Evaluation of maternal and neonatal hospital care: quality index of completeness

Silva, Ana Lúcia Andrade da; Mendes, Antonio da Cruz Gouveia; Miranda, Gabriella Morais Duarte; Sá, Domicio Aurélio de; Souza, Wayner Vieira de; Lyra, Tereza Maciel

doi:10.1590/S0034-8910.2014048004605

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Brasil

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Sumário

Public Health Practice • Rev. Saúde Pública 48 (4) • Aug 2014 • https://doi.org/10.1590/S0034-8910.2014048004605 copy

Evaluation of maternal and neonatal hospital care: quality index of completeness

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE

Develop an index to evaluate the maternal and neonatal hospital care of the Brazilian Unified Health System.

METHODS

This descriptive cross-sectional study of national scope was based on the structure-process-outcome framework proposed by Donabedian and on comprehensive health care. Data from the Hospital Information System and the National Registry of Health Establishments were used. The maternal and neonatal network of Brazilian Unified Health System consisted of 3,400 hospitals that performed at least 12 deliveries in 2009 or whose number of deliveries represented 10.0% or more of the total admissions in 2009. Relevance and reliability were defined as criteria for the selection of variables. Simple and composite indicators and the index of completeness were constructed and evaluated, and the distribution of maternal and neonatal hospital care was assessed in different regions of the country.

RESULTS

A total of 40 variables were selected, from which 27 single indicators, five composite indicators, and the index of completeness of care were built. Composite indicators were constructed by grouping simple indicators and included the following variables: hospital size, level of complexity, delivery care practice, recommended hospital practice, and epidemiological practice. The index of completeness of care grouped the five variables and classified them in ascending order, thereby yielding five levels of completeness of maternal and neonatal hospital care: very low, low, intermediate, high, and very high. The hospital network was predominantly of small size and low complexity, with inadequate child delivery care and poor development of recommended and epidemiological practices. The index showed that more than 80.0% hospitals had a low index of completeness of care and that most qualified heath care services were concentrated in the more developed regions of the country.

CONCLUSIONS

The index of completeness proved to be of great value for monitoring the maternal and neonatal hospital care of Brazilian Unified Health System and indicated that the quality of health care was unsatisfactory. However, its application does not replace specific evaluations.

Prenatal Care; Maternal-Child Health Services; Hospital Care; Quality Indicators, Health Care; Quality of Health Care; Unified Health System

Composite indicator	Simple indicators	Score/Range
Composite indicator	Simple indicators	0	0.2	0.4	0.6	0.8	1
Size	Total number of neonatal beds	0	1 to 4	5 to 9	10 to 19	20 to 29	≥ 30
	Total number of obstetric beds	0	1 to 9	10 to 29	30 to 49	50 to 69	≥ 70
	Total number of neonatal admissions	0	1 to 49	50 to 99	100 to 299	300 to 499	≥ 500
	Total number of obstetric procedures	0	1 to 499	500 to 999	1,000 to 2,999	3,000 to 4,999	≥ 5,000

Complexity	Number of beds in adult ICU	0	1 to 5	6 to 10	11 to 20	21 to 30	≥ 31
	Number of beds in neonatal ICU	0	1 to 5	6 to 10	11 to 15	16 to 20	≥ 21
	Number of beds in pediatric ICU	0	1 to 5	6 to 10	11 to 15	16 to 20	≥ 21
	Number of incubators	0	1 to 5	6 to 10	11 to 15	16 to 20	≥ 21
	Tertiary assistance to high-risk pregnacy	No	–	–	–	–	Yes
	Enteral and parenteral nutritional service	No	–	–	–	–	Yes
	Cleft lip treatment	No	–	–	–	–	Yes
	Referral center for neonatal screening	No	–	–	–	–	Yes

Delivery care	High-risk vaginal delivery	No					Yes
	High-risk cesarean delivery	No					Yes
	% vaginal deliveries with hospital permanence of 24 hours	< 50.0	50.0 to < 60.0	60.0 to < 70.0	70.0 to < 80.0	80.0 to < 90.0	90.0 to 100
	% cesarean deliveries with hospital permanence of 48 hours	< 50.0	50.0 to < 60,0	60.0 to < 70.0	70.0 to < 80.0	80.0 to < 90.0	90.0 to 100
	% cesarean deliveries/year	0 or 80.1 to 100	0.1 to 10.0 or 70.1 to 80.0	10.1 to 20.0 or 60.1 to 70.0	20.1 to 30.0 or 50.1 to 60.0	40.1 to 50.0	30.1 to 40.0

Recommended practices	Shared accommodation	No	–	–	–	–	Yes
	Creation of a milk bank	No	–	–	–	–	Yes
	Accreditation in a baby friendly hospital	No	–	–	–	–	Yes
	Accreditation in an AIDS day hospital	No	–	–	–	–	Yes
	Accreditation for neonatal intermediate care	No	–	–	–	–	Yes
	Accreditation for tubal ligation	No	–	–	–	–	Yes
	Accreditation for organ procurement	No	–	–	–	–	Yes

Epidemiological practices	Commission for fatality analysis	No	–	–	–	–	Yes
	Commission for hospital infection control	No	–	–	–	–	Yes
	Commission for disease notification and investigation	No	–	–	–	–	Yes

Composite indicator	Score/Range						Total
Composite indicator	0	1	2	3	4	5	Total
Size	–	> 0 to 1	> 1 to 2	> 2 to 3	> 3	–	4
Complexity	0	> 0 to 1	> 1 to 2	> 2 to 3	> 3 to 4	> 4	5
Child delivery care	0	> 0 to 1	> 1 to 2	> 2 to 3	> 3	–	4
Recommended practices	0	1	2	3	4	≥ 5	5
Epidemiological practices	0	1	2	3	–	–	3

Index	Scores/Levels/Classification

Completeness of care		1 to 4	5 to 8	9 to 12	13 to 16	≥ 17
		Level I	Level II	Level III	Level IV	Level V
		Very low	Low	Intermediate	High	Very high

Dimension	Indicator	Hospital units/Score
Dimension	Indicator	0	0.2	0.4	0.6	0.8	1
Size	Neonatal beds	2,971	172	136	75	31	15
	Obstetric beds	16^a	1,843	1,209	226	57	49
	Neonatal hospitalizations	613	2,117	176	258	129	107
	Obstetric procedures	0	2,323	433	449	140	55

Complexity	Adult ICU	2,837	60	284	148	35	36
	Neonatal ICU	3,025	60	197	49	30	39
	Pediatric ICU	3,187	102	78	15	9	9
	Incubators	728	2,188	241	96	55	92
	Tertiary assistance to high-risk pregnacy	3,322	–	–	–	–	78
	Enteral and parenteral nutritional service	3,003	–	–	–	–	397
	Cleft lip treatment	3,390	–	–	–	–	10
	Reference in specialized neonatal care	3,391	–	–	–	–	9

Delivery care	% vaginal deliveries with hospital permanence of 24 hours	1,286	392	469	515	442	296
	% cesarean deliveries with hospital permanence of 48 hours	1,283	348	432	474	456	407
	% cesarean deliveries	607	280	572	991	390	560
	High-risk vaginal deliveries	3,248	–	–	–	–	152
	High-risk cesarean deliveries	3,245	–	–	–	–	155

Recommended practices	Shared accommodation	2,018	–	–	–	–	1,382
	Milk bank	3,182	–	–	–	–	218
	Accreditation in a baby friendly hospital	3,108	–	–	–	–	292
	Accreditation in an AIDS day hospital	3,366	–	–	–	–	34
	Accreditation for neonatal intermediate care	3,278	–	–	–	–	122
	Accreditation for tubal ligation	2,602	–	–	–	–	798
	Accreditation for organ procurement	3,116	–	–	–	–	284

Epidemiological practices	Commission for fatality analysis	2,907	–	–	–	–	493
	Commission for hospital infection control	1,291	–	–	–	–	2,109
	Commission for disease notification and investigation	1,567	–	–	–	–	1,833

Dimension/Composite indicator	Level/Number of hospitals
Dimension/Composite indicator	0	1	2	3	4	5
Size	–	2,585	573	200	41	–
Complexity	710	2,228	183	152	75	52
Delivery care	120	1,259	1,517	558	46	–
Recommended practices	982	1,528	588	195	69	38
Epidemiological practices	835	1,063	1,134	368	–	–

Region	Completeness of care										Total
	Very low		Low		Intermediate		High		Very high

	n	%	n	%	n	%	n	%	n	%
North	111	32.6	197	57.9	26	7.6	4	1.2	2	0.6	340
Northeast	440	36.8	623	52.1	98	8.2	25	2.1	10	0.8	1,196
Midwest	73	22.1	218	66.1	26	9.0	9	2.7	4	1.2	330
South	100	16.4	395	64.9	79	13.0	29	4.8	6	1.0	609
Southeast	87	9.4	557	60.2	184	19.9	76	8.2	21	2.3	925
Brazil	811	23.9	1,990	58.5	413	12.1	143	4.2	43	1.3	3,400

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[1] Correspondence: Antonio da Cruz Gouveia Mendes. Av. Professor Moraes Rego, s/n. Campus UFPE – Cidade Universitária. 50670-420 Recife, PE, Brasil. E-mail:antoniodacruz@gmail.com