INTEGRALITY AS A DIMENSION OF NURSING PRACTICE IN MOTHER-BABY WELCOMING

Objective: to analyze the practice of integrality in mother-baby welcoming in the context of primary health care. Methods: It is a cross-sectional descriptive study. Data were collected from medical records of children treated by nurses in a primary care unit in Rio de Janeiro, in the years 2009 and 2011, with 421 and 275 records, respectively. Results: The results showed that, in both years, more than70% of the mothers were between 20 and 35 years old and that, in 2011, there was a significant increase in cesarean births records, children with physiological jaundice and the number of women that were exclusively breastfeeding. Conclusion: It was concluded that comprehensive child careactions constitute one of the dimensions of nursing practice in primary health care and contribute to improve the quality of life of the clients. 1 Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ, Brazil. 2 Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ, Brazil. 3 Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ, Brazil. 4 Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ, Brazil. 5 Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ, Brazil. 6 Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ, Brazil. RESEARCH PESQUISA INVESTIGACIÓN Integralidade como uma dimensão da prática assistencial do enfermeiro no acolhimento mãe-bebê Esc Anna Nery (print)2013 Sep-Dec; 17 (4):677 682 Maria Helena do Nascimento Souza1, Elisabete Pimenta Araújo Paz2, Sheila Nascimento Pereira Farias3, Liane Gack Ghelman4, Camille Xavier de Mattos5, Rebecca Rodrigues de Barros6 Integralidad como una dimensión de la práctica asistencial del enfermero en el acogimiento madre-bebé Comprehensive health care; Child health; Primary health care; Nursing.


INTRODUCTION
In the comprehensive care context, child healthcare is a constitutional premise and an important step in the acknowledgement of children's rights in the Unified Health System (SUS) 1 .In health work, comprehensiveness can be evidenced in each professional's activities by adopting a welcoming attitude that is committed to the users, by putting in practice actions and conducts aimed at caring and curing or through bonding and the establishment of fair priorities to deliver care to them in function of their needs 2 .
The conditions that converge towards comprehensive child care comprise prevention; care delivery to conditions that prioritize not only the reduction of child mortality, but also the reduction of damage to children in situations of social vulnerability; care delivery in case of diseases, rehabilitation and the commitment to offer quality of life to the children.Allowing children to grow and develop to the best of their ability in the primary care context in Brazil is a target the Unified Health System aims to achieve 1 .
The integrality principles represents the population's right to have its needs attended to, and the State is responsible for offering health services that have been organized to deliver comprehensive care to the population, which is closely related to the conception of health and disease.In this sense, the SUS should respond to the needs originating in all complexity levels of the system, through health promotion, protection and recovery actions, as well as through rehabilitation, overcoming the dichotomy between preventive and curative, individual and group actions.The way the service supply is programmed demands articulation among health team professionals and among the different levels in the technological hierarchy of care delivery 3 .The Brazilian health system, as a legal apparatus, is undoubtedly one of the most advanced in the world.When considering the sociocultural, political and economic dimensions in which this system takes form, however, different kinds of contradictions emerge, such as the precarious access to basic services, fragmented care practices in a care network and persistence of socioeconomic inequalities.In this context, the change should be understood as part of a dialectic process.Therefore, advancing in the consolidation of the SUS implies the search for new mechanisms that converge in the overcoming of difficulties inherent in our social reality 2 .
Thus, comprehensive child healthcare is organized around three main axes, which comprise actions that range from contraception to conception, delivery and puerperal care, involving newborn care, which includes growth and development monitoring, immunization, neonatal screening, breastfeeding, prevalent childhood diseases and educative actions.The strategic intervention lines of child healthcare express the integrality concept through the supply of health education, promotion, prevention, diagnosis and recovery actions, representing an important contribution as a public policy in the integrality context 1 .
In this perspective of care integrality, regarding primary care, Mother-Baby Welcoming stands out as an access strategy to the first care actions and professionals have the opportunity to put in practice actions aimed at health promotion, disease prevention and the protection of newborn infants 4,5 .
Nurses have delivered care to mothers and infants during the first week after birth at primary health care centers, including Health Centers, Health Stations and Family Health Units, which welcome the mothers after leaving the maternity hospitals.Although the Mother-Baby Welcoming Strategy was implemented in the city of Rio de Janeiro in 2003 5 , in the literature, a gap in scientific production is observed about the care delivered by nurses active in this strategy.
In view of the above, the objective in this article is to analyze the practice of integrality in Mother-Baby Welcoming in the primary healthcare context.

METHOD
A cross-sectional and descriptive study with a quantitative approach was carried out at a Municipal Health Center (MHC) located in Program Area 2.1 in the city of Rio de Janeiro -Brazil, departing from the list of children attended by nurses from the Child Care sector during Mother-Baby Welcoming Strategy consultations.
To define the sample, the inclusion criterion was focused on patient files that contained the Mother-Baby Welcoming Consultation Activity Script, with completion dates in 2009 and 2011, as this was the period during which nursing students developed activities at the service under the supervision of a faculty member of Anna Nery School of Nursing at Universidade Federal do Rio de Janeiro.The files of children attended in 2010 were not used in this research due to the absence of information, as most Mother-Baby Welcoming Consultation Activity Scripts for this period had been forwarded to the Family Health Strategy team in the coverage area of the child's place of residence, and therefore were not available at the MHC where the study was undertaken.Hence, the sample consisted of 421 and 275 files of children attended in the Mother-Baby Welcoming Strategy, in 2009 and 2011, respectively.
Data from the files were collected in 2012, at the health service.The variables considered for this research were related to the mothers' social, clinical and psychological characteristics, as well as to the infant's age, Souza MHN, Paz EPA, Farias SNP, Ghelman LG, Mattos CX, Barros RR Short title: Integrality in mother-baby welcoming clinical conditions, type of feeding and forwarding to other sectors at the service or to other health services.
The obtained results were included in a database and analyzed using Epi-Info software version 3.5.2.For the descriptive analysis of the study variables, absolute and relative frequency distribution was used for the categorical variables, displayed in the form of tables.
Approval for the research was obtained from the Research Ethics Committee of the Rio de Janeiro Municipal Health Secretary, under protocol No 129/08, in compliance with the guidelines of the National Health Council Resolution 466/2013, Ministry of Health, which rules on research involving human beings.

RESULTS
In Table 1, it is observed that, in both years, more than 70% of the mothers attended were young, between 20 and 35 years of age.As regards the delivery type, a significant difference was observed between the two groups.It is noteworthy that less than 50% of the women attended in 2011 had their children through normal birth.Another remarkable difference is that the number of forceps deliveries is three times higher in the sample for 2011 when compared to 2009.
The observation of Table 2 reveals that, in both years under analysis, about 52% of the consultations took place in the infants' first seven days of life.Jaundice was present in the records under assessment, with a prevalence rate of 44.7% among the children who attended the Welcoming consultations in 2011.As regards the conditions of the umbilical stump, it was observed that, in 2011, a lesser proportion of alterations was found in comparison with 2009 (3.8% and 1.8%, respectively).Concerning the infant's feeding, adherence levels to exclusive breastfeeding were higher.
In Table 3, it is highlighted that, among the nursing care actions, the scheduling of the pediatric childcare consultation and post-consultation forwarding for the heel prick took place in more than 90% of the consultations.With regard to the procedures for the mothers, forwarding to a family planning group stood out, which happened in 69.5% and 81.8% of the consultations registered in 2009 and 2011. in professional qualification, so that they value the benefits of normal birth for the women, infants and families in their prenatal care actions, in view of the World Health Organization's recommended c-section rate of 15% of all births 7,9 .
In the nursing assessment about the breast conditions, records of women with breast alterations varied between 16.7 and 23.8%.A study undertaken in Bahia, involving mothers of children under one year of age, evidenced at least one episode of nipple cracks in 32.8%, 9.2% associated with mastitis 10 , similar to the present findings.Nipple cracks are the most frequent complication in the early breastfeeding period, generally due to the infant's bad positioning while feeding.This injury can serve as an entry door for bacteria, demonstrating the importance of professional support in this phase, through safe orientations and educative actions, aiming for successful exclusive breastfeeding and the reduction of early weaning risks 11,12 .
What the infant's age is concerned, during the Welcoming consultation, it was observed that more than 50% took place after the 15 th day of life, which differs from the period defined by the Mother-Baby Welcoming Strategy.It is recommended that the consultation be held during the first week postpartum, which is the most vulnerable period for the appearance of problems for the infants and mothers 13 .
Jaundice is one of the signs that can be observed in infants during consultations in the first weeks of life and may be present in up to 82% of the children.When the infants are discharged from hospital with physiological jaundice, exposure to sunlight is one of the most simple conducts, to be performed at home, which contributes to prevent the impregnation of the brain by the yellow pigment, thus avoiding bilirubin encephalopathy 14 .
The increased propor tion of children who receive exclusive breastfeeding during the first weeks of life is in accordance with the Ministry of Health and the World Health Organization's proposals, which indicate exclusive breastfeeding during the first six months of life 13,15 .
These study results showed that more than 90% of the women who attended the Mother-Baby Welcoming consultation were exclusively breastfeeding their children.This information was expected, in view of the age when the children were taken to the health service.In a study about breastfeeding suppor t in Rio Grande do Sul, the prevalence of children receiving exclusive breastfeeding in the first month of life corresponded to 60% 16 .
The goal of nursing actions in the assessment of mothers and infants is the continuation of health promotion and preventive care for both at home.The records indicated that the follow-up of welcoming actions can enhance the clients' sensitization as to the importance of childcare monitoring to prevent health problems and promote the children's health, which happens within an interdisciplinary and comprehensive and problem-solving perspective 17,18 .

FINAL CONSIDERATIONS
The organized registering of information about mothers and infants furthered knowledge about the biological characteristics, factors interfering in the clients' health and the most frequent care practices for this group with a view to health promotion.
In view of childcare recommendations, Mother-Infant Welcoming permits a further understanding of nurses' care actions aimed at families that attend the primary healthcare service.In this perspective, this strategy offers access to healthcare services and permits the professionals' comprehensive and longitudinal monitoring of the children.
Concerning the study limitation, it was verified that the patient files analyzed in this research did not relate to all nursing consultations at the MHC, due to the fact that not all files contained the specific Mother-Baby Welcoming Script.Another difficulty was the absence of information about the consultations held in 2010, as the files of the children attended in the Mother-Baby Welcoming Strategy were forwarded to the Family Health Strategy team responsible for the coverage area of the child's place of residence.
Regarding integrality, it was verified that the nurses are putting in practice the dimensions of Primary Care, such as: health promotion, disease prevention, risk and vulnerability assessment of mothers and infants, in their daily care at the primary healthcare units.
Integrality, as recommended by the Unified Health System, is not the responsibility of a sole health professional or service, but departs from the following principles: work in networks, listening to people's needs, adoption of problem-solving measures and bonding with social accountability to the population.
In conclusion, actions aimed at comprehensive care delivery to children represent one of the dimensions of nursing practice in primary health care and contribute to the improvement of the population's quality of life.

Table 1 .
Characteristics of the women attended in the Mother-Baby Welcoming Strategy.Rio de Janeiro, 2009 e 2011.Souza MHN, Paz EPA, Farias SNP, Ghelman LG, Mattos CX, Barros RR