new condition, for both primiparous and multiparous women, being forced to review the role of women and combine a new responsibility, that of mother and caregiver. The lack of skills and the number of tasks for the well-being of the newborn and the family, associated with the insecurity of not suiting the role, and the little encouragement showed by family members to help to cope with this, cause negative feelings in the new routine (18) .
A higher percentage of difficulties was found for women who experienced their first pregnancy, differing from a study carried out in Cianorte, in which the participants presented a similar percentage, regardless of parity (2) .

Conclusion
The primigravid presented greater difficulties regarding the care with the newborns' bathing and the belching. The multigravid expressed hesitation in the correct latching, detection of breastfeeding satiety and excess milking. The care involving the choice of clothes and the umbilical stump were obstacles reported by the participants, regardless of parity. The comparison between the difficulties experienced by primigravid and multigravid women revealed that both had similar doubts in home care for newborns, being mainly associated with insecurity, concern, and helplessness.

Collaborations
Costa LD, Dalorsoletta K, Trevisan MG, Teixeira GT and Cavalheiri JC contributed to the conception and design, data analysis and interpretation, writing of the article, relevant critical review of the intellectual content and final approval of the version to be published. Warmling KM and Perondi AR collaborated with the final approval of the version to be published.