MENTAL DISTRESS DURING THE PUERPERIUM: THE NURSING TEAM’S KNOWLEDGE

Objective: to assess the Rooming-In Nursing team’s knowledge about mental distress during the puerperium and to offer subsidies for educational actions. Method: a descriptive and quantitative study carried out with 30 Nursing professionals from a public teaching hospital in São Paulo, Brazil. The data were collected between December 2020 and January 2021 using a structured questionnaire and analyzed descriptively. Results: 73.3% of the nurse-midwives, nurses, and nursing technicians and assistants were aged ≥40 years old, and 80% had more than five years of working time. There was a predominance of knowledge about the role of Nursing and its respective practices in the assistance provided in cases of mental distress during the puerperium (majority of expected answers in 80% of the questions), in contrast to the knowledge about pathophysiology, symptoms and causes of puerperal blues, depression and psychosis (majority of expected answers in 40% of the questions). Conclusion: the results can support permanent education, aiming to expand the Nursing team’s knowledge and strengthen the care process.


INTRODUCTION
Mental disorders represent a global public health challenge, with nearly 30% of adults included in the detection criteria for these disorders 1 .In turn, the pregnancy-puerperal cycle involves physiological, hormonal, psychological and social changes in women's experience, with repercussions on the postpartum mental health 2 .Among the disorders affecting the psyche, puerperal blues, postpartum depression (PPD) and puerperal psychosis are grouped as mental distress during the puerperium.This clinical condition can occur days or weeks after delivery 3 and compromise parenting behaviour, the relationship with the partner and family members, the mother-child bonding process, and the child's cognitive, motor and psychosocial development [4][5][6][7][8] .
The prevalence of women with mental disorders reaches 10% during pregnancy and 13% during the puerperium.Depression stands out among these cases, especially in developing countries, with 15.6% during pregnancy and 19.8% in the postpartum period 9 .
The study called "Nascer no Brasil" ("Being Born in Brazil") with 23,894 puerperal women analyzed the diverse information on PPD between six and 18 months postpartum and found a 26.3% prevalence 10 .A study conducted during the immediate puerperal period obtained an 18% prevalence of depressive symptoms in the first days postpartum 11 .
The postpartum period is a favourable moment for education in health 12 , even in the hospital context.However, mental distress during the puerperium in this context is scarcely addressed in the literature, with unfavourable repercussions on recognition and understanding of the theme by Nursing professionals who work specifically in Rooming-In (RI) areas.
It is essential that health professionals, especially those from Nursing, are aware of the theme to develop preventive and coping actions.It is recommended that these professionals understand the higher psychological vulnerability experienced by women without trivializing their complaints and, when pertinent, refer them to mental health professionals [13][14][15] .Some women think that the professionals are evasive and disregard their emotional concerns, significantly reinforcing the sense of stigmatization and preconceptions by society [16][17] .Due to unawareness regarding the available resources, maternal-neonatal health care providers offer limited treatment options to puerperal women.This reinforces and problematizes that only 12% to 38.4% of pregnant and puerperal women with clinically significant depressive symptoms receive treatment [17][18] .
A study conducted with nurse-midwives in the United States showed that lack of time and knowledge on references for treating mental disorders during the puerperium are barriers to effective care 19 .
Nurses working in RI services provide direct care to mothers and newborns in the immediate puerperium and should understand the factors related to PPD to deliver good quality care and contribute for puerperal women to exercise motherhood healthily.However, the professionals find it challenging to provide qualified care, identify risk factors and early detection and prevention of complications from PPD due to a lack of specific knowledge about this disorder 20 .
In Brazil, concern about early detection of mental distress during the puerperium is still scarcely considered by nurses and their teams, whether in primary care or hospital care settings.Many of them feel insecure, with little knowledge and experience to assist puerperal women in this clinical condition, with a need for updates on this theme 3,13 .This reality is worrying because Nursing is a critical player in developing early actions Mental distress during the puerperium: the nursing team's knowledge Brito APA, Paes S de OG, Feliciano WLL, Riesco MLG METHOD A descriptive, exploratory, and quantitative study was developed in the RI of a public secondary-level teaching hospital in São Paulo, Brazil.The institution mentioned above has wards with four beds and individual rooms with the RI system, with 28 beds for the puerperal women and their newborns.Nearly 250 deliveries per month were performed in 2020, assisted by midwives, nurse-midwives, and medical and nursing residents.The length of stay of the mother-child binomial in the RI area is at least 48 hours after delivery.
The RI Nursing team comprises 32 professionals (head of the unit, 12 nurses, 17 nursing technicians and two nursing assistants).The study population consisted of the Nursing team professionals from all the work shifts (morning, afternoon, and night) who agreed to participate.However, the results refer to the sample of 30 professionals, as there were two refusals to participate.
The data were collected in December 2020 and January 2021.The professionals explained the project objectives and handed in two questionnaires for them to answer when it best suited each participant.The researcher came back to the locus after some days to collect the answered questionnaires.
The first questionnaire included sociodemographic data (age, gender, professional training, specialization, and training and working time).The second questionnaire was structured around knowledge of mental distress during the puerperium and was adapted from a questionnaire developed by researchers who conducted a similar study with RI Nursing professionals from two hospitals in Sorocaba, São Paulo.The original questionnaire was validated by three judges who specialized in Obstetrics or Midwifery: an obstetrician, an academic professor with experience in the area, and a nurse who specialized in Nursing-Midwifery.Face and content validation was performed 21 , and the mean time to answer the questionnaires was 30 minutes.
The adapted questionnaire assessed four thematic categories: Knowledge about the pathophysiology, symptoms and causes involved in mental distress during the puerperium, consisting of 10 questions; Professional experience and interest in the area of mental distress during the puerperium, consisting of seven questions; Knowledge about the role of Nursing in the assistance provided in cases of mental distress during the puerperium and its respective practices, with 10 questions; Perceptions regarding the mental health stigmas and preconceptions during the puerperium, with four questions, totalling 31 questions with three answer options: (1) True; (2) False; and (3) I do not know/I do not remember).There is no minimum frequency of correct answers for the questionnaire (Chart 1).
Chart 1 -Template of the questionnaire about knowledge on mental distress during the puerperium.São Paulo, SP, Brazil, 2020-2021 to promote health and prevent the harms caused by mental distress during the puerperium.Given the above, the following research question was formulated: "What does the RI Nursing team know about mental distress during the puerperium?" Thus, the study objective was to assess the RI Nursing team's knowledge about mental distress during the puerperium and to offer subsidies for educational actions.One of the researchers typed data into Excel spreadsheet by one of the researchers; the consistency of the database was confirmed by another researcher who checked the records.The data were analyzed using descriptive statistics, using absolute and relative frequencies.
This study was submitted to the Research Ethics Committees of the Nursing School of Universidade de São Paulo (proponent institution) and the hospital (co-participating institution) and was approved under opinion numbers 4.252.390and 4.302.366,respectively.

RESULTS
Concerning the sociodemographic characteristics, all the professionals were female.Table 1 presents the participants' sociodemographic characteristics.Table 2 shows the answers to all 31 questions included in the questionnaire, subdivided into four topics.According to the template presented in Chart 1, the expected answer for each question was highlighted in bold type.
Concerning "Knowledge about the pathophysiology, symptoms and causes involved in mental distress during the puerperium", of the 10 questions addressed, those numbered 12, 15 and 18 had a frequency of expected answers below 50%.It is also worth noting that, in three questions (12, 14 and 15), more than one-third of the participants chose the "I do not know/I do not remember" answer.
Concerning the topic "Professional experience and interest in the area of mental distress during the puerperium", the questions related to permanent education (questions five, 21 and 29) had the lowest frequency of expected answers when compared with the questions on this theme in the initial training (questions three and 28).
The participants from all categories showed weaknesses in their knowledge of psychological disorders in the pregnancy-puerperal cycle concerning the pathophysiology, symptoms and causes of mental distress during the puerperium.
"Knowledge about the role of Nursing in the assistance provided in cases of mental distress during the puerperium and its respective practices" shows the highest rates of expected answers, except for question 9 (50% of the professionals did not believe that the role of Nursing is to perform the clinical and psychological evaluation of the puerperal women in the cases of mental distress during the puerperium) and question 25 (only 36.7% considered that the topic of mental distress during the puerperium is more relevant in the hospital scope than in Primary Health Care).
As for the topic "Perceptions regarding the mental health stigmas and preconceptions during the puerperium", one question (number 31) did not reach 50% of expected answers, indicating stigmatization concerning the psychological distress that affects women in the puerperium.
Mental distress during the puerperium: the nursing team's knowledge Brito APA, Paes S de OG, Feliciano WLL, Riesco MLG In mental distress during the puerperium, attendance to puerperal appointments in Primary Care is essential, as it is essential that women adhere appropriately to the drug therapy.
30 100 ----Perceptions regarding the mental health stigmas and preconceptions during the puerperium 8 Currently, stigma and preconception concerning puerperal women's mental health hinder the approach to mental distress during the puerperium.17 56.7 7 23.3 6 20

23
The issue of gender and violence against women are not related to mental distress during the puerperium or sociocultural conditions and conflicts in love relationships.

DISCUSSION
In the literature, the studies on Nursing professionals' knowledge about the psychological changes during the puerperium indicate several weaknesses.A study conducted with Polish midwives verified unsatisfactory knowledge about pre-and postnatal mental health in its patients 22 .With Australian midwives 23 , the authors identified that, although these midwives had fair knowledge about perinatal depression, they acknowledged inadequate educational preparedness for adequate care provision to women suffering from mental distress during the puerperium.They agreed that additional training sessions would substantially improve their skills in evaluating and caring for women with perinatal psychiatric disorders.
A Brazilian study 3 , conducted with Primary Health Care nurses from Campina Grande, Paraíba, identified vulnerabilities in the curricula of higher-level Nursing courses.These courses are responsible for training professionals who participate in the care provided to women during the prenatal and puerperal periods, and difficulties are not always overcome with permanent health education in employer institutions.
Brito APA, Paes S de OG, Feliciano WLL, Riesco MLG These findings align with the results obtained in this study, as the participants pointed to deficits related to psychological disorders during the pregnancy-puerperal cycle, both in the initial academic training and in permanent education.According to the participants' answers, mental distress during the puerperium is scarcely addressed in the institution under study, although more than half of the professionals seek self-improvement in the subject matter.Therefore, primary, secondary, and tertiary level health institutions should train the health teams to ensure longitudinal care and the development of professional skills for appropriate monitoring of women's mental state during the pregnancy-puerperal cycle.This improves the quality of the services provided, directly reflected in the early identification and timely treatment of perinatal psychiatric disorders.
Regarding recognition of the most incident psychiatric disorders in the puerperal period, almost half of the participants in the current study did not know or remember the clinical manifestations, onset, and duration of symptoms of the different mental disorders during the puerperium.Thus, the results indicate the need to offer educational actions that instrumentalize these professionals' practice, be they nurses or nursing technicians/ assistants.
More than half of the professionals believed that the clinical manifestations, signs and symptoms of mental distress have no impact on the late and remote postpartum periods, being only limited to the immediate postpartum, which hinders the identification of the psychopathologies that may affect women during the puerperal period, as onset and duration of these disorders are variable and may last for days or months after delivery.
Women in mental distress during the puerperium may not have a chance to receive specialized psychiatric treatment.This is partly since these women are often unaware that their mental condition is not necessarily the result of the physiological changes of the postpartum period, and also to the fact that health care professionals are reluctant to provide appropriate treatment -such as referring these women to specialized care services -due to lack of knowledge about the repercussions associated with mental disorders during the puerperium 24 .
In this study, 40% of the professionals stated that women often dramatize their psychological status during postpartum to draw attention.This thinking indicates stigmatization concerning the psychological and mental distress that affects women in the puerperal period, which corroborates the reluctance of women with depression to seek professional help.When women do not feel welcomed, they do not develop enough self-confidence to identify the need to receive therapeutic care; thus, anxieties become trivialized, and no intervention is performed 25 .
A study conducted with midwives in Australia verified that 72.2% of the participants underestimated the percentage of pregnant women who meet the diagnostic criteria for mental disorders 23 .This finding is consistent with a similar study conducted with midwives from the United Kingdom, in which only 47% were aware of the prevalence of PPD in women 26 .
As nurses are frequently responsible for the first contact with women in postpartum, enabling the screening of signs and symptoms of psychological distress, they can and should play an essential role in improving the mental health of these women, and this initial intervention can be very helpful 27 .
Regarding the role of the Nursing team in the care for mental distress during the puerperium, it was verified that almost all the professionals recognize that screening for signs and symptoms is not the sole responsibility of the medical team.However, only half of the participants considered it essential that Nursing clinically and psychologically evaluate women in mental distress during the puerperium.All the current study participants recognized psychological care and support as part of Nursing care.
The study presents the following limitations: the sample size is from a single institution and does not encompass other realities in the RI context.It is suggested to research other scenarios of the health care network with different professional categories, use methods that complement each other, and deepen the knowledge about the phenomenon investigated, such as the mixed-methods research approach.
conflicting relationship with society, the newborn and the family can be a complication resulting from mental distress during the puerperium.25 83sensitive in the postpartum period and report exaggerated symptoms about their health status to draw attention to their condition.1240 14 46.7 4 13.3Source:The authors (2021).

Table 2 -
Questionnaire about Mental distress during the puerperium São Paulo, SP, Brazil, 2021 (n=30) Knowledge about the role of Nursing in the assistance provided in cases of mental distress during puerperium and its respective practices Mental distress during the puerperium: the nursing team's knowledge Brito APA, Paes S de OG, Feliciano WLL, Riesco MLG