Prenatal evaluation in primary care in Northeast Brazil: factors associated with its adequacy

Silva, Esther Pereira da; Leite, Antônio Flaudiano Bem; Lima, Roberto Teixeira; Osório, Mônica Maria

doi:10.11606/S1518-8787.2019053001024

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Sumário

Original Article • Rev. Saúde Pública 53 • 2019 • https://doi.org/10.11606/S1518-8787.2019053001024 copy

Prenatal evaluation in primary care in Northeast Brazil: factors associated with its adequacy

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To characterize prenatal care and verify possible factors associated with its adequacy.

METHODS

This is a cross-sectional study based on interviews with health care professionals and consultations on official documents of women attending prenatal of the primary health care in the city of João Pessoa, capital of Paraíba, in the Northeast region of Brazil. Prenatal care was evaluated by an index with criteria referring to aspects of structure, process and outcome, denominated IPR/Prenatal. The multivariate logistic regression method revealed that demographic, socioeconomic, reproductive and maternal morbidity variables were possible determinants for prenatal adequacy.

RESULTS

The survey involved 130 services and 1,625 primary health care patients. Prenatal care was adequate in approximately 23% of the cases. Low prevalence of referral to maternity, educational strategies and examinations were observed. The analysis showed that non-adolescent women (OR = 1,390), with a longer period of schooling (OR = 1.750), higher per capita income (OR = 1,870) and primiparous women (OR = 1,230) were more likely to have an adequate prenatal.

CONCLUSIONS

Prenatal care, when evaluated by broader criteria, showed a low percentage of adequacy. Strategies should be developed to ensure the referral to the maternity where the birth will take place and health education activities and examinations to provide adequate prenatal care in the municipality under study. In addition, factors associated with adequacy must be considered by managers and health professionals.

Prenatal Care, organization & administration; Health Services Coverage; Outcome and Process Assessment (Health Care); Health Status Disparities

Aspect	Evaluation criteria	Description of the criteria	Grade	Collection form
Infrastructure (services)	Construction in own building	Unit built with physical plant to be health service	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Exposure of health unit operation to users	Present in a visible place the days, shifts and prenatal professionals	1 (Yes) = adequate; 2 (No) = inadequate	Direct observation
	Equipment for prenatal use in operation^a	To have at least six: clinical and Pinard stethoscope, sphygmomanometer, inelastic tape measure, glucometer, clinic table and chairs, stretcher, two-step iron ladder, scale, doppler fetal monitor/sonar, obstetric disk and exclusive cabinet for storage of medicines	1 (Yes) = adequate; 2 (No) = inadequate	Interview and direct observation
	Prenatal routine procedure materials	To have at least seven: exam request card, pregnant woman’s card, daily record map, referral form, medication prescription, follow-up form/handbook, disposable gloves, clean sheets for gynecological tables, materials for cytological collection, garbage basket, soap for personal hygiene, paper towel, gel alcohol, sink and toilet inside the office	1 (Yes) = adequate; 2 (No) = inadequate	Interview and direct observation
	Therapeutic supplies (medicines, quick tests, supplements, vaccines for prenatal use) ^b	To have at least eight: ferrous sulfate, folic acid, hepatitis B vaccine, diphtheria and tetanus (dT), diphtheria, tetanus and pertussis (dTpa) vaccine, influenza vaccine, antacids, antibiotics, antipyretics, anthelmintics, complex B, vitamin C, hypotensives, antiemetics, anti-inflammatories and quick tests (HIV, syphilis and pregnancy)	1 (Yes) = adequate; 2 (No) = inadequate	Interview and direct observation
	Laboratory Support	Guarantee of laboratory support to perform the recommended examinations^c	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Human Resources	Have the minimum team of primary health care^d	1 (Yes) = adequate; 2 (No) = inadequate	Interview
Process (services)	Coverage of pregnant women followed up	Provide coverage of 100% of the pregnant women monitored in relation to the total area covered in the month prior to the visit	1 (Yes) = adequate; 2 (No) = inadequate	Note on documents in the units
	Coverage of pregnant women who met the goals of the Ministry of Health	To present coverage of 100% of the pregnant women who performed at least seven visits beginning in the first trimester and all the exams in the month prior to the visit in relation to the total number of pregnant women followed up (including immunization)	1 (Yes) = adequate; 2 (No) = inadequate	Note on documents in the units
	Multiprofessional service	Performing prenatal care with the presence of more than one senior professional	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Clinical-obstetric procedures	Team performs all the recommended procedures^e	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Presence of clinical information on the follow-up of pregnant women	Team presents the same records on the pregnant woman’s card for the individual monitoring of users	1 (Yes) = adequate; 2 (No) = inadequate	Note on documents in the units
	Prescription of clinical exams	Prescription of recommended exams by professionals^c	1 (Yes) = adequate; 2 (No) = inadequate	Interview
Continue
Box. Classification of prenatal care by IPR/Prenatal. João Pessoa, state of Paraíba, Brasil, 2016. Continuation
Results (users)	Orientação sobre aleitamento materno e sinais e sintomas do parto	To have received guidance on management, duration, possible breastfeeding problems, complementary feeding and birth	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Health Education	To have participated in prenatal health education activities	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Supplementation	Use of iron and folic acid during gestation	1 (Yes) = adequate; 2 (No) = inadequate	Interview
	Onset of prenatal care	To start prenatal care until the 12th gestational week	1 (Yes) = adequate; 2 (No) = inadequate	Pregnant woman’s card
	Number of medical consultations	To have had at least seven prenatal visits	1 (Yes) = adequate; 2 (No) = inadequate	Pregnant woman’s card
	Perform laboratory exams	To have performed the exams according to the Ministry of Health^c	1 (Yes) = adequate; 2 (No) = inadequate	Pregnant woman’s card
	Immunization^f	To have taken hepatitis B, tetanus, and influenza vaccines	1 (Yes) = adequate; 2 (No) = inadequate	Pregnant woman’s card
	Referral to maternity	To have received the referral to maternity hospital from primary care	1 (Yes) = adequate; 2 (No) = inadequate	Interview

Characterization of health services		n	%
Construction in own building		105	80.8
Knowledge of users about the health unit’s functioning		125	96.2
Equipment in operation		92	70.8
Materials of prenatal routine procedures		126	96.9
Vaccines, medications and supplements		97	66.9
Reference laboratory support		130	100.0
Human Resources		115	88.5
Coverage of pregnant women followed up		120	92.5
Coverage of pregnant women who met the goals of the Ministry of Health		38	29.1
Multiprofessional service		110	84.7
Presence of clinical information on the follow-up of pregnant women		130	100.0
Performing clinical-obstetric procedures		130	100.0
Prescription of clinical exams		130	100.0

Characterization of users	n	%	Mean (SD)

Guidance on the type of birth	773	47.6
Guidance on childbirth symptoms	765	47.1
Guidance on breastfeeding	751	46.2
Participation in health education activities	406	25.0
Use of supplementation during pregnancy	1,279	78.7
Start on the first trimester	858	52.8	14.30 (4.55) gestational weeks
Number of medical consultations
< 7	648	39.9	5.86 (1.35) medical consultations
≥ 7	977	60.1	5.86 (1.35) medical consultations
Performing the exams recommended in prenatal care	214	13.2
Immunization	1,154	71.0
Referral to maternity	444	27.3

Categorization	Classification		95%CI

	n	%
Adequate	367	22.6	19.2–26.0
Intermediary	278	17.1	14.0–20.3
Inadequate	980	60.3	50.0–70.6

Independent variables	Total women interviewed		Adequate prenatal care		Inadequate prenatal care		p*

	(n = 1,625)		n = 367 (22.6%)		n = 1,258 (77.4%)

	n	%	n	%	n	%
Health district							0.723
I	330	20.3	66	18.0	264	21.0
II	318	19.6	66	18.0	252	20.0
III	345	21.2	68	18.5	277	22.0
IV	307	18.9	54	14.7	253	20.1
V	325	20.0	113	30.8	212	16.9
Age (years old)							< 0.001
≤ 18	73	4.6	8	2.2	65	5.2
19–29	1,311	80.5	192	52.3	1,119	88.9
≥ 30	241	14.9	167	45.5	74	5.9
Level of education							< 0.001
0–9 years	1,067	65.6	38	10.3	1,029	81.8
≥ 10 years	558	34.4	329	89.7	229	18.2
Monthly average income							< 0.001
≤ 1 MW	372	22.8	127	34.6	245	19.5
> 1 MW	1,253	77.2	240	65.4	1,013	80.5
Work in Pregnancy							< 0.001
Yes	1,001	61.6	100	27.2	901	71.6
No	624	38.4	267	72.3	357	28.4
Lives with a partner							< 0.001
Yes	1,093	67.3	324	88.3	769	61.1
No	532	32.7	43	11.7	489	38.9
Enrollment on the Bolsa Família Program							< 0.001
Yes	517	31.8	241	65.7	276	22.0
No	1,108	67.8	126	34.3	982	78.0
Parity							< 0.001
Primiparous	465	28.6	307	83.7	158	12.5
Multiparous	1,160	71.4	60	16.3	1,100	87.5
Previous abortions							< 0.001
Yes	691	42.5	24	6.5	667	53.0
No	934	54.5	343	93.5	591	47.0
Previous premature infants							< 0.001
Yes	520	32.0	67	18.3	453	36.0
No	1,105	68.0	300	81.7	805	64.0
Intake of alcoholic beverage							< 0.001
Yes	565	34.8	32	8.7	533	42.4
No	1,060	65.2	335	91.3	725	57.6
Smoker							< 0.001
Yes	221	13.6	14	3.8	207	16.4
No	1,404	86.4	353	96.2	1,051	83.6
Diabetes							0.003
Yes	164	10.1	22	6.0	142	11.3
No	1,461	89.9	345	94.0	1,116	88.7
Arterial hypertension							< 0.001
Yes	161	9.9	19	5.2	142	11.3
No	1,464	90.1	348	94.8	1,116	88.7
Presence of edema							< 0.001
Yes	869	53,5	68	18.5	801	63.4
No	756	46.5	299	81.5	457	36.4

Variable	Gross OR	95%CI	Adjusted OR	95%CI
Health district
District I	1
District II	0.750	0.157–1.646
District III	0.820	0.490–1.741
District IV	0.720	0.230–1.950
District V	1.400	0.960–1.620
Age (years old)
≤ 18	1.260	0.870–1.719	0.820	0.320–1.720
19–29	2.720	1.090–3.140	1.390	1.120–2.220
≥ 30	1		1
Level of education
0–9 years	1
≥ 10 years	2.520	1.480–3.160	1.750	1.156–2.233
Monthly average income			1
≤ 1 MW	1
> 1 MW	2.150	1.390–3.260	1.870	1.114–2.420
Work in Pregnancy
Did not work in pregnancy	0.860	0.665–1.054
Worked in pregnancy	1
Lives with a partner
Yes	0.779	0.674–1.459
No	1
Enrollment on the Bolsa Família Program
Yes	0.793	0.623–1.079
No	1
Parity
Primiparous	1.335	1.140–2.020	1.230	1.100–1.879
Multiparous	1		1
Previous abortions
No	1.175	0.865–1.596	0.980	0.806–1.020
Yes	1		1
Intake of alcoholic beverage
No	1.062	0.758–1.206
Yes	1
Smoker
No	1.042	0.914–1.264
Yes	1
Diabetes
No	2.260	0.896–8.059
Yes	1
Arterial hypertension
No	1.036	0.548–1.753
Yes	1
Presence of edema
No	0.870	0.610–1.298
Yes	1
Previous premature infants
No	1.430	0.936–2.325
Yes	1

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[1] Correspondence: Esther Pereira da Silva Rua Sindá Félix de Lima, 11 Jdim. Cidade Universitária 58051-821 João Pessoa, PB, Brasil E-mail: estherp.silva@yahoo.com.br