Maternal predictors related to quality of life in pregnant women in the Northeast of Brazil

Maternal predictors related to quality of life in pregnant women in the Northeast of Brazil Background: Gestation is a period that can positively or negatively influence the life of a woman in the pregnancy- puerperal cycle. Thus, evaluating the quality of life of this population can redirect the implementation of innovative practices, with the goal of making them more effective and practical or the promotion of humanized care. The present study aimed to evaluate the predictors that influence the health-related quality of life of low-risk pregnant women, as well as to describe the main areas affected in the quality of life of pregnant women. Methods: A correlational, quantitative and cross-sectional study was carried out in two public units that provide prenatal care services and a private unit in the city of Fortaleza, a municipality in the Northeast of Brazil. The sample consisted of 261 pregnant women who were interviewed from September to November 2014. The collection instruments were a questionnaire covering sociodemographic, obstetric and quality of life variables, in addition to the Brazilian version of the Mother-Generated Index (MGI). The data were compiled and analyzed through the Statistical Package for the Social Sciences (SPSS) software, version 20.0. A descriptive analysis was performed through the application of Pearson’s chi-square test, Fisher’s exact test and one-way ANOVA. Maternal predictors for the quality of life of pregnant woman were identified through a multivariate analysis/multiple regression. Results: The response rate was 100%, corresponding to 261 respondents. Occupation, parity, partner support, marital status and persons with whom the women live were the predictors that positively interfered in the quality of life of pregnant women. In contrast, gestational age, type of housing, occupation, use of illicit drugs, non-receipt of partner support and maternal age were the predictors that negatively influenced quality of life. Conclusion: Our results indicate that happiness to become a mother and body image were areas with the greatest positive and negative influence on health-related quality of life, which suggests being relevant aspects in the planning and implementation of actions aimed at its improvement. Keywords: Quality of life, Prenatal care, Nursing * Correspondence: cinthiacalou@hotmail.com Nursing Department, Federal University of Ceara, Alexandre Baraúna Street, 1115, Rodolfo Teófilo, Fortaleza, Ceará 60430 – 160, Brazil Nursing Department, Regional University of Cariri, Coronel Antônio Luís Street, 1161, Pimenta, Crato, Ceará 63.105-100, Brazil Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 2 of 10 Background In the Brazilian scenario, the Stork Network was imple- Pregnancy is a singular moment in the life of a woman, ex- mented in 2011 in order to improve the quality of care perienced as a physiological process of the female organism. and increase access to prenatal care. This improvement is However, although it is a natural process, gestation is charac- achieved through comprehensive care, linking pregnant terized by a period of intense transformations in the life of women to referral units, providing safe transportation and the woman, demanding an adaptation towards motherhood. implementing good practices in labor and childbirth care, These transformations occur in emotional and physio- including preserving the right of women’sfree choice of logical contexts, mainly due to hormonal and mechan- companion at childbirth, respecting all the necessary re- ical factors. Changes in posture-ambulation, metabolism, quirements for individualized assistance, and having the urinary system, the respiratory system, and female humanization and fewer damages due to inadequate care genitalia are also present in this period [1]. as the main focus, as well as promoting a better quality of Gestation is a period in which the social insertion of life to the mother-child binomial [7]. women can positively or negatively influence the quality In developed countries, the focus of prenatal care has of life, requiring a maturation and mastery of certain gone beyond traditional principles and now includes in its stages of development established by the pregnancy guidelines psychological support and encouragement to process: the acceptance of the gestation, the conception pregnant women, promoting in some situations the im- of the role of mother, the reorganization of relationships provement of the quality of life of pregnant women [8]. and the preparation for childbirth [2]. The sum of these Thus, during low-risk prenatal care, which consists of changes translates into the need to prepare pregnant gestation that does not present any risk factors of any women to assume new responsibilities and perform their size that may negatively affect the evolution of preg- new role as mothers. nancy [9], the follow-up of qualified health professionals, It is worth emphasizing that the changes that preg- such as physicians and nurses, is an important and nant women experience are transient, but they can timely moment to evaluate the HRQoL in this more spe- change their quality of life. These changes are sig- cific population, since it is understood that low-risk nificant, and those responsible for their care must pregnant women tend to naturalize the transformations know about these changes sufficiently to implement inherent in pregnancy. Because they do not assign the effective health actions through preparing women necessary importance to the process, situations may re- with the knowledge and skills necessary to address sult that compromise quality of life. the pregnancy-puerperal process [3]. In this context, health professionals involved in assist- In 1994, the World Health Organization (WHO) de- ing the pregnant woman will be able to understand how fined quality of life (QoL) as “the individuals’ perception the process of gestation is experienced, considering all of of their position in life in the context of the culture and its peculiar transformations, as well as to meet their in- value systems in which they live in relation to their dividual needs, thus stimulating their autonomy and goals, expectations, standards and concerns [4]”. power of choice and envisaging the achievement of a In the health area, QoL is directed by the collective better health-related quality of life from the perspective construction of comfort and well-being, as well as iden- of health promotion. tifies the impact of diseases, dysfunctions and necessary HRQoL is a construct that is difficult to measure and therapeutic health interventions on quality of life. To is therefore often evaluated by objective instruments, meet these needs and to avoid ambiguity, the concept of characterized by lists of predefined variables that cannot quality of life was sub-divided into health-related quality reach multifactorial dimensions, meanings and experi- of life (HRQoL) [5]. ences. It is noteworthy that the study is innovative be- HRQoL is a concept that represents a person’s own cause it prioritizes the evaluation of HRQoL in pregnant perception of their subjective state of health, functioning women subjectively, in addition to encompassing preg- and well-being in the physical, psychological, and social nant women in the private service, since most studies domains and in their role performance [6]. are performed in public services. Although public policies guarantee women their sexual The present study is relevant due to the scarcity of and reproductive rights, the improvement of the quality international studies evaluating HRQoL during preg- of care regarding the redirection of services often still fo- nancy in women without associated clinical conditions, cuses on a medicalized, hospital-centric and technocratic as well as the importance of understanding the perspec- model, therefore remaining a challenge for the health tives of the women themselves. system. Thus, evaluating the quality of life of this The present study aimed to evaluate the predictors population can provide a foundation for a new look at that influence the HRQoL of low-risk pregnant women, the implementation of more effective practices for the as well as to describe the main areas that affect quality promotion of maternal health. of life of these women. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 3 of 10 Methods information about completing the instruments, with- Participants and procedures out being provided the answers. The instruments This is a cross-sectional study conducted in a large city were filled in a reserved place, with an average dur- in the Northeast of Brazil in three different collection ationof45min perinterview. fields: two public and one private. A public health care unit was attached to a federal university, and served the Measures population ascribed to its surrounding area; while the To evaluate the health-related quality of life of low-risk other health care unit was part of the municipal health pregnant women, two data collection instruments were network. The private health care unit was characterized used: a questionnaire covering sociodemographic, obstet- by being a clinic that offered integrated care in the ob- ric and health-related quality of life data; and an instru- stetric and gynecological area to women with a higher ment associated with quality of life, the Mother-Generated socioeconomic level. Index (MGI), which was adapted and validated into a Bra- For the purpose of sample calculation, the population zilian version by Ribeiro [10]. number of 798 pregnant women was used, resulting The MGI is a single-sheet instrument subdivided into from the sum of monthly visits of the three collection three sections. In the first section, each participant is in- sites. The sample calculation was performed using the vited to identify eight areas of her life that were affected formula for studies with finite samples. A 95% confi- during the last thirty days of gestation since the interview, dence interval was established, with 1.96 as level of sig- classifying them as negative, positive or both/none. Then, nificance expressed as the standard deviation (σ), a in section 2, the women score each area cited in the previ- maximum permissible error (e) of 0.05, and a prevalence ous section on visual analogue scales varying from 0 to 10, (p) of 50%. Thus, the sample consisted of 261 pregnant with 0 representing the worse and 10 the best score. This women, of whom 120 were interviewed in the private in- score indicates the perception of quality of life, consider- stitution and 141 in the public institution. ing how the woman feels during pregnancy. In section 3, As inclusion criteria, pregnant women who were the women must distribute 20 points between the areas under low-risk prenatal follow-up, with confirmed gesta- described, according to the degree of importance they tion, and without cognitive limitations that could pre- have over health-related quality of life [11]. vent them from responding to the interview were The primary score will be the mean scores on the vis- included in the study. ual analog scales identified in section 2. This result re- Prenatal care may be classified in terms of gesta- flects how the woman perceives the influence of every tional risk and may be low risk (or usual risk) and aspect in her life, which has been modified during gesta- high risk. Low-risk or normal-risk pregnancy can be tion or puerperium. It is noteworthy that in this study, defined as a pregnancy that does not require the use the women investigated were pregnant. of high-technological-density health care and in Each score from Step 2 is then multiplied by the which maternal and perinatal morbidity and mortal- points spent in that area in Step 3. The sum of these in- ity are equal to or lower than those of the general dividual scores is then divided by the total (20), which population. However, the classification of gestational gives the secondary score. This article considered the risk can only be defined at the end of gestation, after scores generated by the primary score, following the childbirth and puerperium, considering that its same trajectory of the pilot study that introduced MGI course is dynamic, requiring continuous and specific in the assessment of quality of life in women [12]. evaluations at each period [9]. The coding of the comments in section 1 was per- Data were collected between September and Novem- formed independently by two authors, with more than ber 2014 by the main researcher and master’s and 95% agreement on the classification used. Subsequently, a undergraduate nursing students who were part of the consensus was reached in which the commonly cited areas Sexual and Reproductive Health research group. For this among the pregnant women investigated were listed [12]. data collection, these collaborators were properly trained This instrument allows the pregnant women to identify, in how to approach the research participants and how to based on their reflections on sociocultural elements, the correctly apply the instrument. areas that may influence their quality of life, which could be All women with scheduled prenatal consultations overlooked by pre-formulated measurement instruments were approached by the team of researchers while [12], and which do not allow for such subjectivity when the waiting in the waiting room of the selected health evaluated construct is the health-related quality of life. services; thus, these women served as a convenience MGI content and punctuation scores determined by sample. The pregnant women who met the inclusion mothers may point to areas in which health professionals criteria and who agreed to participate in the study execute strategies to promote quality of life related to signed the informed consent terms and were given pregnant women’shealth [13]. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 4 of 10 Statistical analysis dependent variable (quality of life during the gestational The data were presented in tables and later analyzed in period, i.e., MGI score). These associations were consid- light of the pertinent literature on the subject. ered statistically significant when the p-value was ≤0.05. The analysis of maternal data and quality of life indices Multiple regression analysis (stepwise model) was used to was performed using the Statistical Package for Social determine which of the analyzed variables could be con- Sciences (SPSS) software, version 21.0 [14]. A preliminary sidered predictors for health-related quality of life during analysis was started with descriptive statistics tests pregnancy. (mean, standard deviation and frequency) and outliers This study was approved by the Research Ethics (discrepant values) to clear the data set. The missing Committee of the Maternity School Assis Chateaubriand values, which represented less than 10% of the data, under protocol 770.902. were replaced by the means of the values assumed by the respective variable. Results The variables of the sociodemographic characteristics A total of 261 interviewees, the mean age of the was investigated were as follows: age (years), companion 28 years; 88.5% (231) had a stable partner. A total of 70.9% presence (yes/no), schooling (years), occupation (house- (185) had completed high school, and of these individuals, hold/non-household), marital status (single, married, 44.8% (117) had attended undergraduate or postgraduate stable union), with whom they live (companion/family), courses. A total of 59% (154) had a paid job. A total of 34. type of dwelling (own/non-proper), use of illicit drugs 1% (89) had a monthly family income received between 1 (yes/no), partner support (yes/no) and family income and 2 minimum wages, and 38.3% (100) had family income (minimum wage amount). greater than 6.1 minimum wages. Family income emphasizes that the minimum wage is The obstetric data revealed that 48.1% (125) of the sample the lowest monetary payment, defined by law, that a were in the second trimester of gestation. A total of 76.6% worker must receive in a company for his services. The (200) of the sample had begun prenatal consultations before value of the minimum wage is defined by a decree of na- the 12th week of gestation. Regarding parity, 56.7% (148) tional law and is reassessed annually based on the were nulliparous, and 68.1% (77) of the women who had current cost of living of the population, about the basic previous births underwent abdominal deliveries. needs of workers and their families [15]. At the time of The participants’ responses were analyzed using the the survey, the current minimum wage was R$915.00 Mother Generated Index (Brazilian version) [10]. The (nine hundred and fifteen reais). following data presented in Table 1 are related to the The obstetric variables included the following: gesta- eight most prevalent areas that influenced the health- tional age (weeks), beginning of prenatal visits (weeks), related quality of life of pregnant women, according to parity (nulliparous/multiparous) and type of delivery (ab- the categories positive, negative or both/none. The other dominal/vaginal). The variable health-related quality of areas had less than 5% of citations. Of the variables in- life was categorized as positive, negative, or both/none. vestigated, schooling, income, prenatal start and type of Fisher’s exact test, one-way ANOVA test (one way), chi- delivery were not statistically significant; therefore, they square test and likelihood ratio were used to support the were not considered predictors of HRQoL. bivariate analysis, which aimed to verify the association Among the eight areas mentioned, it was observed between the independent variables (sociodemographic that in absolute numbers, those most cited by pregnant and obstetric characteristics of the mother) and the women were relationship with the partner (172/65.9%), Table 1 Distribution of the most affected areas of the quality of life of low-risk pregnant women AREAS SCORE Total Positive Negative Both/None N Mean (SD) N Mean (SD) N Mean (SD) N Mean (SD) Rel. with partner 172 5.01 (4.07) 134 5.25 (4.00) 24 4.13 (4.52) 14 4.07 (3.58) Rel. with family 140 8.13 (2.81) 107 9.49 (0.90) 19 3.05 (2.73) 14 4.64 (1.33) Sleep 129 3.95 (2.72) 23 8.65 (1.11) 99 2.79 (1.67) 7 5.00 (0.00) Happiness to become a mother 99 9.80 (0.75) 99 9.80 (0.75) –– – – Job 94 4.46 (3.06) 23 8.83 (1.37) 54 2.43 (1.75) 17 5.00 (0.00) Fatigue 87 2.63 (1.75) –– 87 2.63 (1.75) –– Body image 85 4.15 (3.52) 26 8.69 (1.68) 55 1.95 (1.75) 4 5.00 (0.00) Polyuria 65 2.25 (1.92) –– 61 2.05 (1.71) 4 5.00 (0.00) Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 5 of 10 relationship with the family (140/53.6%) and sleep (99/ It should be noted that the confidence interval (95%) 49.42%). The least-cited area was polyuria (65/24.9%). does not contain the value 1, and therefore, the relation- The areas with the greatest positive influence on the ship between predictors (occupation, parity, partner sup- quality of life reported by the pregnant women, according port, marital status and persons with whom the woman to the calculated mean, were as follows: happiness to be- lives) and the dependent variable (HRQoL in pregnancy) come a mother, which had the highest mean score (9.80); is generalizable to the population. and relationship with the family (9.49). The area with the least positive influence was polyuria, with the lowest mean Multivariate analysis: Negative predictors of quality of life score (2.25). in low-risk prenatal pregnant women The areas with the greatest negative influence de- The predictors that negatively influenced the quality of life of scribed by the sample were as follows: body image (1.95) pregnant women and their respective affected areas were as , polyuria (2.05) and job (2.43). follows: gestational age/nausea and vomiting (p=0.000); When considering only the positive scores, happiness type of housing/fatigue (p = 0.002); occupation/work to become a mother had the highest mean (9.80). In the (p = 0.000); polyuria (p = 0.004) and fatigue (p = 0.006); same way, considering only the negative scores, the area illicit drugs/nausea and vomiting (p = 0.005); lack of that stood out as the most negative was body image, partner support/body image (p = 0.031) and age/sleep with a mean of 1.95. (p = 0.47) (Table 3). The mean of the primary scores (mean scores from 0 to The first predictive variable included in the regression 10 described in section 1) of the MGI (Brazilian version) that negatively influenced HRQoL was gestational age, was calculated based on the scores attributed to the most which had the highest bivariate correlation with the affected areas of quality of life, with a value of 4.84. dependent variable, HRQoL (p = 0.000), and was related to “nausea and vomiting”. The predictive variables se- Multivariate analysis: Positive predictors of quality of life lected in the following steps were, consecutively, as fol- in low-risk prenatal pregnant women lows: type of housing, occupation, illicit drugs, lack of The predictors that positively influenced the quality of life partner support and maternal age, which were related to of pregnant women and their respective affected areas the following areas listed by the pregnant women: were as follows: occupation/self-esteem (p =0.000); par- “fatigue”, “work”, “polyuria”, “body image” and “sleep”. ity/relationship with the family (p =0.005); partner sup- Assumptions for multicollinearity were examined be- port/relationship with the partner (p =0.018); marital cause of the combination of variables. The tolerance in status/relationship with the partner (p =0.029) and per- the regression equation was 1.00, and the VIF in the final sons with whom the woman lives/anxiety for the baby’s model was 1.00; thus, the assumptions for multicolli- birth (p = 0.049) (Table 2). nearity were not violated. The first predictive variable included in the regression Regarding the individual predictors, the confidence that positively influenced HRQoL was occupation, which interval (95%) does not contain the value 1, and there- had the highest bivariate correlation with the dependent fore, the relationship between the predictors (type of variable, i.e., HRQoL (p = 0.000), and was related to the housing, occupation, illicit drugs, lack of partner support “self-esteem” area. The predictive variables identified in and maternal age) and the dependent variable (HRQoL the following steps were, consecutively, as follows: par- in gestation) is generalizable for the studied population. ity, partner support, marital status and persons with whom the woman lives, who were related to the follow- Discussion ing areas listed by the pregnant women, respectively: “re- The HRQoL is a broad and subjective concept that al- lationship with the family”, “relationship with the lows the subjects in research studies to show their per- partner” and “anxiety for the baby’s birth”. ception of the object studied. Table 2 Multiple regression (stepwise) between predictors that positively influenced the HRQoL of pregnant women Predictive variable Area Affected B SD β R 95% CI for B p (Lower - Higher) Occupation Self-esteem .375 .095 .259 0.14 (0.188–0.561) 0.000 Parity Relationship with the family .303 .107 .316 0.16 (0.091–0.514) 0.005 Partner Support Relationship with the partner .620 .260 .158 0.22 (0.109–0.132) 0.018 Marital status Relationship with the partner .190 .086 .142 0.23 (0.020–0.360) 0.029 Persons with whom the woman lives Anxiety for the baby’s birth .047 .024 .161 0.30 (0.000–0.094) 0.049 *p < .05, significant correlation B - partial regression coefficient, SD standard deviation, β standardized regression coefficient, CI confidence interval Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 6 of 10 Table 3 Multiple regression (stepwise) among predictors that negatively influenced the HRQoL of pregnant women (MGI Brazilian version) Predictive variable Area Affected B SD β R 95% CI for B P (Lower - Higher) Gestational age Nausea and vomiting 0.460 0.068 0.400 0.15 (0.595–0.325) 0.000 Type of housing Fatigue .353 .112 .202 0.29 (0.132–0.574) 0.002 Occupation Work −0.837 0.179 − 0.350 0.45 (−1.189–0.484) 0.000 Polyuria .411 .143 .227 0.37 (0.130–0.692) 0.004 Fatigue −.413 .148 −.416 0.39 (−0.705–0.121) 0.006 Illicit drugs Nausea and vomiting −2.242 .796 −.171 0.46 (−3.810–0.674) 0.005 Partner support (lack) Body image .647 .298 .151 0.50 (0.060–0.235) 0.031 Age Sleep .221 .111 .165 0.51 (0.003–0.439) 0.047 *p < .05, significant correlation B - partial regression coefficient; SD standard deviation, β standardized regression coefficient, CI confidence interval Among the many tools that evaluate quality of life, the From this perspective, the present study evidenced choice of the MGI is justified by its higher specificity, ab- some predictors that exerted a 30% positive variation in sence of pre-formulated questions, and the possibility of quality of life during pregnancy, namely, occupation, revealing domains of diverse contexts considered import- parity, partner support, marital status, and persons with ant for each woman who is experiencing the pregnancy or whom the women live. puerperal process, according to their life experiences. Occupation as a predictive variable positively influ- The subjectivity inherent to this instrument enables enced self-esteem scores, corroborating the worldwide the researcher to have a closer relationship with the trend that women performing other functions in search pregnant or puerperal woman, thus allowing quality of of financial stability and job satisfaction demonstrate life to be reflected and investigated from the inter- greater self-esteem. However, different results were viewee’s own perspective, which gives the information found in other studies, revealing that pregnant women more depth. According to a systematic review, the ana- belonging to high economic classes were affected with lysis of instruments assessing quality of life during child- low self-esteem [21] and that in pregnant adolescents, birth and the puerperium found that the MGI was the occupation did not influence self-esteem [22]. second-most commonly used quality of life assessment Parity was another predictor analyzed by this study and instrument to evaluate this construct [16]. was associated with the “family relationship” area. It was Despite the subjective nature of the MGI, its use in evident that the support that pregnant women receive from nine countries of different social and cultural configura- their relatives is important for the maintenance or improve- tions has shown similar results of primary and secondary ment of their quality of life. For nulliparous pregnant scores in some countries, which leads us to infer that women, which were the majority in this study, gestation some common aspects pervade the experience of the was considered an important event in the establishment of puerperal cycle of pregnancy, regardless of race or na- a family bond, with major repercussions in the construction tionality, and these aspects can influence the quality of of thefamilyand in theformation of affectivetiesamong life of these women [17–19]. its members. The support network of the pregnant women When a tool is adapted for use in another cultural studied was formed mainly by parents and in-laws, who context, the interpretation of the process and of the re- provided family, emotional, financial and instrumental sup- sult gains an even greater importance [19]. Although a port to mothers, fathers and children. patient-generated instrument eventually eliminates ir- A study carried out with 100 pregnant women evalu- relevant items, this advantage occurs to the detriment of ated the association between social support and depres- generalization [20]. sive symptomatology, stress, anxiety and mother/child The above can justify the choice of the MGI as an ad- bonding, where it was observed that social support was equate tool to evaluate the quality of life of pregnant negatively related to anxiety and depression and posi- women. tively related to maternal attachment. The study also The results of the study showed that physical, psycho- found a negative association between anxiety and de- logical, environmental and social changes during preg- pression and maternal attachment [23]. nancy are influenced by the context in which the Another area of positive outcomes for gestational pregnant woman is inserted and by how she relates to quality of life assessed in this study was the “relationship herself and to other people. with the partner”. The women in the present study who Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 7 of 10 had a stable relationship with their partners had better It is assumed that the process of drug addiction in the QoL indicators. Thus, it is possible to infer that the gestational period is coupled with deficient self-care, as pregnant woman who receives support from her com- well as deficient care with the gestational itself, which panion is more likely to have a positive pregnancy ex- makes the binomial more susceptible to health problems perience. The role of the partner/father is fundamental that interfere negatively with quality of life, given the in the support matrix, through its valorization and omission of this information by pregnant women for fear through protection directed to the mother and the baby. of being reprimanded by health professionals. Social support is support given by the partner, family The type of housing was observed to negatively predict and friends, which makes the pregnant women feel sup- “fatigue” among the pregnant women; however, these as- ported in their needs, increasing their capacity to ad- pects are poorly investigated from the perspective of dress difficult situations [24, 25]. quality of life. The result of a Brazilian study on the “People with whom the pregnant woman lives” was a quality of life of high-risk pregnant women showed that predictor that was associated with the anxiety generated regardless of whether or not the participants had their by the baby’s birth. It is believed that a healthy environ- own housing, the quality of life related to family life was ment is important for the health and development of a a priority [31]. child, promoting comfort to the mother. However, data The results indicated that occupation was a predictor that could reveal similarities to the present findings were of the following areas: “job”, “polyuria” and “fatigue”.In not found in the existing literature. the evaluation of the work activity, 36% of the inter- As to negative predictive variables, 51% of the negative viewed women cited job as an influencer of quality of variation in the quality of life of pregnant women was ex- life, but among these women, 57.44% considered work a plained by gestational age, type of housing, occupation, negative aspect for their quality of life, due to the pre- illicit drugs, lack of partner support and maternal age. occupation with the permanence of their position in the The variables illicit drugs and gestational age influenced job after the birth of the baby, instability in maintaining the area “nausea and vomiting”. The relationship between the employment and lack of support from bosses to- gestational age and nausea and vomiting presents peculi- wards their gestation. arities in each trimester of gestation, linked to psycho- The MGI results in Scotland showed that unemployed physiological changes that may influence these women. women had lower scores than those who were employed Eighty percent of women suffer from nausea and vomiting [11]. The possibility of loss of employment directly re- during their first trimester, more frequently between the flects on the economic conditions of the family, which 6th and 12th weeks, and can continue to experience these can contribute to stressful pregnancy events associated events until the 20th week [26]. with low birth weight, the occurrence of miscarriages Severe episodes of nausea and vomiting can affect preg- and premature labor [32]. nant women’s daily social lives, as well as their relation- A study carried out with pregnant workers revealed ships with family members and partners. These episodes that the occupational situation, considering the physical can also burden the health system with the increasing so- effort, the workload, and the stress, in addition to their cioeconomic costs associated with increasing severity of work in the home, can interfere with exposure to gesta- NVP [27], which has become one of the main justifica- tional risks, such as spontaneous abortions, preterm tions for being on medical leave during pregnancy [28] births and births with low weight. In addition, tiredness and may have an impact on quality of life. and sleep were the main complaints reported by preg- With regard to the use of illicit drugs, it is valid to nant women during the workday [33]. consider that the pharmacological effects enhance the Nocturnal “polyuria” is considered a type of urinary in- already-present predisposition for nausea and vomit- continence (UI) and constitutes the main compromising ing, potentiating their occurrence. However, no data factor of sleep quality among pregnant women at all gesta- were found in the literature on the correlation be- tional ages. Having to wake up several times during the tween illicit drugs and episodes of nausea and vomit- night to go to the bathroom results in drowsiness the next ing during pregnancy. day, leading to a greater need for extra sleep during this Much of the description of the use of illicit drugs dur- period, also resulting in daily fatigue and compromising ing pregnancy has been associated with an increase in quality of life [34]. In addition, polyuria requires attention the prevalence of unplanned pregnancies and sexually during gestation and in the postpartum period, in order to transmitted diseases (STDs), besides HIV infection [29]. strengthen the pelvic muscles as prevention of post- Among pregnant women who are illicit drug users, there pregnancy pelvic floor dysfunctions, a condition that may is lower participation in prenatal consultations, lower cause injury to women’squality of life [35]. participation in health education groups, and greater risk A study conducted to compare the quality of life in of obstetric and fetal complications [30]. pregnant women with and without UI concluded that Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 8 of 10 incontinent pregnant women felt more affected in their support and maternal age were the predictors that performance of daily activities. However, it can be said negatively influenced quality of life. that UI had an impact on the HRQoL of pregnant Thus, individualized, holistic and shared assistance for women [36]. the pregnant woman and her relatives, focusing on the Women perceive changes in their body image starting cited predictors, provides the basis for the planning and at the beginning of pregnancy. The way to cope with implementation of actions aimed at improving health- these changes can be influenced by several factors, in- related quality of life. cluding partner support or the lack thereof. The results Abbreviations indicated that the lack of support from the partner is a ANOVA: Analysis of variance; HIV: Human immunodeficiency virus; predictor of body image, possibly triggering low self- HRQoL: Health-related quality of life; MGI: Mother generated index; QoL: Quality of life; SPSS: Statistical package for social sciences; STD: Sexually esteem, non-acceptance of pregnancy and even depres- transmitted diseases; UI: Urinary incontinence; WHO: World Health sive symptoms. The partner’s emotional support contrib- Organization utes to the strengthening of the affective relationship Acknowledgements and improvement of self-esteem, which positively re- This study was supported by the Doctorate course at the Faculty of Nursing, flects the quality of life of pregnant woman [37]. Federal University of Ceara, the Basic Health Units and the clinical The psychological support provided by health profes- Feminimagem. We wish to thank our colleagues Hellen Catunda, Diego Jorge, Eveliny Martins, Elizian Braga who helped us collect data and to sionals is fundamental both in childbirth and in postpar- Professor Andrew Symon for their willingness to elucidate any doubts about tum, especially in the detection and prevention of the the Mother Generated-Index (MGI) instrument. Last but not least, we conditions such as postpartum anxiety and depression. thank our participants, who shared their time and experiences with us. The variable maternal age was considered a health Funding predictor of quality of life among the participants, influ- Own resources. encing sleep quality. A study of pregnant adolescents re- Availability of data and materials vealed that sleep disturbances were more common in The datasets generated and/or analysed during the current study are not older adolescents, probably reflecting the accumulation publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are of housework and maternal care with other children, available from the corresponding author on reasonable request. resulting in more stress and poorer sleep quality [38]. In Authors’ contributions contrast to this result, other studies indicate a higher CGPC, PRALS, AKBP, RCMBC, MFO, RAB and SKML conceived the study, prevalence of sleep in younger pregnant women, prob- participated in the data collection, coordinated the study, performed the statistical analysis and drafted the manuscript. PSA, FHCC and FJA ably due to the presence of the hormonal changes char- participated in the design and helped to draft the manuscript. All authors acteristic of this age group [39]. read and approved the final manuscript. It is known that sleep is a vital need for human beings, Ethics approval and consent to participate and sleep disorders are a relevant theme that should be Ethical approval to conduct the study was granted by the Committee of taken into account in the planning and implementation Ethics in Research of Maternity School Assis Chateaubriand, under number of of care for pregnant women. opinion 770.902 (Certificate of presentation for ethical assessment (CAAE34931614.9.0000.5050); 2014/08/28). Written pregnant’s consents were Quality health care, when offered to women during obtained before participants were included in the study. Participants were pregnancy, may prevent a number of problems for the reassured that the data would be treated with strict confidentiality and no mother-child binomial after childbirth. This assistance personal information would be disclosed to any third party. Participation was on a voluntary basis and no remuneration was involved. should be based on principles such as integrality, ethics and respect. Considering populations such as pregnant Competing interests women, who, in their exposure to diverse settings, are The authors declare that they have no competing interests. influenced by numerous bio-psycho-social factors, it is imperative to have a plan of care that meets the real Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in needs of this group during the gestational period. published maps and institutional affiliations. Conclusion Author details Nursing Department, Federal University of Ceara, Alexandre Baraúna Street, Theareas with thegreatestpositiveand negative in- 1115, Rodolfo Teófilo, Fortaleza, Ceará 60430 – 160, Brazil. Nursing fluence on the health-related quality of life of preg- Department, Regional University of Cariri, Coronel Antônio Luís Street, 1161, nant women were happiness to become a mother and Pimenta, Crato, Ceará 63.105-100, Brazil. Federal University of Cariri, Juazeiro do Norte, Ceara, Brazil. body image, respectively. In addition, occupation, par- ity, partner support, marital status and persons with Received: 23 March 2017 Accepted: 29 April 2018 whom the women live were the predictors that posi- tively interfered in the quality of life of pregnant References women. In contrast, gestational age, type of housing, 1. Montenegro CAB, Rezende FJ. Obstetrícia Fundamental. 12ª ed. Rio de occupation, use of illicit drugs, non-receipt of partner Janeiro: Guanabara Koogan; 2013. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 9 of 10 2. Maldonado MT. Psicologia na gravidez. Parto e Puerpério. 16ª ed. São Paulo: 20. 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Abstract

Background: Gestation is a period that can positively or negatively influence the life of a woman in the pregnancy- puerperal cycle. Thus, evaluating the quality of life of this population can redirect the implementation of innovative practices, with the goal of making them more effective and practical or the promotion of humanized care. The present study aimed to evaluate the predictors that influence the health-related quality of life of low-risk pregnant women, as well as to describe the main areas affected in the quality of life of pregnant women. Methods: A correlational, quantitative and cross-sectional study was carried out in two public units that provide prenatal care services and a private unit in the city of Fortaleza, a municipality in the Northeast of Brazil. The sample consisted of 261 pregnant women who were interviewed from September to November 2014. The collection instruments were a questionnaire covering sociodemographic, obstetric and quality of life variables, in addition to the Brazilian version of the Mother-Generated Index (MGI). The data were compiled and analyzed through the Statistical Package for the Social Sciences (SPSS) software, version 20.0. A descriptive analysis was performed through the application of Pearson’s chi-square test, Fisher’s exact test and one-way ANOVA. Maternal predictors for the quality of life of pregnant woman were identified through a multivariate analysis/multiple regression. Results: The response rate was 100%, corresponding to 261 respondents. Occupation, parity, partner support, marital status and persons with whom the women live were the predictors that positively interfered in the quality of life of pregnant women. In contrast, gestational age, type of housing, occupation, use of illicit drugs, non-receipt of partner support and maternal age were the predictors that negatively influenced quality of life. Conclusion: Our results indicate that happiness to become a mother and body image were areas with the greatest positive and negative influence on health-related quality of life, which suggests being relevant aspects in the planning and implementation of actions aimed at its improvement. Keywords: Quality of life, Prenatal care, Nursing * Correspondence: cinthiacalou@hotmail.com Nursing Department, Federal University of Ceara, Alexandre Baraúna Street, 1115, Rodolfo Teófilo, Fortaleza, Ceará 60430 – 160, Brazil Nursing Department, Regional University of Cariri, Coronel Antônio Luís Street, 1161, Pimenta, Crato, Ceará 63.105-100, Brazil Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 2 of 10 Background In the Brazilian scenario, the Stork Network was imple- Pregnancy is a singular moment in the life of a woman, ex- mented in 2011 in order to improve the quality of care perienced as a physiological process of the female organism. and increase access to prenatal care. This improvement is However, although it is a natural process, gestation is charac- achieved through comprehensive care, linking pregnant terized by a period of intense transformations in the life of women to referral units, providing safe transportation and the woman, demanding an adaptation towards motherhood. implementing good practices in labor and childbirth care, These transformations occur in emotional and physio- including preserving the right of women’sfree choice of logical contexts, mainly due to hormonal and mechan- companion at childbirth, respecting all the necessary re- ical factors. Changes in posture-ambulation, metabolism, quirements for individualized assistance, and having the urinary system, the respiratory system, and female humanization and fewer damages due to inadequate care genitalia are also present in this period [1]. as the main focus, as well as promoting a better quality of Gestation is a period in which the social insertion of life to the mother-child binomial [7]. women can positively or negatively influence the quality In developed countries, the focus of prenatal care has of life, requiring a maturation and mastery of certain gone beyond traditional principles and now includes in its stages of development established by the pregnancy guidelines psychological support and encouragement to process: the acceptance of the gestation, the conception pregnant women, promoting in some situations the im- of the role of mother, the reorganization of relationships provement of the quality of life of pregnant women [8]. and the preparation for childbirth [2]. The sum of these Thus, during low-risk prenatal care, which consists of changes translates into the need to prepare pregnant gestation that does not present any risk factors of any women to assume new responsibilities and perform their size that may negatively affect the evolution of preg- new role as mothers. nancy [9], the follow-up of qualified health professionals, It is worth emphasizing that the changes that preg- such as physicians and nurses, is an important and nant women experience are transient, but they can timely moment to evaluate the HRQoL in this more spe- change their quality of life. These changes are sig- cific population, since it is understood that low-risk nificant, and those responsible for their care must pregnant women tend to naturalize the transformations know about these changes sufficiently to implement inherent in pregnancy. Because they do not assign the effective health actions through preparing women necessary importance to the process, situations may re- with the knowledge and skills necessary to address sult that compromise quality of life. the pregnancy-puerperal process [3]. In this context, health professionals involved in assist- In 1994, the World Health Organization (WHO) de- ing the pregnant woman will be able to understand how fined quality of life (QoL) as “the individuals’ perception the process of gestation is experienced, considering all of of their position in life in the context of the culture and its peculiar transformations, as well as to meet their in- value systems in which they live in relation to their dividual needs, thus stimulating their autonomy and goals, expectations, standards and concerns [4]”. power of choice and envisaging the achievement of a In the health area, QoL is directed by the collective better health-related quality of life from the perspective construction of comfort and well-being, as well as iden- of health promotion. tifies the impact of diseases, dysfunctions and necessary HRQoL is a construct that is difficult to measure and therapeutic health interventions on quality of life. To is therefore often evaluated by objective instruments, meet these needs and to avoid ambiguity, the concept of characterized by lists of predefined variables that cannot quality of life was sub-divided into health-related quality reach multifactorial dimensions, meanings and experi- of life (HRQoL) [5]. ences. It is noteworthy that the study is innovative be- HRQoL is a concept that represents a person’s own cause it prioritizes the evaluation of HRQoL in pregnant perception of their subjective state of health, functioning women subjectively, in addition to encompassing preg- and well-being in the physical, psychological, and social nant women in the private service, since most studies domains and in their role performance [6]. are performed in public services. Although public policies guarantee women their sexual The present study is relevant due to the scarcity of and reproductive rights, the improvement of the quality international studies evaluating HRQoL during preg- of care regarding the redirection of services often still fo- nancy in women without associated clinical conditions, cuses on a medicalized, hospital-centric and technocratic as well as the importance of understanding the perspec- model, therefore remaining a challenge for the health tives of the women themselves. system. Thus, evaluating the quality of life of this The present study aimed to evaluate the predictors population can provide a foundation for a new look at that influence the HRQoL of low-risk pregnant women, the implementation of more effective practices for the as well as to describe the main areas that affect quality promotion of maternal health. of life of these women. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 3 of 10 Methods information about completing the instruments, with- Participants and procedures out being provided the answers. The instruments This is a cross-sectional study conducted in a large city were filled in a reserved place, with an average dur- in the Northeast of Brazil in three different collection ationof45min perinterview. fields: two public and one private. A public health care unit was attached to a federal university, and served the Measures population ascribed to its surrounding area; while the To evaluate the health-related quality of life of low-risk other health care unit was part of the municipal health pregnant women, two data collection instruments were network. The private health care unit was characterized used: a questionnaire covering sociodemographic, obstet- by being a clinic that offered integrated care in the ob- ric and health-related quality of life data; and an instru- stetric and gynecological area to women with a higher ment associated with quality of life, the Mother-Generated socioeconomic level. Index (MGI), which was adapted and validated into a Bra- For the purpose of sample calculation, the population zilian version by Ribeiro [10]. number of 798 pregnant women was used, resulting The MGI is a single-sheet instrument subdivided into from the sum of monthly visits of the three collection three sections. In the first section, each participant is in- sites. The sample calculation was performed using the vited to identify eight areas of her life that were affected formula for studies with finite samples. A 95% confi- during the last thirty days of gestation since the interview, dence interval was established, with 1.96 as level of sig- classifying them as negative, positive or both/none. Then, nificance expressed as the standard deviation (σ), a in section 2, the women score each area cited in the previ- maximum permissible error (e) of 0.05, and a prevalence ous section on visual analogue scales varying from 0 to 10, (p) of 50%. Thus, the sample consisted of 261 pregnant with 0 representing the worse and 10 the best score. This women, of whom 120 were interviewed in the private in- score indicates the perception of quality of life, consider- stitution and 141 in the public institution. ing how the woman feels during pregnancy. In section 3, As inclusion criteria, pregnant women who were the women must distribute 20 points between the areas under low-risk prenatal follow-up, with confirmed gesta- described, according to the degree of importance they tion, and without cognitive limitations that could pre- have over health-related quality of life [11]. vent them from responding to the interview were The primary score will be the mean scores on the vis- included in the study. ual analog scales identified in section 2. This result re- Prenatal care may be classified in terms of gesta- flects how the woman perceives the influence of every tional risk and may be low risk (or usual risk) and aspect in her life, which has been modified during gesta- high risk. Low-risk or normal-risk pregnancy can be tion or puerperium. It is noteworthy that in this study, defined as a pregnancy that does not require the use the women investigated were pregnant. of high-technological-density health care and in Each score from Step 2 is then multiplied by the which maternal and perinatal morbidity and mortal- points spent in that area in Step 3. The sum of these in- ity are equal to or lower than those of the general dividual scores is then divided by the total (20), which population. However, the classification of gestational gives the secondary score. This article considered the risk can only be defined at the end of gestation, after scores generated by the primary score, following the childbirth and puerperium, considering that its same trajectory of the pilot study that introduced MGI course is dynamic, requiring continuous and specific in the assessment of quality of life in women [12]. evaluations at each period [9]. The coding of the comments in section 1 was per- Data were collected between September and Novem- formed independently by two authors, with more than ber 2014 by the main researcher and master’s and 95% agreement on the classification used. Subsequently, a undergraduate nursing students who were part of the consensus was reached in which the commonly cited areas Sexual and Reproductive Health research group. For this among the pregnant women investigated were listed [12]. data collection, these collaborators were properly trained This instrument allows the pregnant women to identify, in how to approach the research participants and how to based on their reflections on sociocultural elements, the correctly apply the instrument. areas that may influence their quality of life, which could be All women with scheduled prenatal consultations overlooked by pre-formulated measurement instruments were approached by the team of researchers while [12], and which do not allow for such subjectivity when the waiting in the waiting room of the selected health evaluated construct is the health-related quality of life. services; thus, these women served as a convenience MGI content and punctuation scores determined by sample. The pregnant women who met the inclusion mothers may point to areas in which health professionals criteria and who agreed to participate in the study execute strategies to promote quality of life related to signed the informed consent terms and were given pregnant women’shealth [13]. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 4 of 10 Statistical analysis dependent variable (quality of life during the gestational The data were presented in tables and later analyzed in period, i.e., MGI score). These associations were consid- light of the pertinent literature on the subject. ered statistically significant when the p-value was ≤0.05. The analysis of maternal data and quality of life indices Multiple regression analysis (stepwise model) was used to was performed using the Statistical Package for Social determine which of the analyzed variables could be con- Sciences (SPSS) software, version 21.0 [14]. A preliminary sidered predictors for health-related quality of life during analysis was started with descriptive statistics tests pregnancy. (mean, standard deviation and frequency) and outliers This study was approved by the Research Ethics (discrepant values) to clear the data set. The missing Committee of the Maternity School Assis Chateaubriand values, which represented less than 10% of the data, under protocol 770.902. were replaced by the means of the values assumed by the respective variable. Results The variables of the sociodemographic characteristics A total of 261 interviewees, the mean age of the was investigated were as follows: age (years), companion 28 years; 88.5% (231) had a stable partner. A total of 70.9% presence (yes/no), schooling (years), occupation (house- (185) had completed high school, and of these individuals, hold/non-household), marital status (single, married, 44.8% (117) had attended undergraduate or postgraduate stable union), with whom they live (companion/family), courses. A total of 59% (154) had a paid job. A total of 34. type of dwelling (own/non-proper), use of illicit drugs 1% (89) had a monthly family income received between 1 (yes/no), partner support (yes/no) and family income and 2 minimum wages, and 38.3% (100) had family income (minimum wage amount). greater than 6.1 minimum wages. Family income emphasizes that the minimum wage is The obstetric data revealed that 48.1% (125) of the sample the lowest monetary payment, defined by law, that a were in the second trimester of gestation. A total of 76.6% worker must receive in a company for his services. The (200) of the sample had begun prenatal consultations before value of the minimum wage is defined by a decree of na- the 12th week of gestation. Regarding parity, 56.7% (148) tional law and is reassessed annually based on the were nulliparous, and 68.1% (77) of the women who had current cost of living of the population, about the basic previous births underwent abdominal deliveries. needs of workers and their families [15]. At the time of The participants’ responses were analyzed using the the survey, the current minimum wage was R$915.00 Mother Generated Index (Brazilian version) [10]. The (nine hundred and fifteen reais). following data presented in Table 1 are related to the The obstetric variables included the following: gesta- eight most prevalent areas that influenced the health- tional age (weeks), beginning of prenatal visits (weeks), related quality of life of pregnant women, according to parity (nulliparous/multiparous) and type of delivery (ab- the categories positive, negative or both/none. The other dominal/vaginal). The variable health-related quality of areas had less than 5% of citations. Of the variables in- life was categorized as positive, negative, or both/none. vestigated, schooling, income, prenatal start and type of Fisher’s exact test, one-way ANOVA test (one way), chi- delivery were not statistically significant; therefore, they square test and likelihood ratio were used to support the were not considered predictors of HRQoL. bivariate analysis, which aimed to verify the association Among the eight areas mentioned, it was observed between the independent variables (sociodemographic that in absolute numbers, those most cited by pregnant and obstetric characteristics of the mother) and the women were relationship with the partner (172/65.9%), Table 1 Distribution of the most affected areas of the quality of life of low-risk pregnant women AREAS SCORE Total Positive Negative Both/None N Mean (SD) N Mean (SD) N Mean (SD) N Mean (SD) Rel. with partner 172 5.01 (4.07) 134 5.25 (4.00) 24 4.13 (4.52) 14 4.07 (3.58) Rel. with family 140 8.13 (2.81) 107 9.49 (0.90) 19 3.05 (2.73) 14 4.64 (1.33) Sleep 129 3.95 (2.72) 23 8.65 (1.11) 99 2.79 (1.67) 7 5.00 (0.00) Happiness to become a mother 99 9.80 (0.75) 99 9.80 (0.75) –– – – Job 94 4.46 (3.06) 23 8.83 (1.37) 54 2.43 (1.75) 17 5.00 (0.00) Fatigue 87 2.63 (1.75) –– 87 2.63 (1.75) –– Body image 85 4.15 (3.52) 26 8.69 (1.68) 55 1.95 (1.75) 4 5.00 (0.00) Polyuria 65 2.25 (1.92) –– 61 2.05 (1.71) 4 5.00 (0.00) Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 5 of 10 relationship with the family (140/53.6%) and sleep (99/ It should be noted that the confidence interval (95%) 49.42%). The least-cited area was polyuria (65/24.9%). does not contain the value 1, and therefore, the relation- The areas with the greatest positive influence on the ship between predictors (occupation, parity, partner sup- quality of life reported by the pregnant women, according port, marital status and persons with whom the woman to the calculated mean, were as follows: happiness to be- lives) and the dependent variable (HRQoL in pregnancy) come a mother, which had the highest mean score (9.80); is generalizable to the population. and relationship with the family (9.49). The area with the least positive influence was polyuria, with the lowest mean Multivariate analysis: Negative predictors of quality of life score (2.25). in low-risk prenatal pregnant women The areas with the greatest negative influence de- The predictors that negatively influenced the quality of life of scribed by the sample were as follows: body image (1.95) pregnant women and their respective affected areas were as , polyuria (2.05) and job (2.43). follows: gestational age/nausea and vomiting (p=0.000); When considering only the positive scores, happiness type of housing/fatigue (p = 0.002); occupation/work to become a mother had the highest mean (9.80). In the (p = 0.000); polyuria (p = 0.004) and fatigue (p = 0.006); same way, considering only the negative scores, the area illicit drugs/nausea and vomiting (p = 0.005); lack of that stood out as the most negative was body image, partner support/body image (p = 0.031) and age/sleep with a mean of 1.95. (p = 0.47) (Table 3). The mean of the primary scores (mean scores from 0 to The first predictive variable included in the regression 10 described in section 1) of the MGI (Brazilian version) that negatively influenced HRQoL was gestational age, was calculated based on the scores attributed to the most which had the highest bivariate correlation with the affected areas of quality of life, with a value of 4.84. dependent variable, HRQoL (p = 0.000), and was related to “nausea and vomiting”. The predictive variables se- Multivariate analysis: Positive predictors of quality of life lected in the following steps were, consecutively, as fol- in low-risk prenatal pregnant women lows: type of housing, occupation, illicit drugs, lack of The predictors that positively influenced the quality of life partner support and maternal age, which were related to of pregnant women and their respective affected areas the following areas listed by the pregnant women: were as follows: occupation/self-esteem (p =0.000); par- “fatigue”, “work”, “polyuria”, “body image” and “sleep”. ity/relationship with the family (p =0.005); partner sup- Assumptions for multicollinearity were examined be- port/relationship with the partner (p =0.018); marital cause of the combination of variables. The tolerance in status/relationship with the partner (p =0.029) and per- the regression equation was 1.00, and the VIF in the final sons with whom the woman lives/anxiety for the baby’s model was 1.00; thus, the assumptions for multicolli- birth (p = 0.049) (Table 2). nearity were not violated. The first predictive variable included in the regression Regarding the individual predictors, the confidence that positively influenced HRQoL was occupation, which interval (95%) does not contain the value 1, and there- had the highest bivariate correlation with the dependent fore, the relationship between the predictors (type of variable, i.e., HRQoL (p = 0.000), and was related to the housing, occupation, illicit drugs, lack of partner support “self-esteem” area. The predictive variables identified in and maternal age) and the dependent variable (HRQoL the following steps were, consecutively, as follows: par- in gestation) is generalizable for the studied population. ity, partner support, marital status and persons with whom the woman lives, who were related to the follow- Discussion ing areas listed by the pregnant women, respectively: “re- The HRQoL is a broad and subjective concept that al- lationship with the family”, “relationship with the lows the subjects in research studies to show their per- partner” and “anxiety for the baby’s birth”. ception of the object studied. Table 2 Multiple regression (stepwise) between predictors that positively influenced the HRQoL of pregnant women Predictive variable Area Affected B SD β R 95% CI for B p (Lower - Higher) Occupation Self-esteem .375 .095 .259 0.14 (0.188–0.561) 0.000 Parity Relationship with the family .303 .107 .316 0.16 (0.091–0.514) 0.005 Partner Support Relationship with the partner .620 .260 .158 0.22 (0.109–0.132) 0.018 Marital status Relationship with the partner .190 .086 .142 0.23 (0.020–0.360) 0.029 Persons with whom the woman lives Anxiety for the baby’s birth .047 .024 .161 0.30 (0.000–0.094) 0.049 *p < .05, significant correlation B - partial regression coefficient, SD standard deviation, β standardized regression coefficient, CI confidence interval Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 6 of 10 Table 3 Multiple regression (stepwise) among predictors that negatively influenced the HRQoL of pregnant women (MGI Brazilian version) Predictive variable Area Affected B SD β R 95% CI for B P (Lower - Higher) Gestational age Nausea and vomiting 0.460 0.068 0.400 0.15 (0.595–0.325) 0.000 Type of housing Fatigue .353 .112 .202 0.29 (0.132–0.574) 0.002 Occupation Work −0.837 0.179 − 0.350 0.45 (−1.189–0.484) 0.000 Polyuria .411 .143 .227 0.37 (0.130–0.692) 0.004 Fatigue −.413 .148 −.416 0.39 (−0.705–0.121) 0.006 Illicit drugs Nausea and vomiting −2.242 .796 −.171 0.46 (−3.810–0.674) 0.005 Partner support (lack) Body image .647 .298 .151 0.50 (0.060–0.235) 0.031 Age Sleep .221 .111 .165 0.51 (0.003–0.439) 0.047 *p < .05, significant correlation B - partial regression coefficient; SD standard deviation, β standardized regression coefficient, CI confidence interval Among the many tools that evaluate quality of life, the From this perspective, the present study evidenced choice of the MGI is justified by its higher specificity, ab- some predictors that exerted a 30% positive variation in sence of pre-formulated questions, and the possibility of quality of life during pregnancy, namely, occupation, revealing domains of diverse contexts considered import- parity, partner support, marital status, and persons with ant for each woman who is experiencing the pregnancy or whom the women live. puerperal process, according to their life experiences. Occupation as a predictive variable positively influ- The subjectivity inherent to this instrument enables enced self-esteem scores, corroborating the worldwide the researcher to have a closer relationship with the trend that women performing other functions in search pregnant or puerperal woman, thus allowing quality of of financial stability and job satisfaction demonstrate life to be reflected and investigated from the inter- greater self-esteem. However, different results were viewee’s own perspective, which gives the information found in other studies, revealing that pregnant women more depth. According to a systematic review, the ana- belonging to high economic classes were affected with lysis of instruments assessing quality of life during child- low self-esteem [21] and that in pregnant adolescents, birth and the puerperium found that the MGI was the occupation did not influence self-esteem [22]. second-most commonly used quality of life assessment Parity was another predictor analyzed by this study and instrument to evaluate this construct [16]. was associated with the “family relationship” area. It was Despite the subjective nature of the MGI, its use in evident that the support that pregnant women receive from nine countries of different social and cultural configura- their relatives is important for the maintenance or improve- tions has shown similar results of primary and secondary ment of their quality of life. For nulliparous pregnant scores in some countries, which leads us to infer that women, which were the majority in this study, gestation some common aspects pervade the experience of the was considered an important event in the establishment of puerperal cycle of pregnancy, regardless of race or na- a family bond, with major repercussions in the construction tionality, and these aspects can influence the quality of of thefamilyand in theformation of affectivetiesamong life of these women [17–19]. its members. The support network of the pregnant women When a tool is adapted for use in another cultural studied was formed mainly by parents and in-laws, who context, the interpretation of the process and of the re- provided family, emotional, financial and instrumental sup- sult gains an even greater importance [19]. Although a port to mothers, fathers and children. patient-generated instrument eventually eliminates ir- A study carried out with 100 pregnant women evalu- relevant items, this advantage occurs to the detriment of ated the association between social support and depres- generalization [20]. sive symptomatology, stress, anxiety and mother/child The above can justify the choice of the MGI as an ad- bonding, where it was observed that social support was equate tool to evaluate the quality of life of pregnant negatively related to anxiety and depression and posi- women. tively related to maternal attachment. The study also The results of the study showed that physical, psycho- found a negative association between anxiety and de- logical, environmental and social changes during preg- pression and maternal attachment [23]. nancy are influenced by the context in which the Another area of positive outcomes for gestational pregnant woman is inserted and by how she relates to quality of life assessed in this study was the “relationship herself and to other people. with the partner”. The women in the present study who Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 7 of 10 had a stable relationship with their partners had better It is assumed that the process of drug addiction in the QoL indicators. Thus, it is possible to infer that the gestational period is coupled with deficient self-care, as pregnant woman who receives support from her com- well as deficient care with the gestational itself, which panion is more likely to have a positive pregnancy ex- makes the binomial more susceptible to health problems perience. The role of the partner/father is fundamental that interfere negatively with quality of life, given the in the support matrix, through its valorization and omission of this information by pregnant women for fear through protection directed to the mother and the baby. of being reprimanded by health professionals. Social support is support given by the partner, family The type of housing was observed to negatively predict and friends, which makes the pregnant women feel sup- “fatigue” among the pregnant women; however, these as- ported in their needs, increasing their capacity to ad- pects are poorly investigated from the perspective of dress difficult situations [24, 25]. quality of life. The result of a Brazilian study on the “People with whom the pregnant woman lives” was a quality of life of high-risk pregnant women showed that predictor that was associated with the anxiety generated regardless of whether or not the participants had their by the baby’s birth. It is believed that a healthy environ- own housing, the quality of life related to family life was ment is important for the health and development of a a priority [31]. child, promoting comfort to the mother. However, data The results indicated that occupation was a predictor that could reveal similarities to the present findings were of the following areas: “job”, “polyuria” and “fatigue”.In not found in the existing literature. the evaluation of the work activity, 36% of the inter- As to negative predictive variables, 51% of the negative viewed women cited job as an influencer of quality of variation in the quality of life of pregnant women was ex- life, but among these women, 57.44% considered work a plained by gestational age, type of housing, occupation, negative aspect for their quality of life, due to the pre- illicit drugs, lack of partner support and maternal age. occupation with the permanence of their position in the The variables illicit drugs and gestational age influenced job after the birth of the baby, instability in maintaining the area “nausea and vomiting”. The relationship between the employment and lack of support from bosses to- gestational age and nausea and vomiting presents peculi- wards their gestation. arities in each trimester of gestation, linked to psycho- The MGI results in Scotland showed that unemployed physiological changes that may influence these women. women had lower scores than those who were employed Eighty percent of women suffer from nausea and vomiting [11]. The possibility of loss of employment directly re- during their first trimester, more frequently between the flects on the economic conditions of the family, which 6th and 12th weeks, and can continue to experience these can contribute to stressful pregnancy events associated events until the 20th week [26]. with low birth weight, the occurrence of miscarriages Severe episodes of nausea and vomiting can affect preg- and premature labor [32]. nant women’s daily social lives, as well as their relation- A study carried out with pregnant workers revealed ships with family members and partners. These episodes that the occupational situation, considering the physical can also burden the health system with the increasing so- effort, the workload, and the stress, in addition to their cioeconomic costs associated with increasing severity of work in the home, can interfere with exposure to gesta- NVP [27], which has become one of the main justifica- tional risks, such as spontaneous abortions, preterm tions for being on medical leave during pregnancy [28] births and births with low weight. In addition, tiredness and may have an impact on quality of life. and sleep were the main complaints reported by preg- With regard to the use of illicit drugs, it is valid to nant women during the workday [33]. consider that the pharmacological effects enhance the Nocturnal “polyuria” is considered a type of urinary in- already-present predisposition for nausea and vomit- continence (UI) and constitutes the main compromising ing, potentiating their occurrence. However, no data factor of sleep quality among pregnant women at all gesta- were found in the literature on the correlation be- tional ages. Having to wake up several times during the tween illicit drugs and episodes of nausea and vomit- night to go to the bathroom results in drowsiness the next ing during pregnancy. day, leading to a greater need for extra sleep during this Much of the description of the use of illicit drugs dur- period, also resulting in daily fatigue and compromising ing pregnancy has been associated with an increase in quality of life [34]. In addition, polyuria requires attention the prevalence of unplanned pregnancies and sexually during gestation and in the postpartum period, in order to transmitted diseases (STDs), besides HIV infection [29]. strengthen the pelvic muscles as prevention of post- Among pregnant women who are illicit drug users, there pregnancy pelvic floor dysfunctions, a condition that may is lower participation in prenatal consultations, lower cause injury to women’squality of life [35]. participation in health education groups, and greater risk A study conducted to compare the quality of life in of obstetric and fetal complications [30]. pregnant women with and without UI concluded that Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 8 of 10 incontinent pregnant women felt more affected in their support and maternal age were the predictors that performance of daily activities. However, it can be said negatively influenced quality of life. that UI had an impact on the HRQoL of pregnant Thus, individualized, holistic and shared assistance for women [36]. the pregnant woman and her relatives, focusing on the Women perceive changes in their body image starting cited predictors, provides the basis for the planning and at the beginning of pregnancy. The way to cope with implementation of actions aimed at improving health- these changes can be influenced by several factors, in- related quality of life. cluding partner support or the lack thereof. The results Abbreviations indicated that the lack of support from the partner is a ANOVA: Analysis of variance; HIV: Human immunodeficiency virus; predictor of body image, possibly triggering low self- HRQoL: Health-related quality of life; MGI: Mother generated index; QoL: Quality of life; SPSS: Statistical package for social sciences; STD: Sexually esteem, non-acceptance of pregnancy and even depres- transmitted diseases; UI: Urinary incontinence; WHO: World Health sive symptoms. The partner’s emotional support contrib- Organization utes to the strengthening of the affective relationship Acknowledgements and improvement of self-esteem, which positively re- This study was supported by the Doctorate course at the Faculty of Nursing, flects the quality of life of pregnant woman [37]. Federal University of Ceara, the Basic Health Units and the clinical The psychological support provided by health profes- Feminimagem. We wish to thank our colleagues Hellen Catunda, Diego Jorge, Eveliny Martins, Elizian Braga who helped us collect data and to sionals is fundamental both in childbirth and in postpar- Professor Andrew Symon for their willingness to elucidate any doubts about tum, especially in the detection and prevention of the the Mother Generated-Index (MGI) instrument. Last but not least, we conditions such as postpartum anxiety and depression. thank our participants, who shared their time and experiences with us. The variable maternal age was considered a health Funding predictor of quality of life among the participants, influ- Own resources. encing sleep quality. A study of pregnant adolescents re- Availability of data and materials vealed that sleep disturbances were more common in The datasets generated and/or analysed during the current study are not older adolescents, probably reflecting the accumulation publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are of housework and maternal care with other children, available from the corresponding author on reasonable request. resulting in more stress and poorer sleep quality [38]. In Authors’ contributions contrast to this result, other studies indicate a higher CGPC, PRALS, AKBP, RCMBC, MFO, RAB and SKML conceived the study, prevalence of sleep in younger pregnant women, prob- participated in the data collection, coordinated the study, performed the statistical analysis and drafted the manuscript. PSA, FHCC and FJA ably due to the presence of the hormonal changes char- participated in the design and helped to draft the manuscript. All authors acteristic of this age group [39]. read and approved the final manuscript. It is known that sleep is a vital need for human beings, Ethics approval and consent to participate and sleep disorders are a relevant theme that should be Ethical approval to conduct the study was granted by the Committee of taken into account in the planning and implementation Ethics in Research of Maternity School Assis Chateaubriand, under number of of care for pregnant women. opinion 770.902 (Certificate of presentation for ethical assessment (CAAE34931614.9.0000.5050); 2014/08/28). Written pregnant’s consents were Quality health care, when offered to women during obtained before participants were included in the study. Participants were pregnancy, may prevent a number of problems for the reassured that the data would be treated with strict confidentiality and no mother-child binomial after childbirth. This assistance personal information would be disclosed to any third party. Participation was on a voluntary basis and no remuneration was involved. should be based on principles such as integrality, ethics and respect. Considering populations such as pregnant Competing interests women, who, in their exposure to diverse settings, are The authors declare that they have no competing interests. influenced by numerous bio-psycho-social factors, it is imperative to have a plan of care that meets the real Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in needs of this group during the gestational period. published maps and institutional affiliations. Conclusion Author details Nursing Department, Federal University of Ceara, Alexandre Baraúna Street, Theareas with thegreatestpositiveand negative in- 1115, Rodolfo Teófilo, Fortaleza, Ceará 60430 – 160, Brazil. Nursing fluence on the health-related quality of life of preg- Department, Regional University of Cariri, Coronel Antônio Luís Street, 1161, nant women were happiness to become a mother and Pimenta, Crato, Ceará 63.105-100, Brazil. Federal University of Cariri, Juazeiro do Norte, Ceara, Brazil. body image, respectively. In addition, occupation, par- ity, partner support, marital status and persons with Received: 23 March 2017 Accepted: 29 April 2018 whom the women live were the predictors that posi- tively interfered in the quality of life of pregnant References women. In contrast, gestational age, type of housing, 1. Montenegro CAB, Rezende FJ. Obstetrícia Fundamental. 12ª ed. Rio de occupation, use of illicit drugs, non-receipt of partner Janeiro: Guanabara Koogan; 2013. Calou et al. Health and Quality of Life Outcomes (2018) 16:109 Page 9 of 10 2. Maldonado MT. Psicologia na gravidez. Parto e Puerpério. 16ª ed. São Paulo: 20. 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Health and Quality of Life OutcomesSpringer Journals

Published: May 31, 2018

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