SATISFACTION OF PREGNANT WOMEN IN RELATION TO CHILDREN AND BIRTH CARE*

Objective: to evaluate the satisfaction and well-being of puerperal women in childbirth and birth care. Method: this is a quantitative, descriptive and cross-sectional study, with 78 puerperal women, when using a questionnaire for sociodemographic and obstetric characterization, analyzed by descriptive statistics and association tests, using the Chisquare test, adopting significance level of 95%. Results: there was a mean age of 28.4 years, highlighting that 98.7% of those surveyed performed prenatal care, 73.1% received some professional guidance in the hospital and 93.6% had the presence of a companion. It is registered, on the scale, that 62.8% of women showed excellent well-being. It is reported that domains III and V were the best evaluated and domain IV, the worst. Statistical relevance in the correlations between well-being levels and delivery data was denied. Conclusion: it was evaluated that women had excellent well-being in parturition. Skin-to-skin contact and the presence of a companion are important factors. It is considered necessary to incorporate empathy and kindness in care to reduce levels of malaise. Descriptors: Maternal Welfare; Patient Satisfaction; Labor; Natural Childbirth; Obstetric Nursing; Empathy.

It is understood that the moment of parturition is a special and unique event in the life of the woman and her family, causing several biopsychosocial changes, many, permanent, requiring readjustments in daily life to adapt to the transformation. It is evaluated, even if the woman has already experienced this moment and brings with her all the experience acquired in the process, that this event can be marked by new discoveries and experiences, requiring quality assistance in order to obtain a new positive delivery and birth experience. 1 It is noteworthy that patient satisfaction has been used as a tool to measure the quality of care, 2 being directly related to well-being and reflecting on the mental health of individuals, as pointed out by the World Health Organization (WHO), being essential for health in its broadest sense and avoiding future psychological disorders. 3 It is known that patients whose needs are met become more satisfied and, consequently, happier and more prepared to face their new life condition. It is indicated, in the case of pregnant women, that having a health team that provides holistic support can have an impact on the relationship with the child to be born and on the way in which the woman will face the puerperium. [4][5] It should be noted that the rescue of women's autonomy at the time of parturition, through their empowerment, has been increasingly encouraged and practiced by professionals. It is pointed out, when they become protagonists of this moment, that women feel more comfortable in exposing their anxieties, doubts and desires, being, therefore, welcomed, respected and attended by the team in an empathic way, which provides patients with a feeling of security. 5 It is essential, therefore, to improve the practices adopted in the assistance and care for these women, their children and family members, in order to improve maternal well-being and health, respecting the role and the chance to experience a physiological and safe delivery, with professionals who are prepared and trained, being able, also, to establish bonds and affection. 6 Public policies are instituted over time in order to favor this professional qualification. In Brazil, by the Ministry of Health (MH), in 2000, the National Humanization of Childbirth Policy (NHCP) was implemented, whose main focus was the emphasis on humanization, aiming to guarantee the quality of care and the integral assistance to the pregnancy-puerperal cycle, rescuing the importance of the active participation of women, in addition to prioritizing the importance of their satisfaction in the process of childbirth and birth. 7 The Stork Network, also established by the Ministry of Health, encourages the creation of a care network that aims to ensure the rights of women and their children, through quality and equally humanized care. 8 It is noteworthy that the United Nations (UN) and partners launched, in 2016, the Global Strategy for the Health of Women, Children and Adolescents (2016)(2017)(2018)(2019)(2020)(2021)(2022)(2023)(2024)(2025)(2026)(2027)(2028)(2029)(2030), which aims at the equity of peoples through public policies to be adopted by countries. Among the objectives and goals to be achieved, emphasis is placed on the reduction of maternal mortality and the "elimination of all harmful practices and forms of discrimination and violence against women and children", with actions aimed at qualifying childbirth, promoting gender equality and guaranteeing women's reproductive and sexual rights. The document establishes that the guarantee of women's survival, health and wellbeing is fundamental to the full development of nations. 9 It was also launched, in order to qualify delivery and birth, by the MS, in partnership with the Brazilian Hospital Services Company (EBSERH), Brazilian Association of University and Teaching Hospitals (ABRAHUE), Ministry of Education (MEC) and Oswaldo Cruz Foundation (FIOCRUZ), with the Federal University of Minas Gerais (UFMG) as executor, the project Improvement and Innovation in Care and Education in Obstetrics and Neonatology (Apice On), with the proposal to qualify obstetric care, within the scope of university and teaching hospitals in different locations in Brazil, consolidating the evidence-based practice through the effective implementation, for example, of the National Guidelines for Normal Childbirth. 10 The Apice On emphasizes the importance of the work of nurses and obstetricians as agents that lead to the transformation and realization of humanization in Obstetrics, valuing women as protagonists of the event that involves childbirth and favoring the greater satisfaction at that moment. 5,  In the same context, with the purpose of providing a positive experience for women in the pregnancy-puerperal cycle, WHO added, in 2018, a document with recommendations and best practices to be applied in this assistance. Scientific evidences show the routines that should be abolished from assistance and those that should be implemented to improve care for the parturient woman and promote the satisfaction of clients and other people involved in care. 6
J Nurs UFPE on line. 2020;14:e245851 http://www.ufpe.br/revistaenfermagem/ feeling with the assistance received in the hospital environment at the time of delivery?". It is considered that the evaluation of the assistance provided is one of the basic conditions to promote the quality of health services. It is argued that obtaining data about well-being from the perspective of women is an important strategy that allows correcting inadequacies and improving the quality of childbirth care.
It is believed, therefore, that the relevance of this study is to promote reflections in the professionals who perform this care and in the analysis of positive points in the assistance provided, pointing out the details that need to be modified and ascertained.
• To evaluate the satisfaction and well-being of puerperal women in childbirth and birth care. This is a quantitative, descriptive and crosssectional study, carried out in the sector of joint accommodation of a maternity hospital with comprehensive and quality hospital care, together with the training and improvement of health professionals, which is in accordance with the principles of the Unified Health System (UHS), located in the eastern region of the city of São Paulo. Data was collected from October to November 2019.
The study sample was obtained by convenience, comprising 78 postpartum women. Literate women aged over 18 years were included, with physical and emotional conditions to answer the questions of the data collection questionnaire, regardless of parity, who experienced normal birth (spontaneous or induced), whether or not they had any complication during labor, delivery and postpartum, between 12 and 48 hours after completion. Women who underwent cesarean section, who had stillbirths, foreigners who did not have full knowledge of the Portuguese language and those with extra-hospital delivery were excluded.
At the first moment of data collection, secondary information was collected to elect potential participants. Then, visits were made to the beds of the puerperal women in the hospital's joint accommodation and an invitation to participate in the research. The purpose of the visit and the research objectives were explained. After reading, agreement and signature by both parties (researcher and participant) of the Free and Informed Consent Term (FICT), two instruments, by the researcher herself, were applied to the puerperal women. It is pointed out that the first, referring to the data of identification and sociodemographic and obstetric characterization, was collected through the survey of information registered in the medical record. It should be noted that the second instrument applied was the Maternal Welfare Scale in Childbirth Situation (BMSP2).
It is known that BMSP2 is an instrument developed by researchers from Chile, 12 culturally adapted and validated for the Portuguese language of Brazil. 13 It is a self-administered questionnaire containing a total of 47 questions regarding expectations, experience, satisfaction and pain related to labor, delivery and immediate postpartum. It appears that the responses are of the Likert type, on a scale that varies from one to five ("totally agree", "agree", "Neither agree nor disagree", "disagree", "strongly disagree"), obtaining them if the total score by adding the scores of each answer in the subscales. It is possible to calculate, from the sum of the scores, three levels of well-being: excellent well-being (score> 200); adequate wellbeing (score between 183 and 200) and malaise (score <183). Thus, it is established that the higher the score in each subscale, the more positive the experience of that woman is on the assessed dimension. In this study, the seven constituent domains in the instrument were used: I -Quality of the relationship during care; II -Self-care and comfort; III -Conditions that provide contact between mother and child; IV -Depersonalized care; V -Continuous family participation; VI -Timely and respectful care and VII -Comfortable physical environment.
The data collected in a spreadsheet in the Microsoft Excel® 2013 computer program were coded and tabulated, in double typing. Statistical measures of absolute and relative frequencies, mean, median and mode were calculated. Associations between childbirth data and maternal well-being were tested using the chisquare test, adopting a 95% significance level for statistical associations.
The study preceded the submission and approval of the Research Ethics Committee of the Federal University of São Paulo under the opinion of CAAE nº 3,622,204.
The sociodemographic analysis of the 78 women participating in this study was demonstrated.  It appears that the majority of women (98.7%) performed prenatal care, with an average of 9.5 consultations, and only three women (3.8%) performed the delivery plan during the current pregnancy.

RESULTS
Regarding the presence of complications developed during pregnancy, 43.6% had some, being mostly classified as clinical complications (67.5%).
Of the total number of women, 73.1% received guidance from professionals in the hospital regarding labor and delivery and 93.6% had the presence of a companion of their choice throughout the parturition process.
In relation to the place of delivery, 42.3% were registered in the normal birth center and 57.7% in the obstetric center. It appears that 56.4% of births were attended by doctors and 43.6% by obstetric nurses or midwives. It appears that seven (8.8%) had complications throughout the process, five (71.4%), obstetric complications and two (28.6%), clinical. It is observed that 50% of newborns were female and 50% male, with an average birth weight of 3300.2 grams, and that 78.2% were breastfed in the first hour of life.
The level of maternal well-being is shown in Table 3. It was identified that domains III (Conditions that provide contact between mother and child) and V (Continuous family participation) were the best scores, with the highest scores being the items "At the time of delivery and shortly after the birth of my baby, we were able to be in skinto-skin contact "and" At the time of delivery, I was able to be accompanied by my partner or another person important to me ", according to table 4. It should be noted, on the other hand, that domain IV (depersonalized care) was the worst evaluated and that the questions "I felt that some care was performed in a gross way by some member of the team" and "I could receive anesthesia when needed", from the domain VI (Timely and respectful care), received the worst scores.  It is noteworthy, when comparing the items "place of delivery", "professional in delivery", "parity" and "guidelines received at the hospital" with the woman's well-being levels, that no statistically significant correlations were detected.

Numbers of items
In relation to the place and the professional in childbirth, a similar distribution was noticed in the percentage of women who felt with excellent well-being in both places of birth assistance and professionals of the institution, therefore, having no difference or relevance where the women gave birth and who performed the assistance for this delivery (p = 0.14).
Parity was shown to be the main influencing factor in the level of maternal well-being, where the variables reached that same level (p = 0.07).
It is noted, regarding the guidance received at the hospital, that women who did not receive any type of information with those have the level (p = 0.4). It is noticed that the data referring to the sociodemographic profile of the women in this research are similar to what was found in a study carried out with 485 mothers of a maternity hospital in Espírito Santo, which found a predominance of women with an average of 26 years old, of brown color , complete high school, single and with declaration of profession of home, profile commonly identified in Brazil. 14 These findings, as well as those found in the literature, are characterized as social vulnerability, causing a bias as to the veracity in relation to maternal well-being in labor and delivery, since those patients with less education and remuneration also have the least knowledge about parturition. 4,11, In this way, prenatal care is pointed out as a crucial moment to improve this scenario, as it is when women receive guidance, clarify doubts and, thus, assume their role in the choices related to parturition.
It was shown, in relation to the obstetric profile, in the literature, 14 an average of 6.4 prenatal consultations of the puerperal women, corroborating the findings of this study. It was identified, in another research, 17 performed in 2017, with 361 puerperal women, that most of the participants were, at least, pregnant women (63.9%) and, among those who had had a previous delivery, the majority had a normal delivery (74.1%). Another study stood out, 18 that the majority of the sample did not present previous abortion (78.8%), constituting profiles similar to those of this study. Therefore, pregnant women with habitual risk and with prenatal coverage are identified, in accordance with the minimum of six consultations recommended by the Ministry of Health. 19 Thus, it is expected that women are prepared, physically and emotionally, for the stages following pregnancy.
It was observed, as a result of the evaluated scale, that 62.8% of the women interviewed at the institution had excellent well-being during parturition, with the domains III (Conditions that provide contact between mother and child) and V (Continuous family participation ) the best rated. The same was found in a survey 4 of 104 women, who used the same scale to measure the level of well-being of mothers in relation to the care received.
It is pointed out that immediate skin-to-skin contact between the mother-child binomial is recommended by the WHO as a practice that promotes positive experiences with childbirth, 6 as evidenced in this study. There is also evidence of its emotional and physical benefits, such as the promotion of postpartum satisfaction, the creation of a bond, the maintenance of the newborn's body temperature and the promotion of breastfeeding in the first hour of life, 6,20 besides being one of the indicators evaluated by Apice On to favor the qualification of assistance. 10 It was also associated in the literature, 21 the touch to the newborn when the pain of labor ceases and the consequent feeling of relief, promoting greater satisfaction and maternal well-being, being able to minimize the discomfort and bad memories related to pain, inevitably felt during of the process.
The presence of the companion was shown, guaranteed by law in Brazil, 22 directly related to maternal well-being, in line with other studies 5, 20-1, 23-4 who appointed women with a greater sense of security and support to experience the experience. In this way, through these results, the importance of skin-to-skin contact between mother and child and the presence of a companion as a determining factor in the positive experience of women at the time of childbirth is understood. It is also demonstrated that the advocacy for the implementation of these practices is well-founded and encourages increased efforts so that they are increasingly applied and, above all, respected, as these are rights that must be preserved, whenever there are no risks for the mother-baby binomial.
It is evaluated, although, in this study, the parity of women has not been statistically relevant, that this variable could be observed as a contributing factor for maternal well-being in parturition, which corroborates a research carried out in a university hospital in Southern Brazil. Brazil that observed the relationship between the type and number of previous births with the desired event at that time. 17 The choice for normal birth was related to the women's perceptions that it is healthier and allows for a faster recovery. 20,23 It was considered, by the participants of studies found in the literature, that the experience of previous childbirth influences their fears, desires and future choices, justifying the result found in this study.
It is noteworthy that the domain IV (depersonalized care) of BMSP2 was the worst evaluated by the interviewees and the question "I felt that some care was performed in a gross way by some team member" received the lowest score, as identified in another study carried out in a university hospital in Mato Grosso. 4 Thus, treatment and professional care performed improperly in perinatal care are indicated as frequent and harmful actions for satisfaction and maternal well-being during childbirth.
The importance of the technical qualification of the professional assisting the parturient and puerperal woman is frequently discussed in order to improve maternal morbidity and mortality rates. However, it is essential, in the same way,

DISCUSSION
to discuss the importance of qualification in the context of the relationships that professionals experience in the work environment, important skills that they must acquire, develop, improve and apply in the care and assistance provided. 9,21 It is emphasized, therefore, that women want not only technically qualified assistance, but also receive differentiated assistance. It is known that they value the way they are treated, and it is important that they receive an effective and, equally, kind and affectionate service, strengthening a relationship of trust between the professional and the patient. 21,24 It is verified, although no statistical significance was identified between the professional who works at the time of delivery and the level of well-being of the mothers in this research, that the skills and competences that must be acquired during professional training 25 are frequently present in the care practice of obstetric and obstetric nurses, as has been reported by women in several studies. 17, It is considered necessary, in this way, the inclusion of the interpersonal relationship theme in the training of professionals directly involved with perinatal care, aiming to graduate individuals capable of acting with competence and lovingness to provide emotional support to women in a moment of vulnerability such as delivery.
At the same time, it is important that women have access to knowledge and are encouraged to seek safe and quality care. It is suggested, for this to happen, that health professionals should propose that a birth plan be written: a legal document, written by the women themselves during pregnancy, containing personal wishes and expectations regarding childbirth, which can be used as a tool to favor satisfaction with the final outcome of delivery. 15,26 It was observed, in a research carried out with 415 women, 26 that 60% performed a birth plan during pregnancy, evidencing the association of this fact with satisfaction in childbirth, which demonstrates the importance of building this tool. On the other hand, it should be noted that the same was not evident in this study. It is believed that the delivery plan, practically unused, could have helped women in their empowerment and autonomy over their desires and expectations, collaborating to increase positive experiences in childbirth. Once again, the importance of quality prenatal care is emphasized, as women need to be informed about their rights throughout the pregnancypuerperal cycle.
It was identified that the interviewees feel, for the most part, satisfied and with an excellent level of maternal well-being, attributing this data to the conducts that favor skin-to-skin contact with the newborn and the presence of the companion during the labor and delivery. It was concluded, in the same way, that the treatment and professional care performed in a crude way in perinatal care have been frequent, interfering in the satisfaction and maternal well-being. Therefore, it is considered essential that professionals are trained and improve their practices.
It is understood that the study brings important statistical results and that they should be explored further in new research, in order to encourage professionals and institutions to reinvent themselves and provide care in which women have a leading role in decisions and care plans. It is argued that the event of childbirth and birth cannot be restricted to practice and technique. It must be understood as a human event, which requires care and attention about the way women are treated, making them more and more satisfied with the experience and, consequently, more secure about their maternal.
It is informed that all authors contributed equally in the design of the research project, collection, analysis and discussion of data, as well as in the writing and critical review of the content with intellectual contribution and the approval of the final version of the study.
Nothing to declare.