HIGH-RISK PREGNANCY AND SOCIAL DETERMINANTS OF HEALTH: A DISCURSIVE ANALYSISABSTRACT
Objective: To understand the meanings that women who have experienced a high-risk pregnancy attribute to the social determinants of health.
Method: This descriptive and qualitative study was conducted at a university hospital, a referral center for high-risk prenatal care, labor, and childbirth in a region of southeastern Brazil. Semi-structured interviews were conducted with 27 postpartum women between April 2023 and February 2024, and analyzed using Michel Pêcheux’s French discourse analysis approach.
Results: The results were organized into two discursive chunks: The influence of the female role on the social determinants of health; and Behavioral characteristics during the experience of a high-risk pregnancy: adherence to treatment determined by socio-historical subjectivization.
Conclusion: The discursive formations demonstrated how the subject position is rooted in the ideology that is sustained by the place that women historically occupy in society, as it describes how socioeconomic vulnerability, exposure to stressors, the limited capacity of the health system and its public policies interfere with the behaviors and lifestyles of pregnant women classified as high-risk pregnancies.
DESCRIPTORS:
Social determinants of health. Pregnancy; high-risk. Postpartum period. Obstetrics. Address
RESUMO
Objetivo: compreender os sentidos que as mulheres que vivenciaram uma gestação de alto risco atribuem aos determinantes sociais de saúde.
Método: estudo descritivo com abordagem qualitativa realizada em um hospital universitário, referência para pré-natal de alto risco, parto e nascimento de uma região do Sudeste do Brasil. Foram realizadas entrevistas semiestruturadas com 27 puérperas entre abril de 2023 a fevereiro de 2024, analisadas sob a perspectiva da análise de discurso de linha francesa de Michel Pêcheux.
Resultados: os resultados foram organizados em dois blocos discursivos: a influência do papel do gênero feminino nos determinantes sociais da saúde; e, as características comportamentais durante a vivência de uma gestação de alto risco e a adesão ao tratamento determinada pela subjetivação sócio-histórica.
Conclusão: as formações discursivas demonstraram como a posição-sujeito está enraizada na ideologia que se sustenta pelo lugar em que a mulher historicamente ocupa na sociedade, à medida em que descreve como a vulnerabilidade socioeconômica, a exposição a fatores estressantes, a capacidade limitada do sistema de saúde e as suas políticas públicas interferem nos comportamentos e nos estilos de vida de gestantes classificadas como de alto risco gestacional.
DESCRITORES:
Determinantes sociais da saúde; Gravidez de alto risco; Período pós-parto; Obstetrícia; Discurso
RESUMEN
Objetivo: Comprender los significados que las mujeres que han experimentado un embarazo de alto riesgo atribuyen a los determinantes sociales de la salud.
Método: Estudio descriptivo con enfoque cualitativo realizado en un hospital universitario, centro de referencia para atención prenatal, parto y nacimiento de alto riesgo en una región del sureste de Brasil. Se realizaron entrevistas semiestructuradas a 27 mujeres en posparto entre abril de 2023 y febrero de 2024, y se analizaron mediante el método de análisis del discurso francés de Michel Pêcheux.
Resultados: Los resultados se organizaron en dos bloques discursivos: La influencia del rol de género femenino en los determinantes sociales de la salud; y Características comportamentales durante la vivencia de un embarazo de alto riesgo: la adherencia al tratamiento determinada por la subjetivación sociohistórica.
Conclusión: Las formaciones discursivas evidenciaron cómo la posición del sujeto se encuentra arraigada en la ideología que se sustenta en el lugar que históricamente ocupan las mujeres en la sociedad al describir cómo la vulnerabilidad socioeconómica, la exposición a estresores, la limitada capacidad del sistema de salud y sus políticas públicas interfieren en los comportamientos y estilos de vida de las mujeres embarazadas clasificadas como de alto riesgo gestacional.
DESCRIPTORES:
Determinantes sociales de la salud; Embarazo de alto riesgo; Periodo posparto; Obstetricia; Discurso
INTRODUCTION
The World Health Organization (WHO) defines social determinants of health (SDH) as non-biological factors that influence health1. Seeking to clarify the mechanisms by which SDH generate inequities in health outcomes, studies suggest that habits such as smoking, alcohol consumption, physical inactivity, and inadequate nutrition are determined by material and psychosocial circumstances, which, in turn, are influenced by socioeconomic status2-3.
In the context of obstetrics, maternal SDH can be understood as the conditions in which women are born, grow, work and live before, during and after pregnancy, meaning that maternal and child health is profoundly shaped by the broader context in which pregnancy occurs4.
Recent studies demonstrate the association between severe maternal morbidity and social inequities, as they have shown that women with non-white skin color, little education and low income are more likely to become seriously ill or die compared to women of privileged social class or white skin color5-8. This means that women with disadvantaged socioeconomic conditions, the majority of whom are black, are more likely to have previous comorbidities or those developed during pregnancy and childbirth, resulting from greater exposure to risk factors. When they become ill, they find it more difficult to access healthcare services, both for diagnosis and treatment, and therefore have a higher risk of adverse outcomes9.
For instance, although access to prenatal care is comprehensive in Brazil, it is less readily available for black women. A study using data from the Brazilian National Health Survey found that access to prenatal care in the first trimester, as well as having at least six appointments, were influenced by race and education. However, black women with higher levels of education had less access to the health system compared to white women with lower levels of education7.
In this regard, it is important to emphasize that barriers to access to the health system and individual behaviors are influenced by socioeconomic policy, which governs a society’s culture and, therefore, shapes individual behaviors that may or may not be harmful to health. Lifestyle must, therefore, be viewed from the perspective of the collective and not solely from the perspective of individual choice10.
Given these considerations, and assuming that discourses have a historical-social determinant,11 the discourses of postpartum women who presented with a risk condition diagnosed during prenatal care may be able to reveal nuances of health inequities in this population. Therefore, this study aimed to understand the meanings that women who experienced a high-risk pregnancy attribute to SDH.
METHOD
This is a descriptive and qualitative study, whose analysis process was based on the theoretical-methodological framework of French Discourse Analysis (DA) by Michel Pêcheux12. DA considers the conditions of discourse production through the relationship between language, discourse, and ideology. Thus, discourse’s social mode of production is observed based on its implications: conflicts, recognitions, power relations, and the formation of identities11.
The study was developed at a university hospital, a reference for high-risk prenatal care, labor and childbirth, for 27 municipalities in southeastern Brazil, from April 2023 to February 2024. The reference population was composed of pregnant women who were undergoing prenatal care at the high-risk outpatient clinic of the university hospital, regardless of gestational age.
Women with high-risk pregnancies being monitored at the referral center were included. Women with any condition that prevented them from completing the survey, such as not speaking Portuguese or having severe clinical or psychological conditions, were excluded. These conditions were previously assessed by consulting women’s medical records at the center.
Recruitment took place randomly at the university hospital’s high-risk prenatal clinic while potential participants awaited their appointments. At this point, the research objectives were presented, along with data collection procedures, which would take place in the postpartum period, even during hospitalization. Women who agreed to participate read and signed the Informed Consent Form (ICF), keeping one copy for themselves.
Twenty-nine postpartum women were invited to participate in the study; however, two refused and 27 were interviewed. After signing the ICF, data were collected to characterize social, demographic, obstetric, behavioral, lifestyle, health history, and access to the healthcare system. It was agreed that semi-structured interviews would be conducted during the hospitalization period, at least 12 hours after childbirth, if women were in a clinical and psychological condition to be interviewed.
The interviews lasted an average of 25 minutes, were audio-recorded, and conducted by a nurse (BMA), a doctoral student in science with training in qualitative research. The rapport between participant and interviewer was established during the prenatal approach, which facilitated the interview. A single interview was conducted with each participant. Furthermore, to provide privacy, facilitate movement, and proximity to the newborn, spaces within the hospitalization area were set up for the interview, ensuring a private environment between the study participant and the researcher. The presence of newborns was encouraged.
Emotional expressions during the interview were recorded in a field diary, such as descriptions of happiness, sadness, crying, and gestures that connect to anxious moments of fear or anger. When the recording was turned off, when necessary, any anguish or doubts expressed during the interview were addressed. The generated codes were not returned to participants. The criterion for interrupting the interviews was data saturation. The saturation criterion in this study refers to both the saturation of the codes and the meaning associated with them13.
The content of interviews sought to cover topics related to living and working conditions, prenatal, childbirth and postpartum care to answer the following guiding question: How do you (postpartum woman) understand the experience of high-risk pregnancy in your social context?
For the methodological guidelines of qualitative research, among the guidelines recommended by the Equator Network, the COnsolidated criteria for REporting Qualitative research (COREQ) was used14.
The corpus of analysis consisted of the text produced from the transcription of interviews as well as the notes that comprised the broad and immediate conditions of discourse production. The broad conditions of discourse production identified the discursive subject by describing their social context; such data included age, parity, place of residence, and place of birth. To describe the immediate conditions of discourse production, notes were taken on clinical conditions of hospitalization and interview, namely location of interview, couple’s health conditions, type of childbirth, and emotions conveyed during the interview, recorded in a field diary. Therefore, after this delimitation of the corpus, the analysis process was divided into three stages11.
In the first stage, an exhaustive reading of the raw material was carried out with the aim of connecting the subject of discourse and their conditions of production. Regularities in the text that express discursive memories through the repetition of terms were outlined. In the second stage, discursive excerpts were grouped into categories to allow analysis of their meanings, according to each subject’s expression and their connection to the SDH addressed during the interview. In other words, the categories were organized according to the issues surrounding SDH, such as narratives that demonstrate meanings related to predisposing factors such as socioeconomic status, exposure to violence, and self-care behaviors.
To this end, the various possibilities of semantic organizations were observed, since the same thing can be said in different ways - the so-called metaphorical effect11. Within each category, subcategories were described, outlining the various discursive formations. In the third stage, the discursive formations were grouped into discursive chunks according to their common ideological origin.
Thus, by searching for the ideological origin, it was possible to discuss the discursive process. This required a constant back-and-forth between the materiality (interviews) and the theories that shaped this study. Furthermore, during analysis, to ensure the method reliability, the process of identifying discursive formations and chunks involved the collaboration of two researchers. This allowed for discussion of the topics that emerged during the interviews as well as a detailed record of the analytical process to ensure theoretical and methodological coherence.
This research was approved by the Research Ethics Committee (REC) involving human subjects of the proposing and co-participating institutions. The guidelines and standards for research involving human subjects, regulated by Resolution 466/12 of the Brazilian National Health Council, were followed. To ensure participant anonymity, each interviewee was identified with the letters “P” followed in sequential order from “1” to “27”.
RESULTS
When investigating the structural and intermediate social determinants that could interfere with the maternal health of the 27 participants, the following production conditions were identified: they were on average 28.15 years old (±5.04 years). The majority were Brazilian and one was Haitian; 13 (48.1%) self-identified as brown; eight (29.6%) were black; and six (22.2%) were white. Concerning marital status, 23 (85.2%) women reported having a partner. Regarding religion, 12 (44.4%) were Catholic and 11 (40.7%) were evangelical. One (3.7%) participant reported having completed higher education, while 13 (48.1%) completed high school, and three did not complete elementary school (22.2%). The majority (13, 48.1%) were not engaged in paid work at the time of the interview.
In relation to lifestyle habits, four (14.8%) were smokers; three (11.1%) reported alcohol consumption during pregnancy; and one (3.7%) reported marijuana use associated with tobacco. Regarding health history, seven (25.9%) were chronically hypertensive; 12 (48.1%) were obese; three (11.1%) had some type of heart disease; and five (18.5%) lived with some mental disorder. The obstetric risk identified during prenatal care was related to gestational diabetes mellitus (12; 44.4%), gestational arterial hypertension (2; 7.4%), toxoplasmosis (2; 7.4%), and syphilis (1; 3.7%). The majority underwent cesarean section (19; 70.3%), and the contraceptive method of choice after childbirth for the majority was tubal ligation (15; 55.5%).
During the pregnancy of four (14.8%) women, some criterion of severe maternal morbidity was recorded, which represents a severe condition with potential risk to the life of pregnant women or puerperal women.
As for exposure to violence, 14 (51.85%) participants reported having suffered some type of violence during their lives, whether psychological, physical and/or sexual.
The analyzed discourses produced five discursive formations aggregated into two discursive chunks, as presented in Chart 1.
Discursive chunks and discursive formations of results. Ribeirão Preto, São Paulo, Brazil, 2024.
Discursive chunk I - The influence of the female role on the social determinants of health
In participants’ speeches, when analyzing aspects related to education, occupation, income, gender, self-reported skin color, working and housing conditions, as well as exposure to violence and prejudice during the life cycle, issues related to the female gender permeated the discursive formations in each of these spaces.
Education, occupation and income in the female social context
The speeches revealed the weaknesses of the female social context, in which girls and women are naturally chosen to dedicate themselves to caring for family members over studies or entering the job market.
[...] Since I was 9 years old, I’ve been the one who’s taken care of them [the brothers], I’m the one who went to school meetings, because my father was always working and we couldn’t stay with my mother, because they wouldn’t let us [...] (P10).
[...] [I studied] only until the sixth year because I didn’t want to anymore [laughed, looked down], [...] idea, not to listen to my parents (P18).
Now she [the baby] already has something on her spine [meningomyelocele], leaving her with someone else will hurt, it’s really hard. I don’t know if I’ll go back to work because I think I, only I, can take care of her in this condition (P4).
The difficulties women face in entering the job market are further compounded by precarious employment relationships, which contribute to job abandonment. Thus, attempts to break free from women’s caregiving responsibilities upon entering the job market are thwarted, diminishing opportunities for change within a social gradient that would bring them better living conditions.
Today I’m worried about knowing that in four months I’ll have to go back to work and be fired, because that’s how they’re going to do it. There’s all the frustration of knowing that I’m still going to go through some more hardships [...] And, if you’ve left, you’ll be fired (P14).
I actually worked as a street sweeper, sweeping the streets. But I never got to get a work permit, sign a work card, or anything like that [...]. I don’t even have the title [of voter]. I have to get my work permit (P16).
Descriptions of suffering stemming from financial hardship generated discourses with repercussions on physical and mental health. However, discursive formations of coping and resilience also emerged, reflecting attempts to survive through migration processes that bring ideas of change and hope.
[...] Because of this [time off for health treatment during pregnancy], I had a very complicated pregnancy, very anxious, very depressed, wanting to end it all, wanting it all to disappear and that’s it (P14).
No, I don’t miss my homeland, I just miss my mother. It’s very difficult to live there [in the Northeast], not just in terms of work, but everywhere you look, there’s always a different kind of poverty. Here [in my current city], there’s poverty too; all of Brazil has poverty, but the Northeast itself is very difficult. You look in one corner, and there’s a person in need, not because they chose to be in that situation. [...] It’s a land of abundance, but it’s a land that’s exploited, making it difficult for you to live. Our labor is exploited, the natural resources there [in the Northeast] are exploited (P10).
Exposure of girls and women to violence
Reports of exposure to psychological, physical, and sexual violence were frequent, and the following excerpts demonstrate violence as an expression of the power relationship between genders or in the relationship with children. As a result, this relationship delays or prevents a break from the cycle of violence. Analysis of the ideology present in this discursive formation also reveals the State’s negligent role in resolving the issue.
[...] In the 13 years we were married, he assaulted me 29 times, counting. There was even one time, just once, when I filed a police report and got a restraining order. It wasn’t easy, but I managed to leave because a lot of people say, “It’s easy to leave, you don’t leave because you don’t want to”. It’s not, there’s a lot involved. First, we think about the children and then we think we can separate and have something with our own family, because that’s always what we use [participant’s family]. At first, I even thought I was guilty of separating, but I discussed it with a psychologist who accompanied me [...] (P21).
[...] My life story is a little complicated because I grew up in an environment of a lot of violence, from my father, from my mother, [...], also, none of them tried to go after it to resolve it. [...] With this heart problem, I had [heart] surgery when I was 11 years old and I only got this surgery after my grandmother took custody of me and started looking for it [surgery] [...] (P12).
I was very young, that’s when I got married at 12 years old (P18).
The grandson of the woman who raised me abused me, but I never told anyone [...] (P23).
Also noteworthy is prejudice against skin color, which exemplifies yet another form of power relations existing in society, in addition to what is perceived in the discourse that identifies and denounces structural racism.
Look, it’s really complicated because I have three boys [...]. Of the three, only one is my color [laughs]. [...] I was once mistaken for the oldest’s nanny, because the oldest was white with blond hair [...] (P6).
Maternity support networks: a feminine construction
When understanding the construction of participants’ support networks, ideological formation once again clashes with the gender issue. The discourse fragments demonstrated the caregiving role played by women in the family environment and the man’s role as provider. Thus, other women were naturally considered the most capable of helping them (participants) carry out their domestic duties during the postpartum period.
My mother-in-law, my mother are helping me, all crazy waiting for me already. [...] And the husband too, he leaves early and only comes back in the afternoon (P2).
My mom, I’m going to go over the diet [postpartum recovery] at her house because we’ve already agreed this way for a long time. I told her, “My diet [postpartum recovery] is here, how am I going to take care of my husband and everything?” (P20).
My mother, I prefer to stay at my mother’s, because my husband works (P1).
Discursive chunk II - Behavioral characteristics during the experience of a high-risk pregnancy: adherence to treatment determined by socio-historical subjectivization
The predominant ideology in participants’ discourses expresses the influence of the biomedical model, which encourages lifestyle changes to promote health. From women’s perspective, this model is geared toward fetal well-being. However, some discursive formations revealed difficulties in adhering to protective behaviors due to the naturalization of bad habits, daily overload, and/or difficulties coping with psychological distress.
Public health policies and their impact on reproductive planning
Excerpts from the discourse expressed the influence of public health policies related to reproductive planning on participants’ decisions. Supported by changes in legislation regarding tubal ligation and guidelines encouraging other types of contraceptive methods, frequent reports of unplanned pregnancies were accompanied by plans for definitive sterilization after the pregnancy ended and/or adherence to some contraceptive method. Although the value of motherhood was present in women’s discursive memories, contraception also proved important after a high-risk pregnancy.
I was taking [the contraceptive] in secret. My husband wanted more children, I didn’t. If I could have had a tubal ligation, I would have had one a long time ago [...], but thank God the law changed [regarding tubal ligation] [...], I said, “Either I have a tubal ligation or you have a vasectomy because I don’t want any more children!” Men have a taboo that if you have a vasectomy, it won’t work [...]. I said, “Your recovery is faster”. But he didn’t want to do it, and I said, “Then I’ll have a tubal ligation”. (P9).
It was already planned, I got pregnant, because it was planned. I stopped taking medication and got pregnant. My first child didn’t, as they say, come “snapped”. I said that if I got pregnant, I would get a tubal ligation, that I didn’t want it anymore (P2).
I have to avoid having more children, not that I don’t want to, but because of the risk, both for myself and the baby. I opted for this, for tubal ligation. Also, at my age, 24, four children, I’ve had enough (P25).
Risk and protective behaviors: the boundary between the valorization of motherhood and the social context
The discourse excerpts demonstrated health-protective behaviors driven by the valorization of motherhood and the care prescribed by the healthcare team. The prevailing ideology expresses the effects of meaning that refer to behavioral changes to cope with diagnoses, with the primary goal of preserving the baby’s health.
I ate way too much! When I found out I had gestational diabetes, I started cutting back on my food and sweets. It’s kind of hard to cut back on sweets because I’m such a sweet tooth, but I had to think about my baby first (P24).
Some things were difficult, some adjustments. But that’s what helped a lot, because with my second child, even though I didn’t have anything, I gained excessive weight because I ate a lot of junk food, and now I don’t. It was a good thing for me in every way (P21).
I didn’t exercise much, so I started exercising. Because I was only working, the tiredness from work was enough for me. I started exercising and it improved, too, it gave me more energy [...] because when we’re pregnant we don’t think about ourselves first, we think about the baby first (P10).
However, another discursive structure expresses the difficulties in adhering to health recommendations. Eating habits, exercise, and the use of legal and/or illegal drugs are historically determined. Similarly, psychological distress and work overload also shape the ability to adhere to the care prescribed by the healthcare team, even when access to the healthcare system is achieved.
I was going to work and at work I ate something silly, because there [work] was a bar. [...] To avoid snacking, I ate a tomato. [...] But it wasn’t a proper diet, we need to have a complete diet. [...] I left work at midnight, [...], I got home, my body shut down so I could lie down, get to sleep, and the next day at 6 a.m., I was already on the street to drop off my children, each one at their own schools, and for me to go to college (P19).
[...] I tried to do my best during my pregnancy, even though I didn’t want it. I was taking high doses [of insulin] and when I got there [to the healthcare service] I said, “You have to do the treatment, see a nutritionist”. It’s no use! How do you tell someone to do treatment if their mental health is in shambles? I went to the nutritionist, and she said, “You have to follow this diet”. It’s the same as saying, “You can eat anything!” Because I have a compulsive disorder, how do you tell someone with compulsive disorder not to eat when they’re stressed? (P14).
I think I couldn’t [do physical activity] because of laziness, discouragement, tiredness. But, deep down, if I had made an effort, I think I could have done it (P7).
[...] At one party or another, I’d drink two beers. [...] I figured I’d see other people drinking and think, “It’s not going to do anything!” But I used to drink a lot, especially when I lived there [in another state]. When I turned 19, I drank to sleep because I had a lot of insomnia. I couldn’t sleep at night. I went to the psychologist, the psychiatrist, but the medication didn’t help. I took clonazepam, a bunch of medication, Rivotril, but I couldn’t sleep. I drank cachaça, I’d take a sip, two sips, and I’d fall asleep (P23).
I’m cutting back. Now I smoke a cigarette every hour, I smoke marijuana every hour, but I don’t even get that nervous or stressed because of it [use of legal and/or illegal drugs]. Because before I used to get stressed a lot, going five or six minutes without smoking would make me stressed (P16).
DISCUSSION
By seeking to understand the meanings that women who experienced a high-risk pregnancy attribute to SDH, this study identified barriers that interfered with the development of living conditions. The discourse fragments expose the gender discrimination that influenced education, occupation/work, income, and exposure to violence, in addition to highlighting the consequences of these barriers on maternal health. Furthermore, the discourse fragments revealed the health system’s limited capacity to positively influence the promotion of healthy behaviors, as this perception is shaped by life history and culture.
For Pêcheux12, the way subjects position themselves represents them within an ideological identity. In this regard, a speaker recalls what is stored in their memory and reproduces the dominant discourse. Thus, the reproduction of the patriarchal discourse is observed in participants’ speeches, which emphasizes the role of women, i.e., those responsible for caring for children or other family members15 over a prestigious position, exemplified by school dropout and abandonment of work.
Consequently, the social stratification dictated by relationships of domination/subordination creates a greater susceptibility to severe maternal morbidity, especially when more than one social risk factor overlaps. Several studies have demonstrated an association between adverse obstetric outcomes when race and ethnicity are combined with precarious socioeconomic conditions7,16-17. Although the association between these aspects and worsening maternal health is clear in the literature, its mechanism of action still requires further clarification18.
The overlapping inequalities described regarding gender, race, education, and social class reinforce and amplify vulnerabilities. The strength of this intersectionality highlights the need to analyze each of the SDHs in their broader context, considering the interrelationships of these determinants, given that their interactions can increase inequities and, consequently, create conditions of greater risk for pregnant women7.
Another example brought by the discursive excerpts of this study relates to the violence faced by women, a social and cultural problem, as it is also permeated by power relations between genders19. Strategies to combat the cycle of violence encounter obstacles in a wide range of government agencies, from the health sector, where the first report of violence often occurs, to legal bodies, where support and remedial actions are often neglected19,20. In a systematic review of SDH and severe maternal morbidity, a series of studies were found that addressed violence suffered by women, and in all of them, positive associations with unfavorable results for maternal outcomes were described18.
In this study, exposure to violence and racial prejudice was significantly prevalent. Some social groups face stressful circumstances more frequently, which can trigger physical and/or mental illness1. In fact, minority groups experience much more insecurity in their life courses, and these factors affect health inequalities21. Study results indicate that the relationship between low social status and violence in the place of residence with a higher risk of premature birth and, within this perspective, also highlighted the transgenerational effect for these risk factors, i.e., the coexistence between low social status and violence from generations prior to pregnant women is also associated with a poor perinatal outcome22.
In this continuum, when analyzing social cohesion-another important SDH-the support networks that women listed as psychosocial support during the postpartum period consisted of other women. Thus, it was possible to find paraphrastic formations that once again emphasized women’s role as caregivers. Indeed, Brazilian society’s interpretation of the construction of femininity has been reinforced by media and state apparatuses15. The short paternity leave period provided for in Brazilian Law23, for instance, reflects what is already established in society, but also prescribes the maintenance of roles defined by biological sex. Hence, increasing female representation in politics is a movement that can lead to effective changes in public policies that effectively influence the (re)construction of gender roles in a way that is inclusive and respectful of various family structures.
Among the aspects related to behavioral determinants, the choice of contraception was linked to the healthcare service’s ability to carry out educational activities and offer contraceptive methods. In this regard, the health sector is understood as an important SDH because, together with cultural values, it shapes the choice of contraceptive method - a factor that gives healthcare an important role in reducing health inequities24. In another study, it was found that women who experienced an unwanted pregnancy tend to plan highly effective contraception in the postpartum period, such as the insertion of an intrauterine device or female sterilization25. These data are corroborated by the participants of the present study who - faced with the difficulties of a high-risk pregnancy and based on the counseling provided during the prenatal period, as well as the possibility of undergoing surgery for definitive sterilization (available due to the recent relaxation of Brazilian legislation26) - presented tubal ligation as a recurrent solution.
Furthermore, among behavioral determinants, this group of women maintained systematic prenatal care, enabling health education initiatives aimed at changing behavior and lifestyle as an important component of successful treatment. These immediate conditions for the production of meaning, combined with the development of the ideal of motherhood, produced important self-care actions, albeit limited to the gestational period and for promoting the baby’s well-being. However, although educational interventions encouraging healthy habits during pregnancy are important for controlling current or future chronic conditions, population-wide initiatives must begin in adolescence to produce the desired effects on maternal health27.
We also observed the anguish reported by participants when they were unsuccessful in changing habits acquired throughout their lives, even when recognizing the risk of pregnancy. Lifestyle habits are historically constructed based on social relations and subject position, and to understand them, it is necessary to consider the trajectory of socialization and subjectivation. This analysis must connect choices to the socioeconomic reality that dictates culture, currently influenced by globalization, technology, and the media28.
Performing physical activity or following a healthy diet can be culturally difficult or complicated by issues related to architecture and urban safety1. In addition to women’s work overload, which makes it difficult to find time for physical activity and proper nutrition, other factors interfere with the perception that healthy practices produce benefits in the short, medium, and long term. Studies describe that this perception is related to education, age, ethnicity, occupation, and religion5,29, i.e., it is shaped by SDH.
Thus, DA allowed us to uncover how some of the maternal SDH were experienced by participants. From this perspective, it was possible to emphasize how the issue of gender and the influence of public policies were present in the discourses. The discursive formations described here demonstrate how the subject position is rooted in the ideology sustained by the place women have historically occupied in society15.
From this perspective, it is recognized that the empowerment of minority groups drives the recognition of rights and encourages participation in political decisions - which could leverage the construction of a more just society21. For obstetric services, health education - with the aim of encouraging self-care during pregnancy and providing information about assistance during vaginal birth, for instance - encourages adherence to prenatal care and increases awareness of obstetric violence30.
Although efforts were made to generate representativeness, the study has limitations. Since the institution in question is part of the public health system, its population is largely dependent on this system; therefore, it was not possible to incorporate the discourse of women from other backgrounds. Furthermore, discourse analysis considers that meanings are always shifting, making it impossible to achieve completeness. Thus, it is known that the possibility of finding other meanings remains always active and open to new interpretations.
CONCLUSION
Among the structural determinants of health inequalities, it was evident how much gender influenced participants’ life plans, which are built around possibilities generated by education, occupation, income, and exposure to violence. Women’s social position dictates their responsibilities within the home and in society, burdens them, and limits their possibilities for socioeconomic advancement.
The discursive formations presented also revealed, regarding the intermediate determinants of health, how health behaviors lie somewhere between the valorization of the task of motherhood and the way the social context shapes lifestyle. Although the risks of diagnosed comorbidities and ways to mitigate them were recognized, behavioral modification was hindered by the lifestyle already in place before pregnancy, and changes in habits were motivated by concern for the baby’s health and well-being, which generated temporary adaptations.
In short, analyzing the aspects described in the SDH theory, seeking to interpret the meanings that postpartum women attribute to factors that influence health, were a challenge for this research. The connection between living and working conditions, socioeconomic indicators, gender inequality, and health behaviors is not palpable when analyzed from an individual perspective, but it became possible through the DA methodology, which describes the subject as a collective, as it is constituted based on the analysis of the subject position.
ACKNOWLEDGMENT
We would like to thank the Women’s Health Unit of the Hospital de Clínicas, Universidade Federal de Uberlândia, an institution co-participating in this research.
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NOTES
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ORIGIN OF THE ARTICLE
Excerpt from the thesis “Determinantes Sociais da Saúde e desfechos obstétricos em gestações de alto risco: estudo com método misto”, to be presented to the Graduate Program in Public Health Nursing, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, in 2024.
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FUNDING INFORMATION
This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (In Portuguese, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) - Financing Code 001.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
It was approved by the Research Ethics Committee of the Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, under Opinion 6,704,170, Certificate of Presentation for Ethical Consideration 64880922.1.0000.5393. It was also approved by the Research Ethics Committee of the Universidade Federal de Uberlândia, under Opinion 6,778,756, Certificate of Presentation for Ethical Consideration 64880922.1.3001.5152.
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TRANSLATED BY
Letícia Belasco.
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DATA AVAILABILITY
Data from this study are available upon request from the corresponding author, BMA. The data are not publicly available because they contain information that could compromise the privacy of research participants.
Data from this study are available upon request from the corresponding author, BMA. The data are not publicly available because they contain information that could compromise the privacy of research participants.
