Evaluation of prenatal care in Primary Health Care in Brazil

Cunha, Ana Carolina; Lacerda, Josimari Telino de; Alcauza, Mônica Teresa Ruocco; Natal, Sônia

doi:10.1590/1806-93042019000200011

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ORIGINAL ARTICLES • Rev. Bras. Saude Mater. Infant. 19 (2) • Apr-Jun 2019 • https://doi.org/10.1590/1806-93042019000200011 linkcopy

Evaluation of prenatal care in Primary Health Care in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives: to evaluate prenatal care in Primary Care by identifying the aspects that influence structural and operational adequacy.

Methods: evaluation research with analysis of 4,059 municipalities that joined the 2nd cycle of the Program for Improving Access and Quality in Primary Care in 2013-2014. The evaluative model composed of 19 indicators grouped in structural aspects and operational aspects dimensions was validated in a consensus conference. Data analysis was descriptive, with the issuance of value judgment.

Results: in structural aspects, 32.6% of the municipalities presented adequacy, whilst in operational ones, only 24.1%. In the general prenatal evaluation, less than a quarter (24.6%) of the municipalities was adequate, those with up to 10 thousand inhabitants had a higher percentage of adequacy (41.6%). The South region presented adequacy of 33.8%, considering all sizes.

Conclusions: most municipalities presented low adequacy in prenatal care, with better performance of structural aspects. Smaller municipalities presented better results in all analyzed items. Structural aspects and general evaluation of prenatal care are highlighted in the South region. Adequate attention to prenatal care needs to be comprehensive and equitable, with the strengthening of regional networks geared towards social inclusion.

Key words
Health evaluation; Primary health care; Quality assurance; Health care

Evaluative matrix	Measures	Judgment Parameters
Structural aspects
Infrastructure		≥ 90% = adequate (1.0)
Adequacy of the physical space	% BHU with nursing office and waiting room	89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Materials and equipment for prenatal care	% UBS that makes available a pregnant woman's booklet	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	Both adequate= adequate (1.0) Both inadequate= inadequate (0.0) Other situations= minimally adequate (0.5)
	% BHU with availability of equipment and furniture for prenatal care	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Inputs and medicines	% BHU with supply of important vaccines for the prenatal period	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	Both adequate= adequate (1.0) Both inadequate= inadequate (0.0) Other situations= little adequate (0.5)
	% BHU with availability of essential medicines for the gestational period	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Human resources
Adequacy of staff	% FHS with complete minimum health staff*	Dichotomous analysis, according to population size. Parameter to "adequate" Up to 50 thousand inhab. = 100% >50 to 100 thousand inhab. = 90% >100 to 500 thousand inhab. = 85% > 500 thousand inhab. = 60%	Both adequate= adequate (1.0) Both inadequate= inadequate (0.0) Other situations= little adequate (0.5)
	% FHS with oral health*	Dichotomous analysis, according to population size. Parameter to "adequate" Up to 25 thousand inhab. = 100% >25 to 50 thousand inhab. = 90% >50 to 100 thousand inhab. = 85% >100 to 500 thousand inhab. = 75% >500 thousand inhab. = 60%
Structural aspects
Human resources
Population coverage	% population with coverage of the FHS^***	Dichotomous analysis, according to population size. Parameter to "adequate" (1.0) Up to 25 thousand inhab. = 100% >25 to 50 thousand inhab. = 85% >50 to 100 thousand inhab. = 65% >100 to 500 thousand inhab. = 55% >500 thousand inhab. = 40%
Specialized support	% FHS which receives support from experts	≥ 90% = adequate (1.0) 89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Standardization of care			Both adequate= adequate (1.0)
Normatization of care	% FHS which uses protocols for prenatal risk stratification	≥90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	Both inadequate= inadequate (0.0) Other situations = little adequate (0.5)
	% FHS that has protocols with definition of guidelines to host the pregnant woman	≥90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Updated information	% FHS that monthly feed the prenatal information system % FHS with cytopathological collection record	≥90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate

Evaluative matrix	Measures	Judgment parameters
Operational aspects
Organization of care
Appropriation of territory	% FHS with registration of all pregnant women in the territory	≥90% = adequate (1.0) 89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Early capture	% FHS that perform an active search of pregnant women for prenatal care	≥ 90% = adequate (1.0) 89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Adequate access	% FHS that have extended working hours **	Dichotomous analysis, according to population size. Parameter for "Adequate" (1.0) Up to 10 thousand inhab. = 100% >10 thousand inhab. = 80%
Programming of care	% FHS that offer scheduled prenatal consultations	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	Both Adequate= adequate (1.0) Both inadequate= inadequate (0.0) Other situations = little adequate (0.5)
	% FHS that have agenda scheduling according to gestational risk	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Promotion and prevention
Early diagnosis	% FHS that request the rapid pregnancy test	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	All adequate = adequate (1.0) All inadequate= inadequate (0.0) Other situations = minimally adequate (0.5)
	% FHS that request the rapid HIV test	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
	% FHS that request the rapid syphilis test	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Operational aspects
Promotion and prevention
Immunization	% FHS that register the up to date vaccination of the pregnant woman	≥ 90% = adequate (1.0) 89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Identification of diseases	% FHS that request prenatal exams	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	Both adequate= adequate (1.0) Both inadequate= inadequate (0.0) Other situations = minimally adequate (0.5)
	% FHS that receive the examinations in a timely manner for necessary interventions	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Health education	% FHS that offer educational and health promotion actions for pregnant women	≥ 90% = adequate (1.0) 89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Follow-up
Follow-up of the gestational cycle	Proportion of LB of mothers with seven or more prenatal visits***	≥ 90% = adequate (1.0) 89 to 75% = minimally adequate (0.5) <75% = inadequate (0.0)
Reference and counter-reference	% FHS that maintains a register of higher risk pregnant women referred to other points of care	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate	Both adequate= adequate (1.0) Both inadequate= inadequate (0.0) Other situations = minimally adequate (0.5)
	% FHS that receive the counter-referral of maternity hospitals	≥ 90% = adequate; 89 to 75% = minimally adequate; <75% = inadequate
Continuity of care	% FHS which conducted puerperium consultations up to 10 days after delivery	≥ 90% = adequado; 89 a 75% = pouco adequado; <75% = inadequado

Components	A		LA		I
Components	n	%	n	%	n	%
Structural Aspects	1323	32.6	1587	39.1	1149	28.3
Infrastructure	1442	35.5	1130	27.8	1487	36.6
Adequacy of physical space	2825	69.6	485	11.9	749	18.5
Materials and equipment	1735	42.7	2040	50.3	284	7.0
Inputs and medicines	1116	27.5	1898	46.8	1045	25.7
Human Resources	1515	37.3	1063	26.2	1481	36.5
Staff Adequacy	1476	36.4	1542	38.0	1041	25.6
Population coverage	2164	53.3	-	-	1895	46.7
Specialized Support	3509	86.4	273	6.7	277	6.8
Standardization of care	1543	38.0	-	-	2516	62.0
Normatization of care	900	22.2	1557	38.4	1602	39.5
Updated information	1811	44.6	2030	50.0	218	5.4
Operational Aspects	977	24.1	1994	49.1	1088	26.8
Organization of care	1956	48.2	704	17.3	1399	34.5
Appropriation of territory	3340	82.3	321	7.9	398	9.8
Early Capture	2310	56.9	563	13.9	1186	29.2
Adequate access	1464	36.1	-	-	2595	63.9
Programming of care	2226	54.8	1515	37.3	318	7.8
Promotion and prevention	1985	48.9	823	20.3	1251	30.8
Early diagnosis	916	22.6	1668	41.1	1475	36.3
Immunization	3401	83.8	312	7.7	346	8.5
Identification of diseases	1670	41.1	1972	48.6	417	10.3
Health education	2451	60.4	561	13.8	1047	25.8
Follow-up	551	13.6	1125	27.7	2383	58.7
Gestational follow-up	185	4.6	1244	30.6	2630	64.8
Reference and counter-reference	1093	26.9	2737	67.4	229	5.6
Continuity of care	3041	74.9	462	11.4	556	13.7
General Evaluation of Prenatal Care	997	24.6	2153	53.0	909	22.4

Population size (inhabitants)	A		LA		I		p
Population size (inhabitants)	n	%	n	%	n	%	p
Structural aspects							<0.001*
Up to 10 thousand	990	50.8	692	35.5	267	13.7
10 to 25 thousand	214	17.1	569	45.6	466	37.3
25 to 50 thousand	64	13.6	176	37.5	229	48.8
>50 thousand	55	14.0	150	38.3	187	47.7
Operational aspects
Up to 10 thousand	752	38.6	854	43.8	343	17.6	<0.001*
10 to 25 thousand	120	9.6	677	54.2	452	36.2
25 to 50 thousand	51	10.9	247	52.7	171	36.5
>50 thousand	54	13.8	216	55.1	122	31.1
General evaluation of prenatal care
Up to 10 thousand	810	41.6	876	44.9	263	13.5	< 0.001*
10 to 25 thousand	106	8.5	760	60.8	383	30.7
25 to 50 thousand	41	8.7	273	58.2	155	33.0
>50 thousand	40	10.2	244	62.2	108	27.6

Regions	A		LA		I		p
Regions	n	%	n	%	n	%	p
Structural aspects							<0.001*
North	61	22.7	84	31.2	124	46.1
Northeast	431	34.2	576	45.6	255	20.2
Center-west	95	24.1	156	39.6	143	36.3
Southeast	393	31.8	477	38.6	367	29.7
South	343	38.2	294	32.8	260	29.0
Operational aspects							<0.001*
North	33	12.3	133	49.4	103	38.3
Northeast	143	11.3	707	56.0	412	32.6
Center-west	87	22.1	202	51.3	105	26.6
Southeast	420	34.0	535	43.2	282	22.8
South	294	32.8	417	46.5	186	20.7
General evaluation of prenatal care							<0.001*
North	39	14.5	133	49.4	97	36.1
Northeast	180	14.3	773	61.3	309	24.5
Center-west	89	22.6	201	51.0	104	26.4
Southeast	386	31.2	619	50.0	232	18.8
South	303	33.8	427	47.6	167	18.6

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Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
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[TFN1] ^*
Parameters defined according to the tertile distribution for each population size stratum

[TFN2] ^**
Data collected on the site of the CNES, BHU= Basic Health Unit, FHS= Family Health Strategy.