Prenatal care and culture: an interface in nursing practice Atención prenatal y cultura: una conexión en la práctica de la enfermería

Objective: To know the care practices and cultural values from nurses when assisting pregnant women. Methods: This is an ethnonursing study conducted with five nurses working in low-risk prenatal care. The research was carried out from March to October 2013 by observing and interviewing each informant, in four units of the basic health service of a city in Rio Grande do Sul. Data were analyzed according to the guidelines proposed by Leininger. Results: The nursing care has transcended technicist conducts and has been influenced by cultural factors of each nurse’s individual perception. Conclusion: Promoting care permeated by culture is a needed interface in nursing, since that recognizing the sociocultural context of pregnancy allows identifying the ways to perform a culturally congruent care.


INTRODUCTION
For a long time obstetric nursing shared the biomedical assumption, regarding itself as holder of knowledge, which devalued the knowledge experienced by women, and did not take into account beliefs, practices and the context in which they lived.However, a study 1 provoked reflections on this theme and led professionals to rethink their practices, making care more humanized.
In this context, it is necessary to highlight the contribution of nurses in promoting safe maternity, as the qualified prenatal care requires specific knowledge and skills of both the physiology and the sociocultural aspects of women 2 .
From the perspective of pregnant women, it can be seen that when their values and beliefs are respected, they demonstrate more willingness to engage in self-care and come to trust in that professional who serves them.Pregnant women consider positively the prenatal nursing consultation held in basic health care, especially the way the communication relationships are established, in which host and listening are prioritized 3 .
It is understood that when there is dynamism in relationships between the actors of nursing care, beliefs and values are considered, which favors the involvement of the mother in the care of her health.This fact enhances the nursing care before that pregnant woman, as nursing is evidenced as a profession that has the art of care as its essence.Therefore, with regard to the communication process, which is generated in the interaction between nurses and their clients, it is seen that through dialogue and everyday acts that occur in interpersonal relationships, there is scope for the production of health care 4 .
It is noteworthy that the nursing activity in caring for pregnant women should be integrated in activities developed by other professionals of the health team, synchronizing actions of promotion and prevention.The multiprofessional care is relevant to the care of pregnant women, as it prevents diseases, helping to decrease the risk of maternal and fetal morbidity and mortality 5 .
Moreover, pregnancy is a learning phase for the woman and her family, and it is a time of intense physical and psychological changes, requiring thus a qualified and humanized care.In this line of thought, understanding the culture of the mother directs the health care for the family and social core to which she belongs, providing opportunities for the nurse to deconstruct the biologicist paradigm and to promote a holistic and comprehensive nursing care.Under this view, culture is understood as values, beliefs, norms and ways of life of a particular group that are learned, shared and transmitted and that come to guide decisions and thoughts in a standardized way 6,7 .
From this context, the guiding question of this study is "how do the nurses of primary health care of a municipality of Rio Grande do Sul experience the care practice in health care to the pregnant woman, from a cultural perspective?".Thus, the objective is to know the care practices and cultural values of nurses when caring for pregnant women.

METHOD
This is a ethnonursing 7 developed in two Health Family Strategies family and two Basic Health Units that belong to the primary health care service of a city of Rio Grande do Sul.The areas covered by these units are inhabited by low socioeconomic status population.There are, in these units, nurses working in women's health care, performing consultation to low-risk pregnant women and groups for pregnant women.Data collection was carried out from March to August 2013, in a total of 96 hours of observation and a semi-structured interview with each nurse, with an average duration of 1 hour.
The informants a were, initially, six nurses chosen in accordance with the guidelines of Leininger 7 .However, in the course of data collection, one of the nurses was excluded from the study because she departed from the activities related to pregnant women care.
The inclusion criteria of the informants comprised nurses who developed systematic actions with nursing care for pregnant women; and who worked in units located in the urban region.Exclusion criteria comprised nurses who were on leave from work at the time of the research.
Since the study was developed based on the proposal of ethnonursing 7 , guided by the following key-enablers: observation-participation-reflection (OPR) and by a semi-structured interview, which consisted of closed questions for the informants identification and of open questions, related to the experience of the nurses in the care to women and the perception of cultural values that guide this care.The OPR model consists of four phases that help the researcher to enter gradually in the environment in which the informants are inserted 7 .In the first phase the researcher only observes, distant from the phenomenon, however, aware of everything that happens in the cultural context 7 .For this, we used a systematic observation protocol, following the suggestions of elements to be observed 8 (the environment, interpersonal relationships, language, behavior and the time elapsed in the activities).
In the second phase, the researcher continues to observe, but he/she begins to participate in the observed context.At that moment, informal conversations are carried out, in order to encourage interaction between the observer and the informants, and to prioritize the details of the observed actions (care practices, nursing consultation, groups for pregnant women, cultural aspects).
In the third phase, participation becomes more active compared to observation, but the latter is also present.The researcher participated by interacting during nursing consultations and Prenatal care and culture Alves CN, Wilhelm LA, Barreto CN, Santos CC, Meincke SMK, Ressel LB groups for pregnant women, speaking when she was requested; as she also collaborated in the activities performed at these moments.Apart from that, the interview is conducted in this stage, and it is considered as a complementary element to the observation 9 , since the semi-structured interview, when proposed by Leininger, was intended to discover the cultural meanings of the group, through interaction with the social context, i.e., it enables that the phenomenon is investigated from the experience of informants.
In the fourth phase, the researcher makes reflective observations, rethinking the observed phenomenon and evaluating the information found.In this study, it involved discussing about the situations observed and identified in interviews with the informants in order to make sure that the production of data is consistent with all the nurses.This phase also includes resuming outstanding questions with the informants, or in order to validate the results 7 .As a way to record these observations and in order to document the events, we used the field diary 8 .
The data analysis process occurred throughout the research, associated with the data collection step.It is noteworthy that the field diary and the transcribed interviews permeated the moments of analysis, reinforcing the importance of the detailed description in the ethnographic work.
For data analysis we used the analysis guide suggested by Leininger 7 , which offers four sequential phases, summarized as follows: in the first phase, it is held the collection of the data, the description thereof and the documentation of raw data.This phase includes the observations, the record of the participations of the researcher and the interview data recording in order to identify contextual meanings, to make previous interpretations, to identify symbols, and to write data; the second phase is characterized by the identification and categorization of descriptors and components.In this phase, the data is coded and classified according to the domain or research, and sometimes on the issues under study.The recurrent components are then grouped according to their meanings; the third phase of the analysis related to pattern and contextual analysis comprises the review of data to discover saturation of ideas and recurring patterns of meanings, expressions, structures, interpretations or similar and different explanations of data related to the field of research; and the fourth phase comprises the main themes, the research findings, theoretical formulations and the enunciation of recommendations.This is the major phase of analysis of data, synthesis and interpretation, and requires the synthesis of thinking, the analysis of configuration, the interpretation of results and the creative formulation of data from previous phases.At this stage, the researcher's task is to summarize and confirm main themes, research findings, recommendations and sometimes to make new theoretical formulations 7 .
The data were entered in the computer, so that after this phase they were analyzed until they were grouped by similarities and contextual standards.Thus, we were able to identify the nursing care provided, experiences of each informant and the cultural approach to these situations.
In order to keep the anonymity of nurses and health units during the research, the interviews and observation were identified through the alphanumeric system, as follows: by the letter "N" (nurse) and "O" (observation), and through numerical sorting for example, E1, O1.
We respected the rules from the Resolution Nº 196/96, National Health Council of the Ministry of Health, which provides guidelines and regulations for research involving the participation of human beings.The study was approved by the Research Ethics Committee under protocol number 12161913.8.0000.5346.

RESULTS
The results of this study indicate that the nursing care in the prenatal care needs to overstep the technical activities, which are focused on the biological phenomenon of pregnancy, since it is crucial to understand the sociocultural context of pregnant women for the establishment of a comprehensive care.In view of this, we discuss below the testimonies of the informants of this research and the data collected from observations: When talking to mothers, the nurse mentioned that the pregnancy time is important, as it represents a period of several changes in the lives of women and their families [...] she also said that as it is a transitional phase, it is normal that they may have doubts about the bodily changes, and that her presence there in the unit was to meet them and provide peace of mind and confidence.(O2).
They may live here, but each of them has a history, so I have to adapt care, those guidelines to her history, because if I try to make everything the same way for everybody, it will not work out.(N1).

We need to have a close relationship, you can't feel superior, like "I'm a nurse, she is pregnant, and I have to teach her all the guidelines" [...] I actually have to know how her life is [...]. (N5).
The prenatal care is considered an important phase at women's lives.Therefore, nurses seek to know the pregnant women, their context, their history and, above all, to recognize that they have questions, need someone to listen to them and guide them in their needs.Moreover, when nurses consider this moment as unique and full of changes, they come to see the mother as a woman who needs a special care, and seek to answer her questions and to be prepared to meet her and to reassure her.
It is understood that during the care practices, being in tune with women allows the professional to know them and to be Prenatal care and culture Alves CN, Wilhelm LA, Barreto CN, Santos CC, Meincke SMK, Ressel LB organized to take care of them.Therefore, it is important to reject ethnocentric attitudes, as stated by the informant E5, for the imposition of care may have a negative effect for the individual who seeks help 10 , and thus remove them from service.
Pregnancy is a normal process of female physiology; however, it is experienced in a different and unique way by every woman.So when a woman becomes pregnant it is not only her body that will be transformed, the changes involve her family background and her social group, especially her culture, that permeates the expression of needs, values, knowledge, beliefs and practices of care 11 .
The knowledge of values, beliefs and ways of life of human beings in their living context is important to trigger new knowledge for nursing practice and to facilitate the realization of culturally congruent care 7 .
Therefore, recognition of the sociocultural context of women can benefit the course of pregnancy and postpartum period, specifically during consultations, in groups of pregnant women, or other activities carried out in this period, directing the attention of the nurse to the real health needs of mothers and their family.Thus it is ratified the importance of the nurse to know the reality in which the pregnant woman live, her family and the social and cultural environment, welcoming all people involved and enclosing them in the pregnancy care.
There has been reflection on the ethnocentrism, which is predominant in health, since many professionals understand that their knowledge must be the absolute truth.Since this thought is impregnated by the idea that the professional knows what the best is for people who are in their care, in the absence of the body of knowledge, ideas and perceptions about the pregnancy of the woman herself who is gestating, it can lead to the dichotomy of health care, which may be performed by nurses deficiently.
The ethnocentrism is regarded as a world view contrary to the idea of diversity of cultures, based on values of a single society, through a single framework, referring to the culture and values of a society over another 12 .In this line, the informants in this study took a stand and reported how they think the nursing care needs to be done.

If you are passionate about this issue of promotion and prevention and you start to say to patient 'Look how beautiful this way is [...] but it is not part of her every day, she will never join such a dream because it is in your head and not in hers [...] and each person has a point of view. (N4).
Nurses understand that health professionals tend to give the best care.This is the professional care, formally taught, learned and passed on, as well as the knowledge on health, illness, wellness and practical skills that prevail in professional institutions, usually with multidisciplinary staff 6,7 .However, nurses show concern in recognizing the patients' way of seeing the world and in understanding which the best way for each woman is, from their needs and sociocultural conditions.
On that account, this article brings the concept of popular care 6,7 , which is a set of popular knowledge and traditional skills, culturally learned and passed on.They provide acts actions of care, support, training or facilitating to another or by another individual, group or institution with health needs.
It is understood that this care should be valued by the nurse, since traditional knowledge are culturally transmitted between generations, based on trust and affection relationships.This popular system of knowledge enriches the nursing practice through the understanding that family relationships and personal beliefs allow the holistic recognition of the human being that is being cared 13 .
In addition, prenatal care is favorable to nursing care, since the relationship established between the patient and the caregiver care can create conditions that foster the autonomy of pregnant women and promote a bond of trust between them.We think this is possible since this relationship is based on sharing reciprocity.From the perspective of human care, this relationship is built between the nurse and the pregnant woman, on a reciprocal care condition, in which both determine actions and it is noticed the presence of feelings, emotions, beliefs, values and knowledge of both subjects 14 .
Thus, the act of caring, consistent to what Leininger describes, deals with the actions and activities directed to the care, support and training of another individual or group in need of health aid 6 .Thus, care becomes a diverse and dynamic process, which assumes the different facets of cultures and of what is experienced by humans.Concerning the nursing care and the recognition of the cultural context of pregnant women, the field notes show that the informants seek to identify the needs of women through welcoming and dialogue, as explained: The nurse is concerned with organizing activities and care for pregnant women in order to answer their questions, so that their concerns are eradicated and they can experience pregnancy with quality of life, providing nursing guidelines [...] she is attentive to family background and its main features that require attention, such as housing, social life, food and leisure activities [...]

she is always welcoming, calling the mothers by name, listening carefully, seeking to meet all needs, clarifying stages of consultation and reporting
Prenatal care and culture Alves CN, Wilhelm LA, Barreto CN, Santos CC, Meincke SMK, Ressel LB to pregnant women how their health and the health of the baby are.(O1).The nurse's explanations are based on cultural, family and community aspects.For this, she used a personal example to illustrate the care provided to newborns [...]  the conversation was about breastfeeding, so the care explained by the informant was referring to a situation that she experienced herself to provide better comfort when breastfeeding, using a support for the legs, such as stairs and benches.

(O5).
There are continual demonstrations of welcoming, for example, receiving the pregnant woman and her family for consultations, calling them by name, listening to them carefully, meeting their specific needs.There is demonstration of concern about the activities and the care performed by them; the guidelines are related and integrated to the sociocultural context of women and are exemplified in the nurse's experience as a woman who already has experienced the situation now experienced by pregnant women, who are now under their care.
Nursing is a humanistic profession focused on the phenomenon and activities of human care to serve, support, facilitate or enable individuals or groups 6 .So, welcoming, respectful, sharing and dialogical attitudes provide a unique and comprehensive care, since the recognition of pregnancy context, the demonstration of concern and the desire to integrate scientific care to the knowledge arising from pregnant women themselves allow an interaction between care actors and thus improve prenatal care.
It is thought, in line with authors 11 , on the relevance, for nursing, of knowing the care performed by the customers and of analyzing how they are placed in the family context, as this can assist in developing strategies to promote health, respecting customs and valuing the meanings of events for each pregnant woman and her family.It is noticed the importance of care and culture walking together in the nursing actions, so that the popular care permeates nursing care 15 .
In this regard, we bring to this discussion the concept of culturally congruent care 6 , which consists of acts or care decisions that are supportive, enabling or facilitating based and designed to fit the cultural values, beliefs and ways of life of a person, a group or an institution in order to provide or support proper health care.Nursing care is understood as the valuation of the human being in their entirety, so that it is an attitude of being concerned and occupied with others, in which the human being is looked at, heard and felt 16 .
It is understood that there are many cultural values involved in care actions, both popular and professional.Thus, we sought with the informants of this research to identify which cultural influence they have approached when attending pregnant women.
I think these values (house, church) are important to be added in practice; because we are professionals, but we are people serving people then there's no escape from this.(N1).
So, I think it's the academic training [...] I had been on a scholarship at maternity and I learned a lot, there [...]  It is noticed that family, religion, academic training, political conceptions and individual perceptions of each of the informants are intertwined with their care actions.We highlight that their care actions are permeated with feelings and values impregnated by cultural aspects.
It can be seen that cultural factors, absorbed in primary and secondary socialization, directly influence the personal values of the nurses.Regarding this, the primary socialization occurs in childhood, and is related to the world of everyday life, especially in the family.In addition to this, when social roles are identified, and content and attitudes are learned, socialization is achieved 17 .And the secondary socialization results from the internalization of values and rules of society.This content is selectively learned through teachings, which are absorbed by the person concerned 17 .It is understood that through socialization, care can be learned and added to the daily lives of nurses.
It is widely known that the worldview, religion, sociocultural and political context and education influence on the values and cultural care practices 7 , performed both by pregnant women as nurses.There are many dimensions in which the nurse is involved, because the care comprises prevention, promotion and recovery of health.Thus, seeking to understand the beliefs, customs, values and care practices of subjects is a constant challenge, since the nurse is also immersed in a professional and personal culture, from which is difficult to untie, or rather to distance, to avoid being ethnocentrically influenced.
However, as the culture is expressed in the knowledge and care practices, there is influence among producers of different cultures, both from the subjects, as from caregivers.However, it is thought that the sharing of knowledge and ideas, and the search for individualization of the cared subject, as an attitude in the interpersonal relationship between nurse and the mother, can allow a holistic care.Thus, prenatal care needs to value the knowledge and care practices that each pregnant woman and their families have, in order to their approach the reality, and to contribute to a personalized care 18 .

Prenatal care and culture
Alves CN, Wilhelm LA, Barreto CN, Santos CC, Meincke SMK, Ressel LB The cultural influence is also evident in the nurses' speeches when referring to act according to the scientific knowledge they have acquired, but adding their own experiences and nursing care, as mentioned above: During the training I have seen a lot about this, this issue of humanization, about trying to see the point of view of the other person [...] and from my pregnancy also [...] the experiences we have accumulated, the things we have done and we start learning to look at things differently.(N1).

In addition to the scientific knowledge we put our experience in every situation. (N2).
Experiences with their own pregnancy, along with the time of work in this area and the issue of humanization of care received in academic training were present in the informants' statements.The diversity of care actions performed by nurses is influenced by the environment in which they live, by their academic training, by personal experiences and by culture of health services to which they are linked.
Therefore, it is needed that prenatal care overcome scientific knowledge and seek to adapt theory to the living conditions of each pregnant woman, since developing an effective care for these women allows the approach of a culturally congruent care.It should be reiterated that, in knowing the reality experienced by each pregnant woman, nurses are able organize their actions in order to meet the needs of this mother and to consider their sociocultural context.
It is understood that nurses need to incorporate perspectives and attitudes that consider the subjectivity of women, the specificity of them and the uniqueness of each family involved in the gestational process in the care actions to women in pregnancy and childbirth, thus seeking the interface of culture the care provided.

FINAL CONSIDERATIONS
The results of this study indicate that the nursing care in the low-risk prenatal period transcends technicist and dichotomized health care.Therefore, it is crucial to understand that recognizing the sociocultural context of pregnancy is essential for the establishment of a comprehensive care.
The prenatal period consists of an important step of women's lives and, to this end, the nurses sought to know the history of the women, the context of pregnancy and provided moments of listening and interaction that allowed the women to become active agents of their care.
This research revealed how the family, religion, academic training, political conceptions and individual perceptions of each of the nurses were intertwined with their care actions.These are elements that permeate their cultural values.It is believed that cultural factors, which are absorbed in primary and secondary socialization, directly influenced the personal values of the nurses for their care actions.
Therefore, it is strengthened that it is essential that nurses be aware of themselves, their values and beliefs to be able to distinguish the values, beliefs, care practices, the prior knowledge and the cultural context of the individual for whom they provide care.Such an attitude can make them more aware of their actions and prepare them to provide an effective, meaningful and quality service to those who are receiving care.
Moreover, the promotion of care permeated by culture is a necessary interface in nursing, since it is a profession that works directly with the community, knowing the environment in which clients live and that can thus identify the means for the culturally congruent care is performed.Thus, it is hoped that this study will promote discussion on key cultural issues for the nursing care to pregnant women.
It is emphasized that this study does not intend to generalize the data, since the informants compose a particular environment on nursing care, comprising a specific and local scene.Thus, it is suggested that new studies are developed with wider coverage and in other areas in order to contribute to the expansion of knowledge about care during pregnancy and cultural aspects involved.