Hospital trajectory of mother-infant in international displacement situation during the Covid-19 pandemic period: an experience report

Abstracts

During the hospitalization period of infants, feeding is a possibility of bonding between their mothers and the health care team, understanding the feasibility of breastfeeding and/or being fed orally as an indication of health improvement. For the foreign mother, there may be additional stressors arising from cultural differences. In this study, I characterize the hospital trajectory of a Colombian mother and describe representations and practices of her relationship with the health care team. Based on interviews and a field diary, communication difficulties between mothers and health professionals and the lack of knowledge regarding the mother’s cultural practices and traditions were identified. The sociocultural scenario must be considered in the experiences and decisions about how a foreign mother feeds her infant in a hospital environment, with the health care team legitimizing the dialogue of knowledge, inserting it into the health care systems.

Keywords
Cultural diversity; Hospitalization; Newborn; Breastfeeding

Na hospitalização de bebês, a alimentação é uma possibilidade de vinculação entre equipe de saúde e mães, compreendendo a viabilidade de mamar e/ou se alimentar por via oral como indício de melhora da saúde. Para a mãe oriunda de outro país, podem existir fatores adicionais de estresse pelas diferenças culturais. Neste relato, caracterizo a trajetória hospitalar de uma mãe colombiana e descrevo representações e práticas na relação com a equipe de saúde. A partir de entrevistas e diário de campo, foram identificadas dificuldades de comunicação entre mães e profissionais de saúde e o desconhecimento de práticas e tradições culturais da mãe. O cenário sociocultural deve ser considerado nas experiências e decisões sobre como a mãe oriunda de outro país em ambiente hospitalar alimenta seu bebê, com a equipe legitimando o diálogo de saberes e inserindo-o nos sistemas de cuidados de saúde.

Palavras-chave
Diversidade cultural; Hospitalização; Neonato; Aleitamento

En la hospitalización de bebés, la alimentación es una posibilidad de vínculo entre el equipo de salud y las madres, entendiendo la viabilidad de amamantar, y/o alimentarse por vía oral, como indicio de mejoría de la salud. Para la madre proveniente de otro país, puede haber factores adicionales de estrés por las diferencias culturales. En este relato caracterizo la trayectoria hospitalaria de una madre colombiana y describo representaciones y prácticas en la relación con el equipo de salud. A partir de entrevistas y diario de campo se identificaron dificultades de comunicación entre madres y profesionales de la salud y el desconocimiento de prácticas y tradiciones culturales de la madre. El escenario sociocultural debe considerarse en las experiencias y decisiones sobre cómo la madre oriunda de otro país alimenta a su bebé en un ambiente hospitalario, con el equipo legitimando el diálogo de saberes, insiriéndolo en los sistemas de cuidados de salud.

Palabras clave
Diversidad cultural; Hospitalización; Neonato; Lactancia

Introduction

In March 2020, the World Health Organization (WHO) declared the novel coronavirus (Covid-19) pandemic a public global health emergency. As a result, several countries have implemented various measures for preventing the spread of the Covid-19 disease, such as restricting population movement through social distancing interventions. All South American countries closed their borders, impacting transnational displacement in all its aspects, including temporary displacements like vacations¹.

This study arose from the researcher’s professional experience and personal concerns about several foreign mothers cared for in the maternity ward where she works, which is part of a large hospital in the pole city of Baixada Santista.

Neonatal or pediatric hospitalization is above all a stressful experience for the infant and family, given that, in addition to the reasons that led to hospital stay, it requires adaptation to the hospital environment and its routines. This stress factor is enhanced when the mother comes from a different country and culture.

Despite humanization strategies, the mothers of the hospitalized newborns are rarely welcomed by the health care team in terms of respecting their beliefs, traditions, and cultural values.

As of March 2020, the entire Brazilian hospital routine underwent changes due to the Covid-19 pandemic. On the other hand, infants continued to be born, with frightened mothers and fathers, yearning for a quick hospital discharge, distrusting the presence of health care professionals for not knowing if they had had contact with coronavirus patients, but also frustrated for not being allowed to have family and friends visit the maternity ward to welcome their newborn. As much of the personal relationship became virtual in the pandemic, grandparents, brothers, and uncles met the newborn through video calls.

This paper aims to characterize, through the experience report of a Colombian mother, the trajectory focused on the labor and hospitalization of her newborn, identifying the representations and practices in the relationships among the various health team professionals.

It is important to highlight that a tourist trip does not mean what is defined as an international migration process², but rather, in the case reported in this paper, a tourist trip that turned into an “involuntary immigration” because of unpredictable circumstances: the Covid-19 pandemic.

Human mobility and migratory flows were deeply affected, on different scales, from the moment when it started to: have greater control over the entry and exit of people; close borders; intensify the monitoring of displacements through technology; reduce the means of transport, mainly by air; and increase prejudice and discrimination against human mobility.

For data collection, field diaries and interviews were produced with the mother of the infant and the health professionals who helped with her care during the hospitalization period.

This is a part of the research submitted to the Research Ethics Committee of the Federal University of São Paulo (Unifesp) and approved under opinion number 4,130,572/2020. All the names are fictitious to maintain anonymity.

How the walking takes place

Pregnancy, labor and postpartum are fragile periods for any woman. Depending on the migratory status, the case of foreign mothers deserves greater attention due to the difficulties of access to health care and hospitalization. Those difficulties include legal issues, such as lack of documentation, which can lead some women to either avoid or delay access to health care services³.

Prejudice, linguistic and cultural differences, and lack of knowledge about the norms of a health system different from that of their homeland, with unfamiliar routines, can also be cited as elements that make it difficult to fully use and access health care and education services to which they are entitled by Law no. 13,445/17 (Migration Law)⁴ and the Brazilian Federal Constitution^5,6.

Breastfeeding during hospitalization

Boccolini et al.⁷ highlight the importance of breastfeeding as a natural method of bonding, affection, and nutrition for the infant, proving to be an economical and efficient way to reduce infant morbidity and mortality.

The breastfeeding experience is strongly associated with emotional, biological, psychological, and sociocultural factors; thereby, the decision to breastfeed is aligned with the mother’s life story. This experience gains sociocultural influences according to the times and customs of each historical moment. The concrete benefits of the breastfeeding practice have been observed in scientific circles for some decades⁸.

During hospitalization (labor and/or hospitalization of the infant), the infants’ mothers may experience numerous emotions (e.g. fear, anxiety, sadness, euphoria), thus needing to be welcomed by the health care team, which must consider the subjectivity of the mothers and/or families to offer adequate support. It is worth stressing that there are several biomedical interferences, such as complications during labor and/or neonatal difficulties, which delay or undermine the introduction of breastfeeding: surgical delivery; premature babies; newborns’ hospitalization for different reasons that lead to physical and/or emotional separation between the mother and infant⁹.

The mother of a hospitalized infant experiences situations signified by her as obstacles to breastfeeding, such as clinical instability, the fear of baby’s death, its difficulty to suck, the late start of breastfeeding, and milk production usually interpreted by her as insufficient. Hence, exclusive breastfeeding is considered difficult, a risk to slow weight gain, and consequent prolonged hospitalization¹⁰.

Breastfeeding can many times become difficult or even made impossible because of the mother’s feelings and frustrations, and this situation can be even more recurrent when she is alone in a hospital environment with cultural patterns that often cause estrangement, stress and loneliness even among so many people. Emotions affect lactation through specific psychosomatic mechanisms: on the one hand, feelings of calmness, confidence and tranquility favor good breastfeeding; on the other hand, fear, tension, pain, fatigue, anxiety, and food taboos can cause breastfeeding failure, resulting in early weaning¹¹.

For the introduction and assistance of newborns in a hospital environment, it is crucial that the interdisciplinary team act backing breastfeeding, the administration of complementary feeding, or even the definition of alternative feeding forms. It provides a better prognosis for newborns with low birth weight, premature, with anatomical and/or functional or neurological changes, involving and leading families to deal with difficulties, recognizing the limitations and possibilities of their infants.

The issue of nutrition is emphasized by all (mother, family members and multidisciplinary team) throughout hospitalization. It reveals itself as an opportunity of approximation and bonding in which mothers strive to understand the forms and conditions of their infants concerning the possibility of breastfeeding and/or oral feeding. Furthermore, it is a factor always interpreted by them as a sign of improvement in the infant’s condition. In the case of foreign mothers, other stress factors are added, such as their difficulty in understanding what is explained by the language barrier.

In such a scenario, it is challenging to know and respect the cultural diversities of each patient in the day-to-day life of a hospital. It can be noted a lack of information on the particularities related to breastfeeding, food introduction, and the use of alternative feeding forms, in addition to difficulties in communication between doctor/health care team and patients, and sometimes among the health professionals themselves. Based on this lack of knowledge, working with foreign mothers and their infants during hospitalization can be an enriching experience for the health professionals, since it has the potential to stimulate a movement of renewal, knowledge expansion and reflection on our own beliefs and traditions.

Looking at the health-disease process from a cultural perspective

Langdon¹² claims that issues about the processes of health and illness must be thought of and evaluated from the specific sociocultural contexts of each individual in which they occur. They can be health habits and/or techniques of care and attention, beliefs, rituals, and even some restrictions (e.g., blood transfusion), many times distant from, or even opposed to, the cultural standards of the health professionals.

In this process, it is mandatory to understand how culture - here understood as health-related beliefs, behaviors, and values - permeates the processes of diagnosis, treatment, and therapeutic care¹³. Health and disease are socially and symbolically constructed, mingled with the biography of individuals and their social groups, helping in the analysis of the disorders that they are subject¹⁴.

Using a case study of pregnant women, Lazarus¹⁵ observed that the difficulty of communication and understanding in the doctor-patient (patient/health professional) relationship that takes place beyond linguistic differences exists because, during the interaction, each “actor” builds different clinical realities from their own cultural perception or explanatory model of sickness and health.

With respect to food, breastfeeding and food introduction are processes replete with beliefs, traditions, and taboos. The situation is no different concerning hospitalized children, for whom we can still add issues related to the use of alternative feeding forms.

The breastfeeding practice is also associated with the ideal of the “good mother,” as dominant discourses on infant feeding which insist that “breastfeeding is the best thing for the baby,” for its physical and emotional well-being, ignoring aspects related to their mothers¹⁶.

Such discourses allude to hygienist practices, putting childcare as exclusive to mothers, thus contributing to the physical and mental exhaustion of women in the postpartum period, especially in the first months after birth¹⁷.

The motherhood experience assimilates different meanings depending on the sociocultural contexts in which it is inserted, and they must be addressed when mothers accompany their children during the hospitalization period.

Health care is comprehensive, and for the full performance of health professionals, or the team they are part of, it must be realized how their experiences, personal trajectories, and cultural ancestry induce attitudes and values in the analysis of health and illness processes for the care of individuals from other cultures, referring to interculturality.

Interculturality - that is, the interaction/contact between individuals from different shared cultural backgrounds - must happen with the prioritization of interrelation, expanding horizons, encouraging the enrichment of experiences and continuous evolution^18,19.

Kleinman and Benson¹³ claim that cultural factors are crucial to diagnosis, definition of therapeutic processes, and care. They shape values, health-related beliefs, and behaviors. Cultural processes include psychophysiological reactions, interpersonal relationships, the cultivation of collective and individual identity, and religious practices. Those processes usually differ within the same ethnic or social group because of differences in personality, age group, gender, class, religion, and ethnicity¹³.

There is also transnational health care that is not restricted by the borders of a sole country or nation, which include those adopted by individuals outside their territories, including the use of formal and informal health care practices²⁰.

Hence, the plurality of viable approaches in the observation of therapeutic trajectories can contribute to the organization processes of health and management services in the creation of humanized and contextually integrated care practices, accomplishing more effective therapeutic results.

Walking together

I unavoidably reflect on the hospital environment, which, even when it shelters the beginning of life, without anguish or more intense pain, is characterized by estrangement, by the hard, cold, and difficult to understand technology, and a need to stay [in this environment] for the shortest possible period, an urgency which I sometimes interpret as an escape from reality, abandonment, or hopelessness. I also discern people’s loneliness and neediness, even if they are amidst several others over the twenty-four hours of the day. This is intensified when the mother is a foreigner and far from her cultural and family references.

(Field journal)

The male infant under medical observation, born on a Friday morning, was undergoing an infectious screening with blood count and C-reactive protein (CRP) test to verify the possibility of neonatal infection (hospital protocol), as his mother had not undergone the final pregnancy exams, as she was already on international mobility.

The infant’s parents had not imagined living such a defining moment in their lives in an unknown place, without having the option and presence of those they would like to have by their side.

International displacement does not always take place out of necessity or in the search for a better quality of life: many times, it results from an emergency or unexpected situation, as in the case of natural accidents, the outbreak of conflicts, or even an impediment to return home due to a pandemic, as in the case reported in this study.

The multidisciplinar health care team observes a young couple, waiting for the arrival of their first child, but I detect some caution, some fear of the questions and procedures of the team. Communication is a separate chapter: if Brazilian words and expressions are difficult to interpret depending on the region of origin and care reception within the country itself, then a person unfamiliar with the Portuguese language probably feels even more uncomfortable. On the other hand, there are always symbols and strategies that help in the communication process, such as gestures and, more recently, mobile translation apps.

Gaia: multinational family

The couple, formed by the 22-year-old Colombian Gaia, a Business Administration graduate, and her 30-year-old Chilean husband M., a computer engineer, live in Santiago, Chile.

They arrive in Brazil in March 2020, coming on a vacation trip by car from Chile, crossing Argentina, and stay with friends in São Vicente. With the closing of the Argentine borders, they decide to stay in Brazil. This is how Said was born; a Brazilian, son of a Colombian mother and a Chilean father.

One May morning, Gaia started feeling labor pains. By the end of the day, as the pain intensified, she was hospitalized. The labor was long. Her husband accompanied her, and she had the nursing support whenever it was requested.

Her son was born by natural birth. She reported that it was difficult because she had thought it would be a moment with the most important people (her mother and husband) in her life, but that fate had changed those plans.

Gaia was calm, but her facial expression changed whenever the subject inevitably turned to the Covid-19 pandemic. She mentions her fear of having her first baby in a foreign country, during the pandemic, in a hospital that also treats Covid-19 patients.

In the first feeding, Gaia was welcomed by a nurse and did not report difficulties. It is worth mentioning that she had not received prior guidance on breastfeeding in her prenatal care, expecting that it would occur in her last medical appointments.

On the second day of hospitalization, she got scared after the pediatrician’s visit, because her newborn had lost more weight than expected. Consequently, she cried, feeling helpless as she believed she had not enough milk for her son. Once again, she reported missing her mother’s presence and family experiences that would make her feel calmer.

With respect to breastfeeding care, Gaia needed support from the entire health care team (that is, nursing, medical and speech therapist). All routine procedures for breastfeeding were carried out throughout the hospitalization: breastfeeding assessment, follow-up, guidance, assisting and supporting the mother and her newborn in breastfeeding. According to Gaia, “helping with mamá [breastfeeding] is very important, particularly for a young mother with her first child.” She recalls her homeland tradition related to “milk let-down” - that is, after labor, drink two liters of nimalta (non-alcoholic beer malt beverage) -, which is not practiced in Brazil. As for food, she felt no significant differences.

The multidisciplinary health care team calmed the couple, giving them a lot of attention and information. Although some of the health professionals faced language difficulties, they represented no barrier to communication. Hígia, one of the nurses who accompanied Gaia and her baby during hospitalization, confessed that she felt difficulties in communicating with the couple because she spoke no Spanish. The nursing technician Artemis was afraid because she believed that she would not be able to understand Gaia; however, they understood each other quite well through gestures, mimics, and sometimes through repeated lines.

The extended hospitalization of the newborn caused alarm and greater concern for the parents, for two reasons: suspicion of cardiac alterations; and prolonged failure in the neonatal hearing screening, which, after new tests, showed normal results.

Gaia celebrated her first Mother’s Day with her newborn in hospital, during pandemic, far from her homeland, from her family. According to a well-known saying, “when a baby is born a mother is born.” I witnessed the birth of a young mother.

Discussion

Two thematic nuclei emerged from the analysis of the hospital trajectories of Gaia and her newborn baby: breastfeeding as the only and natural choice; and hospital trajectory and interculturality. It should be noted that the findings of each of these nuclei often overlap or complement each other.

Breastfeeding as the only and natural choice

The World Health Organization (WHO)²¹ recommends exclusive breastfeeding for the first six months of life, with the subsequent introduction of complementary foods up to two years of age, promoting the growth and development of children.

It was possible to perceive that, despite her age and life experience, Gaia chose breastfeeding as the natural and ideal way to feed her newborn baby, regardless of her distress when she learned of his weight loss above expectations. Gil-Estevan and Solano-Ruiz²² state that breastfeeding is an organic event, influenced by different biological and cultural aspects, impacted by feelings such as fear and uncertainty, particularly concerning the ability to breastfeed the newborn. They underline that, despite the difficulties faced, many mothers choose breastfeeding as the best, healthiest, most economical and comfortable option, and cite family, professional and social support, and previous experiences as aspects that favor the continuity of breastfeeding.

Gaia reports the anguish of the foreign mother focusing mainly on labor, as she had planned everything for the labor and birth of her first child. She said: “It was very complicated [having my first child in a foreign country], because I thought my mother would be present at the birth.”

In this part that refers to labor, it can be noticed that, for Gaia, the interaction between mother and daughter in the postpartum period is a relevant aspect in maintaining or changing breastfeeding practices or habits, assuming their sociocultural character and allowing women from different generations of the same family or generation experience multiple representations, new meanings and new practices that may or may not otherwise be shared during the puerperium and breastfeeding processes²³.

Interculturality can be noted in the option for breastfeeding, notably in relation to the immediate postpartum period, the dialogue of knowledge: cultural practices and biomedical knowledge for the beginning of breastfeeding, integrating knowledge with neither arrogance nor lack of qualification. Interculturality is manifested in the health care team’s attention and collaboration when Gaia shows her desire to wait 24 hours before giving her newborn baby the first bath so that the beginning of the breastfeeding process is effective, following her mother’s guidance and that she herself observed at her brother’s birth. Gaia felt helpless when her baby lost more weight than usual. She was welcomed by the health care team and, even though wishing exclusive breastfeeding, accepted the temporary introduction of milk formula in her newborn’s diet.

Multiple scientific studies show the breastfeeding practice permeated by sociocultural values. They are beliefs, concepts, customs transmitted from generation to generation that compose important aspects and that should not be neglected by health professionals working with puerperal women. As an example, we point out the recommendations of practices for increasing the volume and quality of breast milk, without scientific evidence, but accepted and deemed valid²⁴.

Puerperal breastfeeding is a reason for attention, care, and affection for women, as it means both the recovery of labor and the quantity and quality of breast milk. The family group, made up of the integration of different generations, can witness by one of the mothers the experimentation of new practices, which may or may not be shared²³. Gaia expresses her practices and beliefs when she mentions that she could not drink nimalta to increase her amount of breast milk.

Qualified breastfeeding support for foreign mothers is extremely important. Health services must provide them culturally appropriate care and information, with the support of health professionals qualified in cultural competence. Developing strategies to engage grandparents in a support network is crucial for long-term breastfeeding. It is also relevant to emphasize actions with health professionals to increase awareness of the existing diversity of cultures, beliefs, practices and experiences concerning breastfeeding²⁵.

Hospital trajectory and interculturality

The difficulty of communication arising from the language barrier was the element that could be distinguished in the relationship between the mother and the health care team. Language is a key tool for coexistence in society. Because it is diversified, it represents a challenge for qualified and humanized health care for all to meet the specific needs of each individual²⁶.

Despite facing difficulties with the Portuguese language, Gaia did not feel like it represented a strong barrier in communication. In a study conducted in a maternity hospital in São Paulo, Avellaneda²⁷ reports having found an evident language barrier, with Bolivian women pointing out the lack of clear information about the health conditions of their children.

The current challenge is how each health professional can contribute to inclusive care, respecting linguistic differences and employing strategies and/or instruments as different forms of verbal and non-verbal language, so that everyone can access and receive humanized, efficient and equitable care²⁶.

In the course of the research analysis, one of the findings was the generalization of a foreigner by health professionals. The reflection on how the foreign mothers are welcomed and cared for in health institutions calls for special attention:

Health professionals’ conceptions are founded on the biomedical model (but not exclusively on it) and, in a situation of intercultural contact, they are opposed to an “other.” It should be noted that both see each other mistakenly. Oliveira (2000) explains how migrant groups offer a privileged opportunity to the study of interaction forms in the articulation between identity, ethnicity and nationality²⁸. (p. 33)

The interviews of the multidisciplinary team members disclosed the representations of foreign mothers as if there were no particularities with reference to nationalities, languages, beliefs, and cultural practices of each people: “(…) I don’t think it differs much from the foreigners I’ve seen. Perhaps they are a little ashamed to show themselves. They avoid exposing their breasts [to breastfeed] in front of the husbands of other patients” (speech by Bolivian pediatrician Athena).

The previous speech corroborates studies on maternal and child health services that indicate lack of cultural sensitivity and the tendency for health professionals to stereotype foreign women and view them as homogeneous groups, rather than diverse individuals, with a variety of cultural practices²⁵.

A topic that we can point out as a confrontation of biomedical knowledge versus traditional knowledge was evidenced in some moments during the mother’s hospitalization. The most representative occurred when the Bolivian pediatrician Athena acknowledged the practice of offering teas to newborns as inappropriate, minimizing the mother’s beliefs and cultural family traditions.

The support of the multidisciplinary team is crucial to enable the mother to experience the hospitalization of her infant in a more humanized way. Foreign mothers may experience different feelings and difficulties (such as the language barrier) than native mothers. Hence, team support with sensitivity to recognize and act on individual needs is essential.

Actions to promote and protect breastfeeding must occur with respect and recognition of the beliefs and practices that permeate the act of breastfeeding²¹.

In the hospitalization period, Gaia mostly used, as a hospital trajectory, the biomedical system resources in the feeding care of her newborn, occurring both through breastfeeding and complementary feeding when she needed support due to her infant’s weight loss.

In this study, it was found that the foreign mother acknowledges the importance of breastfeeding. Nevertheless, because of the context of giving birth in a new country, and without her family support and assistance, she may need culturally appropriate information and care²⁵.

Gaia considered the qualified support of the multidisciplinary team as an important resource for keeping balance and serenity during hospitalization, even for a short period of time. The elements that emerge from this analysis show that the multidisciplinary team members of the hospital have few references to work with cases involving foreigners, which are complex²⁸.

Health professionals sometimes ignore the experiences of mothers, particularly those from other countries, without realizing their importance for the observance and maintenance of breastfeeding, in the case of newborns, and for the understanding and subsequent assistance in the procedures of hospitalized infants related to food introduction and alternative feeding forms.

For this reason, it is important to know and understand the wide range of foreign mothers’ origin and culture and their hospitalized infants, as well as how the multiprofessional team interacts with such diversity so that new strategies, individual and collective actions can be produced in the hospital environment, embracing both the subjective issues of the mothers and the specific knowledge of their place of origin and technical knowledge.

Bearing in mind the increase in the number of people in international mobility who look for health care from the host country, and specifically their stressful situation caused by the hospitalization of their children - which, in the case of foreign mothers, can have additional factors, such as the difficulty in understanding what is explained by the language barrier and cultural difference -, this study seeks to understand: how the mother perceives and deals with her infant’s hospitalization trajectory; and the possibilities and limitations of what she notices about the host country. Accordingly, support and proposals will be created for the solution of everyday problems in the act of feeding infants, so that their mothers can experience such moment in the least traumatic way possible.

Final considerations

The results showed that the sociocultural scenario and interculturality should be considered in the experiences and decisions on how the foreign mother will feed her infant in a hospital environment, with the health care team welcoming her, promoting qualified listening, valuing practices, beliefs and cultural traditions.

The generalization of foreigners/immigrants by health professionals overlooks the great importance of identifying linguistic particularities, beliefs and cultural practices, typical of each people, for the best patient-health professional relationship in the process of care during hospitalization.

The findings showed the need to develop new practices, both for the mother-infant dyad and the multiprofessional health team, with the mother as a protagonist in the infant care in relation to feeding in hospitalization.

The interdisciplinary nature of this study contributes to science so that it can promote dialogue among the different disciplines in the research area (that is, Anthropology, Nutrition and Speech Therapy) and the health professionals who work in maternal/child care, making them more sensitive to understanding the differences and cultural diversity of the population they serve.

Acknowledgments

The author thanks her supervisor, Dr. Claudia Ridel Juzwiak, from the Federal University of São Paulo (Unifesp), for her valued contributions through discussions, reviews and support.

• Blanco ESV. Hospital trajectory of mother-infant in international displacement situation during the Covid-19 pandemic period: an experience report. Interface (Botucatu). 2022; 26: e220157 https://doi.org/10.1590/interface.210679

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Edited by

Editor

Antonio Pithon Cyrino

Associated editor

Dulce Aurélia de Souza Ferraz

Publication Dates

• Publication in this collection
  01 June 2022
• Date of issue
  2022

History

• Received
  18 Oct 2021
• Accepted
  17 Feb 2022