Perception of pregnant women about self-care and maternal care

Objetivo: compreender a percepção de autocuidado e de cuidado materno no discurso de gestantes, sob o olhar psicossocial. Métodos: estudo qualitativo com coleta de dados realizada por meio de entrevista semiestrutura com dez gestantes. Utilizou-se a técnica de análise de conteúdo, associada ao programa computacional Atlas TI. Resultados: identificaram-se duas categorias analíticas, autocuidado: cuidando do próprio corpo e cuidado materno. O pensamento pós-moderno influenciou nas ações de autocuidado das gestantes. Entretanto, o cuidado materno não foi diretamente influenciado e as gestantes demonstraram indicadores de preocupação materna primária, como sentimentos e atitudes que proporcionam acolhimento, proteção e conforto ao bebê. Conclusão: as ações de autocuidado praticadas pelas gestantes demonstraram preocupação com a aparência estética em detrimento de atitudes para preservar a saúde e a qualidade de vida. Descritores: Autocuidado; Comportamento Materno; Gestação; Impacto Psicossocial; Promoção da Saúde.


Introduction
Gestation, a period between conception and childbirth, is a complex and unique phenomenon, since the woman experiences intense physical, psychological and social changes that affect the constitution of motherhood and the cognitive and emotional development of the child (1) .Thus, the gestational period demands that the care performed in prenatal care exceed the biological dimension and consider psychosocial aspects, since psychological and social well-being influences maternal and child health practices (2) .
The formation of the bond between the mother and her baby begins during the gestational period, being the result of the psychological development that occurs during the pregnancy.The sensitivity of the mother to develop the ability to identify with the baby, understand their feelings and meet their needs is achieved at the end of gestation.The result of this transformation, termed primary maternal concern (3) , represents maternal emotional commitment.
This emotional response to pregnancy and the unborn child, intimate and subjective, involves the maternal mental representations of the child and exerts influence on the mother-baby interaction.Maternal-fetal attachment reflects the linkage and quality of the relationship between the mother and her unborn baby, highlighting as an important predictor of self-care practices with health during the gestational period and the maternal behavior established during gestation and postpartum (4) .The expectations, thoughts and feelings of the pregnant woman regarding the baby are categories of analysis of maternal-fetal attachment, since they express the level of maternal sensitivity to play the role of "good enough mother", a mother who, once identified with the her baby, meets her satisfaction, survival and physical and emotional needs (3) .
The association between lower maternal-fetal attachment quality and greater probability of newborn with adverse neonatal outcomes was described in the literature (5) .Events such as depression and anxiety, as well as socio demographic risk factors, influence prenatal care because they compromise a woman's ability to emotionally bond to the fetus and adopt healthy behaviors during pregnancy and after-birth care (5)(6) .Another aspect that affects the state of psychic health of the pregnant woman and the formation of the bond between the mother and the baby is the dissatisfaction with the body image, characterized by the distortion of the perception of the self-image associated with the desire of the idealized body (7) .
In postmodern society, images of femininity are associated with bodily perfection, being mediated by the standards of beauty and youth, in which the real and ideal body comes into conflict and, consequently, dissatisfaction with body size and shape is experienced by the female universe.The dominant beauty pattern instituted explicit censorship of bodies that do not fit into the media impositions, the body as an image produces consumer subjects who, on the one hand, want to acquire the image and the corporeal appearance conveyed in the media and, on the other hand, wish to display the slim and young body image (8) .
Influences from postmodern society on the life of women may reflect negatively on the gestation and formation of affective bonds, since this society, characterized by consumption, has transformed the body into a commodity (9) .Therefore, the value of the body related to the appearance, desire and greed it arouses lies in superficiality, to the detriment of subjectivity, memory of identity, feeling of love and care of one's neighbor.In this society, the individual is not the subject, but the object.The standardized model of individuals and aesthetic standards presented by the cultural industry, lead men and women to seek bodies to make them important and visible in this society (10) .
Therefore, prenatal care should focus not only on the prevention and treatment of gestational intercurrences, but also on the formation and strengthening of the bond between the mother and the baby.The nurse has, as responsibility, to participate in the care provided to the pregnant woman in a humanized way, and qualified listening is a facilitating tool for the reception, capable of detecting emotional situations that may compromise well-being and maternal-fetal attachment.The nurse, as well as the doctor and the professionals who make up the prenatal team, need information and clarification on the subjective processes of the woman during gestation, to help them identify emotional aspects that may jeopardize the gestational process and the interaction between the mother and her baby.Therefore, the present research aimed at understanding the perception of self-care and maternal care in the discourse of pregnant women under the psychosocial perspective.

Methods
It is a qualitative study, carried out in the counties of Atalaia and Mandaguari, both located in the State of Paraná, Brazil.The sample consisted of pregnant women who were performing prenatal care in Basic Health Units, without clinical diagnosis of mental disorders.Data were obtained through a semistructured interview, recorded with the consent of the participants.The recordings were transcribed by a company specialized in shorthand monitoring and transcription of audios, conferring trustworthiness and faithfully revealing the interviewees' testimonies.Initially, identification data were collected and, subsequently, the questions related to the care performed and/or acquired by the women during the gestational period.
The data collection period comprised the months of March and April 2014.The collection ceased due to the saturation of the findings in the interviews, resulting from the convergent discourses that generated the analytical categories.To ensure the anonymity of the subjects, the fragments of the statements were identified by the letter P, which corresponds to the initial letter of the word pregnant, followed by numerical ordering (P1, ... P10).
The interviews were submitted to content analysis (11) , composed of five stages: pre-analysis, coding and categorization, treatment of results, inference and interpretation.Initially, the Atlas TI software was used to perform pre-analysis and content coding.The pre-analysis systematized and operationalized the ideas, while the codification consisted in choosing the units of meaning present in the discourses.In the Atlas TI, coding comprises three stages, the first one refers to the identification of the unit of meaning, and the second stage seeks to give a name or concept to the selected unit of meaning, being the theoretical reference essential for coding.And the last stage, the categorization that corresponds to the classification operation of constitutive elements by differentiation that are regrouped, creating the categories, denomination used in the content analysis (11) .The treatment of the results looked for the significant data to propose inferences, procedure that consisted in the passage from the description to the interpretation.The last stage of the analysis interpreted the discourses according to the previously selected theoretical framework.
The study complied with the formal requirements contained in national and international standards for research involving human subjects.

Results
The pregnant women interviewed were in the age group between 18 and 35 years old, four firsttime mothers and six multiparous who were in their second gestation.In relation to marital status, seven were married and three were single.Schooling ranged from incomplete elementary school to full college; as for the monthly income, they were all concerned with the family budget.However, of the pregnant women who composed the study sample, only three of the married women declared paid work.
Transcripts of interviews with pregnant women resulted in 60 pages and were considered as primary data.The pre-analysis of the data, performed by the computer program Atlas TI, identified two analytical categories: self-care: caring for one's own body and maternal care.The first category represented the care practices of the pregnant woman with herself, while the second category listed care for the baby during the gestational and postpartum period.

Self-care: taking care of one's own body
Content analysis, based on the theoretical framework adopted, allowed us to identify that postmodern thinking influenced the self-care actions of pregnant women during the gestational period.The pregnant women interviewed described self-care related to physical aesthetics and physical appearance, as in the following fragments: After all, my belly does not have; since the first gestation, there are no striae.There's more on the butt and the breast, because I think it stretches more.But I always took care of my belly as well.Quite a few people you look at, who were once a mother, you see those ugly bellies.Oh no, I do not want to have that.I always took care of it; I used creams, all these things.After this pregnancy, I have not had them yet, not yet (P8).So from there on, I started to take care of myself too, so that after I have a baby, I would not suffer consequences as well ... It's not gaining weight like that.It is striae isn´t it?We are vain!I'm careful with my belly, so I do not have stretch marks ... I did not like cream too much, I did not apply these things, now I do.I keep on applying cream; hydrating oil (P3).
The pregnant women, following the social standards of beauty and consumption, reported dissatisfaction with body shape and size, as in this statement: It's nice, but we think we are ugly.The clothes do not match!How ugly!You look at the butt, gosh!The vanity part, I found it so strange!Nothing is good!When it gets good, it is short in front.

The vanity part bothered, but the emotional part is a miracle, isn´t it?
It is very exciting to feel the baby.The attraction of being able to see.
Oh, Lord, prepare soon to see the little face.It´s nice!But in the vanity part, it's complicated ... you think: how will I be after?Will it come back?We're worried if we're going to lose weight again.Because women are silly, we are vain.We worry lot about that part.Look at my feet!Oh, it bothers!(P9).
The care with the appearance of the body was prioritized by the pregnant women to the detriment of the actions of self-care focused on health, which when it occurred, it was in a situation of gestational complication, as can be observed: .. Another fragment that showed concern about health referred to care with food, but facing medical prescription and motivated by factors associated to the presence of physical symptoms: Ah, food, I try to avoid frying, I reduced a lot of frying.Fruit I did not eat much.Yeah, I think that's basically it, and so, I always had a lot of cleaning craze, so I had to calm myself down a bit too, get more calm with this business of taking care of the house, because you do not have the same energy either, or when I tried to do some of these things I got sick (P8).

Maternal care
Contrary to aesthetic concerns, pregnant women verbalized emotional commitment to the baby and the relational transformations necessary for the constitution of both the motherhood and the baby's psyche, the basis of the child's mental health (5) .The care taken concurrently with the baby's gestation can be observed: ... I could not accept that I was pregnant.... I almost lost the child, that's when I got very scared, and I said: Wow, it's my fault, because I did not want to get pregnant.That was when it was changing, as it happened, that I almost had an abortion, and I think it was changing ... so I lost a lot of blood and I lost weight, I did not eat, I did not feel like eating anything, I was too scared of losing the baby.

And also I was not able to sleep, because I was afraid, as I was losing a lot of blood, I was afraid to wake up, because I woke up all dirty every night, so I had to keep going to the bathroom all the time to see (P3).
Pregnant women expressed concern about the exposure of their babies before and after birth, they reported that they did not post ultrasound images and did not intend to post photographs of newborns on social networks, as in the statement: Yes, I want to protect because, to tell the truth, the child is born all messy, so I said I do not know if I want that photo of the first photos, so fragile, there, exposed to so many people.So, I'm kind of boring in that part.Sometimes my sisters keep saying, oh, you will not allow, really?I said: I do not know I might change my mind at the time.But whoever goes there, until then, to photograph, I'll ask not to post on Facebook (P6).
The impact of the second gestation on the firstborn was a relevant issue for multiparous pregnant women, as can be observed: When I am going to do ultrasound, I take her (older daughter) together.Yesterday I went to do the morphological exams.She lay on the stretcher with me.The doctor's pretty good, you know.So, put on the little head here because there is a little sister, who is in the belly, that will be born ... Never wanted to leave my little girl alone in the world (P7).
The complexity of the birth of the second child can also be seen in the following report: No, in the fourth month that I was pregnant, I discovered that he (the eldest son) had diabetes.... and the doctor told me that it was because of a fright.I blamed myself in the beginning because I thought it was because of gestation.... was hospitalized, was in the Intensive Care Unit and everything.Now it's okay, it's well controlled.But it's one thing, like this, that I've always dreamed of having a girl ... I worry that way, in the future, like the two being siblings, she wants to eat something and I cannot give it to her because of him (P9).
The analysis of the statements allowed observing the apprehension of the pregnant women in relation to the return to work, as shown in the following statements: Now there is Igor, who already needs more care, and now comes the baby.Even more!And with the baby, comes food and everything.As much as day-care takes care of the baby, the child who is raised with the father and mother nearby, the teaching is something else as well (P5

Discussion
The construction of motherhood in western culture is a phenomenon inherent to the female universe, in which becoming a mother implies experiencing a specific state of life that involves gestation, childbirth, and care before and after the baby's birth (12) .The present research sought to contribute to the integrality of the care offered to pregnant women; an important prerogative of the Unified Health System, which still presents weaknesses, since the traditional clinical-obstetrical model does not offer a focus on the psychosocial aspects involved in the gestational process.
The adoption of the qualitative approach made it possible to know the perception of self-care and maternal care in the discourse of pregnant women, and to understand the relationships they establish with their own body during the gestational period.It was considered a limitation that the research was performed only with pregnant women, since the testimony of the professionals involved in prenatal care would provide a better understanding of the impact of the corporal transformations that occur throughout gestation in female subjectivity and, consequently, , in the care that is performed and acquired by women during this phase.
The care with the body reflects the concern with oneself and, in this way, the self-care represents the action that the woman exerts to preserve and to cultivate health and quality of life, in a responsible, autonomous and free way (13) .In this study, the selfcare actions described by pregnant women denoted the influence of the cult to image and appearance, suffering being verbalized from the possibility of appearing to be less beautiful after childbirth, not meeting the beauty standards imposed by the cultural industry (10) .
In addition to the preoccupation with appearance, pregnant women expressed deep dissatisfaction with the body and what to wear, the statement which used the expression that nothing is good, exemplified the non-acceptance of pregnant body shapes by pregnant women and demonstrated the disillusionment of that no clothes could turn the body into a more attractive object.The dissatisfaction of the pregnant woman with her appearance and physical form during the gestational period can have negative impacts on maternal-fetal attachment (7) , as dissatisfaction with body image compromises well-being and decreases the pregnant woman's self-esteem.
The results showed that health care was motivated by factors associated with pain or hypertension, so only in the presence of physical suffering or symptom did the women describe selfcare actions focused on health.It was observed through the statements analysis that no pregnant woman reported the importance of prenatal care, essential follow-up for the promotion of maternal and child health in which examinations and consultations are carried out, as well as health education actions that contribute to the reduction of maternal and perinatal mortality (14)(15) .
The care reported in the self-care category presented as a mobilizer of the actions the aesthetic aspects, with more frequency, followed by the aggravation of the state of health.A woman who does not take care of herself is discriminated against in societies that worship the body from the aesthetic point of view, since the idealized body must meet the standards of beauty.In this way, self-care, as a way of relating to oneself, was replaced by concerns about how to obtain a perfect body, in contrast in the maternal care category; maternal subjectivity prevailed over the superficiality and influences of post-modern society.
Postmodern thinking influenced self-care actions of pregnant women during the gestational period.However, maternal care was not directly influenced by postmodern thinking, pregnant women showed fetal maternal attachment and indicators of primary maternal concern in describing feelings and attitudes that provide the baby with comfort, protection and comfort.They were reported by the interviewees' psychological transformations from the recognition that a being inhabits their body.The bond, formed with the presence and recognition of the other, was present in the relationship of the mother with her baby, identified by the feeling of maternal protection.Through the actions of protection and care to promote the well-being of her child, there was, as a result, the formation of bond and maternal love.The presence of the mother in front of the needs of her baby is the foundation of the feeling of mutual love (3) .
In postmodernity, one must consider that the pregnant woman is concerned not only with the visibility of her body, but also with making the child visible by society.Exposure of the child's image occurs during the gestational period, through ultrasonography and, after birth, through photographs, both of which are posted on social networks.The affective bonds and the formation of identity are no longer constituted in the intimacy, in the scope of the secret, to relate to the exteriority, the physical body, through the appearance and the image (16) .However, in the present study, the concern to protect the child, sparing him from overexposure, prevailed against the appeal of visibility.
The birth of the second child causes profound changes in the life of the woman and the family, being an event as remarkable as the birth of the first child.From the psychic point of view, each pregnancy has a singular meaning for the woman, so the second pregnancy is also characterized as a transition period for motherhood, involving different challenges, such as the construction of the place that the baby will occupy in the affective life of the family (17) .The thematic of motherhood mobilized singular internal and affective contents in the interviewed pregnant women, since different feelings and expectations regarding maternal care were reported, highlighting the expectation of multiparous women with the adaptation to the second child.
One of the expectations of the construction of maternity in multiparous women is to preserve the affective space occupied by the first born and, at the same time, to provide the space for the child to be born.The narrative that described the concern of one of the pregnant women with the differences in feeding between the two children showed the reception and the adequacy of the role of mother to the specific needs of each child, this process of recognition of differences provides the formation of the affective bond and of motherhood, a concept understood as the set of care provided to the children, which aims to meet the needs and provide physical and psychological comfort (18) .
The need to work to make up the family income means that the mother is not the only one to play the child care role.The return to work was described by some pregnant women as the moment in which they will need to leave their children with other caregivers, revealing the conflict between the desire to perform maternal care and the professional career.Motherhood promotes changes in the life of women, arousing intense feelings of responsibility, both with the physical and emotional care that the child needs and with the expenses arising from the birth of the baby.Among women's concerns about maternity, financial conditions are characterized as a difficulty to be faced (19) .
Humanized and qualified care for gestation, delivery, birth and the newborn, as well as monitoring the growth and integral development of the child in early childhood, including actions to support families to strengthen family ties, improving the quality of life and reducing child maltreatment, are prerogatives of the National Policy for Integral Attention to Children's Health (20) .Understanding the results of this research in this perspective highlights the integrality of care and the incorporation of new health promotion interventions in the daily routine of basic health care services, as well as the importance of the multi professional health team and interdisciplinary work in maternal health care child.

Conclusion
The self-care actions practiced by the pregnant women showed concern about the aesthetic appearance at the expense of attitudes to preserve and cultivate health and quality of life.It was verified that the identity of the pregnant woman was associated with the image of a woman who cares, in order to meet the standards of beauty proposed by the media.In this way, special attention should be given to women in the prenatal period, in the sense of forming the female identity of the pregnant woman, from a body with new contours, the pregnant body.
The study also revealed that, given the complexity of the gestational process, delivery and puerperium, prenatal care needs to consider the psychological aspects that permeate the subjective world of women, favoring the formation of maternalfetal attachment and the bond between the mother and the baby.

Collaborations
Silveira RAM and Marques AG contributed to the design of the work, data collection, analysis, data interpretation and article writing.Velho APM contributed to the conception of the work.Milani RG contributed to the analysis and interpretation of the data.All authors contributed to the relevant critical review of content and final approval of the version to be published.
. The doctor said that my hypertension is because of the weight.I do not know what you gave me!It came to my head and I lost weight, joking around.I went only once.But otherwise, it made no difference.The difference is that my uterus is very low.And I feel a lot of pain.I cannot lift weight.The doctor forbade me to do everything.And I always did everything in my house.At the risk of high blood pressure, then, I started hydro, cutting salt from food, cutting a lot of things, otherwise I have reflux.But in general, that's it; I think everyone changes a little bit, both for the baby and for the people themselves (P10).
).Like that, I meant, if I did not have another baby to go back to work with, but now I'm not going back, to take care of both.The first one was not in the nursery; it was my mother who took care of him too.But my husband already said: You now you go to work, because the thing is difficult.You have to work because it is not easy.He alone will not be enough, because in the world here if one wants to raise children, he has to work.I do not want them to go through what I've been through.I worked before.I stopped because I had to take care of my boy.I was a seamstress (P8).