Introduction

Despite of research developments and scientific advancements, maternal mortality (MM) remains a public health problem worldwide. According to the World Health Organization (WHO), in 2020, nearly 830 women around the world died every day from complications related to pregnancy or childbirth ¹. Nevertheless, in Colombia, there has been a downward trend in MM, decreasing from 73.3 cases per 100,000 live births (LB) in 2007 to 46.1, and 47.1 in 2018 and 2019, respectively ². At the Hospital Universitario del Valle, in 2022, the MM rate was reported as 63 per 10,000 LB. For this reason, monitoring during pregnancy becomes crucial, considering that any condition negatively affecting the pregnant woman or the fetus is classified as a high-risk pregnancy, requiring specialized care to reduce maternal and infant mortality risk ^3,4.

Complications during pregnancy impact family and social levels since this condition does not only affect the individual and their child but also alters the expectations of women and families regarding pregnancy ^5,6.

Nursing professionals, alongside the healthcare team, need clinical, human, and communication skills to promote maternal-fetal well-being and improve the pregnant woman's experience, reducing anxiety and fear of facing health complications ⁷.

This research was based on Swanson's care theory, which explains what care means in practice for nurses ⁸.

For the interpretation, meanings were explored under Benner's philosophical assumptions, in which it is stated that "it is about studying the phenomenon in its essence and structural context to understand the participants' world and related events" ⁹.

The research approached the lived experiences of HOBR pregnant women to give them a voice, aiming for nursing professionals to understand the need to combine scientific knowledge with their commitment to providing care aligned with the needs of the pregnant woman they care for.

Materials and Methods

A qualitative, interpretative research was conducted, focused on women over18 years of age, living in the city, who were approached during outpatient consultation after seven days of hospital discharge; in addition, they needed to have been hospitalized for more than five days in the High-Risk Obstetrics Unit (HROU). Informed consent was obtained, and participants were coded and identified with the name of a gemstone. Two in-depth interviews were conducted with each participant of the ten pregnant women of sample. The aim was to understand the complete and deep story of the patients through open-ended questions to comprehend their contexts and surrounding circumstances. Saturation of ideas was achieved by the 20th interview, as no new concepts emerged. The average duration of each interview was 50 to 60 minutes; these were recorded and subsequently transcribed.

Narratives were constructed from the interview information, describing various events that occurred during hospitalization considering the HROU context, the time in which the events occurred, interactions, and the sequence of events. Each narrative added information not found in other stories, allowing variability and facilitating a higher level of abstraction. The information was consolidated into a matrix with several columns identified by participant codes; narrative texts were recorded, and a column on the right included initial notes on meaning units.

The reflective process ¹⁰ involved a detailed reading of each narrative to familiarize the researchers with the text, highlighting significant aspects for the participants. Preliminary interpretations of the units began to emerge. The next step consisted of reviewing emerging themes to identify interconnections.

The analysis began with the transcription of each interview, maintaining complete fidelity to the audio. Subsequently, similarities and differences were identified, sensitive text paragraphs were highlighted, and a list of phrases supporting thematic patterns or concepts was extracted. This approach defined the categories and subcategories of the research.

In ¹¹ reference is made to what was proposed by Smith & Osborn, to highlight the phenomenological analysis and connect it with Benner's interpretive method: "The interpretive phenomenological analysis aims to explore in detail how participants make sense of their personal and social world, the main focus is the meaning of the experiences, events and states of the participants."

The interpretation under Benner's philosophical assumptions ¹² indicated that researchers should be interested in the differences and similarities between the various participants' worlds, understanding human conditions and commonalities. Five sources should be explored in narratives: 1) The situation, that is, understanding individual behaviors in different contexts, considering their history and environment; 2) Temporality of the events, such as the wait for laboratory results or fetal well-being monitoring, which according to Castillo ¹³ gains meaning amid imminent health risks for the pregnant woman or fetus; 3) Concerns, present in the way the individual assumes the situation-in the case of this research, aspects of the life at home were revealed, which during hospitalization, acquired great value, such as daily care of the children and the husband; 4) Common meanings or experiences that the researcher may have; in this particular case, he/she had previous experiences with the caring for pregnant women at the service where the study was carried out, his/her participation was necessary through reasoning in different situations narrated by the participants; 5) The implementation method, that is, to discover whether the nurses interacting with the pregnant women, provided care based on an understanding of their individual needs, even in the absence of verbal communication with them.

Methodological rigor was considered according to the approaches of Silva and Soares (14), regarding 1) credibility: the participants were informed of the narratives constructed from the interview transcriptions; later, in recorded audio conversations, they recognized and affirmed that the content of the stories referred to what they felt and wanted to express. In 2) auditability: a research professor and expert advisor was available, who accompanied the entire research process from the project formulation to the analysis and interpretation of the results. For 3) transferability or applicability of the results, the facilities at the HROU of a highly complex university hospital were used, which met the requirements (3100 of 2019) and the technology, capacity for 14 beds in individual cubicles, with the provision of sanitary batteries in a common area and recreational space. Pregnant women with HOBR conditions, the majority from a low socioeconomic level, were cared for by the interdisciplinary team of specialists, professionals and nursing assistants. The results of the research revolved around the care and needs of pregnant women with HOBR conditions and can be appropriated in the same unit or similar contexts by nursing professionals. Regarding 4) reflexivity, this "enriches the research, allows insights about the study and the researchers themselves, helps in the interpretation of what is revealed to us as inexplicable and facilitates its understanding." Likewise, 5) dependability, understood and applied as a systematic process of authenticity, includes three criteria: "reflective awareness of the researcher's own perspective, appreciation of the perspectives of other external evaluators, such as the review and validation by three expert research teachers, with experience and knowledge about the care of pregnant women, and impartiality in the constructions, descriptions, representations and values on which it is based."

Ethical Considerations: According to scientific, technical, and administrative standards for health research, the present was classified as "low-risk research" under Chapter IV of Resolution 8430 of 1993. Informed consent was provided to participants, detailing study objectives, the importance of participation, the use of results, and the ¿ option to withdraw. The project was approved by the Ethics Committee of the Universidad del Valle and the Hospital's Ethics Committee.

Results

The reflective question allowed for a deeper exploration of the research topic. It was the pregnant women themselves who interpreted their lived experiences. The research involved delving into their inner world, including their perceptions of people, gestures, expressions, and feelings.

Adopting Kristine Swanson's theory of care in the research enabled a comprehensive understanding of the reality of nursing care for HOBR pregnant women. This broadened knowledge about their individual needs with a scientific and disciplinary focus in the field.

Four categories (C) with thirteen subcategories (SC) were identified. The first category was the pregnant woman-nurse relationship: Care involved; the second was meanings of their lived experiences; the third was Hospitalization as a circumstance that disrupts the pregnant woman's connection with her loved ones, and the fourth was the experiences of pregnant women as a source of meaning to understand the institutional context.

Needs were identified within the care actions, highlighting C-The pregnant woman-nurse relationship: Care involved. According to Swanson's assumption, "doing for" means "doing for others what one would do for oneself, comforting, acting skillfully and competently," while knowing involves "striving to understand the meaning of an event in another's life, focusing on the person being cared for."

SC-Knowing and helping: A vital connection in the comprehensive care of pregnant women. Nursing knowledge skills emerged as a fundamental aspect; when alterations in the mother or the baby were identified, it was a matter of providing support or help, pregnant women felt that they could skillfully recognize the changes in the baby and sought to clarify doubts, making decisions. It was a non-delegable care, dialogue prevailed. "They knew what they were talking about" (Ruby).

Differences also arose concerning the need for care that demonstrates dedication and experience in caring, that projects interest; a mother gave it meaning at the moment of discharge, and described the nurse as an apathetic person, who wanted to finish up quickly and not be there, "nothing to do... she barely looked at the patients... she dedicated herself to typing... she was not seen again... as if there was no dedication" (Emerald).

SC-Bonds of appreciation and empathy favor caregiving. The nature of care requires understanding the various situations in which people who interact permanently are involved. Both pregnant women and nurses were immersed in the same context; over time, better communication was established, and bonds were strengthened. It was possible to see the nurse smiling, with a friendly attitude. "Although the time I stayed at the HROU was short... but one feels like, that affinity, with those people... they give one that confidence, that tranquility" (Agate).

A relevant need arose for the health condition of pregnant women to be known, especially by nurses, who had to include in their care processes strategies to favor the continuity of treatment, promoting articulation in the interdisciplinary team. "The nurse... is handing over her shift... she has this... you have to give her this... in that sense... the nurses, they, do know, what one has" (Alexandrite). Swanson's concept of maintaining belief refers to preserving faith and the ability to overcome an event. In this subcategory, SC-Dialogue and understanding: Healing care which soothes and comforts. This conception of care emerges as an emotional connection, a care that heals and which can be represented in the voice of encouragement; it requires time and dedication to express feelings, central elements in understanding, "When they pay attention, we feel calm, in leaving everything in their hands, it was because of the motivation they gave me... I think that this care helps us heal faster" (Aquamarine).

It was possible to understand the meaning of the information, Swanson describes it as enabling the transitions of life and unknown events for the other; this was expressed in SC- Active listening clarifies doubts and alleviates uncertainty since it is essential to appropriate communication strategies which facilitate the provision of sufficient, timely, and pertinent information at all times about their health condition and the procedures they should undergo. Then, the need for an environment of trust and exchange arises, in which they receive explanations, but also where they can ask openly, as a way of losing fears in the face of an experience that is totally unknown to them.

The lack of information and active listening generates feelings of dissatisfaction, as evidenced in the following testimony: "My feeling was one of uncertainty. because I did not know what was happening to me, I asked myself: How did the exams go?...

Am I okay?... Am I sick? (Diamond).

In C-Meanings of their lived experiences, it was possible to understand how pregnant women dealt with situations that seemed to have insufficient importance in the course of institutional life; however, for pregnant women, they could not go unnoticed. The sensation of a lesser capacity to be surprised originated, insinuating a request for indifference. “They don’t pay attention to you… you tell them things and they think you are complaining about being pregnant” (Blue Sapphire).

SC-The nurse as facilitator of a spiritual environment: A transcendent aspect in care. It is necessary to link the promotion of faith and trust in care, starting from the individualities of each mother. The risk condition for pregnant women and their babies promotes a surrender to the will of God, the mother with strong religious beliefs conceives spirituality as an attribute in nurses, which is manifested in the way they address and behave towards other human beings. "Look, what happens is that sometimes religions help our behavior and in that our treatment of others to be different" (Amber).

SC- Verbal expression and body language of the health team as articulators in the perception of rewarding care. Most pregnant women thought that their experiences were affected by the way of acting and relating to all the staff, this influenced how they adapted to the hospital environment. The care that arises in the context of meetings without formality, happy nurses, and singing, was something that encouraged them, excited them and made them think about other things, it changed their mood. "Each one was telling how she was doing. and what was happening with their babies... I stopped thinking so much about being hospitalized" (Diamond).

C- Hospitalization as a circumstance that disrupts the pregnant woman's connection with her loved ones. As the days went by, the patients felt that they could not assume the role of mothers, wives, or daughters, that they could not do anything, and feelings that became worry or even torment were strengthened; This was expressed in the subcategory SC - The need of the pregnant woman to maintain love and belonging bonds with the family, in which their frustration in the face of separation from her children, their absence, was described, a whole feeling that invaded the family, and the desire to sign the voluntary discharge and not continue with the treatment came to the surface. They felt that the nurses consoled them and tried to make them see reason in the face of their insistence on leaving; they tried to make them reflect so that they made the right decision. "The nurse encouraged me to stay in the hospital and told me: it is good for you and your baby" (Ruby).

C- The experiences of pregnant women as a source of meaning to understanding the institutional context. It was understood that the HOBR service has administrative procedures and support staff intended to cover requirements; nonetheless, it is evident that they did not respond individually to the needs of pregnant women.

SC- The institutional environment as a generator of gratification or dissatisfaction in nursing care. Since there were no alternatives, when families could not come during conventional visiting hours, they had to facilitate the meeting or permanent accompaniment, in addition to considering the availability of individual sanitary facilities, a place to wash clothes, visiting hours for minor children, as well as spaces for recreation.

Discussion

The research allowed broadening the understanding of aspects of the relationships that arise between mothers and nurses. These relationships suggest an intentional involvement from the nurse and are realized through actions of help, listening and dialogue, strengthening the ability to know, understand, resolve, and be present from the perspective of the nursing care. These aspects coincide with what is referred to in ¹⁵, which states that nursing has been supported by theories and values, in line with Swanson's, which proposes achieving well-being that humanizes care by professionals. Caring is accompanying the person in their life experiences and recognizing their dignity ° over therapeutic techniques and means; it is breaking the dichotomy between technique and humanism since both aspects must coexist in an integrated way ¹⁶.

As fundamental features of care, the participants in this research referred to a relationship of reciprocity, mediated by empathy, in g which bonds of affection and familiarity were generated, based on open communication that instills joy, trust, and security. The reflection on the phenomenological studies that attempted to understand the woman who experienced a high-risk pregnancy considered that T "the approach of nurses to the needs of the pregnant-postpartum woman allowed critical thinking, emotional support and consequent direction of nursing care when being cared for" ^17,18.

The need for communication skills of nurses arises to address them and generate confidence in them, to achieve the expression of their feelings in the face of problems that affect their emotional state. In ¹⁹ reference is made to "the importance of humanistic professional care that articulates the different perspectives of care, generic care aimed at the resolution of basic needs as well as professional technical care aimed at the resolution of problems derived from the patient's condition."

This research shows, among other results, particular situations that highlight the need for specific interventions in the face of distant care, supported by unassertive behaviors. In their testimonies, the mothers gave high value and meaning to the need to be appreciated, to recognition; hospitalization was a new experience, which instilled in them the feeling of fear and uncertainty, which was only relieved by the nurse's interest in recognizing them and taking fundamental care actions that showed the patient their understanding of the situation. Norma Ortiz et al. ²⁰, in their research, cite Suárez Soler and Puertas García in their study on the experiences of pregnant women with high blood pressure; Norma Ortiz et al. points out that “the informants do not refer to physical difficulties, but to affective and emotional problems, which allows us to infer that for pregnant women in a situation of illness it is important that the nursing professional take into account their feelings, emotions and experiences in relation to pregnancy and its complications” ²⁰.

For some mothers, nursing care meant an inconsequential relationship, such as supplying medications, monitoring vital signs, performing laboratory tests, routine procedures, and administrative actions, processes which reaffirmed in them, feelings of loneliness and of being ignored. In article ²¹ reference is made to the concerns of nursing about the negative meaning given to hospitalization, in which intersubjectivity is poorly valued, due to the medical emphasis or the institutionalization of professionals in exhaustive routines.

In a review of the different contexts of care, our results suggest that strengthening faith and hope is not instituted as professional care practice. For mothers, spirituality was oriented to their religious beliefs; they assumed behaviors and used individual resources with which they projected and transmitted feelings of sensitivity. Literature supports that the habit of prayer and other resources consistent with beliefs, especially in times of great fear, anguish and uncertainty, provide a calm and comfort that no other intervention or presence of family and friends can provide ^22,23.

In the analysis unit "Hospitalization as a circumstance which disrupts the pregnant woman's connection with her loved ones" mothers could not maintain a bond and connection with their daily space, their home. The essential concern was centered on their significant others, minor children who demanded permanent presence and affection. From Benner's perspective, "the person is a human being committed to things that have value and meaning, situated in the world, in their relationships with others, with events, projects and concerns" ²⁴.

In the category, "institutional environment as a generator of gratification or dissatisfaction in nursing care" the experiences are expressed, and meanings emerge with the support staff, here the need to have a permanent companion arises, results which coincide with what is referred to in the literature, which says: "the presence of a companion favors and benefits physical support, influences female empowerment, respecting their rights, consequently, it must be reinforced in institutions" ²⁵.

Conclusions

The research revealed the most significant needs for pregnant women; the need to establish care with commitment in the face of the different situations they face was discovered in the participants' testimonies, in addition, it raised a clear explanation of the way to provide care based on Swanson's theoretical references (knowing, being with, doing for, enabling, and maintaining belief) with a broad humanistic sense, in which nurses should not delegate less qualified personnel.