Evaluation of the quality of Prenatal Care in Brazil Avaliação da qualidade da Atenção Pré-Natal no Brasil

The aim of the study was to investigate the characteristics of the structure of the health units and the management and assistance processes of Prenatal Care (PNC) within the scope of Primary Health Care (PHC) in Brazil, in municipalities that joined the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB). This is a normative evaluation with data from 16.566 family health teams that joined the PMAQ-AB. A logical model of the PNC components was elaborated, composed of the analysis, management and care dimensions, and 42 criteria of structure and process and their respective standards. The structure of the basic units and the actions provided by the teams did not comply with the majority of the standards, highlighting the existence of structural barriers, unavailability of medicines and essential tests, problems in the provision of the cast of assistance actions, involving individual attention and clinical care, as well as health promotion and collective and domiciliary actions offered. It is concluded that, despite the high coverage of PNC and its institutionalization in PHC services, problems persist that must be addressed by governmental initiatives that guarantee comprehensive attention and quality in the pregnancy-puerperal cycle and that have repercussions on the improvement of health indicators of maternal and child health.


Introduction
Prenatal Care (PNC) is fundamental for achieving good results in the outcome of pregnancy, and its quality is related to the availability of resources in the managerial and care scope, as well as to the development of actions routinely, obeying technical-scientific standards of quality.To be effective, it is recommended that prenatal care be initiated at the beginning of pregnancy 1 and be constituted by a set of actions established by care protocols that guide the conditions and procedures necessary for the care of pregnant women 2, 3 .
Several studies have demonstrated the association of PNC with the prevention of risks in pregnancy, reduction of complications in childbirth and puerperium 4 and of perinatal complications 5 ; better health conditions of the conceived, with better intrauterine growth 6 , lower incidence of low birth weight 7 , reduction of maternal-infant mortality 2,3,8 and neonatal and perinatal morbidity and mortality 9 .
In Brazil, the notable advances about the expansion of PNC coverage observed in recent years 10 have not been homogeneously distributed in the national territory, with great inequalities persisting.Several studies have demonstrated access difficulties for women with lower schooling, without partners and multiparous women 11 and pregnant women 12 ; highlighting the maintenance of social and racial disparities, especially, in rural areas and indigenous areas of the North Region 11 .
In recent years, several initiatives have been implemented to improve the quality of PNC 2 and Primary Health Care (PHC) 13, 14 , and the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) is one of the most recent and relevant strategies.This Program, created in 2011, was adhered to in the first cycle by 3.935 municipalities and by 17.202 health teams.In addition, all the Basic Health Units (BHU) of the 5.543 municipalities of the Country were registered through observation in the unit.It should be noted that the census took place independently of the accession of the municipal manager 15 .
The aim of PMAQ-AB is to increase PHC access, as well as to guarantee quality standards in the development of care and managerial actions at this level of attention 13,14 .It consists of four phases (voluntary accession and contractualization; development; external evaluation and re-contractualization), and the external evaluation, in short, aims to evaluate the conditions of the units infrastructure, availability of inputs, aspects of the work process, managerial and organizational health services, with a view to certifying the health teams that voluntarily joined the Program 13- 15 .
The PMAQ-AB external evaluation data allow the identification, at a national level, of aspects related to prenatal and puerperium care, which can subsidize planning, monitoring and evaluation practices.In addition, they are sources for the development of research, minimizing knowledge gaps, given the incipience of evaluative studies that consider the aspects of structure and process, at a national level, that go beyond the number of consultations.
Thus, the objective of this study was to investigate the characteristics of the structure of the health units and of the management and assistance processes of PNC in the scope of PHC in Brazil, in municipalities that joined the PMAQ-AB.

Methods
This is a normative evaluation study with secondary data related to Family Health Teams (FHT) from PMAQ-AB, in 2012, in Brazil 13- 15 .

Logical model
The first stage of this study was the elaboration of the model.The theoretical framework of Donabedian 16 was adopted for its construction and it was sought to represent the components of the PNC and their relations with each other, being formulated two dimensions of analysis, managerial and care, composed by attributes of structure and process.
The logic model was elaborated from the norms and laws that regulate the PNC, whose contents were extracted from two manuals elaborated by the Ministry of Health: the 'Primary Care Notebook -Attention to the Low Risk Prenatal' 2 and the 'Manual of Physical Structure of the BHU' 17 , essential for the elaboration of the present logical model ( figure 1).

Population and sample
This study used baseline data from the PMAQ-AB -which refers to the first cycle of the external evaluation of the Program, including the BHU census, in Brazil, carried out in 2012 14 , which covered 38.812 establishments.Of the total number of Brazilian municipalities, 3.935 (70.7%) joined the PMAQ-AB, and 17.202 (51.0%) health teams participated in the evaluation, with the lowest accession among teams in the Northeast Region (23.2%) and higher among the South and Southeast Regions (37.9%, respectively).Among the federated units, the percentage ranged from 3.1% (Maranhão) to 47.9% (Santa Catarina).
Within the scope of primary care, there are different modalities of health teams.Primary care teams are considered family health teams and parametrized primary care teams, oral health team and family health centers.Although the Family Health Strategy (FHS) is the basic option for the organization of PHC services in Brazil, there are basic care teams that organize differently from the FHS.In these cases, for the correspondence of the workload between the teams of the two modalities, an equivalence of teams of primary care was proposed by means of the sum of the minimum hours of doctors and nurses, given that, after the equivalence of the workload, the number of these workloads may correspond to one, two or three FHT 18 .
Of the total number of participating teams, 70% were of the FHT type with oral health, 26% of FHT without oral health and less than 4% of primary care teams of other type or parametrized.The sample, after exclusion of the primary care teams from another modality, was constituted by 16.566 FHT that joined the PMAQ-AB and that participated in the census of the BHU, corresponding to 49.6% of the teams implanted in 2012, covering 69.3% of brazilian municipalities.

Description of the criteria and patterns
The analysis matrix used for evaluation contains two dimensions of analysis, managerial and care, each one composed of structure and process attributes, deployed in 20 subdimensions and 42 criteria, with their respective standards (chart 1).
In the managerial dimension, the structure attributes include the criteria: physical structure, material resources, human resources and reference protocol and flows.The attributes of the process are constituted by the following criteria: operating hours, regulatory center, permanent education and Prenatal, Childbirth, Puerperium and Child Monitoring and Evaluation System (SisPreNatal).In the care dimension, the attributes of structure include the criteria: physical structure; material resources; human resources, instruments of registration and protocols.The process attributes include the following criteria: home visit, laboratory tests, vaccination, record (use of the pregnant woman's booklet and record of information regarding prenatal care) and programming and offer of actions related to consultation, health promotion and risk classification.The criteria are described in detail in chart 1.
Each criterion was constructed, most of the times, by aggregating aspects from more than one issue of the PMAQ-AB 18 instruments, dichotomizing the yes and no response alternatives.In the case of equipment, instruments, inputs, quick test, vaccines and printed material, it was considered as an affirmative answer the cases in which the items were in conditions of use, were in sufficient quantity, always available, or available when necessary, in the case of vehicles.For the questions related to the actions developed by the health professionals, it was considered as an affirmative answer only the cases in which the action was reported with the presentation of documentary confirmation.
Finally, the 'never available/sometimes available', 'do not know/did not answer' and 'not applicable' response options were classified as 'no'.
Each criterion was categorized as 'inadequate', 'intermediate' and 'adequate', based on the adopted standards, constructed according to the adopted norms.The frameworks of the above categories can be found in chart 1. Adequate: with at least one form of external identification; inadequate: without any form of external identification.

Material resources Computer equipment and internet access
Computer equipment (computer, printer, stabilizer) with internet access, under conditions of use.
Adequate: with all the equipment in conditions of use and access to the internet; inadequate: all other situations.

Audiovisual equipment
Existence of television and sound box in conditions of use.
Adequate: with television and sound box; inadequate: without one of the equipment.

Vehicle Existence of vehicle that meets the needs of the team
Adequate: with vehicle that meets the needs; intermediate: does not meet the needs; inadequate: without vehicle.

Human Resources Team coordinator
Have a coordinator in the team for the management of the health unit.

Documents with references and flows
Have a defined flow for serological tests for syphilis, anti-HIV, glucose, urine culture or urine summary (type 1), ultrasonography (USG) and place of delivery, with proof.

Data processing and analysis
Initially, for the construction of the database of the present study, a deterministic linkage was performed which consists of the connection of two or more databases that have common variables, and which allows the establishment of a single database.The linking procedure was performed in the Stata software through the merge, corresponding to the linking of the unit census database (module I) and the external evaluation of the health teams that joined the PMAQ-AB (module II), from of the variable 'CNES', common between the two databases.For 295 (1.78%) units, there was inconsistency in the information on the number of teams between the two databases, which was corrected from the external evaluation information.Simple and relative frequencies were calculated from the number of teams that reached the appropriate level for each criterion alone and by group of criteria, presented in the form of graphs, according to macro-regions and Brazil.Data were processed and analyzed using the Stata 12.0® software.
The research project was approved by the Research Ethics Committee of the Institute of Collective Health of the Federal University of Bahia and received Opinion n° 021-12.

Results
For the managerial dimension, in the structure attributes, the highest adequacy percentages presented by the FHT were for the coordinator availability criteria (98%, ranging from 97.0%, Northeast Region, to 99.5%, North Region) and for external signaling in the units (84.4% in Brazil, ranging from 80.4%, North Region, to 86.5%, Central-West Region).On the other hand, less than half of the FHT were considered

Schedule and offer of actions
Schedule consultations and actions and for prenatal and for users who are part of priority programs or groups, who need continued care, with proof.
Adequate: meets all conditions Inadequate: all other situations.

Organization of the agenda and promotion of health
Organize an agenda for the offer of health promotion in the community and educational actions directed to pregnant and puerperal women (breastfeeding), with proof.
Adequate: complies with all actions and proves; inadequate: all other situations Organization, offer and risk classification Organize the offer of service and referral of consultations and examinations of pregnant women based on the evaluation and classification of risk and vulnerability, with proof.
Adequate: complies with all actions and proves; inadequate: does not meet the criteria or does not prove it.Regarding the process attributes of the managerial dimension, the SisPreNatal regular feeding criterion (75%, ranging from 82.2%, South Region, to 90.9%, Northeast Region) was for the criterion that the teams presented the best percentages of adequacy.On the other hand, less than 50% of the teams were classified as adequate for the two-shift operation criteria and from 12pm to 14pm (45.4%, ranging from 28.8%, South Region, to 67.8%, Southeast Region), link to the regulatory center (25.7%, ranging from 21.5%, in the Northeast Region, to 37.6%, in the South Region) and permanent education actions in the municipality (23.9%, ranging from 8% 1%, Northeast Region, to 35.6%, Southeast Region) (table 1).
Regarding the care dimension, for the structural criteria, more than 75% of the teams were classified as adequate because they had a complete primary care team (84.5%, ranging from 79.0%, South Region, to 86.3%, Northeastern Region) and by having instruments (sonar etc.), under conditions of use (83.3%, ranging from 71.2%, North Region, to 88.6%, South Region).In this dimension, adequacy was found between 50% and 75% of the teams for protocols criteria with a prenatal definition and essential laboratory tests (71.5%, ranging from 60.7%, Central-West Region, to 80.5%, Southeast Region), inputs for women's health (always have a glass blade, etc.) (67.0%, ranging from 55.1%, in the Northeast Region, to 85.3%, in the South Region) and printed material (booklet of the pregnant woman, etc.) (59.6%, ranging from 52.2%, in the Northeast Region, to 68.1%, in the North Region).
It was also observed that less than 50% of the teams had vaccines (seasonal influenza, hepatitis B and adult type dT) (43.5%, ranging from 32.6%, South Region, to 48.8%, North Region) inputs (tongue depressor etc) (28.1%, ranging from 14.3%, in the Northeast Region, to 40.3%, in the South Region) and essential medicines (at least one type of medicine in each group, for example, analgesics, etc.) in sufficient quantity (28.3%, ranging from 10.3%, North Region, to 43.7%, South Region).The worst results, however, were verified for the physical structure criteria for clinical care (offices, etc. present) (8.8%, ranging from 2.8%, North Region, to 13.2%, Southeast Region) and quick test for diagnosis of syphilis, HIV and pregnancy (1.6%, ranging from 0.9%, Northeast Region, to 3.7%, North Region) (table 2).
In the care dimension, for the process attributes, the highest percentages of adequacy were observed only for the criteria collection of failing puerperal and pregnant women (89.6%, ranging from 83.9%, Central-West Region, to 91.2% , Northeastern Region) and guidance on the importance of the dT vaccine and the availability of basic calendar vaccines (78.6%, ranging from 74.2%, South Region, to 83.2%, Northeast Region), for which more than 75% of the teams achieved the best results (table 2 It was also observed that between 50% and 75% of the teams reported scheduling consultations and actions for users of priority programs or groups, of continued care and PNC (73.4%, ranging from 69.5%, Central-West Region, to 76.8%, Northeastern Region), offer services, send pregnant women for consultations and examinations based on the evaluation and classification of risk and vulnerability (67.5%, ranging from 64.0% in the Central-West Region, to 71.7%, Southeast Region), and to organize an agenda for the offer of health promotion activities on breastfeeding (51.7%, ranging from 47.5%, in the Northeast Region, to 57.2%, in the Southeast Region).On the other hand, the most unfavorable results, smaller than 50% of the attribute, were for the domiciliary care criterion by the fulfillment of social and clinical criteria (42.2%, ranging from 18.7%, South Region, to 49.3%, Southeast Region), perform, collect and receive test results in a timely manner (37.3%, ranging from 19.3%, Northeast Region, to 52.9%, Southeast Region), use the pregnant woman's booklet and have the number of high-risk pregnant women in the territory (30.6%, ranging from 26.3%, Central-West Region, to 34.2%, Southeast Region), and conduct consultation on any day and time of the week to ensure puerperium care for up to ten days after delivery (27.1%, ranging from 15.0%, Center-West Region, to 32.1%, Northeast Region) (table 2).

Discussion
Evidences found in the present study on the evaluation of PNC in the Family Health Strategy demonstrated that the structure of the BHU and the processes in the development of the actions provided did not meet most of the standards established in national protocols, both in the managerial dimension and in the care dimension, revealing low quality of PNC and the puerperium in Brazil.These problems referred to several spheres, from the accessibility to actions and services to the accomplishment of health promotion actions and the quality of clinical care, involving not only the individual attention, but also the collective and domiciliary actions offered.
In Brazil, most of the studies related to PNC have focused their analysis on classical criteria of adequacy.The use of data from the PMAQ-AB allowed to reveal, in the light of the Donnabedian approach, the conditions of the family health units and the development of the actions of the FHT in the scope of the PHC, being, therefore, a study that, from the theoretical and methodological point of view, extended the scope of the analyzes related to PNC in the Country.
Initially, it should be noted that several national scope studies have shown that care for pregnant women is universal in Brazil, with persistent social inequalities and inadequacy of care 11,12 .A recent study with data from the external evaluation of PMAQ-AB with users linked to BHU also found inadequacy of care 12 , which is corroborated by the low percentages among the dimensions analyzed.
It has also been evaluated the infrastructure of the basic units in the Country 19 that support the results of the study on architectural barriers for people with some special need, highlighting the structural precariousness and the lack of basic adaptations for the attendance of users in these conditions in the family health units in Brazil.
Contrary to the expansion of the opening hours of the unit, which can guarantee greater accession to PNC and scheduled visits, increase the satisfaction of pregnant women and favor the continuity of prenatal care 20 , the results showed weaknesses in their functioning.In addition, frailties were found in reception, a situation described in an integrative review 21 .
The percentage of teams with material resources available for the resolubility of prenatal care in the units was quite inexpressive, being consistent with evidence found in the literature regarding the lack of medicines in the units 22 ; difficulties in performing exams 23 , or the low application of existing HIV and syphilis tests, with a high percentage of units with material expired 24 ; documents and flows agreed by municipal management 25 ; and, moreover, absence of several structures in the units investigated in a study of local coverage 26 .
One of the most encouraging findings, in summary, was the presence of coordinators for the management of the units and health professionals of various categories for the development of clinical activities and health promotion, in addition, the development of actions such as the capture of puerperal and pregnant women for early start of care, guidance on vaccination status and offering of basic calendar vaccine, as well as feeding of the SisPreNatal.
Health promotion actions have a positive impact on the achievement of breastfeeding and on birth weight 27 .However, in this study, only the organization of agendas of the teams to offer such actions was investigated, and it is not possible to measure if they are, in fact, carried out.The incipience of actions to promote health in the context of PHC, in general 28 , and, specifically, aimed at breastfeeding in pregnant and puerperal women 29 has been described in other studies.
The international literature has highlighted problems related to the quality of PNC in several countries of different continents, which reinforces the relevance of studies on the subject.In Europe, a recent systematic review has shown that although maternal care systems are well implemented across the continent, inequalities persist in Central and Eastern European countries, which suffer from barriers to maternal care, obsolete material resources, lack of medicines and protocols inadequate and outdated, among others 30 .A study carried out in a more populous and developed region of Asia pointed out that the quality of the PNC was extremely inadequate, especially due to factors such as inadequacy and low coverage at managerial and care levels, especially regarding the distance of the units, facilities deficiency and time of work and availability of human resources, among others 31 .In a Latin American context, in Mexico, it was evidenced low referral of pregnant women to educational activities 32 , and, specifically in Brazil, low quality of the PNC has been commonly described 12,33 .
As a limitation of the study, the use of secondary data can be highlighted due to possible data quality problems, such as, for example, the information bias.In the case of PMAQ, as the coordinators of the units were responsible for the information provided, there could be an overestimation of the activities carried out by the teams.In addition, the diversity of institutions involved in data collection could have compromised the standardization of procedures.However, this study revealed several weaknesses in the units and the managerial and care processes of the teams, which does not reinforce the hypothesis of masking the problems by the coordinators.Moreover, even with the possibility of attenuating the structural and care problems of the teams, it is necessary to emphasize that, in all the sub-dimensions studied, although some percentage variations between the regions were observed, it was evidenced that the problems were present in all the national territory, with very similar regional standards, which reinforces the reliability of the data and the speech in favor of the robustness of the presented results.
As main potentiality of the study, the use of a vast amount of information on the characteristics of the structure of the family health units and the actions carried out by health professionals in the PNC is highlighted, covering a large number of municipalities, allowing a delineation of a current situation in Brazil with a broader scope of analysis related to PNC in the Country.Another positive fact was the use of a theoretical-logical model, based on theoretical reference on the use of structure and process attributes in the quality evaluation 15 , considering base normative and legal provisions on PNC.
Finally, the results presented in this study demonstrate that, despite the high coverage of the PNC and its institutionalization for many years, on standards and protocols, in Brazil, there are still problems of many natures, with potential damages to maternal and child health.These findings are fundamental for the understanding of the current situation of large public health problems, such as maternal mortality, which remains at levels above what was established in international pacts, and the increase in the incidence of congenital syphilis, which evidences limits in the effectiveness in PNC [34][35][36] .

Collaborators
Luz LA and Aquino R were responsible for the conception, planning, analyzing, interpretation of data, elaboration of the draft, critical review of the content and approval of the final version of the manuscript.Medina MG was responsible for elaboration of the draft, critical review of the content and approval of the final version of the manuscript.s

Figure 1 .
Figure 1.Logical model of quality of Prenatal CareManagerial Results(expected)

of the criteria Managerial dimension: Structure attributes Sub* Criterion Pattern Categorization of criteria
Chart 1. Criteria and Standards of the managerial and care dimensions, sub-dimensions, attributes of structure and process of the PNC and categorization Adequate: with all items; intermediate: with at least one of the resources; inadequate: all other situations.External signalingExternal identification visible as a plaque on the facade, suitable external totem or other form of signaling.

Managerial dimension: Structure attributes Criterion Pattern Categorization of criteria Opening
: with documents containing references and flows related to prenatal care; intermediate: only for the calls of users of the team territory; inadequate: all other situations.Hours Operation of the unit The health unit should operate in two shifts and at lunch time (12 a.m. to 2 p.m.).Adequate: work in two shifts and at lunch time; inadequate: all other situations.Adequate: with link to RC for appointment of specialized consultation, examinations and beds; intermediate: only with RC; inadequate: all other situations.Inputs: general population Input sufficiency: tongue depressor; disposable needles; bandages; measuring tape; PPE -gloves, goggles, masks, aprons, burrows; speculum; serum equipment; disposable syringes; hard containers for sharps disposal; gauze; plastic bottle with lid; tape/ micropore tape and others; and thermal boxes for vaccines.Adequate: with all inputs; intermediate: with 8 to 13 inputs; inadequate: with less than 7 inputs.Inputs: women's health Sufficiency of inputs directed to WH: reagent strips of capillary glycaemia measurement; glass blade with matte side; blade holder; blade fastener; ayres spatula Adequate: with all the inputs; intermediate: with 3 inputs; inadequate: with less than 2 inputs.Adequate: with all groups of medicines; intermediate: with 4 to 8 groups of medicines; inadequate with only 3 groups.Controlle30 d medicines Sufficiency of medicines controlled at the BHU or dispensed at the central level by the municipality Adequate: with at least one of the medicines controlled at the BHU or dispensed by the municipality; inadequate: without controlled or nondispensed medicine at central level.Quick test Existence of rapid tests syphilis, HIV, pregnancy Adequate: with all quick tests; inadequate: without one of the tests.Adequate: with all protocols (3); intermediate: with 2 protocols; inadequate: with only 1 or no protocol Protocol: home visit Protocols with definition of priority situations to carry out a home visit, with proof.Adequate: with protocol and proof; inadequate: without protocol and without proof Care dimension: Process attributes Adequate: meets all conditions Inadequate: all other situations.Adequate: meets all conditions Inadequate: does not perform at least one of the actions.

Table 1 .
Adequacy of the attributes of structure and process, managerial dimension, according to Regions.Brazil, 2012

Table 2 .
). Adequacy of the attributes of structure and process, care dimension, according to Regions.Brazil, 2012