Meaning of the spiritual aspects of health care in pregnancy and childbirth

Abstract Objective: to know the importance of the spiritual aspects of health care during pregnancy and childbirth, in the light of complexity thinking. Method: qualitative research, based on complexity thinking. Twenty-seven postpartum women with children between one month and six months old participated in the study. The data were collected between August and November 2021, based on individual interviews with guiding questions. Thematic analysis was used for data analysis. Results: three themes were obtained: The inseparability of spiritual care and emotional care; Connection between spirituality and the uterus - sacred temple; Alternative techniques for spiritual health care. Conclusion: the spiritual aspect of health care during pregnancy and childbirth can be considered an essential resource in the support of autonomy, security, and comfort. In addition, it can enable favorable outcomes in childbirth by strengthening the maternal-fetal attachment.


Introduction
Pregnancy and childbirth are a unique and complex course (1) . Each pregnant woman is a different construct of physical, mental, social, and spiritual aspects. In the pregnancy course, the physical, mental, and social dimensions are easily recognized and considered in health care. The spiritual dimension, however, is superficially perceived, stimulated and considered by healthcare professionals (2)(3)(4) . Hence, the questions arise: what exactly is meant by health care? Is it possible to fragment the care of human beings -a complex system with bio-psychosocio-spiritual centers?
A study shows that pregnancy and childbirth involve a mix of feelings such as pain, fear, anguish, uncertainties, joy and, at the same time, involve autonomous choices made by the pregnant woman. These choices are related to the preparation and type of delivery, companion of choice, basic care for the newborn, among others (5) . In parallel, another study shows that prenatal care needs to consider multi-dimensional and multi-professional care.
From this perspective, the spiritual dimension represents a resource that enhances decisions and helps to overcome adverse events (6) .
The conception of Nursing as a science, art/technology of providing care for human beings/pregnant women in their uniqueness and multiple dimensions, in coordination with other professionals of health (7) presumes that only an expanded and complex care is capable of prompting interactive and associative processes. Spirituality is a phenomenon that gives meaning to the different movements of human beings and to their own existence, through unique and indivisible experiences. Therefore, it is important that spirituality be welcomed and encouraged as an inseparable part of multi-dimensional care (8)(9) .
Studies show that spirituality represents a prospective strategy for coping with existential pain and adversities.
In cases of infertility, spirituality increases the ability of couples to overcome the existential void. In patients diagnosed with cancer, spirituality alleviates suffering and distress and nourishes hope. In patients on palliative care, spirituality creates and strengthens bonds between team members and patients/families, among other benefits (10)(11)(12) .
In relation to pregnancy and childbirth, the question remains: what is the importance of the spiritual aspects of health care in pregnancy and childbirth?
In the search for a unique and multi-dimensional understanding of health care and wishing to contribute to the institutionalization of approaches that perceive, integrate and expand, the objective of this study is to know the importance of the spiritual aspects of healthcare during pregnancy and childbirth, in the light of complexity thinking.
In this study, the term complexity is understood as everything that is woven together and that evokes at least more than one circumstance or possibility of interaction.
It is understood that both the knowledge of the whole depends on the parts, and the knowledge of the parts depends on the knowledge of the whole (13)(14) .

Type of study
Qualitative research based on complexity thinking and guided by the uniqueness and multiple dimensions of health care. We aim to develop a methodological path in which the researcher is induced to learn, invent, and recreate their own path, through interpretative and significant processes in the here and now (15) .

Setting, participants, and selection criteria
The study was carried out with 27 postpartum women to address the spiritual aspect of health care during pregnancy and childbirth? If yes, how can this be done?
It should be noted that the professional interviewer had previous experience in leading groups of pregnant women, which favored the dialogue with the participants.
The interviews had an average duration of 30 minutes and were recorded on a digital recorder for subsequent analysis. The process considered the uniqueness of each participant, so that they could express their perceptions with security and tranquility. After being organized, the interviews were fully transcribed by two researchers using a text editor. The transcribed data set resulted in 79 pages.

Data processing and analysis
Thematic Analysis was used as an analysis technique, systematized in six stages: Data familiarization -the researcher was immersed in the data to become familiar with the content in depth and breadth; Inductive generation of initial codes -at this stage, the researcher manually and systematically coded the data set, with full and equal attention to each item; Generation of themes -at this stage, the different codes were clarified according to the proposed theoretical framework, in order to combine them into comprehensive themes; Reviewing the themes -at this stage, the researcher refined the themes, based on a pattern that showed things in common and clear distinctions between the themes; Definition of the themes -The themes were (re)defined, identifying the essence of each of them and of the set of themes; Writing of the research report -it consisted of the final analysis and writing of the report (16)(17) . This analysis process, however, was not isolated and linear; it required a recursive approach, going back-and-forth between stages, as necessary.
Data analysis started with patterns of meanings, which occurred during data collection, that is, during the conduction of the interviews. Throughout the process, the constant recording of ideas, insights, drafts, and schemes was valued, not for accuracy, but with the purpose of enabling a deep immersion in the data.

Connection between spirituality and the uterussacred temple
The report of most of the participants showed that the search for the spiritual aspect of health care is associated with the ability to believe in a higher power, out of a connection that does not happens in everyday life, but is felt deeply (the baby in the womb). The participants acknowledged that the new being allows deep connections that transcend the reality that can be perceived or  The participants' reports showed the desire for the spiritual aspect of health care to be considered and addressed during pregnancy and childbirth, to provide relief from suffering and to strengthen the connection between mother and baby. In the understanding of the participants, the spiritual aspect of health care is not reduced to isolated and simplified approaches; it requires welcoming attitudes that can promote and strengthen transcendent connections. There is an expressed and/or unexpressed desire for alternative therapies in the participants' speech.

Alternative techniques for spiritual health care
These therapies are seen as resources that can balance mind/body/spirit and that should be widely adopted in health services. It is essential, therefore, to overcome interventionist and one-dimensional approaches, to provide health care centered on the user -the subject of the action.

Discussion
Important progress in the quality of maternal and child health care has been achieved in the last two decades. However, maternal and neonatal mortality rates decrease slowly. Studies (18)(19)(20)(21) show that pregnancy is a period that requires attention, as it can affect the pregnancy-childbirth course both positively and negatively. Even though they could not clearly define spirituality or spiritual health care, the participants in this study showed connections and meanings that are not reduced to the biological, mental, and social dimensions. This perception was more evident when they mentioned the connection between spirituality and the meaning attributed to human existence, which is not restricted to material and random thoughts. This idea is confirmed by scholars who show that mystical experiences induce positive feelings and emotions, capable of releasing underlying energies and stimulating connections with the sacred and the transcendent (25)(26) .
Another relevant aspect that emerged in this study refers to the relationship between the spiritual connection and the maternal uterus/sacred temple where the new being lives. Despite the lack of evidence on this association, the results indicate that nursing/health professionals should increase their awareness, in order to understand healthcare in its multiple aspects, that is, beyond the physical aspect. In this context, the Nurse has the decisive and proactive role of identifying unique care needs, as well as promoting and protecting the health of pregnant women, in its different dimensions and expressions of reality (7) .
According to scientific evidence, the pregnancypostpartum period requires professional approaches that go beyond interventionist and biomedical models (24)(25) . In the process of generating a new being, the pregnant woman experiences fear, uncertainty, and anguish combined with a mix of expectations, dreams, and achievements. In this context, it is essential that the pregnant woman is welcomed, supported, and strengthened in her initiatives and life perspectives throughout the whole pregnancy process. Nursing/healthcare professionals, especially those who work in prenatal care, must be aware of the different movements and feelings that are encompassed in pregnant women's process, so that they can encourage them to be the protagonists of their own story (27) .
A study recognizes the spiritual aspect as inherent to the human being, as it is characterized by unique experiences that enable connections with oneself, with others, and with the transcendent (24) . In this context, the spiritual aspect of health care can enable circular and interactive possibilities in pregnancy and childbirth, enhance convictions, and minimize adverse events.
Therefore, pregnancy and childbirth are phenomena that allow pregnant women to experience spirituality in a more or less intense way, depending on their characteristics, trajectories, and personal experiences. Health care can only be understood in the light of complexity thinking, which requires acceptance and respect for the multiple aspects it can have. The construction of multi-dimensional/multi-professional care requires knowledge and practices that go beyond the mechanical work and that consider individual values, beliefs, and convictions (12) .
In the perspective of complexity, the conception of a unique and multi-dimensional care for pregnant women goes back to a historical and hegemonic tradition in the obstetric area, characterized by prescriptive and hierarchic practices, in which a professional relationship of subjectobject prevailed. In this traditional model, the pregnant woman did not have the autonomy to make her own decisions. However, spiritual health care is always unique and multi-dimensional, that is, it is complex and made from everything that is woven together and that evokes more than one circumstance or interactive and associative possibility (10)(11) .
The contributions of this study to the advancement of Nursing science are related to the awareness that nursing professionals have the potential to expand their perception and to develop spiritual health care, along with the other members of the multi-professional health team. The present study may also be seen as a stimulus for other researchers who intend to address the multidimensional and multi-professional nature of health care.
A limitation of this study is the insecurity of some study participants during the individual interviews.
Although the COVID-19 contingency plan was followed, a feeling of insecurity due to pandemic was perceived in some interviews, but this did not hinder the research.

Conclusion
The spiritual aspect of health care during pregnancy and childbirth can be considered an essential resource in the support of autonomy, security, and comfort. In addition, it can enable favorable outcomes in childbirth by strengthening the maternal-fetal attachment. Therefore, spirituality is a phenomenon that gives meaning to each stage of life, while also giving meaning to human existence itself.
It is imperative to overcome the logic of fragmented, linear, prescriptive, and one-dimensional health care.
The understanding of care as a complex unit -unique and multi-dimensional -is essential in the process of encouraging autonomy, creativity, interactivity and close, dialogical, and humanized relationships.
The present research emphasizes the importance and recommends further studies on the spiritual aspect of health care during pregnancy and childbirth, so that spirituality may become a knowledge that can be employed in the professional's daily practice, especially in the context of primary health care. www.eerp.usp.br/rlae