Primary Health Care Follow-Up Visits : Investigation of Care Continuity of Preterm Newborns from a Kangaroo-Mother Care Unit

Marielle Ribeiro Feitosa1, Fabiane do Amaral Gubert2, Marcela Ariadne Braga Gomes Tomé3, Maria Talyta Mota Pinheiro3, Clarice da Silva Neves3, Jéssica Lima Benevides3, Lidiane Nogueira Rebouças4, Leonardo Alexandrino da Silva5, Sarah Rayssa Cordeiro Sales Pinheiro5, Êmile Costa Barros5, Clarissa Costa Gomes5, Mariana da Silva Diógenes5, Amanda Rebouças Bezerra de Menezes5, Essyo Pedro Moreira de Lima5, Daiana Rodrigues Cruz Lima5, Larissa Ludmila Monteiro de Souza Brito5, Márcia Maria Coelho Oliveira Lopes2, Regina Cláudia Melo Dodt2, Gláucia Maria Nóbrega Rocha6, Paulo César de Almeida7 1 RN. Master's Degree in Family Health Strategy. Fortaleza, Ceara State, Brazil. 2 RN. PhD. Professor. School of Nursing. Federal University of Ceara. Fortaleza, Ceara State, Brazil. 3 RN. Master’s Degree Student. Graduate Program in Nursing. School of Nursing. Federal University of Ceara. Fortaleza, Ceara State, Brazil. 4 RN. PhD Student. Graduate Program in Nursing. School of Nursing. Federal University of Ceara. Fortaleza, Ceara State, Brazil. 5 Undergraduate Nursing Student. School of Nursing. Federal University of Ceara. Fortaleza, Ceara State, Brazil. 6 RN. Federal University of Ceara. Fortaleza, Ceará State, Brazil 7 Statistician. PhD. Professor. School of Nursing. Ceara State University. Fortaleza, Ceara State, Brazil.


Introduction
Preterm birth has been described as a major public health problem, since it has been responsible for a high percentage of neonatal morbidity and mortality rate in different regions of Brazil [1].
In 2012, the neonatal component accounted for 71% of mortality in the first year of life with 52.5% of premature deaths, and 25% of them occurred within the first 24 hours after live birth in Brazil.These numbers require attention because of the relationship between death rate and the quality of care that is provided to pregnant women, newborns and during labor.Moreover, the main causes of newborn deaths are prematurity, perinatal infections and maternal factors, which have impact on child survival rate [2,3].
The above scenario requires the investigation of the relationship between vulnerability conditions and death risk in the first year of life with the purpose of elaborating interventions, which decrease the number of deaths by providing a better healthcare plan.In order to provide better health interventions, some strategies aim to improve not only the technical care of mothers and newborns, but also stimulate health professionals to offer care that is based on integrality between obstetric and neonatal care.
Therefore, Kangaroo Method (KM), which is a health policy in Brazil, was launched with the purpo-se of improving the quality of health care provided to pregnant women, newborns and their families.KM is defined as a perinatal care method from the Child Health Technical Sector and Breastfeeding Area of the Brazilian Ministry of Health, which follows the regulatory rules of the Reduction of Maternal and Neonatal Mortality Pact.KM is also a component of the Humanized Care for Low Birth Weight Newborn Pact, through the Brazilian Ordinance Number 1683/2007 [2].
KM is also a biopsychosocial intervention that is based on three steps, which can be identified in the entire process of preterm newborn (PN) hospitalization as follows: (1) intensive neonatal care unit or conventional intermediate neonatal unit (CINU); (2) PN transference to the kangaroo intermediate neonatal unit (KINU) to provide care instructions that increase self-efficacy of mothers by stimulating them to use the kangaroo position during day and night; (3) home visit care services that should be provided to PN and their families after hospital discharge by health professionals of primary health care facilities [4].
Prematurity requires adaptation and specific skills from mothers as a way to develop new behaviors for taking care of their children.As a result of these characteristics, the knowledge of mothers regarding to care is crucial to facilitate motherhood cation, marital status, and family income.Regarding findings from the follow-up home visits in primary health care, most of the participants were still breastfeeding and using the kangaroo position.However, 60.5% of the interviewed mothers reported not receiving home visits from health professionals of primary health care facilities.development, and the overcoming of difficult experiences related to this complex process [5].This adaptation process may be strengthened through the support and participation of important family members in the three steps of KM.In addition, the support of health professionals as health educators, especially from nurses, can also improve the self-efficacy of mothers by reaffirming that they have the required maternal abilities to perform baby care duties [6].
In order to achieve a high standard level of neonatal care, KM, which offers a new approach to provide a better care plan for PN, requires the reshuffling of the current health care model, and the conceptions of health professionals that are related to neonatal care and the participation of families before during and after hospital discharge [6].Therefore, because of the necessity of strengthening the care provided to newborns, especially after hospital discharge, and the follow-up home visits that should be ensured by primary health care professionals, the authors aimed to investigate continuity care of preterm newborns from the kangaroomother care method in primary health care of a Brazilian Northeast capital.

Methods
It was a transversal study developed in a reference university hospital of a Brazilian Northeast capital.The public maternity school, where this research was carried out, has the certification from the Baby-Friendly Hospital Initiative (BFHI) that is a global strategy developed by the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) to promote, protect and support breastfeeding [7].
The participants of this study were 43 mothers of PN admitted to the KINU.The total of participants was based on sample calculation.Data collection occurred between September 2015 and February 2016.
The first data collection was performed in a Brazilian public maternity school.After interviews, mothers and their families were exposed to health education sessions, which were mainly composed of user embracement and newborn care duties.Educational strategies were applied to identify personal and collective weaknesses, to improve the knowledge of mothers related to taking care of PN, and to inform the advantages of kangaroo position and exclusive breastfeeding (EBF).The educational sessions also provided socio-educational meetings, educational games, group discussion forums, and conversation circles with mothers and their families.
For the analysis of follow-up home visits of PN from the KINU, which aimed to investigate PN care performed by mothers and continuity of care in primary health care, participants were contacted by phone after 15 days of hospital discharge.The authors wanted to investigate the occurrence of follow-up home visits after hospital discharge because the continuity of care is crucial for the reinforcement of care duties provided to PN at home.During the first home visit (HM), health professionals of the Family Health Strategy have to provide a general risk evaluation of PN, and EBF reinforcement [2,8].
The authors used one instrument to collect data, which had the following variables: (1) socio-demographic data (age, region of origin, education, marital status, employment status, number of people in household, and family income); (2) reproductive profile (family planning, birth numbers, history of premature births, and attendance to prenatal visits in primary health care (minimum of six visits adopted by the Brazilian Ministry of Health).
The authors also collected data of newborns, as follows: anthropometric profile, gestational age, and birth weight.These data were classified according to World Health Organization recommendations, the content of patients record regarding the use of kangaroo position and breastfeeding, and findings from follow-up home visits (third step of the KM).
Data were organized in an Excel database for Windows XP and later analyzed using SPSS version 20.0.
Data collection was performed after approval of the Ethics Committee of the Federal University of Ceara, under the number 1.311.767.The procedures of this study were in accordance with the national and international resolutions on the conduction of research with humans.
The authors state that they have no conflicts of interest.

Results
In regard of the sociodemographic characteristics of mothers, the majority of the participants were aged between 17 and 32 years (74.4%), from a Brazilian capital or metropolitan region (65.1%), and had a least high school education (62.8%).About the employment status of the respondents, 54% were housewife, 63% were unemployed, 88.4% lived with a partner, and 49% received at least one Brazilian minimum wage (Table 1).The majority of the interviewed mothers affirmed not having previous experience with taking care of PN (67.4%).Overall, 46.5% of participants were primiparas, and 48.8% had a planned pregnancy.Regarding pregnancy care, 97.6% of mothers attended prenatal visits; however, only 41.8% attended six prenatal visits or more.
Data related to the use of kangaroo position at home revealed that 90.7% of mothers were still using this position after hospital discharge (Table 2).The authors also found that 33.3% of the respondents used kangaroo position for two hours per day, and 48.7% between 3 and five hours per day.However, only 17.7% used kangaroo position for more than five hours per day.Furthermore, 79% of the participants stated that not having a special bag or kangaroo pouch was the main reason for not using the kangaroo position, and 2.3% did not use kangaroo position because of discomfort or pain.
In regard to breastfeeding, all participants were breastfeeding after hospital discharge, but only 60.5% were providing EBF.The main reason for not providing EBF and feeding with infant formula was low milk production (32,5%); however, all of these mothers affirmed that breast milk was not totally excluded from their children's diet because they were worried about the health of their PN.
About follow-up home visits after 15 days of hospital discharge, only 11.6% of mothers of PN from a KINU sought care in primary health care facilities.According to Table 3, the main reason for not seeking care in these facilities was lack of awareness of this possibility (69.8%).
When the participants were asked about the occurrence of follow-up home visits performed by health professionals of primary health care, 60.5% stated not receiving care at home.Furthermore, from the total of mothers that received care at  home after 15 days of hospital discharge, 76.5% were visited by community health workers, and only 23.5% by nurses, which revealed that recommendations of the Brazilian Ministry of Health were not followed in primary health care.During follow-up home visits, the most discussed topics EBF (82.3%) and care duties that should be perform by parents of PN.Unfortunately, only 29.4% of the health professionals of primary health care discussed about the benefits of the kangaroo position after hospital discharge.Among 28 mothers who stated feeling insecure to take care of PN after hospital discharge, the most cited reasons for this lack of confidence were the existence of obstacles to breastfeeding (75%), and lack of knowledge to identify warning signs in PN that were discussed in health education sessions (14.2%).Moreover, 57.1% of mothers sought help from family members (62.5%) and health professionals (37.5%).

Discussion
The authors pointed out that socio-demographic conditions may be related to risk of premature births, low vitality at birth, low weight at birth, and specially the following variables: age, marital status, education and family income.It was also found a predominance of mothers aged between 17 and 32 years.Similar data were reported in a research carried out in Piaui State, Brazil, in which the majority of interviewed mothers were in the reproductive phase of life, and the minority were adolescent women [9].On the other hand, a Brazilian study conducted in Rio Grande do Norte State, which analyzed the profile of mothers, identified an increase in the age of participants.Therefore, these mothers preferred to get pregnant when they were older [10].
In regard to the prevalence of mothers who were from a Brazilian capital, similar data were also described in a research developed in Maringa, Parana State, Brazil, where women from capital cities had a high probability of accessing more appropriate health care facilities, which increased the standard of provided care [11].It is possible that many women in preterm labor often do not have access to health care services because of the distance between their region of origin and specialized hospitals.
Concerning familiar income, most of interviewed mothers were unemployed and had a low income.Although this fact may enhance breastfeeding and strengthen the attachment bond between mother and child because of more free time spent at home with newborns, low socioeconomic status is a serious social issue, since it increases maternal and infant mortality risks.Therefore, low socioeconomic condition negatively affects nutritional status of mothers, which has impact on child health [12].
A research revealed that in order to assess the knowledge of mothers on the importance of breastfeeding and its promotion, it is extremely important that nurses, especially at well-child care appointments and home care visits, use instruments that provide information about the confidence of mothers to breastfeed, and their likelihood to breastfeed as well [13].
During the education process of teaching how to take care of newborns, mothers and their families can also help this development because their awareness can be initiated before hospital discharge, which provides a safer discharge and returning to home.This type of health intervention may have impacted the continuity of using kangaroo position and EBF after hospital discharge.It was implied when mothers said that were using kangaroo position.The main reason for this statement was their worries about the health of their PN, which is in accordance with the Brazilian ministry of health [2,4] Regarding breastfeeding, the respondents affirmed they were breastfeeding even after hospital discharge, but some mothers were not providing EBF at home.Low milk production and difficulties to wake up at night were referred as reasons for not providing EBF.
About the previous finding, there are authors who agree that low milk production is one of the most important reasons for not providing EBF, followed by the strong influence of sociocultural beliefs of family members, which increase the likelihood of early exposition of newborns to other liquids [14,15].Other barriers for not offering EBF are: working outside home; lack of EBF orientation, support and stimulation from health professionals; socioeconomic status; education; pain and diseases; first pregnancy; pacifier use; child behavior; low weight at birth and prematurity; and type of parturition [16].A research also pointed out that a reason for early weaning at home is the fact that mothers have to return to work and leave their children with people who often do not know how to offer breast milk in a cup [17].
These above aspects revealed the importance of family and health professionals' support and encouragement in hospital and home environments in order to ensure the continuity of EBF.In addition, mothers can be exposed to anxiety and lack of confidence, and have problems in managing breastfeeding, which can negatively affect EBF and trigger health problems in newborns caused by early weaning [18].
After hospital discharge, mothers are calm and more comfortable because they have more availability for the practice of breastfeeding, but they are still reporting lack of confidence to take care of their newborn by themselves at home.At this period, it is very important to ensure primary health care follow-up visits, which improves the practice of breastfeeding [19].
The kangaroo-mother care method has proved that family involvement with newborn hospitalization, mother care, early orientations for breastfeeding, and skin-to-skin contact facilitates the production of breast milk and ensure the continuity of EBF, even after hospital discharge.Therefore, primary health care professionals have the responsibility to provide interventions that can be applied in different contexts and family types [1,4].
Efficient health interventions, delivered through health education and primary health care follow-up visits, improve mothers and family motivation and may increase the length of EBF [20].Nevertheless, this study revealed that only 11.6% of mothers of PN from a KINU were visited by professionals of primary health care facilities after 15 days of hospital discharge, which shows the discontinuity of care at the third step of the kangaroo-mother care method in a public maternity and primary health care services, proved by the lack of awareness of the participants about this possibility of care.
Therefore, communication between health professionals of hospitals and primary health care facilities is extremely important to ensure care continuity, which is not a simple appointment, but an approach to stimulate knowledge exchange and enhance confidence between family and health professionals through health interventions designed based on family needs.The authors have to emphasize that the third step of the kangaroo-mother care method is characterized by follow-up care visits of newborns and their families performed in hospitals and at home, and have the goal of helping newborns to reach at least the weight of 2,500 grams, which also ensure a biopsychosocial approach [2,4].
The kangaroo-mother care method has also an impact on the development of motherhood because it allows skin-to-skin contact, and ensure the active participation of mothers in duties related to taking care of their newborns.On the other hand, a study revealed that difficulties of using kangaroo position were a sign to stimulate this position in hospitals and at home because there was an association between not using kangaroo position and non-adherence to health orientations given after hospital discharge [5].

Conclusion
This study showed the importance of health education approach in primary health care facilities to the development of competence of mothers and family members, which were related to taking care of PN, breastfeeding and benefits of kangaroo position after hospital discharge.
The authors emphasized that is importance for nurses, who are members of health care teams, to assess in which aspects of taking care of PN mothers require more support and orientation from health services.This identification is essential because it can improve mothers' confidence and autonomy regarding taking care of PN.
It is important to state that the complexity of continued breastfeeding and the use of kangaroo position after hospital discharge among mothers of PN is a public health issue because prematurity is one of the major cause of infant mortality.However, this problem could be minimized by ensuring primary health care follow-up visits after hospital discharge, which are described in the third step of the kangaroo-mother care method.These visits have positive impacts on the provision of safe and efficient care of PN delivered by mothers at home.
The authors recommend the conduction of studies which aim to identify other factors that negatively affect the continuity of PN care at home.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.