Nurse Care and Comfort in the Puerperium of Girls/Women: Protocol for a Scoping Review ()
1. Introduction
The mortality of women during the pregnancy-puerperal period is a public health problem. Pregnant adolescents aged 10 to 18 years face greater risks of eclampsia, puerperal endometritis and systemic infections than women aged 20 to 24 years [1] . The main causes of mortality among girls/women aged 15 to 19 in the world are complications arising from pregnancy and childbirth [2] .
Thus, the Sustainable Development Goals (SDG) advocate reducing global maternal mortality rates by the year 2030, to less than 70 deaths per 100,000 live births. They also advocate reducing the incidence of preventable deaths of newborns and children fewer than 5 years of age in all countries to 12 and 25 deaths per 1000 live births. The 2030 agenda emphasizes the importance of access to sexual and reproductive health services, and the need to increase the development and training of health professionals. It emphasizes that it requires investment, especially in developing countries, to strengthen its capacity to reduce and manage national and global health risks, such as maternal and child mortality [3] .
Pregnancy, childbirth and early puerperium can constitute a risk for healthy development for adulthood, for education, and for the work and health of mothers and families. For this reason, specific care should be directed to this population [4] [5] [6] [7] . In these cases, school dropout is frequent and can result in reduced status at home and in the community, stigmatization, rejection and violence [8] [9] . Faced with these conditions, the prevention of adolescent pregnancy and child marriage is also covered in SDG [3] .
Newborns of adolescent mothers have a higher risk of near-miss than adult mothers. Studies show an association between adolescent mothers and neonates with low birth weight and severe and extreme prematurity, and these conditions make up near-miss neonatal [10] [11] [12] . In the management that occurs during childhood and adolescence, another outcome that requires prevention is the repetition of pregnancy in a short time interval, with 54% of all non-primary births of adolescent mothers being rapid repetition childbirth [13] .
Although the pregnancy of adolescents can be planned and desired, there are indications that the puerperal pregnancy process in this age group can generate crises and worsen in the health of girls/women and their newborns [4] [14] . A systematic review revealed that pregnancy in adolescence was linked to a higher frequency of neonatal and maternal complications such as: pregnancy-specific hypertensive disease, prematurity and low birth weight [4] [15] .
Thus, assimilating all the physiological, emotional and social transformations common in the puerperal phase requires from the woman’s conditions, which are often difficult because the puerperal woman experiences the dilemma of caring for a newborn in a moment when she is fragile and in need of help [16] . Thus, girls/women may suffer a greater impact in the postpartum period, often due to non-planning and the biological and emotional aspects inherent in the phase of adolescence they live. Adolescent mothers, when compared to adult mothers, are more likely to present: less responsible behaviors, not verbalizing concerns, not providing adequate environments for neonatal care, difficulty in adapting to the new role, less cognition to provide care to the newborn and high levels of anxiety [4] [17] [18] .
The quality of health care before, during and after childbirth is directly related to the prevention of complications and death of women and newborns. According to estimates, the probability of a woman up to 15 years old dying from maternal causes in developing countries is 1 in 54. On the other hand, in developed countries, the chance is 1 in 4900 [19] .
Investments in postnatal care must expand beyond maternal and infant coverage and survival, it is essential to ensure the quality of care in order to improve the health and well-being of mothers and children, providing a positive postpartum experience for the family [20] [21] [22] . In this sense, adherence to prenatal activities, delivery and postpartum care, a qualified discharge plan and home visits in the immediate puerperium are fundamental for the prevention of injuries and health promotion [23] [24] [25] [26] [27] .
Thus, the care for adolescent puerperal women provided by nurses involves considering human multidimensionality, by attending to the social, physical, emotional and spiritual dimensions, observing the integrality and conditions that can affect comfort and health [26] [28] [29] . The nurse is a key professional in the process of caring for maternal health. This professional has access to adolescents from the community, school, and the health unit itself. In the nursing consultation, the nurse is able to provide care to women, from the evaluation of socioeconomic vulnerabilities, with stratification and classification of risks related to the pregnancy-postpartum period, as well as provide care considering the biological health needs of the woman and her family unit. Thus, the approach to family planning, prenatal, and postpartum care by the nurse contributes to the quality of care and positive health outcomes.
In this sense, scoping reviews have stood out worldwide in the last decade, as it allows the identification of knowledge gaps; evaluation of the literature; clarification of concepts and investigation of research conducts [30] . Furthermore, building a protocol of this nature that synthesizes knowledge contributes to the recording of different study methods. In the consulted literature, we did not identify scoping reviews directed to this field of investigation, confirming the need to carry out research on nursing care to promote comfort among young mothers as a strategy to reduce maternal mortality. In view of what was previously presented, in this scoping review, the literature will be reviewed and the findings may provide an overview of the research required in the context presented [31] [32] .
2. Methods
In this scoping review protocol, the methodological guidelines proposed by the Joanna Briggs Institute (JBI) [32] were adopted. Therefore, we have developed the present scope review protocol, which includes detailed information about the objective of the review, inclusion and exclusion criteria, search strategy, and analysis of results. After a clear definition of the research question and objectives, a systematic and comprehensive search of studies will be conducted through clear and well-defined search strategies. The selection of studies will apply well-established inclusion and exclusion criteria. The evaluation of the methodological quality of the studies will be observed through the resources available in the Enhancing the QUAlity and Transparency Of health Research (Equator Network). For the analysis and synthesis of results, we will highlight the main findings of the review by constructing representative categories, graphs, and presentation tables. The review report will follow the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), emphasizing the implications for practice and/or future research in the conclusions, making it a relevant publication for decision-makers.
Below will be described in detail the following steps: 1) identification of the research question; 2) identification of studies; 3) selection of studies; 4) data extraction; 5) interpretation, synthesis and dissemination of results.
This scope review protocol will ensure consistency, transparency, and readability in the analysis and presentation of data [33] . This will be achieved firstly through systematic planning of the research, respecting criteria recommended in guidelines regarding data collection, extraction, and analysis, ensuring consistency in the final product to be proposed. Transparency, in turn, will be guaranteed by the rigorous reporting of the research procedures carried out, making them replicable. Additionally, the dissemination of this scope review protocol in a high-circulation nursing journal minimizes potential biases influenced by the obtained results.
Other elements are also essential in the development of a scoping review such as: team with experience in the topic, methods and literature research requirements; pre-planning phase to confirm the methodology; use mnemonic CCP (concept and context population); adhere to updated guidelines and criteria for reporting. Therefore, the researchers must develop a protocol and register or make publicly available and subsequently reference in the scoping review article submitted for publication; plan in advance how the data will be presented, using visual resources to increase the impact [34] . The present protocol is found and registered at Open Science Framework, in the link: https://osf.io/cdhye/.
Step 1: Definition of the research question
The research question was defined using the strategy: Population, Context, Concept (PCC). The PCC mnemonic is presented in the Table 1.
This review seeks to answer the following research question: “What are the main comfort needs in the care offered by nurses to girls/women during the puerperium?”
Step 2: Identification of relevant studies
Inclusion Criteria
Studies available in full published in scientific journals, without restriction as to study design or time frame, presenting nursing care and promotion of comfort
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Table 1. Preparation of the research question based on the PCC mnemonic. Florianópolis, Santa Catarina, Brazil, 2022.
Source: The authors.
for girls/women between 10 and 19 years of age, published in English, Spanish or Portuguese.
Literature review articles will have their references analyzed for the possibility of including new studies not yet extracted with the adopted search strategy.
Exclusion Criteria
Books or book chapters, theses or dissertations, editorial and review articles; studies that include populations other than girls/women aged 10 to 19 years; studies that present care provided by other professionals besides nurses; studies directed to the field of education.
Strategies for the search of studies
For planning and organizing the search strategies, a previous search was carried out in the main thesauri (DESCs/MeSH) of the health area and with the help of a librarian listed the necessary terms and built the search keys according to Table 2.
Step 3: Study selection
A pilot test will be carried out for the selection of articles in advance, with analysis and discussion of the inclusion criteria, seeking agreement of at least 75% among the reviewers [34] .
1st Combine the health descriptors (DECs and MESH) with the related keywords through crosses with the boolean operators AND and OR according to each database, as shown in Table 2.
2nd Forward the identified works to the EndNote Web bibliographic reference manager software, in order to point out repeated materials and exclude them. Subsequent reading of titles will be performed with the same purpose.
3rd Screen the materials, with reading of titles and abstracts by two researchers, independently, for selection and exclusion according to eligibility criteria. In cases where the abstract is unavailable for reading, articles may be included in the next stage if their titles are suggestive of the research objective. The Rayyan system will be used for the selection of articles independently by two researchers [35] .
4th The reverse or cross search (analysis of the references of the articles selected for full reading) will be used to identify any relevant study that is not found in the defined search strategy.
5th The degree of agreement between the researchers will be measured by applying Cohen’s Kappa coefficient [36] . Disagreements between reviewers will be
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Table 2. Strategy for searching for studies. Florianópolis, Santa Catarina, Brazil.
Source: The authors.
resolved by discussion and in collaboration with a third party researcher, to achieve consensus among all.
Step 4: Data extraction
Data collection and analysis
To extract and systematize the data, a spreadsheet in Excel software will be used listing: Order number, year of publication, origin, language, identification of authors, country where the research was carried out, characteristics of participants, objectives, study design, outcomes and recommendations.
The extraction of the aforementioned data will serve to descriptively map and obtain the frequency of concepts, populations and characteristics. To expand the analysis, qualitative data coding will be carried out in order to obtain a summary of the data for the construction of specific categories [32] . To do that, it will be use the resources found in Equator Network “Enhancing the QUAlity and Transparency of Health Research Network”
For the classification of studies regarding the level of evidence and degree of recommendation of the included works, the evaluation will be carried out after analyzing the results obtained. In view of data consistency, two researchers, independently, will apply the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) [37] .
Step 5: Interpretation, synthesis, and dissemination of results
The review report will follow the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), emphasizing in the conclusions the implications for practice and/or future research, making it a relevant publication for decision makers [38] .
The procedures for identifying and selecting references, along with their respective exclusion justifications, will be presented using the PRISMA flowchart. Likewise, the reporting of results will be in accordance with PRISMA guidelines. The selected studies will be organized and classified by categories based on the subthemes that emerge from the results, and their presentation will be in tables. A narrative analysis will be conducted with a discussion considering the updated literature on the topic.
The results of this review will be made available in publications such as scientific articles in indexed journals and relevant academic events aiming at its wide dissemination.
3. Results/Discussion
It was identified that there were a limited number of researches [39] [40] investigating care and comfort in girls/women during puerperium, even considering that those were essential to the prevention of diseases and maternal-childhood death [41] [42] .
A synthesis of the main information available in the literature on the subject will be made to map the current knowledge on nursing care for adolescent/women in the puerperium and identify their main comfort needs during this period. Therefore, the results of this investigation will provide information to instruct, correct and promote effective health actions related to nurse practice, which will directly impact the global maternal/child health scenario.
The review must be read taking into account some limitations. First, emphasis is placed on the possibility of not including any study due to the constant updating of world scientific knowledge; indexing in platforms or databases of other areas of knowledge that were not included in the review protocol. In addition, the language is a limitation to be pointed out because, although the English language has notorious worldwide recognition and still includes two more languages (Spanish and Portuguese), we can leave out some important study that is published in another language. Finally, scoping reviews can expand the field of knowledge about a given theme, requiring further development of systematic reviews.