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                    Original Article

Maternal care of the premature child:
a study of the social representations*
O cuidar materno diante do filho prematuro:
um estudo das representações sociais
Los cuidados maternales al hijo prematuro:
un estudio de las representaciones sociales

Sumaya Medeiros Botêlho1, Rita Narriman Silva de Oliveira Boery2, Alba Benemérita Alves Vilela3,
Washington da Silva Santos4, Lara de Souza Pinto5, Vivian Mara Ribeiro6, Juliana Costa Machado7
Abstract

resumo

Resumen

descriptors

descritores

descriptores

The objective of this study was to identify
the social representations of mothers regarding the maternal care provided to a
premature child. The participants were 30
mothers of premature infants, who attended three early stimulation classes in JequiéBA. The Free Words Association Test was
used for data collection. Participants were
asked to say five words about provision of
maternal care to the premature child and
to rank the words according to importance.
The data were processed using EVOC 2003,
generating a four-place chart. In the upper left corner, the words love and affection appeared; in the upper right, anguish,
attention, affection, and patience; in the
lower left, fear and prevention; and in the
lower right, joy, devotion, dependence, difficulty, experience, protection, responsibility, and overcoming. Love and care appear
to be the center of the representations.
Love refers to the exercise of the mother
role. Care may represent the wish to find
improvements for their child.

Infant, premature
Mothers
Home nursing
Mother-child relations
Neonatal nursing

Este estudo teve como objetivo apreender
as representações sociais de mães sobre
o cuidar materno diante do filho prematuro. Participaram da pesquisa 30 mães
de bebês prematuros que estiveram em
três serviços de estimulação precoce em
Jequié-BA. O instrumento de coleta de
dados foi o Teste de Associação Livre de
Palavras, que solicitou às participantes que
evocassem cinco palavras sobre o cuidar
materno diante do filho prematuro e que
atribuíssem ordem de importância para as
palavras. Os dados foram processados pelo
EVOC 2003, gerando um quadro de quatro
casas. No quadrante superior esquerdo
apareceram as palavras amor e cuidado;
no superior direito, angústia, atenção,
carinho, paciência; no inferior esquerdo,
medo, prevenção; no inferior direito, alegria, dedicação, dependência, dificuldade,
experiência, proteção, responsabilidade,
superação. O amor e o cuidado aparecem
como núcleo central das representações.
O amor diz respeito ao papel de mãe a ser
exercido. O cuidado pode representar o anseio de encontrar melhorias para seu filho.
Prematuro
Mães
Assistência domiciliar
Relações mãe-filho
Enfermagem neonatal

Se interpretaron las representaciones sociales de madres sobre cuidados maternales al hijo prematuro. Participaron 30 madres de bebés prematuros que estuvieron
en tres servicios de estimulación precoz en
Jequié-BA. El instrumento de recolección
de datos fue el Test de Asociación Libre
de Palabras, solicitándose a las participantes que evocaran cinco palabras sobre el
cuidado maternal ante el hijo prematuro,
atribuyéndoles orden de importancia. Se
procesaron los datos con EVOC 2003, generando un cuadro de cuatro casas. En el
cuadrante superior izquierdo aparecieron
las palabras amor y cuidado; en el superior derecho, angustia, atención, cariño,
paciencia; en el inferior izquierdo, miedo,
prevención; en el inferior derecho, alegría,
dedicación, dependencia, dificultad, experiencia, protección, responsabilidad, superación. El amor y el cuidado aparecen como
núcleo central de las representaciones. El
amor habla del respeto al papel maternal
a ejercerse. El cuidado puede representar
el ansia de encontrarse con mejorías para
sus hijos.
Prematuro
Madres
Atención domiciliaria de salud
Relaciones madre-hijo
Enfermería neonatal

*Extracted from the dissertation “Representações sociais de mães sobre prematuros hospitalizados e o cuidar materno”, Graduate Program in Nursing and
Health, Universidade Estadual do Sudoeste da Bahia, 2011. 1Master in Nursing and Health, Universidade Estadual do Sudoeste da Bahia. Professor of
the Health Department at Universidade Estadual do Sudoeste da Bahia. Jequié, BA, Brazil. sumayamedeiros@hotmail.com 2Full Professor of the Health
Department and of the Graduate Program in Nursing and Health, Universidade Estadual do Sudoeste da Bahia. Jequié, BA, Brazil. rboery@gmail.com 3Full
Professor of the Health Department and of the Graduate Program in Nursing and Health, Universidade Estadual do Sudoeste da Bahia. Jequié, BA, Brazil.
albavilela@gmail.com 4Master in Nursing and Health, Universidade Estadual do Sudoeste da Bahia. Professor of the Health Department at Universidade
Estadual do Sudoeste da Bahia. Jequié, BA, Brazil. wssfisio@hotmail.com 5Physiotherapy undergraduate, Universidade Estadual do Sudoeste da Bahia.
Jequié, BA, Brazil. lara.souza@live.com 6Master in Nursing and Health, Universidade Estadual do Sudoeste da Bahia. Jequié, BA, Brazil. vivianmararibeiro@
yahoo.com.br 7Master in Nursing and Health, Universidade Estadual do Sudoeste da Bahia. Professor of the Health Department at Universidade Estadual
do Sudoeste da Bahia. Jequié, BA, Brazil. julicmachado@hotmail.com

Maternal care of thePortuguês
premature /child:
Inglês
a study of the social
representations
www.scielo.br/reeusp
Botêlho SM, Boery RNSO, Vilela ABA, Santos
WS, Pinto LS, Ribeiro VM, Machado JC

Received: 08/02/2011
Approved: 01/06/2012

Rev Esc Enferm USP
2012; 46(4):923-8
www.ee.usp.br/reeusp/

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INTRODUCTION
Premature babies are considered high-risk children,
who, after being discharged from the hospital, require
special care from their mothers for a long period of time
in order to improve their neuropsychomotor development
and particular health conditions. Therefore, their development depends on the care they receive from healthcare
professionals and parents, particularly from their mothers
in order to be satisfactory.
It is observed that premature babies have a higher risk
of not developing appropriately, due to the immaturity of
their organs and systems, as they are born with less than
37 weeks’ gestation. Full-term infants are those born between 37 and 42 weeks’ gestation(1).

child, and going home with the fruit of her gestation – her
baby, a desire that is postponed when a premature child
is born. The idealizations once built are undone and the
birth of a preterm infant, most often, is something difficult
for mothers to accept(5-6).
Preterm births usually occur as emergencies, which
means the mother is not psychologically prepared, and,
thus, feels premature as a mother, and, often, not ready
to take care of her child, showing different reactions to
this tense situation(7). Therefore, several feelings and reactions may emerge; and, in many cases, it is common that
the mother will try to escape from the situation so she is
not made responsible for taking care of a preterm child,
while others try to be with their child every second they
are allowed by the health team, aiming at learning how to
take care of the baby and increase the affective interaction between them.

According to the gestational age, preterm babies can
be classified as near-term (between 35 and 36 weeks),
Hence, actions developed during the preterm infants’
moderately preterm (between 31 and 34 weeks) and extremely preterm (less than 30 weeks)(2). Regarding the hospitalization period should include the mothers, aiming
at their participation of the care to the babirth weight, infants are classified as low
by, thus reducing their fears and anxiety(8).
birth weight if below 2,500g; very low birth
The communication of the health team with
weight if below 1,500g; and extremely low
Preterm births
the parents, the welcoming and interaction
birth weight if below 1,000g(1).
usually occur as
between them, are essential to reduce the
A 2009 study reported a rise in the num- emergencies, which parents’ suffering during the hospitalization
ber of newborns hospitalized in nurseries means the mother is of their children, and to help them (parents)
and Neonatal Intensive Care Units (NICU).
not psychologically learn the homecare procedures.
The study authors analyzed the data from prepared, and, thus,
the Live Births Information System (SisteHowever, the hospital discharge of these
feels premature as a
ma de Informações sobre Nascidos Vivos
preterm babies does not always mean their
mother, and, often,
- SINASC), which showed that the premacomplete recovery, which may imply sevnot
ready to take care eral concerns for the family, the healthcare
ture birth rates in Brazil increased from 5%
in 1994 to 5.4% in 1998, 5.6% in 2000, and of her child, showing professionals, and also for the government
reached 6.6% in 2005(3).
different reactions to authorities involved in the management of
public healthcare(9).
this tense situation
Together with the increase in the prematurity rate, technological advancements
Therefore, within the context of materhave taken place in neonatology, because
nal care of the premature baby after hospital discharge,
there has also been a progressive increase in the survival some particularities in the home are necessary, which
rates of premature infants. The modern NICUs have been namely include: the availability and skills of one or more
equipped with a good technological apparatus, which im- caregivers; some changes in the family to welcome the
proves the healthcare provided to high-risk infants. How- child at home; financial resources to continue the treatever, the baby’s family, particularly the mother, also needs ment; and help from public services in case there are any
special attention because they are experiencing unex- changes in the baby’s health condition(9).
pected and/or undesired feelings. Therefore, there have
However, when the preterm baby undergoes hospitalbeen more discussions on this topic in the academic environment, with the purpose to change this reality, aiming ization, in the future, that child can develop some type of
not only at the healthcare of infants, but also that of the complication. It is for this reason that, after discharge, the
medical team refers preterm infants to an early stimulamother/child/family triad (4).
tion service with the purpose to achieve satisfactory deThis follow-up is necessary, because, in the gestational velopment and autonomy.
period, women experience a number of different feelings,
Therefore, it was from dealing with these infants and
which are often contradictory, such as the joy and happiness of becoming a mother versus the anguish, anxi- their mothers that the interest in this topic emerged, beety and fear towards a preterm baby, with some type of cause different forms of mother-child relationships were
congenital pathology or complications due to a difficult observed, showing that there is a connection between
childbirth. In this period, she dreams with the moment of some of them, with more care, affection and attention,
becoming a mother, of touching her perfect and healthy while others appear to be more distant in this affective

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Rev Esc Enferm USP
2012; 46(4):923-8
www.ee.usp.br/reeusp/

Maternal care of the premature child:
a study of the social representations

Botêlho SM, Boery RNSO, Vilela ABA, Santos
WS, Pinto LS, Ribeiro VM, Machado JC

relationship, showing fear, anguish, and anxiety when taking care of a premature child.
The theoretical framework used was the Central Nucleus Theory of Social Representations, which seeks the
structural elements of a representation(10). The objective
this study was to identify the social representations of the
mothers of preterm babies about maternal care at home.
Hence, the relevance of this study consists of the contribution to promoting/strengthening the educational policies and humanization interventions aimed at training the
professionals involved, considering that the orientations
provided to the mothers of preterm children are essential
to assure that the care to that child, after discharge, is efficient and satisfactory.
METHOD
The design of this study was supported by Jean-Claude
Abric’s Central Nucleus Theory of Social Representations,
which is a complementary approach that presents detailed descriptions of the supposed structures, explaining
how they function, and thus, is compatible with the general theory(10).
The participants were 30 mothers who took their preterm infants, after being discharged from hospital, for
treatment at three early stimulation services in Jequié-BA,
between March of 2010 and March of 2011. The inclusion
criterion was that they should were mothers of children
three years of age or younger undergoing treatment in
the referred stimulation services. After identifying the
mothers, all of them agreed to participate, so none were
excluded from the study.
Considering the 30 mothers who participated in the
study, 25 took their children for treatment at the Teaching
Physiotherapy Clinic at Universidade Estadual do Sudoeste
da Bahia (CEF-UESB); four mothers took their children for
treatment at the Jequiá Municipal Center for Physical Prevention and Rehabilitation (Núcleo Municipal de Prevenção
e Reabilitação Física de Jequié - NUPREJ); and one to the
Association for the Parents and Friends of the Mentally Disabled (Associação de Pais e Amigos dos Excepcionais - APAE).

Therefore, the mothers were asked to evoke five words
that came to their minds after the triggering question: associate five words to taking care of a premature child, and
then they were asked to rank the words according to their
order of importance.
It should be highlighted that, before the free words association test was applied, a random stimulus was used
with the participants with the objective to clarify the procedure that would be applied. When it was realized that
the participants had understood how the test worked, the
actual research test was applied.
The data were statistically processed using EVOC 2003
software, with the purpose to perform the statistical analysis of the textual data of a specific associative network, in
which it is permitted to combine the frequency in which
the evoked words appeared, assigning their order of importance(14). The data were analyzed using the four-place
chart, which specified the central nucleus, the intermediate elements (or 1st periphery system and contrast elements) and the peripheral representation elements (or 2nd
periphery system)(12), using the appearance correlation of
the structural approach of the Central Nucleus Theory (10).
The structural approach establishes that a social representation is adequately described or identified only when
its content and structure, of the central and peripheral nuclei, are learned. Hence, the representations are organized
into two connected systems, the central system responsible
for the materialization of the representation in the mental
structure, and the peripheral system containing the elements that support the central nuclei, with transformations
mediated by the changes in the peripheral nuclei(10).
This study resulted from a dissertation research and
complied with the norms of Resolution 196/1996, which
regulates human research(15). Therefore, the study was
submitted to and approved by the Research Ethics Committee at Universidade Estadual do Sudoeste da Bahia,
under protocol 203/2010, and the participants only initiated the test after signing the free and informed consent
form; if the participant was a minor, the term was signed
by a parent or legal guardian.
RESULTS

After identifying these mothers, a visit was scheduled for the data collection at their homes, considering
it would be more comfortable for them. The data collection was performed in the period between February and
March of 2011 in Jequié, in Southeast Bahia, 365 km from
Salvador, the state capital. Jequié is a city with a total area
of 3,227 km², and 151,921 inhabitants(11).

The present study results showed that the 30 participants were able to contemplate the requested orientation, as each of them evoked five words, totaling 150
words, and then ranked the words according to their order of importance, from the most important to the least
important.

This quantitative study used the free word association
test for data collection, which quickly reveals the content
of the social representations, and allows participants to
freely express themselves (12). This technique identifies implicit or latent elements that could be lost or masked in
other methods(13).

Considering the 150 words, there were 22 different
words, but some were very close in meaning, and were,
therefore, standardized under the same designation (semantic approximation), assuring that they would be processed by the software as synonymous(12). Based on this
approximation, 16 specific words were generated.

Maternal care of the premature child:
a study of the social representations

Botêlho SM, Boery RNSO, Vilela ABA, Santos
WS, Pinto LS, Ribeiro VM, Machado JC

Rev Esc Enferm USP
2012; 46(4):923-8
www.ee.usp.br/reeusp/

925

However, considering the 150 evoked words, six were
evoked only once, accounting for only 4%, which is considered insignificant. These words were, therefore, disregarded. Hence, 96% of the evoked words were used (144
words), which made the analysis more consistent and representative.

The analysis generated the necessary data to create
the four-place chart. Based on this chart, it was observed
that the words’ mean frequency (upper cut-off point) of
occurrence was 9; and the average order (RANG) was 3;
and the minimum frequency (lower cut-off point) was 2,
as shown in Chart 1.

Chart 1 – Four-place chart regarding the triggering question Taking care of a premature child
CENTRAL NUCLEUS ELEMENTS
Frequency > = 9 / Rang< 3
FREQ
RANG
Love
25
1.680
Care
20
2.950

ELEMENTS OF CONTRAST
Frequency < 9 / Rang < 3
FREQ
Fear
8
Prevention
2

RANG
2.375
1.500

ELEMENTS OF THE 1st PERIPHERAL SYSTEM
Frequency > = 9 / Rang> = 3
FREQ
RANG
Anguish
14
3.071
Attention
17
3.941
Affection
15
3.333
Patience
10
3.100
ELEMENTS OF 2nd PERIPHERAL
Frequency < 9 / Rang > = 3
FREQ
RANG
Joy
3
4.000
Devotion
8
3.000
Dependence
2
3.500
Difficulty
6
3.667
Experience
4
3.750
Protection
2
4.000
Responsibility
6
3.500
Overcoming
2
4.000

RANG: 3 Minimum frequency: 2 Mean frequency: 9

The evoked terms, distributed in the four-place chart,
permit to identify not only the content of the representation, but also its organization or structure(10). This way,
the upper left quadrant of the chart groups the evocations
that represent the elements of the central nucleus, considered the most frequent and most important ones; the
upper right quadrant gathers the most important peripheral elements; the lower left quadrant contains the elements with low frequency, but considered important by
the subject; and the lower right quadrant is comprised of
the least frequent and least important elements(12).
In this study, it was observed that the words love and
care were the most frequent and of greater importance,
which shows they are part of the central nucleus. The
words anguish, attention, affection, and patience, on the
other hand, were considered the most important peripheral elements. The words fear and prevention appear less
frequently, but at a higher level of importance. Finally, the
words joy, devotion, dependence, difficulty, experience,
protection, responsibility, and overcoming appeared less
frequently and at a lower level of importance.
The present study results showed that taking care of a
premature child involves a number of feelings, both positive and negative. It is also emphasized that because they
are so small and fragile, their mothers often feel somewhat afraid of taking care of a baby in these conditions,
and, thus, become anxious and insecure for some time.

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Rev Esc Enferm USP
2012; 46(4):923-8
www.ee.usp.br/reeusp/

Considering the results presented herein, it was observed that the social representations of the mothers of a
preterm child showed that taking care of these children at
home is directly associated with love and care, and these
are the two elements that comprised the nucleus center
of their social representations of maternal care of a premature child. Therefore, we found that love is a feeling
related to the mother’s role towards her child; and care is
an attitude regarding the desire to see her child improve
every day.
After the elements found in the central nucleus, those
comprising the 1st peripheral system were identified
(which reinforce the central elements), considered to be
the peripheral elements of greatest importance: anguish,
attention, affection, and patience. Thus, it was found that
to take care of a preterm child, the mother deals with the
anguish of having a fragile child that depends on her care;
she needs attention to be able to make the adequate improvements for her child; affection is indispensible so the
mother is devoted to her child; and, finally, patience is
a crucial element for mothers to accept taking care of a
child with special needs.
The words fear and prevention appeared as contrast
elements. Fear appears as the apprehension of taking care
of a child with special needs, and prevention emerges as
the precaution that mothers take to avoid their preterm
child from developing any complication.

Maternal care of the premature child:
a study of the social representations

Botêlho SM, Boery RNSO, Vilela ABA, Santos
WS, Pinto LS, Ribeiro VM, Machado JC

Hence, the elements of the 2nd peripheral system were
understood by the words joy, devotion, difficulty, experience, responsibility, and overcoming. They can be considered the true peripheral elements because they appear
in lower frequency and importance to the participants. It
is noted that the word overcoming may be related to the
word joy, because it is considered that overcoming the
difficulties involved in taking care of a preterm child is a
reason of joy to these mothers. It is understood that they
need devotion to reach their goals, they undergo difficulties during the most critical period of care, gain experience in this context, and eventually protect their children
more and more, and, therefore, gain more responsibility.
DISCUSSION
It is understood that the expectation of having a fullterm healthy child is completely different from the reality
of having a child born preterm and needing special care.
When the baby is discharged from the hospital and goes
home, it means that from that moment on the hospital is
no longer responsible for the care, which is now responsibility of the family, particularly of the mother.
Not all mothers are prepare to take care of a premature child at home, and this fact can be revealed as
something somewhat frightening. The condition of being
a mother of a premature baby unfolds into several meanings in view of the specific situations that the mothers assign to the as the days went by(4).
The results found in the central nucleus of the present study reinforce those of a prior study(16) that demonstrated that the mothers see to the basic physiological
needs of their child, such as feeding, hygiene, sleep and
rest, among others, and also give them emotional support
through affection, playfulness and love. It also confirms
that their way of caring may reveal feelings of affection,
attachment, and pleasure, but also reinforces feeling
of demanding and a surveillance for the promotion and
maintenance of a healthy growth and development.
However, the family context and the home environment have a strong influence on the recovery of the premature baby and in his/her development process. Usually,
children who were in a NICU, cared by specialist professionals, and that now need special care, suffer a strong
impact after being discharged and going home, because
it usually lacks the adequate infrastructure to receive that
child, besides the fact that the situation, in most cases,
is completely new to the main caregiver – the mother(17).
The anxiety, insecurity and doubt were evidenced for
most women who participated in a 2011 study. Those
mothers reflected about the importance of being trained
during their child’s hospitalization and how these lessons
about homecare were important. They revealed that day
after day they became more and more adapted to the
routine of giving the baby the necessary care, overcoming
Maternal care of the premature child:
a study of the social representations

Botêlho SM, Boery RNSO, Vilela ABA, Santos
WS, Pinto LS, Ribeiro VM, Machado JC

their lack of preparation and fear, and that this daily experience of care developed a relationship of love(18).
In view of the representational elements found in
the present study, it is also concluded that the mothers
of premature babies need to be instructed by healthcare
professionals still while their children are hospitalized. It
is considered that through health education and by giving pertinent orientations about the homecare that they
will provide, it is possible to reduce the mothers’ concerns
and anxiety.
The results found in recent studies also demonstrate
the importance of a more frequent follow-up by healthcare
professionals with the purpose of preparing the mothers
for homecare, in order to prepare them to deal with possible complications and tranquilize them regarding the development of their child, understating that the parents will
be responsible for the continuity of the homecare(16-17).
This way, it should be understood that, during hospitalization, healthcare professionals should not focus the care
exclusively on the child, but also gather their universe of relationships, considering that the family and child become
one single client. Based on this conduct, care is humanized
and will make the family feel welcomed and valued(19).
Therefore, the parents’ restlessness after the birth of a
premature child and during his/her hospitalization is concentrated on the child’s survival, and, after the child is discharged, that restlessness is replaced by the maintenance of
health and the search to improve his/her development (16).
This study shows that the mothers undergo difficulties
to take care of their premature child, particularly related
to their feelings and limitations; however, they manage to
overcome those difficulties, as they demonstrate, above
all, their will to win the obstacles they find.
CONCLUSION
This study identified the social representations that
mothers of premature children have regarding the maternal care at home, and achieved its objective, as it identified several feelings and meanings related to the theme,
categorizing them into the central nucleus, intermediary
and peripheral elements of these social representations.
It was evidenced that in order to perform this care,
the mothers deal with several difficulties, both negative
and positive feelings, but in the end they are capable of
achieving their goals, because of their courage and determination to always improve their child’s development.
Therefore, this study contributes with the strengthening
of humanization policies in view of actions that can change
neonatal care so as to provide premature children with care
not only during their hospitalization, but also after they
are discharged, by providing the parents with orientations
about homecare, and preparing them for a new reality.
Rev Esc Enferm USP
2012; 46(4):923-8
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Maternal
care of the
premature
child:
Correspondence addressed
to: Sumaya
Medeiros
Botêlho
study of the social representations
Rua do México, 19 - BairroaRecreio
Botêlho
SM, BoeryBA,
RNSO,
Vilela ABA, Santos
CEP 45020-390 – Vitória da
Conquista,
Brazil
WS, Pinto LS, Ribeiro VM, Machado JC