Mental disorder in the puerperal period: risks and coping mechanisms for health promotion

Abstract

Objective: The study’s aim was to understand the risks and coping mechanisms presented by puerperal women in the face of postpartum mental disorders. Methods: It is a descriptive study with a qualitative approach that was carried out with twelve puerperal women, in the age group from 16 to 35 years old, who underwent prenatal care at the Multiprofessional Specialized Care Unit in Petrolina city, Pernambuco State. The investigation took place during semi-structured interviews and the observation of contents implicit in the behavior of these women. Data collection was performed in November and December of 2016. Results: Based on the data obtained, it was identified that factors such as early or unplanned pregnancy, lack of support from the partner, family instability, and low socioeconomic conditions may contribute as facilitating agents in the emergence of some mental disorder in the puerperal women. Conclusion: Considering that chronic disorders are common during the puerperium, the earlier the risk factors are detected, the better care may be given to the woman. 

Headnote

ABSTRACT

Objective: The study's aim was to understand the risks and coping mechanisms presented by puerperal women in the face of postpartum mental disorders. Methods: It is a descriptive study with a qualitative approach that was carried out with twelve puerperal women, in the age group from 16 to 35 years old, who underwent prenatal care at the Multiprofessional Specialized Care Unit in Petrolina city, Pernambuco State. The investigation took place during semi-structured interviews and the observation of contents implicit in the behavior of these women. Data collection was performed in November and December of 2016. Results: Based on the data obtained, it was identified that factors such as early or unplanned pregnancy, lack of support from the partner, family instability, and low socioeconomic conditions may contribute as facilitating agents in the emergence of some mental disorder in the puerperal women. Conclusion: Considering that chronic disorders are common during the puerperium, the earlier the risk factors are detected, the better care may be given to the woman. Descriptors: Puerperium, mental disorders, health promotion.

RESUMO

Objetivo: Compreender os riscos e os mecanismos de enfrentamento apresentados pelas puérperas diante dos transtornos mentais no pós-parto. Métodos: Pesquisa qualitativa, de caráter descritivo, realizada com 12 puérperas, na faixa etária de 16 a 35 anos, que fizeram o acompanhamento do pré-natal na unidade de Atendimento Multiprofissional Especializado em Petrolina/PE, por meio de entrevista semiestruturada e observaçâo dos conteúdos implícitos no comportamento das puérperas. A coleta dos dados ocorreu em novembro e dezembro de 2016. Resultados: Identificou-se que fatores como gravidez precoce ou nâo planejada, carencia de apoio do companheiro, instabilidade familiar e baixas condiçöes socioeconómicas podem contribuir como agentes facilitadores no surgimento de algum transtorno mental na puérpera. Conclusāo: Considerando que os transtornos mentais sâo comuns no puerpério, quanto mais precocemente detectar os fatores de risco, melhor assistencia poderá ser oferecida a puérpera.

Descritores: Puerpério, Transtornos mentais, Promoçâo da saúde.

RESUMEN

Objetivo: Comprender los riesgos y mecanismos de enfrentamiento presentados por las puérperas ante los trastornos mentales en el posparto. Métodos: Investigación cualitativa, de carácter descriptivo, realizada con doce puérperas, en el grupo de edad de 16 a 35 años que hicieron el seguimiento del prenatal en la unidad de Atención Multiprofesional Especializado en Petrolina-PE, por medio de entrevista semiestructurada y observación de los contenidos implícitos en el comportamiento de las puérperas. La recolección de los datos ocurrió en noviembre y diciembre de 2016. Resultados: Se identificó que factores como embarazo precoz o no planificado, carencia de apoyo del compañero, inestabilidad familiar y bajas condiciones socioeconómicas pueden aportar como agentes facilitadores en el surgimiento de algún trastorno mental en la puérpera. Conclusión: Considerando que los trastornos mentales son comunes en el puerperio, cuanto más precozmente detecte los factores de riesgo, mejor asistencia podrá ser ofrecida a la puérpera.

Descriptores: Puerperio. Trastornos mentales. Promoción de la salud.

INTRODUCTION

The puerperal period is considered a phase where biological, emotional and social changes take place, involving not only the woman but also her whole circle of relationships. During this period, she is more sensitive, requiring more attention and emotional support, since she is more likely to have physiological, hormonal, psychological and social changes that can directly influence her mental health. This phase involves a process of identification between the mother and the child in the face of real and preexisting subjective experiences, what makes it an emotionally vulnerable period.1

According to the Ministry of Health, puerperium refers to the period from the first postpartum hour to the forty-second day. It is a temporary moment, nevertheless, of great psychic vulnerability with possible unleashing of psycho-emotional and bodily variations.2,3

The puerperium is an eccentric period of the pregnancy-puerperal cycle. It is at that moment, imaginations are put into practice and some bonds are constructed, providing a familiar structure. It is extremely important that professionals understand the emotions experienced during the puerperal period, thinking about the best way to promote qualified care for health promotion purposes.4,5

The great majority of women consider this moment of being a mother as one of greater fullness and fulfillment as a woman, a transition that marks one period of life to another. However, not all are prepared for the psychological and physiological changes that occur during gestation and postpartum. Therefore, facing such significant landmarks, that require such reorganization and learning, may not be well processed by these women.4

Baby-blues or puerperal sadness is the most prevalent mental disorder during the puerperal period. It is estimated that it affects about 85% of women, although it is still underreported by the fact that they recognize this moment only as a difficulty of the puerperal adaptation to play their mother role, and not as a possible postpartum mental disorder. Some risk factors, such as psychiatric antecedents, lack of social support, unplanned pregnancy, difficulties in breastfeeding and stressful events increase the probability of developing some of these disorders.6,7

The more intense and lasting puerperal sadness increases the probability of a Postpartum Depression (PPD), which is a severe and acute clinical condition that requires psychological and psychiatric support, as well as a Puerperal Psychosis (PP) that is a psychotic mood disorder that presents with a severe mental disorder.8,9

Overall, puerperal depressive disorders present clinical signs and symptoms similar to the depression of other moments of life, but with the characteristics related to maternity and the role of mother. Lack of interest in the child and guilt for not being able to take care of him may result in improper and disturbing development on mother-child interaction.10

Considering this perspective, the relationship between the mother and the child, still poorly structured, may provide ambivalent behaviors in puerperal women who live between disturbed sensations in the binomial mother-son relationship. Thus, these women may present some signs related to mental disorders due to the psychic frailties faced at this stage which may be aggravated or precipitated by social, behavioral and relationship factors.6

Attention focused on the symptoms manifested by women in the puerperal period is of fundamental importance, unleashed by routine risks factors to diagnose and treat prematurely some emotional disorder that may arise. It is essential to encourage and stimulate puerperal women to talk about themselves, to question what they feel, what are their frustrations, doubts, and with that, to seek support, advice, and clarification. In this vein, understanding the reality that these people live, knowing how to listen and passing trust, are essential skills that are required from health professionals.1,4,5

Insecurity and fear can create feelings such as anguish, worry, and doubt, which may lead to the frustrations of her perspectives on the motherhood that has been idealized and the motherhood that must be put into practice. The theories and practices contradiction generate conflicts of thoughts and attitudes that can culminate in the emergence and development of mental disorders in this phase.4, 6,7

Given the aforesaid context, the concern arose to carry out a study related to the psychological disorders developed in puerperal women, in order to problematize and understand the risks and coping mechanisms related to the mental disorders that puerperal women suffer in the postpartum period. In addition to this, the present research aims to contribute to the number of studies about this subject, which still has a reduced focus in scientific investigations.

From this viewpoint, it is understood that the process of clarification and knowledge about the physiological and psychosocial changes is linked to postpartum period and will favor the adaptive and coping processes that puerperal women face during this cycle, enabling health promotion and quality of life for these women. Thus, preventive actions can reduce the damages caused by mental disorders faced in the postpartum, which can put in check their relationship with the child.11

This study contributed to identify the possible risks and coping mechanisms for women because the difficulties experienced in their puerperium can lead to mental disorders. The typical and atypical signs and symptoms of this phase could be clarified for these women, as well as improving the care provided by health professionals, in order to help them cope with and overcome difficulties encountered in this cycle transition moment of life. In addition to this, it is important that health services are organized and trained to adequately deal with the problems related to women's postpartum needs.

Therefore, the present study aims to understand the risks and coping mechanisms presented by puerperal women in the face of postpartum mental disorders.

METHODS

The research is consisted of a descriptive study with a qualitative approach performed with puerperal women registered at the Atendimento Multiprofissional Especializado (AME) [Specialized Multiprofessional Care Unit] Dr. Manoel Possídio, in the Petrolina city, Pernambuco State, and over the period from October to November 2016.

The material was collected through individual semistructured interviews, recorded at the puerperal woman's home after a previous appointment. The survey form contained objective questions and questions related to the research subject guided by the following ones: what risks lead the puerperal woman to develop some type of mental disorder? And how do health promotion actions contribute to the prevention and control of the risks of mental disorders during the puerperal period?

After the material was collected, Bardin content analysis technique was used for data analysis and treatment. The content analysis corresponds to a set of communications analysis techniques that aims to obtain, through systematic procedures for describing the content of the messages, indicators that allow the inference of knowledge regarding the conditions of production/reception (inferred variables) of the messages.12 The discussion of the data was based on the dialogue among the speech fragments, the results derived from these statements and the pertinent literature.

The research was attended by 12 postpartum women who were included in the study according to the following criteria: women who were in the puerperal period and had undergone prenatal care in the AME. Regarding the exclusion criterion, women who were not in the puerperal period, those who were physically unable to receive a visit to the interview, and those who did not agree to participate in the study were not included in it. In order to ensure confidentiality and rights preserved, puerperal woman were identified with the initial P, followed by a numbering, for instance: P1, P2, P3.

The search for information took place until data saturation derived from the answers of the research participants, which occurred when researchers realized that the contents of answers had become repetitive. In this sense, we sought the understanding of the speeches and behaviors meanings of puerperal women, and the research was contemplated with the information obtained by twelve women. After collecting the data from the semi-structured interviews, the information was organized into categories according to the speeches of the participants and their points in common. These data were grouped descriptively, always conditioned to respond to the study's subject.

The research respected the precepts established in the Resolution No. 466, December 12th, 2012, from the National Health Council. This study received approval from the Human Research Ethics Committee from Universidade de Pernambuco (UFPE), according to the Certificado de Apresentaçao para Apreciaçao Ética (CAAE) [Certificate of Presentation for Ethical Appraisal] No. 5790.7916.9.0000.5207 and, by signing the Free and Informed Consent Term.

RESULTS AND DISCUSSION

Risk factors that may lead to the development of some mental disorder during puerperium need to be elucidated as a strategy to prevent and promote women's health at this stage. Hence, understanding the causes of illness will be placed, discussed and understood in order to deepen the comprehension of the subject.

The analysis of the empirical material collected through the interviews allowed the appearance of manifest and latent contents from the participants, which resulted in meaning cores. Based on these data, the following categories were articulated: The socioeconomic context: risks for maternal illness; A new mother is born: the threshold between love and pain; Quality assistance and risk reduction.

The socioeconomic context: risks for maternal illness

In addition to the physical and hormonal changes inherent to the puerperium, social issues are added as factors that may be involved in psychic issues of these women, such as the planning and the desire of this pregnancy, gestational risk, age limit, cultural aspects, socioeconomic issues, peer and family support, adaptability and resilience.13, 14

The interviewed puerperal women belong to the age group from 16 to 35 years old, with an average age of 25.6 years old. It is observed that the most prevalent age range corresponded to 25-35 years old, totaling 50% of the interviewees, while 16.66% of the surveyed women belongs to the age group of 16 to 21 years old.

Early motherhood/paternity leads to an anticipation for the adult phase and at the same time may lead to health problems in the maternal-infant area.15,14 Based on the results achieved, it was possible to verify that most of the puerperal women were within an age group of younger ages. In the present study, it was possible to observe that most of the puerperal women did not have a planning for pregnancy, contributing as a stress factor for the installation of anguishes and conflicts, as mentioned by an interviewee.

(...) it was an unplanned gestation, I rejected the pregnancy at the beginning (...) (P2)

When questioned, 83.33% of the puerperal women reported that there was no pregnancy planning, while 16.67% said they had been scheduled for this time with their partner.

Unplanned pregnancy in young women becomes a critical moment that significantly interferes with their routine and the risk of developing postpartum disorders becomes imminent due to lack of maturity. This condition mainly involves affective immaturity, judgments of society, the early abandonment of studies, the sudden separation of friends, the abandonment of single life, as well as the frustration in loving relationships with which they are involved.15 This fact can be demonstrated in the following speech:

(...) it was a shock, I was divorced from the child's father, I am lost (...) do not know what to do sometimes (...) (P2)

Regarding the occupation performed by interviewees, three of them were students, four worked doing household activities, and other professions reported were sales clerk, saleswoman, sales consultant, school educator and general service assistant. It was analyzed that 66.66% of participants had a financial income equivalent to a minimum wage, while 33.33% lived with an income of two to three minimum wages. Added to this financial situation, it was found a higher level of schooling, in which 75% finished high school.

The poor socioeconomic status ofthe puerperal women can influence the appearance of puerperal disorders, aggravating the personal and familiar problems that may exist. The lack of financial resources can contribute to a feeling of powerlessness because they cannot fulfill their desires and those of their children, making this anguish due to the monetary shortage an important factor for the accumulation of negative feelings on the part of the woman.16,15

When the socioeconomic condition was observed, it was identified that more than half of participants survived with up to a minimum wage, these data become relevant since the financial situation was addressed by 33.33% of the interviewee as the cause of sadness or concern. It is possible to verify this in the following speeches:

I get very anxious when I want to buy something for them and I cannot (...) (P2)

(...) my financial situation is complicated, so I'll go to sleep to forget. (P1)

Some aspects such as civil status and with whom they reside are factors of determinant risks of psychological well-being, due to the support or interferences during the puerperal period. About 41.66% of the interviewees live in a stable union, 33% of the women are single and 25% are married. On the living situation, 50% live only with their partners, 8.33% with their parents, 16.66% with their father-in-law, including their partner, 25% live only with their children.

The conjugal life declining, its stability and, the type of family living, can adversely influence this phase. Women who live with their partners have a lower index of puerperal disorders and those who reside in the company of family members and partners or alone have a higher index.17,15,14

Through research, it was possible to observe this vulnerability on the part of women who live together with relatives, so this coexistence did not influence in a beneficial way at that time because what puerperal women understood as family support, was not offered at the precise moments.

Living with my parents is not as good as I imagined (...) because I wanted them to help me, but they do interfere in my children's upbringing and my relationship with my husband (P4).

Frequent coexistence in the home environment may lead to a greater tendency for women to feel distressed and reserved due to a lack of privacy because of the tightening family bonds and the constant proximity with other members. Moreover, being a single mother or not having the presence of the father in the home is also a risk factor due to emotional and affective deficiency, increasing the risks if associated with other factors.17

Factors such as pregnancy complications, support to take care of the child, anxiety, concerns, fears and, needs of support may be related as potential risks to the generation of some mental disorder in the puerperium. The incidence of complications during childbirth was 25%, most of the puerperal women 66.66% received help to take care of the child and 41,66% stated that they needed some support.

In relation to religion, it was identified that six puerperal women were Catholic, four were evangelicals, one had no religion and one possessed another religion, different from those presented among the multiple choice options.

Through the speeches analysis, it was perceptible to note that there is a contribution to the aspects addressed in the questionnaire, regarding culture and religion. The nonacceptance of judgments made by society in the face of the "faults" committed by these mothers or even by the negative feelings produced, which may generate tension and unresolved conflicts, leading to inadequate coping and thus contributing to the onset of disorders.18 This fact can be observed in the following statements:

After I discovered that I was pregnant, I was sad, I was trying to hide, because I am evangelical, I was not married, I was not prepared at all, and I cared about what people could say (...) (P11).

The future is uncertain. I am going to the church (...) (P4)

Regarding the causes of fear, distress and sadness were reported by puerperal women, the financial situation was pointed out by 33.33% of these women. Excessive concern with the health and well-being of the child was reported by 25% of them, while 8.3% said that conflicts with their partner made them sad. A total of 33.33% reported having no cause for distress or fear. In relation to the number of children, five puerperal women had only one child, four of them, two children, two had three children and only one was the mother of four children at the time of research.

This situation associated with other aspects and the presence of other minor children can interfere in the process of adapting to the new maternity, constituting, in this way, a risk factor for the development of anxiety and sadness. Additionally, not being able to dispense attention and care to the other children, due to being hospitalized or having to dedicate more to the new child, besides not always being able to count on the family's willingness to attend to their needs, contributing further to the installation of emotional distress and consequently the appearance of some disorder. 17

(...) and I still feel sad when my daughters are sick and I get myself very anxious (...) I cannot pay attention (...) (P2)

In this context, it was possible to understand a parallel between socio-cultural factors with the emergence of anxiety, sadness or concerns that can become contributing factors for the development of puerperal disorders, which can directly interfere in women 's health.

Identifying and acting on these risk factors, elucidating doubts and seeking solutions with the woman and her family, can contribute to the early resolution of disorders and, thereby, improve their quality of life.

A new mother is born: the threshold between love and pain

The puerperium is considered a moment of transition where new roles need to be taken, whether the woman is prepared or not. It is characterized by the acquisition of responsibilities and the accumulation of tasks, which can make it more sensitive and confused, with the appearance of anxious and depressive symptoms.19,7

In the study, although it has been pointed out by some puerperal women that they were satisfied with having become a mother, it is possible to perceive that they feel obliged not to show weakness or pain and that their new role must overcome any adversity. This fact can be demonstrated in the speech that follows:

It happened as I expected, as soon as the baby was born I felt a moment of peace, tranquility, relief, I like to breastfeed and take care of the baby, but I'm in a lot of pain and, I cannot get depressed because of it (...) (P1)

(...) I suffered a lot (...) I get anxious and sad... stay with the baby now makes me feel good. (P10)

The ambivalence of feelings has influence in this moment of adaptation to the new role and it may bring risks that contribute to the appearance of signs and symptoms typical of psychological changes of this period. Motherhood is part of a process of rearrangements for a new identity, recognition of a new family element and restructuring of social relations. This phase is marked by emotional instability, requiring understanding, family and social support.20,15,21 This can be understood from the following speech fragment:

I feel unwell, very tired, I try to rest at the same time as the baby, but the concern with him, fear and anxiety do not let me relax. So sometimes I ask my mother to stay with him, so I can rest a little (...) (P2).

In the emotional-affective area, the preparation for challenges that motherhood imposes on this mother in her puerperium can be neglected most of the time. This fact generates deficits in knowledge, preparation and consequently lead to inadequate coping, due to the overload of activities, marital dissatisfaction because of the lack of emotional and professional support. The non-recognition of these symptoms by the puerperal women and relatives themselves may affect the interaction of the mother-child binomial and promote a progressive break down towards the puerperal relationship, then allowing an increase of an emotional imbalance.22,4

Social support, as well as family support, is very important for the maintenance of mental health and coping with stressful situations peculiar to the puerperium phase. The role of this assistance in the different phases of life is also fundamental for mitigating stress factors that occur in the daily life, especially in moments in which several psychosocial and physiological changes are observed, as happens in this phase.15,19

The absence of this support can bring risks to the woman, which may maximize the impact of psychiatric symptomatology in the mother-child relationship, as well as in the intra-family relationships, inadequately causing these bonds, where social support and, more specifically, the family support, can be very important in order to avoid the development or worsening of depressive symptomatologies.23,18

I have everyone's help to take care of the baby (...), my mother-in-law, my mother, my partner, my friends, there is no lack of help... I like to stay with the baby in my spare time, I feel very well with him (P10).

The greater the support offered to the puerperal women from their family context, without judgments and prejudices, the better will be their coping strategies in the face of stressful situations, which will better adapt the changes experienced with the childbirth contributing to the reduction of factors of risks that would culminate in possible psychic changes.

Quality assistance and risk reduction

The actions carried out in prenatal, childbirth and puerperium refer to the set of measures that aims to provide conditions of physical, mental and social well-being, ensuring the birth ofa healthy child, as well as the promotion of maternal health with a view to the reduction of morbimortality.3,19, 21

In the puerperium, the physiological and anatomical changes are in regression, however, it is a phase that requires a holistic and humanized assistance, through the construction of a link that transmits confidence and security to the puerperal women, in order to avoid discomforts, to minimize the risks that the woman is most vulnerable. For this to happen, it is essential to have a precise and comprehensive view of both, health promotion and the health/disease process.24

Lack of knowledge about a health problem or the fear of any negative events during the puerperal period can be considered risk factors and stressors that may contribute to the facilitation of emotional installation of distress and possible disorders, as can be explained in the following speeches:

The experience of childbirth was not as good as I had imagined, I hoped it would be easier, I had pre-eclampsia and went to the ICU (Intensive Care Unit). I wish I had not been through any of this (...) (P4)

I was afraid of having pre-eclampsia, I heard people talking about and I thought I would faint. And I was very worried about the zika virus disease, as I had two months ago, I get very distressed, afraid (...) (P11).

Health professionals must carry out preventive, educational and therapeutic interventions, seeking to improve the level of women's knowledge since their prenatal care. The early empowerment at this stage may avoid possible risks and physiological events, making the puerperium not filled by so many doubts and fear of the uncertain, greatly reducing risk factors that would lead to more serious problems in their emotional health.21,23

The woman, who carries fears, longings, doubts, and crises of her roles, is inserted in a new conjuncture where her priorities were suddenly replaced by the needs of someone totally dependent on her. In this respect, the non-processing of this new routine, together with the non-identification and resolution of pre-existing risks, besides the lack of comprehension by their social and familiar circle of the new role, will contribute to the outbreak of typical psychological disorders of this phase.8, 15

It is fundamental the participation of health professionals in the prevention of puerperal disorders. The actions of the team may contribute significantly in a satisfactory way, offering confidence and security in the face of the presented difficulties, without hostility or criticism, being patient and collaborative in moments of greater emotional fragility.11,24,25

Bearing this in mind, integral and holistic care is crucial, not only in the process of providing gestation and childbirth care but also an intensive care in the puerperal period in which attention is focused almost exclusively on the child. Therefore, the mother, although in a state of emotional alteration with deficits of care, is in the second plane of attention which possibly will contribute to a greater psychic vulnerability.7

Among all the puerperal women interviewed, eight classified their gestation and the care they had during the period as good, four reported they had experienced a bad moment, where presented fear and insecurity. It was possible to observe that women consider it important to perform prenatal care, the majority started in the first trimester, performing more than five visits.

I started prenatal care with two months of pregnancy, performed fourteen consultations and found great assistance offered by the unit team (P9).

My prenatal care was good, but I wanted to receive an orientation about postpartum because I did not receive it, 1 performed eleven prenatal consultations, I started with 2 months of gestation (P6).

In this context, the prevention actions established by a qualified health team, bringing the elucidation of risks, the involvement, and participation of the woman and the family, from their prenatal and continuing in this phase, will help the process of health promotion and, therefore, prevention of psycho-affective diseases and quality of life of these puerperal women. Furthermore, it will allow the adherence of your new routine, which does not need to replace or override your previous roles.

FINAL CONSIDERATIONS

Taking into consideration this study's perspective, it was possible to understand that factors such as early or unplanned pregnancy, lack of partner support, family instability and low socioeconomic conditions may contribute as facilitating agents in the emergence of some mental disorder during the puerperal period.

Furthermore, this phase can be permeated by social judgments as well as a combination of ambivalent feelings and, sometimes, it is not well processed by the woman, this situation may generate stressful conditions for her mental health. The elucidation of risk factors added with a qualified attention from the prenatal period may be determinant for the reduction of mental disorders identified in the puerperium.

The psychic disorders developed during the puerperal period are quite common, but many cases are still underdiagnosed. Thus, the damage caused by this pathology may affect the health not only of the mother and the child.

In order to prevent complications and to construct a satisfactory prognosis, it is worth to emphasize the importance of identifying the initial symptoms in a timely manner, which unleashes the pathological condition in the puerperium. The earlier the risk factors are detected, the better care may be given to the woman.

Hence, it is necessary to prepare the professionals to approach and prepare these women and people of their conviviality, identifying the risks early, so that they can receive psycho-emotional support, avoiding the appearance or aggravation of some mental disorder in the puerperal period and conducting actions and postures that contribute to their health promotion.

Sidebar

How to cite this article:

Maciel LP, Costa JCC, Campor GMB, Santos NM, Melo RA, Diniz LFB. Mental disorder in the puerperal period: risks and coping mechanisms for health promotion. Rev Fun Care Online. 2019 jul/set; 11(4):1096-1102. DOI: http://dx.doi.org/10.9789/2175-5361.2019.vni4.1096-n02.

Received in: 23/11/2017

Required revisions: did not have

Approved in: 15/05/2018

Published in: 01/07/2019

Corresponding author

Luciana Pessoa Maciel

Address: Rodovia BR 203, Km 2, s/n - Vila Eduardo,

Petrolina, Pernambuco, Brazil

Zip Code: 56328-903.

E-mail address: [email protected]

Telephone number: [phone]

Disclosure: The authors claim

to have no conflict of interest.

References

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