ADHESION TO THE USE OF FERROUS SULPHATE BY

Cassimiro GN, Mata JAL. Adhesion to the use of ferrous sulphate...

English/Portuguese

J Nurs UFPE on line., Recife, 11(Suppl. 5):2156-67, May, 2017 2156

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.9302-81402-1-RV.1105sup201722

ADHESION TO THE USE OF FERROUS SULPHATE BY PREGNANT WOMEN SERVED IN THE UNIFIED HEALTH SYSTEM

ADESÃO AO USO DE SULFATO FERROSO POR GESTANTES ATENDIDAS NO SISTEMA ÚNICO DE SAÚDE

ADHESIÓN AL USO DE SULFATO FERROSO POR MUJERES EMBARAZADAS ATENDIDAS EN EL SISTEMA UNICO DE SALUD

Gabriele Nogueira Cassimiro¹, Júnia Aparecida Laia da Mata²

ABSTRACT

Objective: to identify the factors that influence the adherence of pregnant women to the use of ferrous sulfate during prenatal care in the Brazilian Unified Health System. Method: a descriptive, exploratory, qualitative approach. We interviewed 11 pregnant women with gestational age of 20 weeks or more, assigned to a Family Health Strategy unit. The data analysis was based on Thematic Content Analysis. Results: three categories emerged: I - Pregnant women's knowledge about the prescription of ferrous sulfate; II - Factors that negatively influence the adhesion to the use of ferrous sulphate; III - Factors that contribute to the good adhesion to the use of ferrous sulfate. Conclusion: forgetfulness and difficulty in accessing the supplement were shown to be factors that hinder the adherence of pregnant women. The influence of the pre-natalist revealed a positive contribution to the adherence. Descriptors: Unified Health System; Nursing; Pregnancy;

Prenatal Care; Ferrous Sulfate.

RESUMO

Objetivo: identificar os fatores que influenciam na adesão de gestantes ao uso de sulfato ferroso durante o pré-natal no Sistema Único de Saúde. Método: estudo descritivo, exploratório, de abordagem qualitativa. Foram entrevistadas 11 gestantes com idade gestacional de 20 semanas ou mais, adstritas a uma unidade de Estratégia de Saúde da Família. A análise dos dados fundamentou-se na Análise Temática de Conteúdo. Resultados: emergiram três categorias: I - Conhecimentos das gestantes acerca da prescrição do sulfato ferroso; II - Fatores que influenciam negativamente na adesão ao uso de sulfato ferroso; III - Fatores que contribuem para a boa adesão ao uso de sulfato ferroso. Conclusão: o esquecimento e a dificuldade de acesso ao suplemento mostraram-se como fatores que prejudicam a adesão das gestantes. A influência do pré-natalista revelou contribuir positivamente na adesão. Descritores: Sistema Único de Saúde; Enfermagem;

Gravidez; Cuidado Pré-natal; Sulfato Ferroso.

RESUMEN Objetivo: identificar los factores que influyen en la adhesión de mujeres embarazadas al uso de sulfato ferroso durante la atención prenatal en el sistema único de salud. Método: descriptivo, exploratorio, cualitativo. Fueron entrevistados a 11 mujeres embarazadas con edad gestacional de 20 semanas o más, sujeto a una unidad de la estrategia de salud de la familia. El análisis de datos se basó en el análisis temático de contenido. Resultados: surgieron tres categorías: I - Conocimiento de las mujeres embarazadas sobre el requisito de sulfato ferroso; II - Factores que influyen negativamente en el uso de sulfato ferroso; III - Factores que contribuyen a la buena adhesión al uso de sulfato ferroso. Conclusión: la falta de memoria y dificultad de acceso al suplemento se demostraron como factores que afectan la adhesión de mujeres embarazadas. La influencia de (el) pré-natalista reveló una contribución positiva en la adhesión.

Descriptores: Sistema Único de Salud; Enfermería; Embarazo; Atención Prenatal; Sulfato Ferroso. 1Nurse, Specialist in Family Health by the Municipal Health Department of Curitiba and Pequeno Príncipe Colleges. Curitiba (PR), Brazil. E-mail: [email protected]; 2Obstetric Nurse, PhD in Nursing, School of Nursing, State University of Campinas - FEnf / UNICAMP. Campinas (SP), Brazil. E-mail: [email protected]

ORIGINAL ARTICLE

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English/Portuguese



The World Health Organization (WHO)

considers iron deficiency anemia as a major

public health problem, and is one of the

major nutritional deficiencies. In 2012, 41.8%

of the pregnant women in the world presented

this aggravation. In Brazil, although there is

no national survey, a prevalence of around

30% is estimated.

Anemia is determined by a condition in

which the concentration of hemoglobin level

is relatively low in the blood and is defined by

values below 10.5 g/dl. About 50% of the

cases have iron deficiency as the main

contributor, and can occur due to several

factors, such as inadequate intake of this

nutrient, parasitic infections or even

conditions that increase the need for iron,

with emphasis on pregnant women and

younger children of two years.2 In the

gestation, the physiological processes

contribute to the decrease in the absorption

of this micronutrient. In contrast, it

considerably increases its need for fetal

growth.3

According to the WHO, the use of ferrous

sulfate improves the development of

gestation, maternal health and mainly reduces

the infant mortality rate. With these results,

prophylaxis is extended worldwide, especially

in developing countries.1

When considering the high prevalence of

iron deficiency anemia, Brazil proposes

strategies for its prevention and control.

Ordinance No. 730, of May 13, 2005, it

instituted the National Iron Supplementation

Program (NISP), which adopts supplementary

measures to stimulate healthy eating and

supplementation in prophylactic doses.2

Adherence to the use of iron in the

Gestational cycle is a crucial point following

the recommendations of the NISP.1

Adherence is defined as the behavior that

indicates user agreement, following the

instructions of health professionals, according

to the dose of medications / supplements and

schedules previously agreed upon. There are

several causes of noncompliance, treated as

preventable and not preventable. Among the

avoidable ones, are forgetfulness, lack of

understanding about prescription or even

barriers to obtaining medication; in relation

to unavoidable ones, untreatable side effects

and adverse events are highlighted.4-5

The evaluation of adherence to the use of

medications and supplements should be

frequent in the daily routine of health

professionals, to monitor the proposed

treatment and promote adherence by the

recipient of the care. It can be done by direct

or indirect methods. The former include

laboratory techniques that quantify the drug,

metabolites or biological fluids, relating to

the use of medication and direct observation

of the user, usually performed in hospitals.

The indirect ones evaluate the behavior of the

individual associated with the reported

information and/or estimates, such as, self-

report, the application of structured

questionnaires, the verification of the drug

withdrawal record from the pharmacy and the

evaluation of the clinical response.5-6

The consequences of low adherence are

significant, causing debate in many countries,

as they imply an increase in direct and

indirect health expenditures and social costs

due to the loss or reduction of labor

productivity and the reduction of quality of

life. It is fundamental that managers and

health professionals recognize the problem of

lack of adherence to medication, adopting

actions to improve the performance of the

health system, optimizing resources,

improving health indicators, effectiveness of

interventions and, consequently, impacting

morbidity and mortality.4-5

Studies associate the low adherence to iron

supplementation with its side effects.7-8

Prenatal professionals are considered as

potential identifiers of the elements that

interfere with the continuity of treatment

with ferrous sulfate, and may promote care

that favors greater adherence of pregnant

women.

In professional practice, the authors

realized that only the recommendation of the

Ministry of Health (MH) of Brazil and the

routine prescription of this supplement have

not guaranteed the adoption of women to

their daily use. Therefore, it is argued that it

is important to research and know the factors

that influence adherence, which may support

the elaboration of prenatal care strategies

that potentiate adherence to iron

supplementation, contributing, positively, to

maternal- child health.

Therefore, the objective, of this study, was

to identify the factors that influence the

adherence of pregnant women to the use of

ferrous sulfate during prenatal care in the

Unified Health System (UHS).

It is a descriptive, exploratory, qualitative

study.9-10 It was developed in a Family Health

Strategy (FHS) unit, belonging to the Bairro

Novo Health District, in the city of Curitiba

(PR), Brazil. This service integrates the Mãe

INTRODUCTION

MÉTHOD


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Curitibana Program, whose purpose, is to

improve the quality of humanized, qualified

and safe prenatal care. At the time of

collection, it had three teams, each consisting

of: one general practitioner, one nurse, three

Nursing assistants, one dental surgeon, one

oral health assistant, one oral health

technician, and six community health agents

(CHA). It had 9,111 registered users, of whom

93 were pregnant.

Eleven pregnant women with gestational

age of 20 weeks or more, with prescription of

ferrous sulfate, were enrolled in the study.

The type of sample was for convenience and

its size, defined by means of data saturation,

in which the capture of new components is

interrupted when the data obtained present,

in the evaluation of the scientist, a certain

repetition.11

The recruitment of the participants

occurred in two moments: 1 - consultation on

the users in the electronic medical records,

considering the inclusion criteria; 2 -

invitation of the possible participants, through

telephone contact and / or in the waiting

room for prenatal care. All the invited ones

accepted to participate, signing the Free and

Informed Consent Term (FICT). In order to

preserve anonymity, the pregnant women

were coded with Brazilian stone names.

The data were produced between October

and December 2015, and were obtained

through an individual interview, audiograved

by digital recorder, guided by a guide script,

consisting of two parts: A- characterization of

the participants; B- guiding questions. All

interviews were transcribed concomitantly

with the collection.

The analysis and interpretation of the data

were based on the technique of Thematic

Analysis of Content, proposed by Laurence

Bardin.12 They were carried out in three

stages: 1) Pre-analysis, in which the floating

reading of the material was carried out and

the data organized in Categories and themes;

2) Exploitation of the material, in which the

coding units were chosen; 3) Treatment of

results (inference and interpretation), in

which the contents of the speech were

interpreted, basing them on the theoretical

reference of this research.12

This study was approved by the Research

Ethics Committee of the Faculdades Pequeno

Príncipe (CAAE 44283215.5.0000.5580) and

authorized by the Municipal Health

Department of Curitiba (CAAE

44283215.5.3001.0101).

Characterization of Pregnant women

The participants' ages ranged from 18 to 36

years. Six had fixed employment, with a

workday from six to eight hours. The average

monthly income ranged from R$430 to R

$4,300. Ten pregnant women said they were

married. Five were primiparous and six, were

multiparous. Regarding schooling, six of the

interviewees had completed high school;

three had incomplete high school, one,

complete primary and one, incomplete

elementary school.

Six pregnant women were prematurely

prenatal, while five started late after 120

days of gestation. This is a worrying situation,

since the MH maintains that, in order to

ensure a quality and effective prenatal care,

it is essential to link the pregnant woman as

early as possible to pre=natal care.

The number of prenatal consultations,

carried out until the moment of the interview,

remained between three and nine. When

considering the gestational age of the

investigated patients and the periodicity of

the visits, recommended by the MH, it was

verified that all the pregnant women were up

to date with the prenatal calendar. Most of

the consultations were performed by the

medical category. Seven of the interviewees

had undergone only one Nursing consultation,

prevailing the one of bonding.

According to the Nursing Professional

Exercise Law, No. 7.498 / 86, the nurse is

qualified to perform prenatal care, as it has

the technical-scientific competence to

properly perform care for the pregnant

woman. The MH corroborates with this

legislation and affirms that in the basic health

network, the nurse can fully follow the usual

prenatal risk. It also determines, that both

the doctor, and the nurse must perform the

prenatal relationship, which includes filling

out the pregnant woman's card and registering

her in the Pregnancy Monitoring System

(SisPreNatal).13,14 It was verified that, in the

studied scenario, there is the centralization of

bureaucratic functions, such as the user's

registry in SisPreNatal, in the figure of the

Nursing professional, with care under medical

responsibility.

At the time of collection, all participants

stated that they were using ferrous sulfate.

Ten of them also expressed the use of folic

acid; one was taking fluoxetine and one, a

vitamin-mineral supplement.

Prescription of ferrous sulfate before the

20th week of gestation was observed in five

RESULTS AND DISCUSSION


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pregnant women, with only one being advised

that it could be used after 20 gestational

weeks. There are recommendations for the

use of supplementary iron starting at 20

weeks of gestation, since, during this period,

there is a significant increase in the

absorption of this micronutrient, decreasing

maternal reserves.15

As for the prescriptions of ferrous sulfate,

nine were made by doctors and only two, by

nurses. It is believed that this situation is

related to the reduced number of

consultations performed by Nursing

professionals in the unit studied.

Only two prescriptions contained the

dosage: one performed by a doctor and

another, by a nurse. Only four pregnant

women reported having been instructed on

the use of ferrous sulfate until the third

month after delivery. It was identified that,

the recommendations of the WHO and the Mãe

Curitibana Program regarding the prescription

of ferrous sulfate and orientation of the users

were not followed in the care of the majority

of the pregnant women (six).

Analysis categories

The categories and subcategories of

analysis, shown in Figure 1, were constructed,

from the pregnant women's statements.

Categories Subcategories

I- Knowledge of pregnant women about the prescription of ferrous sulfate

- Prevention of anemia - Iron replacement in the maternal organism

II - Factors that negatively influence the adhesion to the use of ferrous sulfate

- Lack of access to ferrous sulfate in the health service - Fragility in the guidelines offered to pregnant women - Side effects in the use of the supplement

III- Factors that contribute to the good adhesion to the use of ferrous sulfate

- Concern about the baby's well-being - Positive influence of the prenatalist

Figure 1. Categories and subcategories elaborated from interviews with pregnant women. Curitiba, PR. 2015.

Category I - Pregnant women's

knowledge about the prescription of

ferrous sulfate

In Category I, the units of significance that

demonstrate the knowledge of pregnant

women about the prescription of ferrous

sulfate during the pregnancy cycle, namely

prevention of anemia and replacement of iron

in the maternal organism, were collected.

Anemia prevention

The majority of users (eight) showed to

know the main purpose of iron

supplementation during gestation: the

prevention of anemia.

That I knew, I think it's because of vitamins,

right? From the baby, to avoid anemia for

the baby and me. I got this information

from my first boy, the doctor had explained

more or less, that I remember. (Turquoise)

Because of anemia, right? This kind of thing.

It was very low and he [the doctor]

prescribed it for me. It's for anemia, that's

all. (Emerald)

Because of anemia, right? That I know is to

prevent anemia. (Grenade)

Because of anemia. I already knew the

ferrous sulfate before, because I already

had anemia. (Ruby)

It was noticed the existence of previous

knowledge of pregnant women about the use

of ferrous sulfate, sometimes due to the

experiences of the previous gestation, as well

as the presence of anemia in the current

pregnancy.

In Western societies, women are more

likely to develop anemia, considering that iron

intake is below recommended levels, resulting

in low levels of this nutrient in the bone

marrow and, when they become pregnant,

they end up being unfavorably with the

reduced reserves.16 In the gestational period,

the total blood volume increases, about 40 to

50%, as a consequence of the increase in

plasma volume, which is disproportionate to

that of red cells, starting at the 16th week,

resulting in a gravidic modification called

hemodilution17 or Pseudoanemia.

Hemodilution is a physiological process of

adapting to the needs of oxygen transport to

the fetus. This condition makes it difficult and

confusing for some professionals to diagnose

anemia during pregnancy. In order to avoid

unnecessary prescription of ferrous sulfate in

prenatal care, it would be ideal for the pre-

natalist to know the hematological status of

the woman, prior to pregnancy. However, in

the public health service, most women seek

care already suspected of pregnancy,

manifesting clinical signs and symptoms

without preconception planning. This makes it

difficult to distinguish between anemia and

hemodilution in the clinic.

The need for iron varies during the

pregnancy cycle. This micronutrient is

intended for the demands of maternal

circulation, including, for the expansion of the

erythrocyte mass, development and growth of

the fetus, placenta, umbilical cord, as well as


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eventual losses (during childbirth and

puerperium). 17

Anemia has implications for maternal and

child health in the short and long term.

Pregnant women may present with fatigue,

dizziness, headache, impaired muscular

performance, reduced physical fitness for

work and behavioral disorders including

depression, irritability, emotional instability,

difficulty concentrating and attention.18 One

of the pregnant women demonstrated

knowledge about some of the changes that

Anemia cause:

In order not to let anemia, not to let it

weaken me, to prevent it from

strengthening during pregnancy, I have been

taking ferrous sulfate for a long time,

because I have always had anemia, that, is

something, I know. (Amber)

Anemia prevention measures, adopted in

Brazil, include nutritional and food education

actions, so that nutrition is healthy and

adequate, taking into account individual

needs; fortification of wheat and maize flour;

control of parasitic diseases; improvement of

sanitation conditions; and prophylactic

supplementation with iron and folic acid,

especially, in pregnancy and in children.2

Health education is a relevant strategy in

promoting knowledge during prenatal care.

Among the points to be addressed by the

prenatalist, prophylactic iron supplementation

should be presented to the pregnant woman in

order to aggregate previous knowledge,

orienting her on the importance of adherence

to treatment, on possible side effects that

may during the use of the supplement, and

the importance of its use until the third

month after giving birth.2

Iron replacement in the maternal

organism

Some pregnant women (four) stated that

ferrous sulfate was prescribed to replace iron

in their body in order to supply their needs

and of the baby.

I know it is to raise the iron level of the

body because of gestation and the baby's

iron. (Agate)

To raise the level of iron in the blood

because I'm having anemia and that could

happen to the baby. (Amethyst)

It serves to replace the iron that I do not

have in the body. (Crystal)

Iron plays important roles in the human

body. The concentration of iron in the body is

about three to five grams, being

approximately 30 to 50 mg / kg, varying

according to sex, age, tissue examined and

geographical regions in which The

bioavailability of iron is altered, both, for

excess and shortage. 19

For the monitoring of circulating iron

levels, hemoglobin concentration is often used

because it is simple and inexpensive.

However, it is not sufficient to evaluate,

being necessary the complementation with

biomarkers, as for example, the concentration

of serum ferritin and transferrin receptors.

These complementary exams are not always

available and have limitations in their

interpretations, in some cases, where there

are infections such as malaria, HIV / AIDS and

vaginosis during pregnancy.20,21

Food is the main source for obtaining iron,

and foods of plant origin, such as, dark green

leafy vegetables, and legumes have low

bioavailability, requiring the recommendation

of the ingestion associated with foods that

improve their absorption, which contain

vitamin C or A, available in fruits like lemon,

orange, papaya and mango. Foods of animal

origin, such as red meat, poultry, pork, fish

and shellfish have better absorption.2

Iron deficiency is a clinical problem

associated with several negative consequences

for maternal and child health. So, ensuring an

adequate level of this micronutrient in the

pregnant woman's body is necessary to avoid

complications as well as to improve the

development and maturity of the fetus.20

The aforementioned statements were

identified in the discourses of pregnant

women, which reveals a level of knowledge

about iron supplementation, whether acquired

through information obtained in previous

pregnancies, or even due to the need for

anemia treatment prior to pregnancy. The

information facilitates the process of

adherence, since it promotes the user's

understanding of the importance and motive

of the treatment proposed during the

pregnancy-puerperal cycle.

Category II - Factors that influence

negatively in adherence to the use of

ferrous sulfate

In Category II, meaning units were

identified that reveal the factors that

negatively affect the adherence of pregnant

women to the use of ferrous sulfate, being:

the lack of access to ferrous sulfate in the

health service; fragilities in the guidelines

offered to the pregnant woman and side

effects in the use of the supplement.

Lack of access to ferrous sulfate in the

health service

Pharmaceutical assistance in UHS is

organized in levels of complexity, financed by

blocks classified into three components: basic,


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specialized and strategic. Currently, the

National List of Essential Medicines - RENAME,

guided by the National Policy on

Pharmaceutical Care, lists all medicines that

citizens should have the right to free access,

considered essential to guarantee improved

access to the health of the population.22

For a quality prenatal care, it is necessary

to guarantee some elements, such as the

availability and access to basic medicines,

such as ferrous sulfate and folic acid.2 Some

disrespect to this recommendation has been

identified. The interviewees expressed that

they had ceased the use of ferrous sulfate

because of difficulty in accessing the

supplement in the health unit, noting that it

was missing for a certain period.

So until these days I made a stop, because I

was missing here, it's still in the truth,

there I bought it yesterday. Stay for about

two weeks without the medication. I think

even, I do not know, but I needed it, the

body got used, right? And then I stopped.

And it was at this time that my immunity

went down a lot, that even I went to

maternity because it gave a little problem, I

do not know if it has to do right? But when

the immunity of the low people gives of

everything in the people and gave of

everything in me, type urinary infection, I

was very bad. (Amber)

I do not take it just now, because it does

not have in the unit, I have to inform myself

today. (Tourmaline)

The lack of the supplement in the health

unit made it difficult to join and to continue

the treatment of the aforementioned

participants. Since the supply of a drug,

considered as basic in the public health

network, is interrupted, it directly affects the

UHS principles, influencing the quality of the

care provided and the expected results.

According to the NISP, obtaining the

supplements should be performed by planning

through the basic component of

Pharmaceutical Assistance, with tripartite

responsibility. For the acquisition, the

municipalities can perform the prioritization

of the population to be served and must

stipulate the amount of necessary inputs, as

well as the costs of the program so that it is

always available to SUS users. The absence of

these inputs reflects the resolubility of actions

and programs and compromises the

performance of services and professionals.2

Research shows that one of the main points

to check adherence is to assess whether the

drug is available for free or even at low cost,

as well as the accessibility of medication in

pharmaceutical care. Consideration is given to

whether the patient has the financial

resources to join, if he or she does not have

public health availability.23

It is important to emphasize that the

adhesion to ferrous sulfate depends directly

on the distribution of the drug free of charge,

because, when the user does not have

financial resources or even have difficulty

accessing it, it will hardly have a good

adherence.

In a scientific study, which evaluated

prenatal care in Brazil's basic network,

analyzing several points, such as the physical

evaluation of the place, human resources,

materials, norms, activities, procedures and

the reference system, it was verified the

existence Of unsatisfactory and precarious

resources, such as the lack of medication,

which limits the follow-up of pregnant women

and weakens the quality of prenatal care as a

whole.24 It can be seen that the reality

investigated in this study is not unrelated to

other Brazilian scenarios, and it is

fundamental to reflect and address the issue

of the user's access to qualified, resolutive

and safe prenatal care.

The promotion of adherence to the use of

supplements, when indicated, in the

pregnancy-puerperal cycle, is not limited to

aspects of care. It also involves the

management of public health services, which

must be in line with current public policies,

ensuring compliance with its guidelines by

Through a strategic planning that considers

the profile and needs of the assisted

population and an ethical and responsible

administration, committed to the principles

that govern UHS.

Fragility in the guidelines offered to

pregnant women

The majority of pregnant women (ten)

expressed weaknesses in the guidelines

received regarding the use of ferrous sulfate

during prenatal care, such as: prescription

with total lack of information; lack of

information about the reason for the use;

dosage and effects Collaterals.

In fact, she [prenatalist] only told me what

it was and passed me, she said it was to be

able to help in the "thing" of the blood and

for the baby and only. (Amethyst)

No, I did not receive any guidance in this

gestation. (Turquoise)

I did not receive any information. (Sapphire)

No, just said it [professionals], that I was

having anemia and passed me the ferrous

sulfate. (Tourmaline)

One of the important factors raised as

determinants of adherence is the relationship

between professional and user. It is necessary

to understand the client as an active subject


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in their treatment, participating in the

decisions and assuming the responsibilities

proposed in an agreed and not imposed

manner. Professional attitudes also deserve

attention, such as the language used during

the service, the time spent, the questioning,

the guidelines and motivations for compliance

with the treatment.23

In scientific research, the importance of

achieving a good prescription was verified.

However, it is not usually observed and

performed because the prescriber does not

encourage the user to participate in the

choice of treatment, often imposing what

should be done and also does not provide

enough information about his or her health

problem and the proposed treatment, positive

for the individual to adhere to its

recommendations. Another point identified in

the study was that the professional does not

verify the understanding about what was

exposed to the user, and still less about its

acceptability. All behaviors become especially

detrimental to the client, who does not know

and does not receive the necessary

information about their health condition and

the importance of the recommended

treatment.25

The pre-natalist has a strong influence on

the quality of the care given to the pregnant

woman. It should consider, in the attendance,

the relevance of the practice of health

education that, if performed in a satisfactory

manner, generates a positive impact on the

professional-user relationship, providing a

more complete information exchange,

influencing the decision power of the

pregnant woman about her health, promoting

a healthy and pleasant gestational cycle for

the woman.25

Other participants reported that they

received guidance regarding the use of ferrous

sulfate, however, it is noted, in the

statements, that the users felt a lack of

something (frequent occurrence of the word

"alone"), perhaps some recommendation or

the clarification of doubts.

Just for use, one capsule a day next to some

food and only. (Crystal)

He [the doctor] just told me how to take it.

(Emerald)

He [the doctor] just said it was for me to

take once a day, half an hour before lunch.

(Grenade)

Just from the use, it was to take one tablet

a day, up to three months after gestation.

(Jade)

The Mãe Curitibana Protocol recommends

the prescription of a 40mg ferrous sulfate

tablet for prophylaxis, with daily use for

prophylaxis, as well as the orientation of

regular use at the same time, daily, between

meals, being at least 30 minutes before

feeding and, Preferably with vitamin C-rich

juice. In case of forgetfulness should be taken

soon after feeding.15

It is important to discuss with the pregnant

woman about the uninterrupted use until the

end of gestation. For this, it is necessary to

clarify about the possible effects, that can

generate the resistance in the continuation of

the supplementation and, in cases of

intolerance, guide to take at least twice a

week.15

Nonadherence to treatment may be linked

to both the pregnant and the pre-natal, which

does not adequately guide the importance of

the use, continuity, risks to which women are

exposed and, often, Does not perform health

education, so significant for the performance

of a prenatal resolution.23

Two participants showed adequate

guidelines regarding dosage and the reason for

the prescription. One of them had anemia

prior to pregnancy. Prescriptions were

performed by nurses.

[...] that I take three times a day, every

eight hours, not to weaken and help during

pregnancy. (Amber)

[...] for me to take it once a day until the

third month after the baby is born. (Agate)

The daily dose of ferrous sulfate, as

reported by the interviewees, was in

accordance with the prescription made by the

professional and recorded in the medical

record. In this way, it was verified that the

investigated ones were following the

recommendations of the pre-natalistas that

prescribed.

Seven participants reported having

forgotten to take the supplement as

prescribed, a factor that also interferes with

adherence.

Sometimes we forget. I did not tell the

doctor. Oh, it was only one day. (Jade)

Already [stopped taking] because I forgot. I

did not tell the doctor. (Emerald)

Yes [stopped taking], by forgetting.

(Grenade)

Just to have forgotten, I never stopped

taking no, sometimes I forget. (Ruby)

Oh, there are two times I forgot [to take].

(Sapphire)

The WHO cites forgetting as a problem of

preventable noncompliance, being a factor

connected to the user. Adherence is related

to the motivation and meaning that the

subject has with the recommended

treatment, the importance that is seen for

health and well-being, demonstrating that the


English/Portuguese



trust and belief that is deposited in the

therapy outweigh the effects or even the

change in lifestyle necessary to achieve better

results.4 In the consultations, it is essential

that the prenatal care provider verify that the

pregnant woman has followed the dosage,

reinforcing the need for maternal and fetal

health supplementation.

Side effects of supplement use

Side effects, caused by ferrous sulphate,

appeared in the pregnant women's speeches,

being revealed as factors that influenced the

adhesion.

I had a lot of dryness, I had constipation, so

I talked to my doctor, who advised to eat

more greens, drink plenty of liquids, eat

fruits. The doctor advised that it could be

for ferrous sulfate, yes. (Turquoise)

I stopped taking it, I took it for three

months in a row, along with folic acid, but I

always put it out, I always vomited, from

there I stopped drinking. And then,when I

did the blood test again, gave it again right?

That I was close to having anemia, so I went

back to taking only the ferrous sulfate. I

told the doctor and he fought with me, he

directed to return to use. Nobody told me

that the vomit was related to the ferrous

sulfate, but I took it with the folic acid

together and consequently I vomited, hence

that iron taste was strong in the mouth and

from there I interrupted. (Crystal)

It was verified, in the speeches, that the

most common side effects experienced by the

interviewees were: constipation and vomiting.

Research shows that one of the main

reasons for the difficulty in adhering to the

use of ferrous sulfate is the side effects,

especially, those related to the

gastrointestinal tract. These include epigastric

pain, nausea, vomiting, dark stools,

abdominal cramps, constipation, and less

frequently, diarrhea and heartburn.7-8

Some authors propose the use of different

doses of ferrous sulfate, since, they

demonstrate that, in smaller doses, this

supplement presents better results, reducing

the side effects. There are debates on daily or

weekly supplementation, on its benefits and,

especially, on the impact of reducing anemia

rates.7,21

Category III - Factors that contribute

to good adhesion to the use of ferrous

sulfate

Concern about baby's well-being

In the interviews, there was a frequent

appearance of concern about the health of

the baby, a factor that contributed to the

frequent use of ferrous sulfate by pregnant

women.

Because it's good right, for the baby to be

born healthy, important for me too, right?

(Turquoise)

Because I'm scared to death [something

happens to the baby], I actually, think it's

very important for the baby. (Agate)

[...] because I'm having anemia and this

could happen to the baby. (Amethyst)

Oh, because of the baby, right, to avoid

passing anything to the baby. (Grenade)

Prenatal care is a time when the pregnant

woman experiences the gestational process

proactively and has many worries and doubts

about her well-being and the baby. Among the

concerns shown by women, studies have

revealed that concern about fetal

abnormalities is one of the most cited, as well

as the chance of spontaneous abortion. Some

doubts assume specific stages in gestation,

which increases anxiety in these periods. The

performance of procedures, examinations and

educational activities are valued in the hope

of the child's health and also in the prevention

of complications during the pregnancy cycle.26

The fetus, during its development, has high

dependence on the mother to reach its

nutritional needs and, among the main

micronutrients, the iron is outstanding. In

order for the baby to receive adequate

amounts, this nutrient is supplied to the

mother from body stores, absorption through

feeding or even hemolysis, and she transfers it

to the baby, who is a major consumer of

iron.27 Iron Is an essential element for the

development and growth of various organs of

the fetus, especially the hematopoietic ones,

which are very important for the healthy

formation of the brain.20

Studies have shown that children of women

who have iron deficiency during pregnancy

have a lower cognitive development and even

a lower level of intelligence when compared

to the children of mothers who did not

present the deficiency in pregnancy.

Therefore, babies born with iron deficiency

have many negative repercussions on their

health, especially, on the nervous system,

affecting their behavioral development and

intelligence in childhood.20

Iron deficiency anemia is associated with

risk factors such as premature labor,

increased complications or adverse events,

and low birth weight. In addition to increasing

the chance of developing postpartum

depression, difficulty in mother-child

interaction and the compromise of the

important emotional ties in the puerperium,

especially, for breastfeeding.20

Iron deficiency in the baby may be due to

factors such as impaired absorption of this


English/Portuguese



micronutrient, cord clamping time, time of

introduction of complementary foods,

frequency of infections, excessive blood loss,

malnutrition, parasitic diseases and other

diseases. 28 These factors elucidate the

relevance in promoting prenatal strategies

that promote adequate adherence to the use

of ferrous sulfate in women who require this

supplement.

The recognition by the pregnant women of

the importance of the supplementation for

the health of the baby can be considered a

promoter of the adhesion, after all, taking the

ferrous sulfate means for them the guarantee

of the well-being of their child, as well as the

prevention of aggravations that may affect it,

taking them to follow the recommendations

made by the pre-natalist.

Positive influence of the prenatalist

When asked about adherence to the use of

ferrous sulfate, three investigators reported

that they were following supplementation

because their prescriptions had been

prescribed by their pre-natalist, highlighting

the influence of the professional figure on

adherence.

I have taken it. Because she [the

prenatalist] has passed, so I take.

(Amethyst)

Yes [takes]. Because the doctor prescribed

and because of the baby, right? (Jade)

As I am, because the doctor prescribed me.

(Emerald)

It was identified, in the speeches, the

influence that the prenatalist exerted on the

volunteers, overcoming the lack of

information about the treatment, the side

effects, etc. They have shown great

confidence in the prescription of

professionals. A study shows that the main

references of pregnant women are health

professionals. Confidence is an important link

that must be built during prenatal care,

facilitating the professional-user relationship

and, in addition, improving the exchange of

information on pregnancy, childbirth and the

puerperium.29

Iron absorption depends on a number of

factors, including the nutritional orientation

associated with measures that promote the

change in micronutrient consumption habits.30

Thus, health education, related to nutritional

aspects in pregnancy, becomes indispensable

in the care offered .

When there is a good relationship between

the pregnant woman and the prenatal care

provider, the information offered throughout

the gestational cycle goes beyond mere

transmission and becomes significant for the

use of the recommendations in the daily

routine of the pregnant woman. It is

important to raise the awareness of the health

professional to deal with maternal and child

care, taking into account the innumerable and

large changes that involve pregnancy.29

Continuing health education can be a strategy

adopted to keep professionals up-to-date on

the related guidelines Prenatal care,

enhancing adoption and respect for WHO

recommendations, public policies and national

protocols.

In this research, prenatal care issues, were

identified, that should be reflected and

discussed, with the purpose of promoting the

improvement of the quality and safety of the

care offered to pregnant women in the

scenario studied. It was verified the existence

of fragilities that directly interfere in the

assistance performed by the prenatalists, such

as: the lack of medication and the non-

effective communication between

professional-user.

Brazilian maternal and child health has

protocols, ordinances, laws and resolutions,

which were elaborated with the objective of

improving health care in the country.

However, this study failed to meet some

recommendations of the Ministry of Health

and WHO, such as access to necessary

supplies, the application of health education

and qualified human resources in prenatal

care.

Despite the increasing drop in maternal and

infant mortality rates in Brazil, rates for

preventable causes are worrying, which points

to the current discussions on the issue of

increased prenatal coverage. It is argued that

it is necessary to go much further than the

extension of coverage, since the need to

qualify the health service and to improve the

skills and commitment of prenatal care

providers is emerging.

It was evidenced, in the research, that

inadequate communication between pregnant

women, with lack of information and lack of

clarity, or lack of communication, when

essential guidelines were not offered to

women, may negatively influence adherence

to iron supplementation. Effective

communication is an important prenatal tool.

Building a relationship of trust with the user

makes it more positive, facilitating the

exchange of knowledge and stimulating the

adherence of pregnant women to the

practices and recommendations of the

prenatalist.

CONCLUSION


English/Portuguese



It was observed that one of the reasons

that led the pregnant women to stop taking

ferrous sulfate was oblivion and that they did

not communicate it to the health professional.

It is necessary to be attentive and frequently

check adherence to the prescribed therapy,

identifying the reasons that caused the

interruption, guiding pregnant women about

the need to use the supplement and its

importance and conducting health education

on an ongoing basis.

Health education is a fundamental point in

prenatal care and, to exercise it, professionals

must always update their knowledge, based

on protocols and scientific evidence. This

facilitates the fulfillment and the

accomplishment of an integral care, with

greater security and quality.

When considering the importance of the

topic of this study, it is recommended to carry

out new work on the subject, including, in the

municipality of this research scenario, so that

health professionals reflect how essential it is

to perform a responsible, safe, Qualified to

promote the adherence of iron

supplementation as a form of protection and

promotion of maternal and child health.

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English/Portuguese



Submission: 2016/02/08 Accepted: 2016/04/11 Publishing: 2017/05/15

Corresponding Address

Gabriele Nogueira Cassimiro Rua Vereador Engenheiro Ernani Batista Rosas, 3131, Bloco 23, Ap. 1 Bairro Jardim Carvalho

CEP: 840150150 Ponta Grossa (PR), Brazil

Documents

ADHESION TO THE USE OF FERROUS SULPHATE BY