Process and outcome of prenatal care according to the primary care models: a cohort study*

Objective: to evaluate the process and outcome indicators of the prenatal care developed in primary care, comparing traditional care models and the Family Health Strategy. Method: this is a cohort study, conducted with an intentional sample of 273 mothers/babies from the neonatal period and followed up for one year. Donabedian evaluation was adopted and data were discussed based on the Social Determination of Health. The independent variable was the care model. The dependent variables in the process evaluation were related to the quality of prenatal care and to the quality score created and the evaluation of the outcome, to the conditions of birth and the first year of life. The evaluation of the process was performed by estimating the relative risk and the evaluation of the outcome was performed by the Cox Multiple Regression Model. Results: lower income and risk of the low prenatal quality score were identified in the Family Health Units, where there were more puerperium consultation and health education actions. There was no difference in outcome indicators. Conclusion: possibly the best quality of prenatal care was able to minimize negative socioeconomic effects found in family health, so the outcome indicators were similar in both models of the primary care.


Introduction
The perinatal period is among the priorities of global public policies because, despite the significant progress in reducing deaths during the last 15  Sustainable Development Objectives era (1) .
In Brazil, the quality care to the maternalinfant group is still a challenge and, therefore, issues such as early access to prenatal care and constant search for pregnant women without care, gestational risk identification, with integration of programs and activities in care networks and development of health education actions should be considered as a priority in primary health care (2) . In this sense, the Family Health is considered a new way of health work organization and a priority strategy for health services consolidation and expansion, without breaking completely with the traditional model, but seeking to improve the practices, improving the care actions and the determinants of morbidity and mortality (3) . The link between professional and patient is emphasized, having actions that enable to know the particular reality of each individual and family, which is one of the tools for its consolidation (4)(5) .
The Basic Health Units of the Family Health Strategy Family Health Strategy teams. In both care models, the professionals work with patients´ ascription in a delimited area (6) .
Both models of care: BHU-FS and BHU-T develop actions directed to the maternal-infant group.
Specifically regarding to the prenatal care, a study conducted in southern Brazil comparing the traditional models and the Family Health Strategy found more guidelines on breastfeeding, postpartum contraception, puerperal consultation, care of the newborn, type of delivery and on the test for the detection of Human

Immunodeficiency Virus (HIV) in the Family Health
Strategy. Also, the pregnant women seen in the Strategy had more frequently their breasts examined and procedures such as blood pressure and uterine height verification performed, reinforcing the importance of this model for women's health care (7) .  (8) .
Several Brazilian studies evaluate prenatal care based on the activities developed, or the care process (7,(9)(10)

Method
This is a prospective cohort study, aimed at the evaluation of prenatal care. The data source was the Botucatu-CLaB Infant Cohort study, whose objective was to know data, events, and situations related to the health of children living in that municipality, during their first year of life.
The study was developed in a municipality located in the center-south region of the state of São Paulo, with an estimated population of 144,820 inhabitants (11) in 2018. It belongs to the Regional Health Department There was a total of 650 mothers in the cohort.
During the follow-up, there were 65 losses/refusals (10%), resulting in 585 binomials (mothers and babies) followed up to the 12 th month of life, of which 338 cases were eligible for this study because they were followed up exclusively in the public service during the prenatal.
An intentional sample consisted of 273 mothers, whose records were located in the Basic Health Units (Figure 1).
The proportions intentionally obtained of 128 binomial mothers/infants (46.9%) assisted in BHU-T and 145 (53.1%) in BHU-FS, are similar to those found when considering the location of follow-up of Botucatu in 2017: 48.4% in BHU-T and 51.6% in BHU-FS (12) . The place where the recruitment took place assists women from all the basic health units of the municipality.
All the instruments used in the data collection were constructed specifically for this study and tested on 12 puerperal women not included in the sample, to adjust the questions that could have difficulties. Data collection was performed by a properly trained and remunerated team supervised by one of the authors of this study. The integrity of the interviews was verified by phone, in a random sample of 5% of the participants, through re-interviews performed by the field supervisor, also responsible for checking for inconsistencies and correction of the database.
The data obtained were discussed based on the theoretical reference of the social determinants of health, whose studies began in the 1970s to subsidize the understanding of the social relationships in the healthdisease process and the causality of health problems.  In this perspective, to analyze the health services and extending care coverage assists in improving the quality of care provided (13) .
The methodological reference of the evaluation proposed in the 1980s by Donabedian (14) was adopted, specifically regarding the process components and outcomes. For this author, the study of the process has actions of health care, including diagnosis, treatment, preventive care, and health education, and therefore, its For each yes answer (best situation), a score was assigned. Thus, these seven variables used to evaluate the quality of the prenatal process allowed the construction of a score, which ranged from zero (worse situation) to seven points (better situation). The score was considered low when equal or less than three points and this value was established after evaluating the mean and median scores of the group: 3.1 and 3, respectively.
For the outcome analysis, as proposed by Donabedian (14) , the dependent variables (outcome)

Results
Women who underwent prenatal care in the BHU-FS had a significantly higher risk of per capita income equal or lower than 0.5 MW (RR=1.52, 95% CI=1.04-2.21) when compared to those with a prenatal in the BHU-T (Table 1).  Table 2).
The median prenatal quality score for the two care models was 3.0, ranging from 0-6 to 0-7 for BHU-T and BHU-FS. The mean score was significantly higher (p<0.001) in the BHU-FS (3.53, SD = 1.50) than in the BHU-T (2.71, SD = 1.33) (data not shown in the table).
When there were confounders, there was no difference between BHU-T and BHU-FS for the early indicators studied: school approval equal or less than 8 years, paid maternal work and family per capita income equal or less than 0.5 minimum wages (Table 3). There was also no difference between BHU-T and BHU-FS for the late indicators when considering the confounders: school approval equal or less than 8 years, paid maternal work and family per capita income equal or less than 0.5 minimum wages (

Discussion
The analysis of the indicators of the prenatal care process, based on the created score, showed a better situation for women attending the BHU-FS. However, there was no difference between the models of primary care in the outcome of care, both when considering the early and late indicators.
Also, it was found that the women attending the BHU-FS had worse socioeconomic conditions, since they were more frequently classified in the lower income group and, therefore, they were expected to have worse indicators.
It is already known that the health-disease is In the isolated approach of the variables with the quality score, a better performance of the BHU-FS in health education actions is observed. In this context, the differential role of nurses has been emphasized, since it has acted from raising awareness about the importance of follow-up in this period, understanding the meaning of this moment in the pregnant woman's life (20) . A recent study carried out in Portugal corroborates it since more than half of the mothers who were considered to have a higher level of knowledge reported being the primary source of information during prenatal care (21) .
Theoretical research reporting that the Family Health Strategy is a technological innovation in the health area, in the work carried out, includes the assistance accomplished, adding multiple dimensions, such as the educational actions, which highlights the importance of its performance (3) . Regarding these actions, life habits according to the care model (7,23) .
Regarding early outcome indicators, unlike the findings of this research, a national study reveals that not having performed prenatal care adequately, that is, poor quality prenatal follow-up, it has decreased the probability of breastfeeding in the first hour of life (24) , and in another study, there was a significant correlation between ICU stay and prenatal care, and the children of women who did not perform prenatal care were hospitalized for longer.
This last research, corroborating with the findings of this study, found no association between intercurrences at birth and prenatal follow-up (25) .
Low birth weight as another indicator of early outcome adopted, was addressed in a study on prenatal quality developed at BHU-FS in the metropolitan region of Campina Grande, Paraíba. The conclusion also suggests that adequate prenatal care may have mitigated the influence of socioeconomic inequalities related to health care (26) .
Regarding the late indicators, regardless of the care model, research developed in Canada did not show a relationship between prenatal quality and duration of breastfeeding in the first six months of the baby (27) , findings that corroborate this research. As for weaning, a study in southwestern Michigan found that women who started prenatal care in the first trimester of pregnancy were more likely to continue breastfeeding than those who started prenatal follow-up belatedly, highlighting the importance of follow-up in prenatal care (28) .
This study was developed in a medium-sized municipality in the interior of São Paulo, and it is possible that the results obtained are also found in other municipalities with similar characteristics. This, the fact that part of the data was obtained from the records of attendance of the children in the neonatal service, the card of the pregnant woman and the baby's book is a limitation to be considered. Thus, in any study in which data collection is dependent on the registry of professionals, which was not registered, it was considered not performed.

Conclusion
The mothers attended at the BHU-FS had worse socioeconomic status and the evaluation of the prenatal care process was more favorable in this group.
There was no difference between BHU-T and BHU-