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Conteúdo (article):

Methodology
This is an expanded action research12, based on complexity thinking, which does not foresee a predefined methodological path to analyze and describe social phenomena. The researcher is induced to lead their own path and to modify this same path as they learn about interculturality, solidarity, equity, ethics and human rights13. This study considered the stages of the Consolidated criteria for Reporting Qualitative research (COREQ)14.
This study addresses only the investigative stage of the action research, developed with indigenous health managers from Querência, in the state of Mato Grosso, who are part of the Xingu Indigenous Territory formed by peoples who have similar ways of life and worldview, namely: Aweti, Kalapalo, Kamaiurá, Kuikuro, Matipu, Mehinako, Nahukuá, Naruvotu, Trumai, Wauja and Yawalapiti. Health care for indigenous women is provided in these indigenous territories by the Multidisciplinary Indigenous Health Teams (MIHT), guided by the PNASPI, which articulates indigenous knowledge and practices in order to value the protagonism of indigenous women9.
Ten (10) indigenous health managers working in Base Hubs I or II participated in the research, including five nurses and one dentist with specific training in indigenous health, one SIHD coordinator, one manager of the Indigenous Health Council, one technical supporter of Indigenous Health and one indigenous advisor to the SIHD. The inclusion criteria were: holding a management position in indigenous health in Base Hubs I or II, SIHD, Indigenous Health Council or in some indigenous advisory body, for more than one year of experience. The exclusion criteria were managers who were away from work for some justified reason or who were on leave or vacation during the data generation period. Data were collected between May and October 2023, from two focus group sessions, on previously scheduled days and times, with the ten managers mentioned above. The two meetings were led by the main researcher and a professional moderator with experience in action research, who contributed to the recording of the pertinent data and records.
In the first focus group meeting, the strengths and weaknesses related to the pregnancy-puerperal cycle of indigenous women were discussed, based on the following guiding questions: What strengths and weaknesses do you identify in the care provided to indigenous pregnant and postpartum women? What care related to the pregnancy-puerperal cycle of indigenous women needs to be improved? In the second focus group meeting, opportunities were discussed and strategies capable of inducing good practices in the pregnancy-puerperal cycle of indigenous women were listed, based on the questions: What opportunities do you see for improving the pregnancy-puerperal cycle of indigenous women? What strategies are needed to improve access for indigenous pregnant and postpartum women?
The meetings lasted an average of 120 minutes and were held in a private, quiet room at the city`s Health Department. Participants\' statements were recorded (on a cell phone) for later transcription and analysis, and manual field diary entries were also made to capture in-depth perceptions related to the object under investigation. Each meeting included specific sessions, such as: opening (10 minutes); rapport (10 minutes); reflection and discussion (60 minutes); critical-reflexive analysis (30 minutes); and closing (10 minutes).
The data were analyzed based on thematic analysis: (a) in the pre-analysis, the data was read exhaustively and the material was explored with a view to possible interpretations; (b) in the second stage, the material was explored in light of complexity thinking, aiming to obtain cores of meaning and understand the discourse. The analytical work was directed towards finding meaningful words and expressions based on the organization and reduction of the content of the speeches, in order to describe the characteristics of the speeches and define the categories of analysis; (c) the third stage of the analysis consisted of defining the thematic axes or analytical categories, based on the agglutination of the nuclei of meaning anchored in the thought of complexity15.
The recommendations of Resolution No. 466/2012 of the National Health Council16 were observed throughout the action research process. The project was approved by the Ethics Committee under the number: 6,042,588. After the objectives of the study were explained, the participants who accepted their participation signed the Free and Informed Consent Form. To maintain anonymity, the participants\' statements were identified throughout the text with the letter "G" for Manager, followed by an Arabic numeral, corresponding to the order of the statements: G1, G2... G10.
Results
The analysis resulted in three thematic categories, namely: Weaknesses associated with prenatal care for indigenous women; Tactics that strengthen the pregnancy-puerperal cycle of indigenous women; and Strategies to promote the best practices in the indigenous context. The process of refining the thematic categories is shown in Box 1.
Box 1. Refinement of thematic categories from the initial codes

Weaknesses associated with prenatal care for indigenous women
At various times, participants associated weaknesses related to the quality of prenatal care, the organization of prenatal care in the territory, the excessive workload due to travel, the long distances from the villages, the regulation of secondary and tertiary care services, among other aspects highlighted in the following excerpts:
The quality of prenatal care is not limited to weighing and measuring the uterine height or listening to the fetal heartbeat, it goes beyond that. It is the welcoming and understanding, especially when I talk to you about indigenous women [...] who in most cases are already in an advanced stage of pregnancy, and they go through several weaknesses, from acceptance to relationship issues. (G3)
Here everything is very far away. The villages are spread out and you have to get on a boat and travel for hours and hours to get from one village to another. There is a single work team, located in a base center, that travels back and forth between these villages, distributed throughout the territory covered by a microregion, where a nurse is stationed. (G9)
As it can be noticed in the statements of G3 and G9, the weaknesses related to prenatal care for indigenous women have multifactorial causes, involving objective but, above all, subjective issues, such as acceptance of pregnancy and family relationships, lack of care at all levels and territories due to logistical issues, distance from villages, and turnover of health professionals. Other statements referred to the logistics of the health team\'s travel, which do not favor the creation of bonds with patients, as it can be seen in the following excerpts:
The work shift rotates every 30 days. For example: a team leaves and a new team, composed by another nurse, joins us to serve that area. In that center, two nurses remain per shift, plus a nursing technician, to be able to travel to all these villages. What does that mean? The team leaves the base center today, rotates, and other professionals will take their place. (G6)
Logistical issues and the demand for a large number of villages, a demand that cannot be met all at once. In one of the meetings with one of the regulators, he said: “Oh, she can’t go to the city to take the exam,” and then the team asks to reschedule the exam, but many services don’t understand the distance and the conditions for this pregnant woman to be in the city to take a simple exam and try to penalize her because she didn’t show up on the scheduled day and time. (G10)
The statements of G6 and G10 reaffirm the weaknesses related to the logistics of travel and care, faced by the health team, due to the distance between the villages. Therefore, the participants repeatedly mentioned the impossibility of forming a professional-user bond in the indigenous context, although everyone understands its real importance in the pregnancy-puerperal cycle. These aspects are questioned, again, in the following statements:
How can I build a bond if this pregnant woman is hours away from the base center, I only go there once a month and when I do go, I can’t always have a bond with her. How will this pregnant woman have the confidence to talk to me and trust my work and say: “I’m pregnant, 8 weeks, 10, 12”. Today, the mother of that 15-year-old girl who is pregnant said: “Look, could my daughter be pregnant?” But for this to happen, for this mother of the pregnant woman to feel comfortable there in her fifth pregnancy, for example, there needs to be a bond. And how are we going to create a bond if there is constant professional turnover? (G8)
The questions associated with the difficulties in establishing a bond between health professionals and users reflect the weaknesses of the Brazilian health system. How can you talk about personal issues with a professional you don’t know or with whom you haven’t developed empathy? Ethical issues, respect and human dignity that indigenous health professionals need to deal with are evident. In contrast, the leaders\' statements revealed weaknesses associated with the qualifications of health professionals, as per the following statements:
Working to understand the desires of this pregnant woman due to sociocultural and linguistic weaknesses is a weakness that we, as health professionals, are also weak. Sometimes we encourage births to take place in the reference city, not because I believe that the birth needs to happen there, but to justify a weakness that is mine in not feeling prepared to attend the birth in the village. (G5)
If the woman\'s desire is to give birth within the territory, I see that this is associated with this issue of weakness with professional qualifications, as there is a deficiency in the continuity of prenatal consultations, which support the birth. (G9)
The testimonies reaffirm the need for technical and human qualifications for health professionals, who require specific intercultural training. It is understood that, at times, professionals do not feel qualified for the role they perform, whether due to technical issues or cultural, linguistic and human issues. The fragility of professionals was highlighted when participants questioned the turnover of professionals and the discontinuation of prenatal consultations, among other aspects. The statements converged on the context of submission of indigenous women, since participants referred to violence, the submission of women due to fear, fear due to language issues and, also, the issue of pregnant women arriving at health units in labor due to lack of information.
At the time of delivery, you need to have an affinity to talk to the pregnant woman or woman in labor; I have heard reports of women who were abused. (G2)
Sometimes, the woman agrees with you because, in fact, she did not understand what you asked and you will make a decision thinking it is a respectful decision, with her consent, when in fact, she did not understand what was said. (G4)
It was noted in the statements above that the geographic and cultural context loses weight due to the singularities of each pregnant and postpartum woman, who are doubly vulnerable, given the specific sociocultural conditions. In this sense, the need for reception and individualized attention on the part of the health team is reinforced, as well as the understanding of the cultural specificities of the indigenous peoples, present in several Brazilian states.
Tactics that strengthen the pregnancy-puerperal cycle of indigenous women
Although several weaknesses in the pregnancy-puerperal cycle of indigenous women have been pointed out, various aspects strengthen and enhance this journey. The participants\' statements clearly show the midwives\' technical knowledge in dealing with the cultural specificities of indigenous women, according to the narratives of G1 and G4.
They were waiting for me to tell them that they were pregnant or that their daughter was pregnant, because, from the moment you have this bond, and it is strengthened, as a professional, you demand a much greater responsibility of "taking care of" and committing to the progress of this pregnancy and, also, what to do, what can be achieved so that this pregnancy occurs with minimal quality. (G1)
I go to do the exams with the pregnant women, they already schedule them, they schedule the dentist part right away. When I get there, there is a complete screening with this pregnant woman, it is not a simple and quick consultation of questions and answers, the care in the village is always an in-depth consultation to clarify all doubts and, also, to obtain as much information as possible. (G4)
The statements show that participants recognize the importance of qualified consultations in order to establish a professional-user bond. Other statements highlighted the efforts of Indigenous Health Agents (AIS) in actively searching for pregnant women, guiding and referring them to the appropriate service, as well as the important role of the volunteer indigenous health agent who, comparatively, assumes the role of a doula and contributes to strengthening family bonds.
CHAs, community health agents in the city, are the ones who visit their micro-areas described in their homes, where they actively search for those identified as pregnant, provide guidance or go to their homes. Sometimes, they even give warnings: “Your appointment is late, you need to go there, you need to get vaccinated, you need to do prenatal care, and go to the dentist.” In indigenous health, the AIS does what is within their power according to their knowledge. (G2)
Someone worthy of appreciation is the indigenous volunteer health agent, a person who is responsible for serving the community, who is not paid, but is there. Most of these villages have an indigenous agent and not a technical or higher education professional, and it is he who makes these visits within the territory. (L6)
The relevance of the actions of the volunteer agent as tactics that strengthen the pregnancy-puerperal cycle of indigenous women is clear. In general, volunteering is gaining strength in all sectors and it could not be different in relation to indigenous health. It was noted, in G3\'s speech, in particular, that the success of prenatal care and favorable birth outcomes were attributed to the formation of the professional-user bond, as mentioned:
In indigenous health, quality prenatal care is achieved through bonding. All the prenatal care I have performed that was very successful was created through bonding, being able to provide comprehensive care to that woman and make the necessary referrals, because often, she goes to the city to do the tests and is not seen, and then she returns to the village, and is able to continue that prenatal care in terms of childbirth, to find out what she wants as a pregnant indigenous woman. Sometimes, she is in her fifth, sixth, or seventh pregnancy and she is tired. (G3)
Participant G3 reinforces the importance of establishing bonds and knowledge among the population to ensure the continuity of prenatal care for the indigenous pregnant woman. In the speech of manager G9, the value of traditional medicine in indigenous culture and the need to combine cultural and scientific knowledge, without disregarding specific practices, became evident.
Traditional medicine helps a lot, but our indigenous land medicine complements each other and the families believe in this a lot. We need to learn the value of this wisdom. (G9)
The participants\' statements demonstrate the importance of the professional-user bond, the relevance of indigenous midwives, as well as community health agents (technicians or volunteers) who play a mediating and guiding role in culturally relevant aspects for indigenous women.
Strategies to promote best practices in the indigenous context
Participants listed several strategies that can contribute to the induction of better practices in the pregnancy and puerperium cycle of indigenous women. The prenatal training courses for pregnant women and the training of Indigenous Community Agents stand out, as well as strategies associated with the inclusion of indigenous doulas and the training of partners in basic care, as follows:
The courses for pregnant women are important and they really like it. Traveling is difficult. We would have to study a way to train them. (G1)
There could be more courses for the agents to update their techniques, postures and acquire new knowledge in this context. Also courses for health agents. (G8)
Other strategies mentioned by participants are related to the adaptation of prenatal flowcharts and the implementation of clear and objective booklets in indigenous language.
The flowcharts and booklets in the language of indigenous women help a lot. They like to help build it. There is a booklet that they still keep to this day. Everyone helped build it. (G7)
In other statements, strategies associated with the implementation of teleconsultations and telecare for indigenous pregnant and postpartum women were highlighted, due to logistical issues of transportation and others.
The villages are very far away, and we would have to think about technologies to connect users and find ways to do this to facilitate communication. (G6)
During the pandemic, we learned a lot of things, and we would have to study how to provide online care. It would be very helpful in terms of information and guidance. (G10)
In addition to the weaknesses, the participants, in general, indicated good practices that can be promoted in the indigenous context, without disregarding cultural and ethnic peculiarities. In general, the participants make personal and professional efforts and want to improve care during the pregnancy-postpartum cycle, but they need more incentive for the intercultural training of health professionals.

Discussion
The findings of this study demonstrate that there is specific cultural knowledge that should be considered in the pregnancy-puerperal cycle of indigenous women, which requires interpretation and broader discussion, in light of references capable of contextualizing, making flexible, confronting certainties and analyzing facts and social events in a multidimensional, ethical and responsible way. For this purpose, the complexity thinking proposed by Edgar Morin was adopted, with the aim of conceiving complexity as a fabric of events, actions, interactions and feedbacks that aim to reconnect cultural knowledge dispersed by modern rationality13.
The participants in this study indicated that the main weaknesses and, in turn, also the main strategies are associated with the professional-user-family-community bond, access to and quality prenatal care, and the insufficient number, turnover and qualification of professionals (technicians or volunteers) to consider cultural specificities. Therefore, both weaknesses and strategies are associated with the induction of analytical-interpretative paths that are capable of (re)thinking care approaches, in order to transcend the specific and welfare-based practices still in force in the indigenous context.
The differentiated care approaches provided for in the PNASPI often translate into inclusive regulations that hegemonize cultural specificities. In this logic, a linear and reductive interculturality prevails, in which respect for cultural diversity is transformed into a new strategy of domination, which reproduces colonial difference based on the discursive rhetoric of pluralism17.
The strategies that induce best practices in the pregnancy-puerperal cycle of indigenous women, guided by interculturality, must necessarily be articulated with traditional indigenous knowledge and practices, in order to promote dialogues that broaden perspectives and the production of shared knowledge18. From the perspective of complexity thinking, intercultural understanding is an interactive and associative process in which the evolution of significant knowledge occurs through the exchange of culturally different knowledge and practices13, According to Morin, a proponent of complexity thinking, the most successful strategies are generally those that generate the greatest number of systemic relationships, interactions and associations, in which it is necessary to know the whole in order to know the parts in particular, and to know the parts in order to understand the whole. From this perspective, Morin defends and conceives knowledge in unity and multidimensionality, as incomplete and in constant evolution19-20.
Based on the above, qualifying care for indigenous pregnant and postpartum women implies designing strategies that foster evolutionary paths capable of bringing together apparently distinct realities and qualifying interactions between professionals and indigenous users and vice versa. Autonomy and empowerment will be achieved by indigenous women to the extent that they feel close to, welcomed, protected and supported in their unique and multidimensional cultural manifestations.
By inducing a reform of thought through transdisciplinary and intercultural practices, Morin questions the fragmentation and hyper-specialization of knowledge, as well as the excessive and linear order, without taking into account racial, ethnic, religious and cultural specificities13. The development of good practices in the pregnancy-puerperal cycle of indigenous women, under this thinking, necessarily requires evolutionary intercultural dialogues and the combination of scientific and cultural knowledge, in order to understand the woman (pregnant/puerperal) as an evolving being - a complex and multiple unit.
The results of this study showed that indigenous women want to be assisted and supported by people close to them and whom they trust. In this sense, Indigenous Health Agents and traditional midwives play a relevant role in the pregnancy-puerperal cycle of indigenous women. These professionals, due to their proximity and associative ties, are able to develop a bond with users and, in this way, better understand their singularities/specificities. This finding is corroborated by studies, which demonstrate favorable repercussions of traditional midwives who, due to their linguistic ties, translate meaningful information to users, based on specific linguistic and cultural codes that favor the construction of positive experiences in the pregnancy-puerperal cycle21-22.
Strengthening the bond between professionals and users (indigenous pregnant women/postpartum women) is therefore a relevant and promising strategy for achieving more effective results during pregnancy, childbirth and postpartum, as well as contributing to reducing maternal and child morbidity and mortality. Establishing bonds goes beyond technical-assistance approaches and requires overcoming verticalized interventions. Complexity thinking aspires to shared evolutionary knowledge, to openness of mind to understand, welcome and respect cultural diversity23-24.
The health system, a complex system par excellence, increasingly requires professionals willing to deal with the unpredictability, ambiguities and growing complexity of reality, in which cultural forces, ideologies and antagonisms move, which are equally important and necessary for the evolution of knowledge13. It requires professionals capable of acting from the intercultural and indigenous perspective of PNASPI, based on the articulation of knowledge, respect for the values of the traditional system, and capable of overcoming the specific practices translated, according to the participants of this study, into weighing, measuring and providing specific guidance to indigenous pregnant women.
The quality of indigenous health care permeates, from the perspective of complexity thinking, the quality of systemic relationships, interactions and associations, the strengthening of the reception and bond between professionals and users and the ability to dialogue and bring together knowledge that is apparently distinct and contradictory25. In addition to multiplying new studies related to indigenous health, contributions are required that are capable of questioning the established scientific rationality and (re)signifying knowledge that has been relegated to a secondary plane, such as popular knowledge arising from the existential daily lives of users - voluntary health actors.
Indigenous women during pregnancy and childbirth cannot be seen as “just another pregnant or postpartum woman” without significant knowledge, experiences and practices. The findings of this study are corroborated by previous studies, in which researchers indicate that pregnancy and birth in indigenous culture involve a mix of feelings, values, attitudes and beliefs that must be respected and strengthened in order to ensure more effective results in the area of health26-27.
Therefore, we return to the initial question of this study: How can we achieve the goals proposed by the 2030 Agenda in a country with continental geographic dimensions, with such disparate social inequities and such cultural diversity? Promoting good practices in the pregnancy and childbirth cycle of indigenous women requires, based on this question and the findings of this and other studies, understanding the singularities without minimizing distinct cultural aspects; recognize existential plurality without harming specificities, transcend scientific rationality normally established as absolute truth and prospect improvements in health without incurring in rational scientism28.
The contributions of this study to the advancement of public health are associated with the perception that it is necessary to reconnect elements of indigenous culture, underestimated by the supremacy of hegemonic scientific rationality in the health area. In this process of (re)signification, valorization and enhancement of specificities of indigenous culture, managers of indigenous health services can appear as protagonists and inducers of specific assistance policies that contemplate the social, cultural and geographic diversity in the pregnancy-puerperal cycle of indigenous women.
The small number of participants and the fact that this study was conducted only with managers of indigenous health services do not allow for generalized conclusions to be drawn about the pregnancy-puerperal cycle of indigenous women. Because of this, more comprehensive studies with the inclusion of professionals and Indigenous Health Agents should be encouraged to achieve the sustainable development goals.

Conclusion
It is concluded that the pregnancy-puerperal cycle of indigenous women, from the perspective of managers of indigenous health services, comprises unique cultural specificities associated with language, ethnicity, values, access and inviolable religious beliefs, which transcend the scientific rationality normally established as absolute truth.
Prospective strategies are required that place indigenous women at the center of prenatal and postpartum care, based on horizontal and dialogical approaches. Specific strategies associated with reception, the professional-user bond and the strengthening of the indigenous women\'s protagonism are also required. Considering the geographic characteristics of the studied territory, the logistics of understanding and the determinations of public health policies, it is therefore suggested that new qualitative studies be carried out with the inclusion of Indigenous Health Agents and indigenous midwives.

Collaborations
L Boer worked on the conception and design; wrote the article and revised it critically; and approved the final version. LSB Haeffner worked on the conception and design; wrote the article and revised it critically; and approved the final version. N Boer worked on the conception and design; wrote the article and revised it critically; and approved the final version. BMK Halbertandt worked on the design; wrote the article and approved the final version. CLL Ferreira worked on the conception and design; wrote the article and revised it critically; and approved the final version. DS Backes worked on the conception and design; wrote the article and revised it critically; and approved the final version.

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