The nursing care and consumer satisfaction during postpartum Os cuidados de enfermagem e a satisfação dos consumidores no puerpério

The present analytical cross-sectional study had the aim to investigate the satisfaction of hospitalized post-partum women with the specialized care provided by nurses at the obstetrics service of a health unit in Portugal. The sample comprised 120 post-partum women who were selected as per the following inclusion criteria: being hospitalized due to the delivery and for a period not shorter than three days. Data were collected between February and April 2013. The collected data revealed that the women were very satisfied as for the care received in general (50%) and satisfied with the care received toward bathing techniques (99%), breastfeeding (94%) and self-care (89%). The evidence of the results allows to support the need for more efficacy from professionals in the care provided so that post-partum women become more autonomous and satisfied with their care. Descriptors: Personal Autonomy; Nursing Care; Hospitalization; Postpartum Period; Consumer Satisfaction. RESUMO O presente estudo, de natureza transversal e analítica, teve como objetivo investigar a satisfação das puérperas, em internação, com os cuidados especializados prestados pelos enfermeiros num serviço de obstetrícia de uma unidade de saúde de Portugal. A amostra incidiu sobre 120 puérperas selecionadas de acordo com os critérios de inclusão: internação, ter como motivo o parto e esse período não ser inferior a três dias. A coleta de dados decorreu de fevereiro a abril de 2013. Os dados revelaram que as mulheres se encontravam muito satisfeitas quanto aos cuidados recebidos em geral (50%) e satisfeitas quanto aos cuidados acerca da técnica do banho (99%), da amamentação (94%) e do autocuidado (89%). A evidência dos resultados permite fundamentar a necessidade de maior eficácia dos profissionais nos cuidados prestados, para que as puérperas se tornem mais autônomas e satisfeitas nos seus cuidados. Descritores: Autonomia Pessoal; Cuidados de Enfermagem; Hospitalização; Período Pós-parto; Satisfação dos Consumidores. Correia TIG, Pereira MLI. Rev. Eletr. Enf. [Internet]. 2015 jan/apr;17(1). Available from: http://dx.doi.org/10.5216/ree.v17i1.28695. 2 INTRODUCTION Women’s health have been historically centered in their reproduction function, especially during pregnancy and birth. Considering the global panorama, the World Health Organization (WHO) considers priority actions regarding women’s health: the demand to ensure prenatal, delivery and postpartum care, accessible and available for all pregnant women and the increase in delivery number assisted by trained personnel. Sexual and reproductive health implies specific care in general and, in particular to women, being maternity/paternity an acquisition and a transition process of the role started before pregnancy and that continues after postpartum. Postpartum is a critical phase to review maternal and child care. Because it is considered a risk period for physiological and psychological changes, specialized maternal and obstetric health nursing care becomes essential, those based on the prevention of complications, physical and emotional comfort and health education, conducting the puerperal to a clear autonomous state that allows her to reach the balance needed during the maternity process. Specialized care promotes safety for costumers receiving it as well as for the professionals providing it, resulting in a higher or lower satisfaction specially for those receiving it. This satisfaction arises from the consumer’s assessment due to the realization of their needs, from what they expect and the obtained results, being able to result in an attitude or response from costumers over the healthcare system, a health establishment, a behavior from the provider or to their own personal assessment in front of a provided care concrete experience. For an effective specialized nursing care to postpartum women, in a way to promote her adaptation to the specificities during this period, the interaction between her and the caregiver is essential, and the nurse should acknowledge the recognition of assimilated information by the woman. To understand the satisfaction of consumers during postpartum, it is fundamental to have an idea of how they comprehend the nurses in their daily practices, as well as if their attitudes meet what is expected from them. In general, self-care is a practice of an activity learned by the individual, it is initiated and executed for their own benefit, aimed at health maintenance and wellbeing. Specific self-care during postpartum englobes basic care concepts and techniques, already addressed during prenatal care and will be continued in the period when the woman is on admission at the maternity. Thus, it is crucial the attention to breastfeeding during this period, once the puerperal needs to learn the correct technique to breastfeed with good hospital practices which will be translated into multiple benefits for the binomial mother/baby. This way, it increases breastfeeding knowledge and, consequently, increases the prevalence and the duration of the breastfeeding process. Another of the learning tasks needs during this period is the newborn bath technique, and the technique demonstration in maternities starts to be a common practice, where the nurse incentives the mother’s presence during the first shower stimulating the observation of the physical condition, the promotion of comfort and socialization. The privileged relationship between maternal and obstetric health specialists’ nurses and the puerperal during the hospitalization days, allow them to identify their needs and plan interventions adequate to each situation regarding autonomy after clinical dismiss. Education actions should be based in active listening, welcoming and appreciation of women specificities that are known to be influenced by social expectations regarding maternity, allowing the development actions that are effective support for puerperal women because these actions have been effective for health promotion. Assistance to these women for the baby care and self-care promotes quality of assistance and meet the specific postpartum interests recommended by


INTRODUCTION
Women's health have been historically centered in their reproduction function, especially during pregnancy and birth (1) .Considering the global panorama, the World Health Organization (WHO) considers priority actions regarding women's health: the demand to ensure prenatal, delivery and postpartum care, accessible and available for all pregnant women and the increase in delivery number assisted by trained personnel (2) .
Sexual and reproductive health implies specific care in general and, in particular to women, being maternity/paternity an acquisition and a transition process of the role started before pregnancy and that continues after postpartum.
Postpartum is a critical phase to review maternal and child care (3) .Because it is considered a risk period for physiological and psychological changes, specialized maternal and obstetric health nursing care becomes essential, those based on the prevention of complications, physical and emotional comfort and health education, conducting the puerperal to a clear autonomous state that allows her to reach the balance needed during the maternity process (4) .
Specialized care promotes safety for costumers receiving it as well as for the professionals providing it, resulting in a higher or lower satisfaction specially for those receiving it (5) .This satisfaction arises from the consumer's assessment due to the realization of their needs, from what they expect and the obtained results, being able to result in an attitude or response from costumers over the healthcare system, a health establishment, a behavior from the provider or to their own personal assessment in front of a provided care concrete experience.
For an effective specialized nursing care to postpartum women, in a way to promote her adaptation to the specificities during this period, the interaction between her and the caregiver is essential, and the nurse should acknowledge the recognition of assimilated information by the woman (5) .To understand the satisfaction of consumers during postpartum, it is fundamental to have an idea of how they comprehend the nurses in their daily practices, as well as if their attitudes meet what is expected from them (6) .
In general, self-care is a practice of an activity learned by the individual, it is initiated and executed for their own benefit, aimed at health maintenance and wellbeing (7) .
Specific self-care during postpartum englobes basic care concepts and techniques, already addressed during prenatal care and will be continued in the period when the woman is on admission at the maternity (8)(9) .Thus, it is crucial the attention to breastfeeding during this period, once the puerperal needs to learn the correct technique to breastfeed with good hospital practices which will be translated into multiple benefits for the binomial mother/baby.This way, it increases breastfeeding knowledge and, consequently, increases the prevalence and the duration of the breastfeeding process (10) .Another of the learning tasks needs during this period is the newborn bath technique, and the technique demonstration in maternities starts to be a common practice, where the nurse incentives the mother's presence during the first shower stimulating the observation of the physical condition, the promotion of comfort and socialization (8) .
The privileged relationship between maternal and obstetric health specialists' nurses and the puerperal during the hospitalization days, allow them to identify their needs and plan interventions adequate to each situation (11) regarding autonomy after clinical dismiss.
Education actions should be based in active listening, welcoming and appreciation of women specificities that are known to be influenced by social expectations regarding maternity, allowing the development actions that are effective support for puerperal women because these actions have been effective for health promotion (10) .Assistance to these women for the baby care and self-care promotes quality of assistance and meet the specific postpartum interests recommended by the WHO.
Considering that puerperal women is on her own after leaving maternity and the adverse role that insecurity can play during recovery in this period, it is justified the importance of the present study on the impact that women's satisfaction with the received care can have on her adaptation to the woman and mother situation.
Thus, to identify and measure the consumers' satisfaction related to care during postpartum can contribute with aids for higher knowledge of the woman's experience during the postpartum period, considering the importance given to them.
There are few studies in the scientific literature about women's satisfaction of received care specifically during the postpartum period in which women are still hospitalized.Some studies mention this theme but includes delivery and postpartum care, and they do not highlight satisfaction during postpartum (12)(13) .However, the client's opinion is increasingly considered by social partners to monitor the services' quality and to assess the efficacy of measures implemented at the health systems level assuring the coherence of health care in all sectors (14) .
The present research is a contribution to improve puerperal women satisfaction knowledge which will serve as scientific support for a growing refinement of specialized nursing practices.It is also a stimulus to the development of new investigations (12) . in which authors were based on the guidance from the Nurse's Order that allowed to define the care items related to the bath technique, breastfeeding and self-care (17)(18) .

This
The questionnaire was composed by four distinct parts.The first and second parts (15) were regarding sociodemographic elements (age, marital status, education and occupation) and obstetric data (number of pregnancies, number of deliveries, desired pregnancy, supervised pregnancy and preparation for delivery).The third (16) part referred to the opinion about received care (technical aspects, given attention/care, nurses' answers, care and attention/courtesy and received information).
The fourth part referred to care made available by the nurse and preconized by the Nurse's Order related to bath technique, breastfeeding and self-care after clinical discharge.
Data collection was conducted through questionnaires and it was performed in a room where puerperal were gathered for this purpose.This room was located in a unit when the women were admitted.
Questionnaires were applied on the third day during their time in their admission period, between February and April of 2013.Questionnaires were distributed to clients, individually, explaining its context and purpose and it was asked to be answered at the moment and return it to the investigators who were in the room.
This research project was previously submitted to appreciation and approval of the Clinic Directory and the Ethics Committee from the respective health institution.
Confidentiality and anonymity related to information provided was secured and each participant signed the Informed Consent Form.
In mean terms, for each study item, a scale was used ranging from value 1 (one) to 5 (five).This classification corresponded to the women's opinion about the nursing care variables, since 1 (Bad), 2 (Regular), 3 (Good), 4 (Very Good) and 5 (Excellent).
For data analysis, inferential descriptive statistical techniques were used.Spearman's correlation coefficients were used (once the involved variables were ordinal) to assess the possible correlations between satisfaction variables.The level of statistical significance adopted was 0,05.For the treatment of information, the program Statistical Package for Social Science-SPSS, version 20.0 was used.

RESULTS
One hundred and twenty puerperal participated in the study, with ages ranging from 18 to 43 years old, being the mean 30 years.
Regarding socio-demographic characteristics, it was found that most women were married or was in a stable relationship (70%), had a medium education level (60%) and had a professional occupation (80%).
More than half of women had two or more previous pregnancies (55%).Regarding number of deliveries, it was observed that for most women (55%) this was the first, being a desired and monitored pregnancy for 95,8% and 95% of women, respectively.
About their opinion on nursing care, from which they were consumers, most of puerperal manifested being really satisfied and satisfied (49,2% and 48,3%).From the items assessed about nursing care, the item most assessed was care and attention/courtesy (60%), being the item technical aspects, the one which caused less excellence satisfaction.
Analysis of Table 1 showed that the items better assessed for nursing care was attention/courtesy and the nurse's answer, being classified by the puerperal women as good.
The items attention provided/care and received information obtained similar scores (mean of 3,741 and 3,750 respectively).About 30% considered these cares excellent.Technical aspects obtained the lowest mean, reinforcing their dissatisfaction.
For each one of the five items, it was verified the obtained mean values being superior or approximately similar to 3,7, indicating a favorable general opinion about nursing care.Regarding the information about bath technique for newborns provided by the nurse, puerperal considered that it was explained and it became clearer how to deal with the baby, providing them comfort, prevention of complications and socialization with their baby.While analyzing Table 2, it was verified that practically all puerperal women affirmed that bath technique for newborns was explained and they were satisfied with the received information related to the procedure to be developed.However, from those procedures, it was verified that the ones in need of more specificity, for example, to hold and disinfect the umbilical stump, were the ones considered least explained by puerperal.The puerperal also appreciated the explanations provided regarding the breastfeeding technique (Table 3) and they manifested their satisfaction (94%).However, these women showed some dissatisfaction related to the clarifications about duration, frequency and breastfeeding initiation (approximately one third) considering those as the items appearing as the least well explained.Explanation about recognizing the signals of an effective breastfeeding also did not received recognition of about 9% of them.Self-care (Table 4) was the one less explained in women's opinion (86%) and for this reason received less satisfaction (89%) in comparison with the newborn care and breastfeeding.
Nevertheless, a higher percentage of puerperal (95%) affirmed to feel confident in the execution of all tasks related to their self-care.Information about how to alleviate the pain felt during breastfeeding left about 13% of women dissatisfied.Nonetheless, these women declared to feel capable of performing self-care outside the hospital environment and without needing the presence of a nurse.
Through analysis of Table 5, where items related to global satisfaction and some specific nursing care items were presented, it was observed that practically all presented correlation coefficients were statistically significant and positive; the increase in satisfaction in one variable conducted satisfaction increase in another that was correlated.For global satisfaction, it was noted that Spearman correlation values regarding all aspects assessed revealed a moderate correlation, highlighting smallest association between puerperal satisfaction and the nurses' answer to the call.

DISCUSSION
In the present study, we sought to know puerperal satisfaction, in an obstetrics admission service, with specialized care provided by nurses.
The main results of the present study allow us to verify that most women were married, an identical situation to female population at a national level, although the national prevalence is smaller (54%) (19) .
Maternity in more advanced ages is a reality in more developed societies, in spite of being a situation with different interpretations.In one hand, it is stated that little is known about the potential effects on satisfaction of these women who are older mothers (20) ; on the other hand, it is assumed that it may involve increased health risk (21) .
In a study aimed to analyze women's satisfaction with life during pregnancy and the first three years of motherhood, it was observed that levels of satisfaction with life decreased as the pregnant age increased and the time of pregnancy progressed.It was also verified that the puerperal satisfaction was higher at six months after delivery in comparison to three years of motherhood (20) .
The global puerperal satisfaction in the study is corroborated by another study in which the puerperal related high levels of satisfaction with nursing care (22) .
Unlike, other studies pointed puerperal dissatisfaction relative to service and care given, referring that they experienced nursing care negatively (5,23) .Satisfaction of clients regarding nursing care is in general, an indicator of provided care (17)(18) .Effective puerperal care at the community can avoid short, medium and long-term consequences related to problems not recognized and poorly managed (14) .
There were few items relevant to newborn bath technique care, that were not so well explained, that could bring out doubts about this procedure, going in the direction of another study in which puerperal women informed being afraid of giving hygiene care and comfort for the baby due to lack of knowledge and insecurity handling the baby (1) .The aspects that seemed to be less clear were related to umbilical stump care that can be translated in a risk factor for possible infections and consequently, more in hospitalization, translated in dissatisfaction for women.In the study referred in which stump care were analyzed, it was verified that admission time increased when the umbilical stump had infection signs, requiring a longer hospitalization (24) .This is a technique that seems to be simple, it requires skills and training and it is essential for nurses to receive subsides from women, in a sense to perceive if the information provided was assimilated and if the knowledge to guarantee autonomous care is present.These puerperal have only 12 years of education in its majority, which can be insufficient to perceive the information provided and for this reason, resulting in dissatisfaction (20) .
In relation to the information provided by the nurse regarding breastfeeding technique, puerperal affirmed being satisfied, this data agrees with another study, but in which half of puerperal (47,4%) referred difficulties with breastfeeding implementation (25) .Duration and frequency of feedings were not clear for puerperal opinion, and it could have contributed with difficulties pointed out.These results are consistent with another study that aimed to assess the quality of life of Iranian women.Factors affecting negatively the global score of quality of life in the postpartum period were, among others, difficulties with breastfeeding (14) .In this context, it is necessary to teach and redeem acquired knowledge, strengthening the care conducts and important skills for the success of breastfeeding that besides the high investment that has been done and the WHO guidelines, it is still a difficulty for puerperal.Nurses are in an ideal position for breastfeeding counseling, because if everyone is concise and have coincident knowledge about this topic, they can help those mothers more easily (8) , and it is important for them to be motivated to teach.
Self-care was the item that caused less satisfaction.
This fact contradicts the idea, in which the puerperal not always attribute the needed importance to the care for their own body at this phase of life, because they are not centered in themselves but in the child, so self-care stays in a secondary plan (21) and sometimes are neglected.
Puerperal complained about more information and sometimes they may not take care of themselves because they do not know how to do it.
The demonstration repetition of care with the newborn, with the breastfeeding and with self-care can be effective while learning, once doubts can be immediately clarified.Thus, the nurse is sure that the woman acquired the ability to provide care before dismissal from the maternity clinic.After dismissal, puerperal are guided to primary care services where care is continued.Maybe it is important to have a call support during the postpartum period.This support has grown in popularity and it is valued by women, especially in environments with few resources and where distance to the maternity is long.There is some evidence that supportive calls can increase women's general satisfaction with their care during pregnancy and postpartum period.
Puerperal global satisfaction seems to depend on the satisfaction of each care in particular, therefore being fundamental that provided care are effective since the first moment aiming puerperal satisfaction.
For most of those puerperal, this is the second child, and for this reason, care tasks should be performed with more confidence.It seems evident that professional care, especially during hospitalization, is still not sufficiently effective for puerperal to learn and later provide this care for herself and for the baby without having difficulties.
Maybe nurses think that these care and the respective techniques are so basic that they do not require much explanation and for that, they are not sufficiently clear and persistent when teaching them and demonstrating the skills.
With the exposed results, some obstacles were evident in relation to satisfaction and competencies expected from puerperal to acquire until the dismissal moment, being the maternity the place for this learning process.In a mentioned study, in which they tried to assess the quality of clinical guidelines about routine postpartum care, the authors verified that the scope of guidelines varied a lot, however, the guidelines' recommendations were consistent in general (14) .
In this line of thought, the role of the specialist nurse is highlighted and it aims to give women competencies, which will promote independency for self-care and for newborn care, promoting puerperal satisfaction, making them autonomous and confident in their own procedures after going home and producing gains in sexual and reproductive health.

CONCLUSION
When addressing the phenomenon of puerperal satisfaction with specialized nursing care provided, this study allowed to verify that puerperal are satisfied in general.
We refer in first place, as a limitation of this study, the fact that we had a relatively small sample, which can limit the generalizability of results.Other limitations can be pointed out, as the not inclusion of other variables considered relevant in the literature (health education, social support, personality).
The majority of results in the present study points to the quality of nursing specialized care based on confidence that puerperal affirmed to have regarding provided care with their self-care and newborn care.
However, this study confirms some difficulties that women still have regarding care procedures with newborns and to themselves.Puerperal revealed difficulty in basic care resulting in dissatisfaction, for example, related to knowing when to breastfeed the baby, for how long the feeding should last and how often it has to be made.
Despite some difficulties, the security provided by the acquisition of competencies related to their own care and the baby, contributes to a better adjustment of these women as care providers without direct support of nurse professionals.
Data from this study and the reflections made from it, especially the ones related to the simplest procedures, justify the conduction of similar investigations, aimed to deepen the empirical comprehension about the way women deal with postpartum situations (in the hospitalization context).Evidence from results also allows support the need to of specific guidance by region, paying attention to educational level of the female population during reproductive age.It is important to develop more research with international criteria, for the recommendations to be done inside the evidence-based international guidelines, improving the puerperal care and securing the coherence in health care at all sectors.

Table 1 :
Characterization of nursing care at a health unit in northern Portugal, 2013.

Table 2 :
Characterization of care during newborn bath at health unit in northern Portugal, 2013.

Table 3 :
Characterization of breastfeeding care at a health unit in northern Portugal, 2013.

Table 4 :
Characterization of care in the self-care after a delivery at a health unit in northern Portugal, 2013.

Table 5 :
Spearman correlation coefficients between global satisfaction and aspects assessed by puerperal women at a health unit in northern Portugal, 2013.
* The more elevated the satisfaction with care, the higher obtained score.Statistically significant value.