The percepTions of nursing sTaff regarding The risk facTors of drug use for pregnanT women

The consumption of psychoactive substances by pregnant women is worrying due to the damage caused to the pair of both mother and child. The aim of this study is to identify the perception of nursing professionals working within Family Health Services in São Paulo state and the risk factors for substance abuse in pregnant women. The study consists of qualitative research conducted with five nurses and nine nursing aids, from October 2013 to March 2014, through semi-structured interviews, and using the Bardin method for content analysis. The results of the study showed that the risk factors are related to family, socio-economic, cultural and bio-psychological issues. It was concluded that professionals should pay attention to pre-natal care, living conditions and family dynamics of pregnant women.


Introduction
The consumption of psychoactive substances is considered a major public health problem because it can cause changes in consciousness and modify the behavior of people who use them (1) .
Referring to pregnant women, the use of alcohol and other drugs becomes more worrisome because it represents a risk to the woman and the fetus, since these substances may exceed the transplacental and blood-brain barrier.We must assume then that there are no safe amounts of the consumption of drinks, or any other Psychoactive Substance (Substância Psicoative -SPA) by the pregnant woman (2)(3)(4) .
The harm caused by drugs to the newborn involve physiological and psychosocial damage, such as fetal withdrawal syndrome, fetal alcohol syndrome, and is characterized by damage to the central nervous system, birth defects, cognitive and learning deficits, psychiatric disorders (5) in addition to low weight (6) , irritability, and behavioral problems, among others.With regard to pregnant women, the consequences involve premature births, abortion risk, characteristics of an alteration or change to breast milk production, placental abruption, cardiovascular problems, risk of suffering violence, sexual abuse, sleep changes, depression, and irritability among others (7)(8) .
This study used the screening instruments for alcohol (Cutdown, Annoyed, Guilty and Eyeopener-CAGE, Tolerance, Cut down, Annoyed and Eye-opener-T-ACE and Tolerance, Worry, Eye-opener, Annoyed, Cut down-TWEAK).The results indicated that 40.6% of pregnant women had used alcohol at some point during pregnancy, while 10.1% used the drug through to the end of their pregnancy.The excessive consumption of alcohol by pregnant women older than 30 years, and who had a low educational level, was also identified.However, many of these cases are not declared as abusive users of SPA for fear of them being stigmatized, a factor which makes them more difficult to be identified by health professionals (9) .
In the dimension of substance abuse, pregnancy is considered a high risk both because of the issue of drug use and the social and emotional vulnerability of pregnant women.Most of them do not adhere to pre-natal care or participate in the help groups available to pregnant women.They represent a high risk to fetal and obstetric complications, to abandoning children and can be prevented for justice to care for them (8) .
Based on a review of the literature, it is understood that the pregnant woman needs the guidance of health professionals, including nurses, about the risks of alcohol consumption and other drugs, and on the damage caused to themselves and the fetus (10).It is understood that the Family Health Unit (Unidade de Saúde da Família -USF) is a strategic and important space for preventive and therapeutic interventions for this specific population.However, for the nursing staff to perform an approach or to offer preventive and therapeutic counseling, they also need to have knowledge about the risk factors of drug use by pregnant women.
They are understood as variable risk factors or conditions that can make a person vulnerable to take on risky behavior (11)(12) .
In this way, we have as a research question: what is the perception that nursing professionals from Family Health Units have regarding the risk factors that lead a pregnant woman to drug use?
This study is justified by its relevance, when considering the irreversible damage to the binomial mother / child caused by the consumption of psychoactive substances during pregnancy, requiring training of nursing staff to intervene, welcoming attitudes and understanding of the life context of the pregnant woman.

Objectives
The aim of this study is to identify the perception of nursing professionals within Family Health Services in São Paulo State on risk factors for substance abuse in pregnant women.

Methods
This is an exploratory research with a qualitative approach, based on an analysis of the understanding of human social reality lived and seeking to understand and explain the dynamics of social relations.
The study was conducted in 4 USFs in a city in São Paulo state in order to fully develop some core measures for women's health, as described in the Operating Rules of Health Care (NOAS-SUS 01/02).The study subjects consisted of nine nursing assistants and five nurses from the USFs.Inclusion criteria was of nurses who worked in USFs and met pregnant women.Exclusion criteria consisted of being on vacation or sick leave, or pregnant at the time of data collection.
The data was collected via semi-structured interviews (13) , with the guiding question: what are the factors that lead a pregnant woman to use drugs?The meetings were scheduled in advance, according to the convenience of health workers and researcher, and were held in a place that best suited them.For the capture of the information, the study used a digital recorder throughout the interview.Informed Consent (IC) forms were signed by the subjects.
All interviews were transcribed and analyzed later.The study used the content analysis technique, the thematic category described by Bardin (14) , which seeks to discover the units of meaning that constitute a communication.The analysis consisted of three phases, namely: pre-analysis, material exploration and treatment of results and their interpretation (13) .
The pre-analysis was outlined via the choice, organization and initial reading of the interviews for the constitution of the corpus.In this sequence, the study highlighted points for consideration and registered units (theme) which were referenced to the information obtained through the decomposition of all the messages.In the exploration phase of the material, the study sought the elaboration of thematic areas, categories of analysis and coding, i.e., group ideas around a concept.Thematic analysis was to find units of meaning whose presence or frequency of appearance may mean something for the chosen analytical objective (13)(14).
The treatment stage of the results and interpretation was the compilation of information obtained through the qualitative process, unraveling the underlying content to what was manifest, inferring and interpreting according to the theoretical foundation.
The interviews took place from October 2013 to March 2014, with an average duration of 20 minutes.Respondents were identified with the letter "E", together with a number/letter as a result of interviews and professional category, i.e.AuxE for nursing assistants and Enf for nurses.
The study observed and respected all ethical aspects as specified by Resolution 466/12, regulated by the National Health Council, in addition to maintaining the confidentiality of the collected information and privacy of the participants.This study was approved by the Ethics Committee of the Federal University of São Carlos, as shown No. 400,945 / 2013.

Results
Analysis of interviews revealed three broad categories.The nursing staff realized that drug use during pregnancy is related to family factors (1) , socioeconomic factors (2) and bio-psychological and cultural factors (3) .

Family Factors
The nursing staff realized that the prevalence of drug use in pregnant women increases in vulnerable families, particularly those in which other family members or partners are drug users and can influence the woman in terms of consumption.Another factor which was identified was related to the imitation by the daughter to the pregnancy situation experienced by her mother, which is; both having early pregnancies, symptomatic of the life cycle of adolescence.The placing of a pregnant woman in a family environment in constant conflict, where the use of psychoactive substances is freer, is also an aggravating factor which helps to expose women to drug use during pregnancy.
I think that means that it is embedded, right?Often, she even intends to stop using alcohol and other drugs.But the partner uses, the brother uses, the father uses and the mother uses too.And so it is like this, it is very difficult for them to stop using when everyone near them is using it.It is even hard for her to adhere to prenatal, right?So of course it is hard for her to come here to deal with us, right (E12-Nurse).
They were people who did not lead a very orderly life.I didn't have this definition of the family, I really didn't...They had no interests, no cultural life, but they also had no notions of the problems all this can bring (E2-AuxE).

Socio-economic Factors
Professionals considered that the cases of pregnant women who use psychoactive substances tend to run in families and / or pregnant women in situations of social vulnerability and / or unstable economic conditions, with little information on the subject.However, they did not rule out the occurrence of problematic drug use in families with better social and financial conditions.However, they found a higher prevalence of the problem in situations with greater social risk.
Another social problem identified by nursing staff was related to the lack of social support, especially with pregnant adolescents, single mothers and cases arising from 'dysfunctional' families.
I think it's... really a socio-economic matter.We realized that the financial part is also influential.The subjects didn't have a good cultural level to know about the problems drug use can bring, right.It comes from the family foundation, right.I believe this.Although it can also happen in a well-off family.But it really stems from needfulness.At least this was the case with the people I was in contact with (E2-AuxE).
They're in a place with the risk of vulnerability, and the risk is too high... and it is all the time (E4-Nurse).
We try to work on this issue, the family she doesn't have...

It is the difficulty of the environment and the difficulty of the net-
works she has.She has no support.They are often single mothers, teenagers and did not choose to be pregnant, who come from an already dysfunctional family and will go on to form other types of networks...But it's not family.Because they are alone (E12-Nurse).

Bio-psychological and Cultural Factors
The risk factors identified in the psychological and biological fields have been related to situations of intergenerational and genetic predisposition, respectively, with the latter being recognized as a vulnerable person because of his personality, or at an early age.In the psychological context, the study also recognized situations involving low self-esteem, permissible parents, feelings of hopelessness and grief experienced during the mother's life, as well as fear, insecurity and search for personal pleasure through the use of drugs.

You know, and I still have drug addiction in the family (E9-AuxE).
No, because well ... I had people from 13 to 30.So this age group is very broad (E12-Nurse).

Since the creation of father and mother, they had been using drugs. Something must have triggered her use because a woman will not get into drugs. 'Ah! I started because I liked.' No. There's always some cause (E11-AuxE).
Low self-esteem, I think this is their problem here, yes...

(E4-Nurse).
Ah perhaps there is a feeling of disgust.This pregnant woman was desperate because her husband... she did not expect her husband to be arrested.And then she sank deeper into her malaise (E8-AuxE).Hm!...I think it is insecurity, fear... and there is pleasure too.Drink, right... Hm!Not only drink.All that is wrong contains a certain pleasure, right.So I think people start... especially with the drink... everyone starts for the pleasure (E9-AuxE).
In the cultural dimension there are contributing factors related to the environment in which pregnant women live, and we have to recognize them as places that can promote drug use, naturalizing the act of using drugs within the neighborhood.And they live within this situation.Another responsible element involves drug use in permissible situations like parties and other fun times, or the use of psychoactive substances by pregnant women for the purpose of fun and disinhibition.Another factor was the lack of leisure and cultural activities that would provide entertainment, and therefore lead to drug use.Another perception of nursing staff was the loss of life perspectives that can motivate the mother to use drugs, especially teenagers, including the idea that a pregnancy can lead to greater status in the neighborhood.
Ah! I think so, the medium surrounding that person?Oh, I think it's the culture.Here it really is the culture, what is it... out of 100% of those here, 80% mess with drugs.Or sell, or... it is always there.I think... it is the environment right?It is everything Most girls are like this already...The environment makes the person.This environment is inviting for it.So you know all of them... not all... but most have come with the idea of "I'm going to use drugs, I use drugs, I'll get pregnant by the 'guy' [dealer]   there," right.So it is a natural cycle here, I have seen it in these six months here.For them it is a normal thing, they were born with it, they lived with it and perhaps their mothers use drugs or

sell. And things more or less work like this (E14-AuxE).
There are things that are cultural and there are things which go beyond, regarding the issue of dependency.If the use is a cultural issue: 'Ah!I use when I go to a party, right'... 'Ah!I take it from time to time'.'Ah!I take it at the weekend, I take it to have fun.If I do not take it, I can't let go of things and relax, you

Discussion
The studies highlight risk factors for substance abuse in the female population with no or little family structure, lack of affection, a family history of psychiatric disorders (1) , precedents of psychological distress in drug dependent women, such as anxiety, depression and aggressive behavior, impatience and lack of concentration (15) .The study found that the profile of pregnant women with suspected alcohol use was found to be prevalent in women with an advanced age, low education, smokers, low social support, multiple pregnancies and a previous history of abortion (9) .
It appears that children of drug dependents have a greater predisposition to psychiatric disorders, and "development of physical and emotional problems and learning difficulties" (16) .Living with an alcoholic in a home environment can trigger stressful situations to other family members, including physical assaults, death of family members and problems with the police (16) .
It turned out that one of the risk factors in terms of the family dimension was related to the modeling of parental roles in which the daughter, in seeking and building her identity, seizes, learns and plays the norms and values transmitted by the mother, which in this case have been identified with regard to teenage pregnancy.Thus, there was an intergenerational transmission, with repetitive behavioral patterns as well as experience and values passed on from generation to generation.Some situations are repeated and are perpetuated through generations, leading to a forming axis of emotional, cultural and social content for the family.However, the way that this is formed relates to the way that women attribute these ideas to their own lives.The intergenerational transmits, permeating the familiar relational structures, add further meanings attributed to certain experiences and values (17) .
Drug addiction is a clinical condition that can cause intergenerational impact, affect and significantly influence family functionality standards (18) .
The main risk factors for drug use among pregnant adolescents in the city of São Paulo consisted of low family income, the social class they belong to, low education, exposure to difficult events in life (2.19) and low social support (9) .It is noteworthy too that unstable romantic relationships between the woman and her husband or partner are considered predictors of alcohol and tobacco use during pregnancy (9) .Considering pregnancies in unmarried women, these are often associated with other risk factors for the use of alcoholic beverages such as poor education, low socio-economic status and unwanted pregnancy (20) .
The study sought to ascertain the perception of pregnant women with regard to illicit drug use during pregnancy, and identified family problems, lack of mate or partner, financial problems, low self-esteem and loneliness as key risk factors (21) .The literature also points out that there are family situations where pregnant women are encouraged by colleagues, friends and family to consume alcohol in times of festivity, leisure and socializing, regardless of financial conditions (22) .It is therefore important that nursing professionals pay attention to lifestyle and family routines, identify risk factors for exposure to alcohol and other drugs during pregnancy, and perform routine orientations.
The use of psychoactive substances during pregnancy is also associated with neurological disorders, depression and various affective disorders.However, the unfamiliarity of nursing professionals to the factors that lead pregnant women to substance abuse prevents early identification of this problem, which makes preventative intervention and appropriate treatment and assistance for these women more difficult (23) .

Final Considerations
With regard to the risks of substance use and pregnancy, most nursing staff understand that such use during pregnancy relates to family, economic, bio-psychosocial and cultural weaknesses.These professionals recognize that the main risk factors for drug use by pregnant women are related to the inclusion of pregnant women in families considered "dysfunctional" and have easy access to substance abuse in the family environment.Thus, nursing professionals need to strengthen guidance in relation to the damage caused to the binomial mother / child via the use of substances in various moments during pregnancy.It must be established that no amount of alcohol or other drugs can be considered safe for consumption during this phase, and to stress the importance of abstention and the need for attention and intervention throughout the pregnancy.
It is important that the nursing staff, during prenatal, be attentive not only to the questions of the evolution of the gestational process, but also to the economic conditions, structure and functioning of the pregnant woman's family.The aim is to identify possible risk factors for exposure to drugs during pregnancy, and to prepare preventative and / or intervention action for this issue.
To conclude, there is a need for further research about the perception of nursing professionals regarding this controversial issue; however, it is believed that the results obtained may contribute to both the learning of knowledge regarding drug use by pregnant women, and the identification of risk factors for an effective and efficient intervention.
Yes, the lack of family structure.Most of these girls, what happens is... Their mothers also had them at 14 or 15-years-old, you know.So now these mothers are around 35-40-years-old and are already grandparents...So in fact, the new mothers reproduce what happened with their own mothers.Then, right ... one will reproduce the same as the other and find it natural, right (E4-Nurse).