Care for high-risk pregnant women: Primary Health Care nurses’ perspectives

Ana Luísa Serrano Lima¹, Giovana Munhoz Dias², Heloisa Bortolossi de Oliveira³, Marcelle Paiano⁴, Gislene Aparecida Xavier dos Reis⁵, Flavia Cristina Vieira Frez⁶, Sonia Silva Marcon⁷, Viviane Cazetta de Lima Vieira⁸

^{1,2,3,4,5,6,7,8}State University of Maringá. Maringá (PR), Brazil.

Introduction

Pregnancy is a physiological phenomenon, and in most cases, its development occurs without complications. However, certain individual conditions, such as previous reproductive history and clinical conditions prior to pregnancy, can increase the chances of complications and maternal and neonatal deaths.¹

The Maternal Mortality Ratio in Brazil increased considerably, reaching 107.53 deaths per 100,000 live births in 2021, the highest in the last 20 years. Compared to 2019, the ratio was 55.31 per 100,000 live births, representing an increase of 94% in that period.² Efforts motivated by the Sustainable Development Goals seek to reduce maternal mortality in Brazil to less than 30/100,000 births by 2030.³

Monitoring high-risk pregnant women requires support from their territory, but also from a specialized and multidisciplinary team, since care coordination occurs from Primary Health Care (PHC), which allows pregnant women to be linked to the territory. The specialized team’s work should be understood as a diversification of care spaces, and the responsibility that PHC has for pregnant women in its coverage area should not be transferred. It is in the territory where pregnant women live and where care actions should be carried out, through medical and nursing consultations and home visits, ensuring the link and responsibility for care.¹

The first prenatal consultation in Family Health Strategy (FHS) teams is primarily carried out by nurses, with the others being alternated with the general practitioner or specialist. The role of nurses in prenatal care is supported by the Professional Practice Law 7,498/86 and regulated by Decree 94,406/87, which describes nursing professionals’ duties.⁴ Federal Nursing Council Resolution 477 of April 14, 2015 addresses the role of nurses in assisting pregnant women, women in labor and postpartum women, including obstetric nursing consultation and direct nursing care for critically ill obstetric patients.⁵

The consultation carried out by nurses has the potential to address women in their entirety, overcoming fragmented care based on the biomedical model. However, factors such as deficiency in the early identification of pregnant women, lack of active search for absentees, late referrals, fragmentation of care and ineffective communication between referral and counter-referral are challenges to be overcome. Moreover, the limitation of human and material resources, especially pharmacological, is pointed out as a weakness in high-risk prenatal care.⁶

A preliminary note from the Ministry of Health reveals that, in Brazil, there were more than 260 thousand births to high-risk pregnant women, which is considered an alarming condition for public health.¹ These data impact both health indices and government spending on care for pregnant women in high-risk situations, requiring support in their territories, care from specialized and multidisciplinary health teams, and, eventually, even in secondary or tertiary referral services with neonatal facilities that offer specific care.⁷

Maternal and child health care policies have been implemented over time with the aim of improving care for these groups. Among them, the Stork Network, created in 2011, and, more recently, the Maternal and Child Care Network, created in 2022, stand out. These policies were implemented with the aim of organizing prenatal care, childbirth, postpartum care, and monitoring the growth and development of children, especially in their first year of life. Among the various actions proposed by this network, we have organization of care processes, early reception of pregnant women in prenatal care, risk stratification and connection of pregnant women, coordination between networks, reception of complications during pregnancy, and access to high-risk prenatal care in a timely manner.⁸

From the above and considering the lack of studies related to the provision of nursing care for high-risk pregnant women⁹, Primary Health Care as the coordinator of health actions, and the nurse as the professional responsible for monitoring high-risk pregnant women within the referral and counter-referral network, this study aims to understand the perspectives of nurses working in Primary Health Care regarding the assistance provided to high-risk pregnant women.

Method

This is exploratory research with a qualitative approach carried out with nurses working in PHC, in a municipality located in the northwest region of the state of Paraná, carried out from August to October 2023. The care network for pregnant women in the aforementioned municipality, at the time of data collection, was composed of 35 Basic Health Units (BHU) and 99 Family Health teams (FHts).

Referrals to high-risk prenatal care are made primarily by PHC. Intermediate-risk pregnant women are referred for consultations at the northern Paraná Intermunicipal Public Health Consortium, and high-risk pregnant women, depending on their region of residence, are referred to the outpatient clinic of one of the two hospitals that provide this type of monitoring: one philanthropic and the other university hospital.

The study population consisted of nurses working in the Family Health Units who have been providing care to high-risk pregnant women in the municipality under investigation for at least six months. Those who were on sick leave, sick leave or vacation at the time of data collection were not included. 

The invitation to participate in the study was made via a message on the electronic application WhatsApp, whose contact details were made available by the Primary Care coordination. Twenty-five nurses were contacted, and of these, six claimed to be unavailable and another six did not meet the inclusion criteria (five were on vacation and one was on sick leave). New participants were included until the information of interest was exhaustive, i.e., when it was observed that the content of interviews became repetitive and that the new data collected did not add information to the understanding of the phenomenon, the search for new informants was stopped. Thus, 13 nurses effectively participated in the study.

The researchers scheduled the best day and time for the interviews according to participants’ availability and preferences. Prior to data collection, the Informed Consent Form (ICF) was read and any questions regarding the study were clarified. If a participant agreed to participate, they were asked to sign two copies of the document.

Data were collected between September and November 2023 through semi-structured audio-recorded interviews after authorization. All interviews were conducted by the same researcher and lasted between 30 and 40 minutes. Afterwards, speeches were transcribed in full, in the same week, with the help of a previously trained external collaborator. The speeches were identified with the letter N (nurse), followed by a numerical algorithm, according to the order in which the interviews were conducted.

The interviews flowed with a free expression approach, allowing a spontaneous narrative by participants about their performance in relation to the object of study, and were guided by the following guiding question “tell me about your work with high-risk pregnant women in this PHC service”, following a pre-defined script, as shown in Chart 1.

Chart 1 - Predefined data collection script. Maringá, Paraná, Brazil, 2024

Data collection instrument

Nurse characterization: Time since graduation:__________________ (months/years) Age:______ years Longer experience while practicing the profession: ____ years ( ) hospital ( ) outpatient clinics ( ) clinics ( ) Basic Health Unit Has some specialization in obstetrics or other areas ( ) Yes. Which __________________ ( ) No Has completed any training in the last 3 years in obstetrics ( ) Yes. Which __________________ ( ) No Guiding question: 01)   Tell me about prenatal care for high-risk pregnant women in your area. 02)   How do you perceive the role of nurses in high-risk prenatal care in Family Health Strategy teams? Support questions: 1)    How do you identify and refer high-risk pregnant women in your area of ​​coverage? 2)    What activities do you and your team carry out for high-risk pregnant women? 3)    In your opinion, what are the difficulties encountered in monitoring high-risk pregnant women in Primary Care? 4)    How do you perceive communication between referral and counter-referral services in the care network for high-risk pregnant women? 5)    What are the main skills that you perceive in the work of nurses when monitoring high-risk pregnant women? 6)    What are the main pieces of information/guidance that you see as fundamental in the nurse’s consultation with high-risk pregnant women?

It is worth mentioning that the interviews were closed when the data saturation criterion was reached.¹⁰ After the transcriptions were completed, the interviews were subjected to content analysis, in the thematic modality, with the material being organized in the pre-analysis stage according to the research needs and the preliminary ideas systematized. The material was then explored through data categorization/coding. Finally, the last stage involved the processing of results, through inference and interpretation, seeking to attribute meaning to the messages.¹¹

It is important to note that, in order to obtain greater methodological rigor, during data analysis, emerging results were peer-reviewed and researchers’ previous conceptions were left in suspension so as not to directly impact the analysis.

Through in-depth analysis, it was possible to identify key categories in the care of high-risk pregnant women in PHC services, discussed in light of Theory of the Health Work Process, which favored and expanded the understanding of the context and effectiveness of these practices to meet the health needs of this group. In the Theory of the Health Work Process, the organizational dimension of services’ daily routine is defined based on the praxis of health professionals who, when seeking to meet users’ needs, induce new practices, while at the same time being induced by this consumption.¹²

All ethical principles of research involving human beings were respected, in accordance with the guidelines of Resolutions No. 466/12 and No. 510/16 of the National Health Council. The study was approved by the Permanent Committee on Research Ethics Involving Human Beings at the State University of Maringá, under Opinion No. 6.224.813. To ensure anonymity, participants were identified according to the order of the interviews (e.g., E1 for Nurse 1).

Results

The nurses participating in the study were between 34 and 59 years old, with training time varying between ten and 35 years. The time working in PHC varied between two and 23 years. Regarding additional training, two professionals did not have a specialization, one specialized in women’s health, and ten specialized in different areas. However, none of them had a specialization in public health. Ten nurses reported having participated in training in ​​obstetrics in the last three years, covering topics such as breastfeeding, delivery routes and humanized childbirth, and matrix support.

The approach used made it possible to understand the complexity of the contexts involved in the work process of nurses in PHC teams in relation to the care of high-risk pregnant women.

The role of nurses in prenatal care: establishing links and ensuring continuity of care

“When the understanding of nurses who work in the Family Health Unit in the care of high-risk pregnant women involves, mainly, the importance of establishing bonds, contributing significantly to the comprehensiveness of prenatal care and respect for the individuality of each pregnant woman. You manage to establish a bond of trust with this pregnant woman, she will come to you to tell you whether or not she is well with her husband, whether she can afford to buy such and such, if she is going through any difficulties. So, like this, I know all my pregnant women by name. If you say so-and-so, I already know what the family structure is like.” (N13)

“I see that we have a stronger bond; sometimes, we wish we had an hour and a half to open a nice prenatal appointment, so that we can create a bond, talk, and understand, they come here in the hallway, and who knows, their name is us. Our bond with them is stronger. There are things that they will tell us that they won’t tell the technician or the physician. This bond and connection are great with them.” (N2)

“I think, like this, we can create a bond with the pregnant woman, so they trust us, and so they come back here.” (N12)

In addition to the bond, nurses highlighted the importance of continuity of care when monitoring pregnant women to ensure that they undergo protocol exams and attend scheduled medical appointments. Any absence from appointments or exams is promptly identified during continuous monitoring by nurses, who notify community health workers (CHWs) or use digital devices such as WhatsApp to locate absent pregnant women.

“My role is monitoring, so I assess when she had her appointment, if all those came in that month that we are in, I go through the exams pregnant woman by pregnant woman to assess the results. Sometimes, I set three weeks, but I already identify abnormal lab exams; in this case, I already anticipate this appointment, so I actively search for the pregnant woman who missed it…” (N13)

“We nurses are more in the opening, and there in the monitoring, for instance, if someone missed an appointment, we go after them, if the exam showed an abnormal result, we go after them. If there was time to do the exam and the person didn’t come, we go after them”. (N11)

“If someone missed an appointment, we do an active search via WhatsApp or I put the CHW on the trail.” (N3)

The importance of care that is not limited to medical consultations was highlighted by nurses in the study, aiming at comprehensive care and considering the diversity of perspectives and health needs of pregnant women.

“I think that the nurse cannot fail to provide care, there are many things that require the nurse’s attention. High-risk pregnant women also get vaccinated, they have to use sunscreen, and these are things that, whether we like it or not, end up being the nurse’s responsibility to guide them.” (N7)

“It is there during the pre-consultation that we provide guidance on vaccinations. During the postpartum consultation, we provide guidance on breastfeeding, guidance on general care. High-risk pregnant women also need this.” (N5)

“We provide guidance here together, because this is a high-risk pregnant woman, but she is a pregnant woman who will go through the same peculiarities as low-risk pregnant women. Since this is Primary Care, we cover the basic care aspects... we consult with both the physician and the nurse, so she receives the nursing guidance and the medical guidance as well.” (N7)

Nurses recognize the importance of maintaining a quality professional/pregnant woman relationship through skills such as qualified listening and dialogue, which make it possible to identify fundamental information early on for monitoring pregnant women as well as to resolve pregnant women’s doubts during this period of intense changes.

“We always have to offer and always pay close attention to the communication part, to the part of providing information and trying to make sure everything is well understood, because sometimes, for instance, in the first consultation, there is so much information that we pour out all at once, right? We spend a lot of time, we do so many things. So, I think that this part of offering information, of clarifying doubts that she may have.” (N1)

“... my partnership with my physician is very good, and she is an exceptional professional... if a patient comes to her and she needs maybe 1 hour of prenatal consultation or maybe 1h30 of consultation to clear up all doubts, to receive the greatest amount of information effectively, she spares no effort.” (N13)

Therefore, the work of nurses in FHS teams in caring for high-risk pregnant women requires a comprehensive and personalized approach. Establishing bonds and continuing monitoring are key elements to ensure that necessary exams and consultations are carried out, as well as to identify any absences early. Moreover, nurses recognize the importance of skills such as qualified listening and dialogue, which allow them to understand the diverse health needs of pregnant women.

Challenges in nursing care for high-risk pregnant women: integration, training and holistic approach

Although the nurses in the study listed essential actions for monitoring high-risk cases, statements are in line with the recommendations for centralizing high-risk prenatal care in medical care, focusing mainly on the pathology, in a biological management model. Thus, some of the nurses justified their absence based on the medical team’s availability.

“Today, we know that nurses can provide prenatal care. It doesn’t necessarily always have to be the physician, but since we have the physician available here... the nurse is more involved in monitoring.” (N11)

“Here, we don’t use this routine of alternating appointments, like having one appointment with the nurse and the other with the physician. Since the number of pregnant women is not that large, we can accommodate them. There are teams that must have a much larger volume, but here we don’t have that difficulty, because there are a lot of pregnant women, and the physician can’t see them all.” (N9)

“We only do the first appointment, stratify them and refer them to the physician. We don’t alternate the rest of the appointments, the physician, the general practitioner and the gynecologist are the ones who follow up most of the prenatal care.” (N1)

“... we don’t alternate appointments (physician and nurse), unless she (the physician) is not at the unit, then I see her, if not, she is the one who continues.” (N13)

The absence of nursing consultation in high-risk care was also justified by reasons such as lack of availability of pregnant women and lack of interest, especially because the majority have an employment relationship and do not recognize the importance of being accompanied by more than one professional category.

“The only problem is that if they don’t have a medical certificate, if they don’t have a medical appointment, they don’t come. So, the difficulties for the group of pregnant women were this... so, I think there really should be this issue of encouraging nurses to carry out nursing appointments, because we see that, today, the pregnant woman I see, the physician does the physical exam, because she will have to go to the physician, so we would have to, I don’t even know how to say it, you know, organize, standardize, what would it be, for the nurse to go back to seeing her. Because like that, we are very tied to the physician in relation to the certificate itself and in relation to the exams.” (N12)

“Sometimes, they say, there are too many appointments. Sometimes, she works and has to miss 2x a month to go to the physician. That’s one of her complaints.” (N3)

Although most participants mentioned taking advanced training courses in obstetrics, it is necessary to reinforce specific situations of direct care for pregnant women in courses and training to increase the confidence and security of professionals, better preparing them for care.

“Since we are general nurses, we do not have the same training as obstetric nurses, so I think there is a lack of training, especially for those who enter the PSF.” (N10)

“So, in terms of palpation, physical examination, all of that. I think we need to have more training. These are things, skills that, if we do not practice, we will lose.” (N12)

Furthermore, professionals reported difficulty in maintaining follow-up due to vulnerabilities in the profile of pregnant women treated, who are sometimes reluctant to receive care, highlighting important social issues that may influence the lack of interest in the assistance received.

“They are very uninterested in coming to the appointment. Almost every week, they miss appointments, we call them, but we can’t get them. The CHW goes to their house and can’t find them, we have to keep begging them to come for prenatal care.” (N4)

“I believe that the worst thing is when the pregnant woman doesn’t want to be monitored; she’s a little more rebellious. This happens more often, for instance, with patients who are drug users and things like that; they’re not interested in participating. So, you go and it’s that tedious work, calling, scheduling, rescheduling again, calling again, until they come. But they don’t attend 100% of prenatal care.” (N11)

“... what we may come across are some pregnant women who are more difficult... they don’t adhere to treatment, which makes it much harder for the prenatal care to progress properly.” (N5)

A protocol-based work routine was identified, characterized by difficulty in communication between the different points of care. The available information systems do not establish an effective connection between PHC and specialized care, resulting in weaknesses in ensuring comprehensive care.

“The reference is all on paper, so we don’t have contact with the medical records. The information I have is what they send in writing or write down on the card, and what they have is the same information. Of course, if it were a connected system, wonderful, I would have access to exams and everything else. We don’t have that, the contact we have is paper, what they send and what we send.” (N2)      

“The biggest difficulty is that our electronic system, the electronic medical record, is not the same as our high-risk referral system. If we were to collect more information, we would have been advised to do so, because something always goes unnoticed.” (N5)

“Sometimes communication is a bit lacking. There is no communication between the high-risk patient and us, so we only find out what happens to the pregnant woman through her or through her card.” (N7)

“So, if she says something happened, I find out through the pregnant woman, not because she received a counter-referral, a referral reporting it, so the physician will write down on her card what happened there, but a specific thing, a referral or a counter-referral, not.” (N9)

“There is no communication. For instance, when the pregnant woman is followed up at the high-risk outpatient clinic, we do not get any feedback here at the BHU, to find out what was done. I always ask. We know it’s high risk, so I always ask when the follow-up appointment is scheduled and so on. But for instance, if they don’t show up for the follow-up appointment, at least I’m not hearing here that they didn’t show up. We don’t even know that, I know from the pregnant woman’s mouth whether she went or not.” (N12)

In this sense, it is important to highlight the need to improve integration between PHC and specialized care in order to ensure continuity and comprehensive monitoring of high-risk pregnant women. It is crucial to strengthen the confidence and security of nursing professionals through specific training so that they can take on a more active role in assisting this population together with the medical team. Furthermore, it is essential to understand and address the social vulnerabilities that may influence pregnant women’s lack of interest in the care they receive, aiming to promote a more holistic and humanized approach to maternal health care.

Discussion

The results presented provide support for understanding contextual factors that can strengthen or weaken the quality of care offered by PHC nurses to high-risk pregnant women, highlighting the importance of bonding, qualified listening, as well as the organization of care flows as fundamental elements for comprehensive and longitudinal care. 

Similar results were found in a study conducted with 30 PHC nurses from a city in the southern region of the country, whose objective was to describe the reflection-action process for the development of nurses’ skills in prenatal care. In this study, the differential of nursing care was highlighted, especially the creation and strengthening of bonds, the use of active listening, the organization of services, the resolution of cases, and health education, factors that contribute to comprehensive and humanized care.¹³

In their work process, nurses need to consider the use of an individualized care plan based on the nursing process and the development of interventions that favor the provision of humanized care, the promotion of healthy behaviors, the encouragement of active participation by pregnant women, support in decision-making and the strengthening of the social support network. Through these actions, nurses provide clarification of doubts and promote women’s autonomy.^14-15 To this end, it is essential to pay attention to the way in which these guidelines are transmitted and, thus, ensure that they are understood, especially for high-risk pregnant women, who usually have to deal with even more complex problems.^16-17

The role of nurses in prenatal care carried out in PHC involves, among other actions, periodic monitoring and continuous involvement with the target population to ensure coverage of prenatal care throughout pregnancy, providing care, monitoring and assessment of actions on maternal and perinatal health.¹⁸ A study carried out with nurses working in FHS in a municipality located in the north of Minas Gerais showed that active search and monitoring of the territory allowed the mobilization and recruitment of pregnant women, results in line with the findings of this study.¹⁹

In addition to monitoring and actively searching for pregnant women, home visits are also an essential practice, presenting themselves as an alternative for care coordination between professionals, pregnant women and their families, since they allow these professionals to be closer to real life contexts in which subjects are immersed. The closeness made possible by home visits brings to light the appreciation of the subjective dimension of subjects, building spaces for communication and dialogue, in addition to favoring the sharing of practices and knowledge.^20-21

The use of home visits as a strategy in prenatal care for high-risk pregnant women allows for continued monitoring of users in an environment full of subjectivity and that permeates the biomedical model.²¹ The broadening of professionals’ perspective, beyond the gestational period, is consistent with what is proposed by the Brazilian National Policy for Comprehensive Care for Women’s Health guidelines. This is possible when the focus of care is expanded beyond the biological, i.e., adopting an understanding that this is a citizen with full rights, including their health needs that are not limited to the conditions of pregnancy.²²

Health education practices represent an alternative to consolidate care that is not restricted to medical-centric issues. A study conducted with 50 mothers from two BHUs in Mato Grosso highlighted the effectiveness of using technologies for health education, providing a favorable and accessible environment for different forms of expression. The WhatsApp communication platform allowed guidance, clarification of doubts, interaction between participants, exchange of experiences, knowledge and needs, in addition to access to scientifically based information to identify risk situations and anticipate conduct, thus demonstrating that health education practices do not need to be restricted to traditional care. ²³

Innovative forms of care, as well as the improvement of skills already acquired, are made possible by continuing health education practices, which aim to refine care practices and contribute to the organization of work processes.²⁴

However, it was noteworthy that the nurses in the study reported a lack of training and actions that would assist and equip them to provide care for high-risk pregnant women. A study conducted in Nigeria, however, shows that professionals in that country are constantly subjected to courses and training, and that this practice is a true pillar for workers’ knowledge, ²⁵ differing from the reality found in the present study. As a consequence, as identified in the reports presented, the nurses in the study have a very limited role, i.e., they are rarely involved in the care of high-risk pregnant women.

The centrality of prenatal care focused on the role of physicians, especially in high-risk pregnancies, reflects national data such as those found in the “Nascer no Brasil” survey, which identified that approximately 89.6% of prenatal consultations took place in PHC units and that 75% of pregnant women were seen exclusively by physicians.¹⁵ 

A study conducted with pregnant women admitted to a maternal and child unit of a university hospital in southern Rio Grande do Sul, which sought to understand the perception of high-risk pregnant women about nursing care, corroborates the findings of this study by highlighting physician-centered care, neglecting the contribution of other professionals without considering the benefits of a multidisciplinary team, including clinical care, emotional and educational support at all times of care. In this care model, nursing care is limited to welcoming and triaging pregnant women, reinforcing the idea of ​​care focused only on the clinical problem without assessing other human conditions.²⁶

The profile of pregnant women was considered by nurses in the study as a challenge for care, contributing to low adherence to prenatal care. Low education level, depression during pregnancy, unplanned pregnancy, partner’s dissatisfaction with pregnancy, violence against the pregnant woman and risky behavior, such as the use of alcohol and legal and/or illegal drugs, are factors that predispose pregnant women to low adherence to prenatal care.²⁷

A study conducted in Rio Grande do Sul found an association between incomplete higher education and low adherence to prenatal care, justified by long working hours and the consequent lack of time for consultations, especially among high-risk pregnant women, who need to be monitored in two services.²⁸ A contrasting reality was found in a small municipality in Rio Grande do Sul, where high adherence to prenatal care was identified even among women with low income, low education and a number of children greater than the national average.²⁹ This result highlights the importance of the team, especially nurses, knowing the profile and specificities of the population being assisted. This knowledge enables more individualized care that is closer to the real needs and, consequently, greater interest and willingness on the part of pregnant women to attend prenatal consultations.

The lack of coordination between the different points of the Health Care Networks was a challenge presented by the research participants. The findings of this study support the results of research in different regions of the country, highlighting the difficulty in maintaining counter-referral, which harms the quality of prenatal care. The fragmentation and disarticulation of health services, together with failures in communication between the different points of care, are challenges to be overcome to ensure comprehensive care for high-risk pregnant women.^28,30

Regarding the study limitations, it is worth highlighting the approach to FHS nurses’ work in high-risk pregnancies only from the perspective of nurses themselves, excluding other professionals. However, this research allows the formulation of new hypotheses, which can be explored in additional analyses, such as the impact of complementary professional training on the care models implemented in these services.

Conclusion

The role of Primary Health Care (PHC) nurses in caring for high-risk pregnant women is essential to ensuring comprehensive and high-quality prenatal care. Establishing bonds, maintaining continuous follow-up, active listening, and open dialogue are key elements highlighted in this study to provide individualized care that attentively meets the needs of pregnant women. However, challenges such as fragmented communication between different levels of care and the lack of integration between PHC and specialized care must be overcome.

Enhancing training in specific situations of direct care, strengthening professionals' confidence, and addressing social vulnerabilities are crucial measures to improve the quality of care and promote a more holistic and humanized approach to maternal health. This study advances by presenting the perspectives of nurses working in PHC regarding the care of high-risk pregnant women, highlighting aspects of the care model that need refinement to ensure effective assistance and promote favorable obstetric outcomes.

Authors Contributions

Study Design: Ana Luísa Serrano Lima, Viviane Cazetta de Lima Vieira. Data Collection: Ana Luísa Serrano Lima, Viviane Cazetta de Lima Vieira. Data analysis and interpretation: Ana Luísa Serrano Lima, Viviane Cazetta de Lima Vieira. Manuscript Writing: Ana Luísa Serrano Lima, Viviane Cazetta de Lima Vieira, Giovana Munhoz Dias, Heloisa Bortolossi de Oliveira, Marcelle Paiano, Gislene Aparecida Xavier dos Reis, Flavia Cristina Vieira Frez, Sonia Silva Marcon. Critical review of the manuscript:  Ana Luísa Serrano Lima, Viviane Cazetta de Lima Vieira, Giovana Munhoz Dias, Heloisa Bortolossi de Oliveira, Marcelle Paiano, Gislene Aparecida Xavier dos Reis, Flavia Cristina Vieira Frez, Sonia Silva Marcon. Approval of the final version of the text: Ana Luísa Serrano Lima, Viviane Cazetta de Lima Vieira, Giovana Munhoz Dias, Heloisa Bortolossi de Oliveira, Marcelle Paiano, Gislene Aparecida Xavier dos Reis, Flavia Cristina Vieira Frez, Sonia Silva Marcon.  

Conflict of interest

There are no conflicts of interests.

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Ana Luísa Serrano Lima

E-mail: analuisa095@gmail.com

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