Prenatal care in the Brazilian public health services

Leal, Maria do Carmo; Esteves-Pereira, Ana Paula; Viellas, Elaine Fernandes; Domingues, Rosa Maria Soares Madeira; Gama, Silvana Granado Nogueira da

doi:10.11606/s1518-8787.2020054001458

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Brasil

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Sumário

Original Article • Rev. Saúde Pública 54 • 2020 • https://doi.org/10.11606/s1518-8787.2020054001458 copy

Prenatal care in the Brazilian public health services

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To verify regional inequalities regarding access and quality of prenatal and birth care in Brazilian public health services and associated perinatal outcomes

METHODS

Birth in Brazil was a national hospital-based survey conducted between 2011 and 2012, which included 19,117 women with public-funded births. Regional differences in socio-demographic and obstetric characteristics, as well as differences in access and quality of prenatal and birth care were tested by the χ² test. The following outcomes were assessed: spontaneous preterm birth, provider-initiated preterm birth, low birth weight, intrauterine growth restriction, Apgar in the 5th min < 8, neonatal and maternal near miss. Multiple and non-conditional logistic regressions were used for the analysis of the associated perinatal outcomes, with the results expressed in adjusted odds ratio and 95% confidence interval.

RESULTS

Regional inequalities regarding access and quality of prenatal and birth care among users of public services are still evident in Brazil. Pilgrimage for birth associated with all perinatal outcomes studied, except for intrauterine growth restriction. The odds ratios ranged between 1.48 (95%CI 1.23–1.78) for neonatal near miss and 1.62 (95%CI 1.27–2.06) for provider-initiated preterm birth. Among women with clinical or obstetric complications, pilgrimage for birth associated with provider-initiated preterm birth and with Apgar in the 5th min < 8, odds ratio of 1.98 (95%CI 1.49–2.65) and 2.19 (95%CI 1.31–3.68), respectively. Inadequacy of prenatal care associated with spontaneous preterm birth in both groups of women, with or without clinical or obstetric complications.

CONCLUSION

Improvements in the quality of prenatal care, appropriate coordination and comprehensive care at the time of birth have a potential to reduce prematurity rates and, consequently, infant morbidity and mortality rates in the country.

Prenatal Care; Maternal-Child Health Services; Health Care Quality, Access, and Evaluation; Socioeconomic Factors; Health Status Disparities

	North (n = 2,143)	Northeast (n = 5,683)	Southeast (n = 7,838)	South (n = 2,244)	Midwest (n = 1,209)	Brazil (n = 19,117)	p-value^a

	%	%	%	%	%	%
Age in years
12–19	28.1	24.9	19.8	20.4	24.4	22.6	< 0.001
20–34	66.4	66.5	71.3	68.9	68.5	68.8
≥ 35	5.6	8.6	8.9	10.7	7.1	8.5
Skin color
White	12.1	17.2	33.3	59.3	25.5	28.7	< 0.001
Black	6.0	11.6	10.8	6.9	8.3	9.9
Brown	81.9	71.2	55.9	33.8	66.2	61.4
Years of schooling
≤ 7	37.5	43.3	24.7	30.6	24.0	32.3	< 0.001
8–10	30.9	24.7	30.6	32.2	35.5	29.4
11–14	29.0	29.8	41.7	33.2	37.2	35.5
≥ 15	2.7	2.2	3.0	3.9	3.3	2.9
Economic class
D+E	39.4	48.4	18.4	12.0	20.7	29.0	< 0.001
C	51.2	45.5	63.3	60.9	63.9	56.4
A+B	9.4	6.1	18.3	27.1	15.4	14.5
Marital status
Does not live with a partner	19.3	18.2	24.5	14.9	19.2	20.6	< 0.001
Lives with a partner		81.8	75.5	85.1	80.8	79.4
Wage labor
No	75.0	75.1	63.3	57.4	64.2	67.5	< 0.001
Yes	25.0	24.9	36.7	42.6	35.8	32.5
Previous births
0	40.1	47.6	44.7	42.7	43.9	44.8	< 0.001
1–2	41.4	39.7	44.6	44.8	44.7	42.8
≥ 3	18.5	12.6	10.7	12.5	11.4	12.4
Clinical or gestational complications
Pre-existing hypertension	1.5	2.8	3.1	2.8	1.6	2.7	< 0.001
Hypertensive syndromes^b	8.2	10.5	11.6	11.5	11.7	10.9	< 0.001
Pre-existing diabetes	0.5	1.0	1.3	1.4	0.8	1.1	0.015
Gestational diabetes	7.6	5.5	9.5	11.1	5.5	8.0	< 0.001
Other chronic diseases^c	0.6	0.8	0.8	0.8	1.2	0.8	0.465
Placenta praevia	0.7	0.4	0.4	0.8	0.4	0.4	0.261
Placental abruption	1.1	1.2	1.7	1.7	1.2	1.5	0.046

	Women without complications							Women with complications							All women

	N n = 1,773	NE n = 4,674	SE n = 6,143	S n = 1,727	MW n = 993	Brazil n = 15,310	p-value^a	N n = 370	NE n = 1,008	SE n = 1,696	S n = 518	MW n = 215	Brazil n = 3,807	p-value^a	N n = 2,143	NE n = 5,682	SE n = 7,839	S n = 2,245	MW n = 1,208	Brazil n = 19,117	p-value^a

	%	%	%	%	%	%		%	%	%	%	%	%		%	%	%	%	%	%
Received prenatal care
No	2.8	1.7	1.5	0.9	1.6	1.6	0.001	0.5	1.8	0.5	0.0	1.6	0.8	< 0.001	2.5	1.7	1.3	0.7	1.6	1.5	< 0.001
Yes	97.2	98.3	98.5	99.1	98.4	98.4		99.5	98.2	99.5	100.0	98.4	99.2		97.5	98.3	98.7	99.3	98.4	98.5
Type of basic unit ^b
FHP/birthing center/BHU	94.1	88.2	92.1	91.6	92.2	91.1	< 0.001	89.8	82.9	84.5	83.1	85.2	84.5	0.039	93.4	87.3	90.4	89.6	91.0	89.7	< 0.001
Outpatient clinic	5.9	11.8	7.9	8.4	7.8	8.9		11.2	17.1	15.5	16.9	14.8	15.5		6.6	12.7	9.6	11.4	9.0	10.3
Onset of prenatal care ^b
Up to12 weeks	45.2	52.0	59.3	57.1	65.2	55.6	< 0.001	49.7	57.7	63.7	59.7	65.7	60.3	< 0.001	46.0	52.2	60.1	57.6	65.0	56.5	< 0.001
Second trimester	49.8	43.9	36.8	37.5	31.4	40.2		46.2	38.7	32.0	37.0	32.9	35.9		49.2	43.0	35.8	37.5	31.4	39.3
Third trimester	5.0	4.1	3.9	5.4	3.4	4.2		4.1	3.6	4.3	3.3	1.4	3.8		4.8	4.8	4.1	4.9	3.6	4.2
No. of prenatal appointments ^b
Between 1 and 3	17.7	14.1	9.0	9.9	8.5	11.7	< 0.001	15.1	8.4	5.7	6.9	4.3	7.4	< 0.001	17.2	13.1	8.3	9.2	7.7	10.9	< 0.001
Between 4 and 5	28.1	27.0	14.0	17.3	21.2	20.4		24.6	23.0	16.0	15.4	15.9	18.6		27.5	26.3	14.4	16.9	20.3	20.0
6 or more	54.2	58.9		77.0	72.8	70.3	67.9		60.3	68.6		78.3	77.7	79.8	74.0	55.3	60.6	77.3	73.9	72.0	69.1
Have received hand-held prenatal notes ^b
No	0.7	1.1	1.4	0.8	2.4	1.2	0.001	0.5	1.6	0.5	0.6	0.9	0.9	0.043	0.7	1.2	1.1	0.8	2.1	1.1	0.002
Yes	99.3	98.9	98.6	99.2	97.6	98.8		99.5	98.4	99.5	99.4	99.1	99.1		99.3	98.8	98.9	99.2	97.9	98.9
Took the hand-held prenatal notes on admission for birth ^b
No	35.9	25.8	20.0	16.4	54.0	25.4	< 0.001	22.9	17.9	13.5	10.4	38.4	16.5	< 0.001	33.6	24.4	18.5	15.0	51.2	23.6	< 0.001
Yes	64.1	74.2	80.0	83.6	46.0	74.6		77.1	82.1	86.5	89.6	61.6	83.5		66.4	75.6	81.5	85.0	48.8	76.4
Blood sugar level ^c
No	23.3	23.7	17.7	10.4	18.8	19.2	< 0.001	12.4	16.0	12.0	6.5	11.5	12.2	< 0.001	21.1	22.2	16.4	9.5	17.1	17.7	< 0.001
Yes, once	49.3	54.4	45.7	40.0	52.7	48.2		48.6	49.1	40.4	33.5	43.1	42.5		49.2	53.4	44.4	38.4	50.5	47.0
Yes, twice	27.4	21.9	36.6	49.5	28.6	32.6		39.0	34.9	47.7	60.0	45.4	45.3		29.7	24.4	39.2	52.1	32.4	35.4
Urine (AES) ^c
No	24.8	19.1	14.9	8.4	18.3	16.4	< 0.001	12.5	13.7	11.5	5.8	10.0	11.2	< 0.001	22.3	18.0	14.1	7.8	16.4	15.3	< 0.001
Yes	75.2	80.9	85.1	91.6	81.7	83.6		87.5	86.3	88.5	94.2	90.0	88.8		77.7	82.0	85.9	92.2	83.6	84.7
Ultrasound ^c
No	32.9	18.9	9.6	9.2	14.3	14.8	< 0.001	27.0	15.8	8.2	6.7	8.5	11.6	< 0.001	31.7	18.3	9.3	8.6	13.0	14.1	< 0.001
Yes	67.1	81.1	90.4	90.8	85.7	85.2		73.0	84.2	91.8	93.3	91.5	88.4		68.3	81.7	90.7	91.4	87.0	85.9
VDRL test results during the pregnancy ^c
No	22.8	17.7	9.5	5.5	17.2	13.1	< 0.001	14.6	11.5	7.4	4.5	9.3	8.7	< 0.001	21.1	16.5	9.3	5.3	15.4	12.1	< 0.001
Yes, one	50.0	54.2	46.9	38.7	45.8	48.3		53.7	50.5	44.0	34.2	45.0	45.2		50.7	53.2	46.0	37.6	45.6	47.7
Yes, two	27.2	28.1	43.6	55.8	37.0	38.6		31.7	38.0	48.6	61.3	45.7	46.1		28.2	30.3	44.7	57.1	39.0	40.2
HIV test results during the pregnancy ^c
No	31.6	35.5	14.3	8.1	19.6	21.9	< 0.001	28.8	28.4	11.5	6.9	15.4	16.8	< 0.001	31.0	34.1	13.7	7.8	18.6	20.7	< 0.001
Yes, one	50.5	51.3	53.4	49.8	47.9	51.8		52.8	51.5	55.4	48.0	48.4	52.8		51.0	51.4	53.8	49.4	48.1	52.1
Yes, two	17.9	13.2	32.3	42.1	32.5	26.3		18.4	20.1	33.1	45.1	36.2	30.4		18.0	14.5	32.5	42.8	33.3	27.2
Bond with maternity hospital ^b
No	52.1	50.4	40.1	41.2	43.5	45.0	< 0.001	50.7	40.7	36.0	34.9	34.4	38.4	< 0.001	51.8	48.7	39.2	39.7	41.8	43.6	< 0.001
Yes	47.9	49.6	59.9	58.8	56.5	55.0		49.3	59.3	64.0	65.1	65.6	61.6		48.2	51.3	60.8	60.3	58.2	56.4
Birthed in the bonded maternity hospital ^d
No	14.2	23.3	19.7	8.7	16.0	18.5	< 0.001	14.5	25.0	17.9	10.4	19.0	18.4	< 0.001	14.2	23.7	19.3	9.0	16.6	18.5	< 0.001
Yes	85.8	76.7	80.3	91.3	84.0	81.5		85.5	75.0	82.1	89.6	81.0	81.6		85.8	76.3	80.7	91.0	83.4	81.5
Pilgrimage for birth
No	80.0	67.2	78.5	89.9	76.4	76.4	< 0.001	78.2	65.0	81.0	87.0	75.8	77.0	< 0.001	79.7	66.9	79.1	89.2	76.3	76.5	< 0.001
Yes, one hospital	17.3	27.7	17.2	9.2	20.1	19.7		19.6	29.6	16.0	12.2	21.9	19.8		17.7	28.0	16.9	9.9	20.4	19.7
Yes, two hospitals	2.7	5.1	4.3	0.9	3.5	3.9		2.2	5.4	3.0	0.8	2.3	3.2		2.6	5.1	4.0	0.9	3.3	3.8
Type of hospital
Public	71.8	58.6	42.8	28.9	56.5	50.3	< 0.001	83.0	67.1	48.1	35.6	63.2	55.7	< 0.001	73.5	60.1	43.9	30.4	57.5	51.3	< 0.001
Mixed	28.2	41.4	57.2	71.1	43.5	49.7		17.0	32.9	51.9	64.4	36.8	44.3		26.5	39.9	56.1	69.6	42.5	48.7
Location of hospital
Capital	45.2	34.7	32.2	22.3	64.3	35.4	< 0.001	45.8	50.2	39.2	30.5	70.4	43.4	< 0.001	45.2	37.5	33.7	24.1	65.2	37.0	< 0.001
Non-capital	54.8	65.3	67.8	77.7	35.7	64.6		54.2	49.8	60.8	69.5	29.6	56.6		54.8	62.5	66.3	75.9	34.8	63.0

	Women without complications							Women with complications							All women

	N n = 1,773	NE n = 4,674	SE n = 6,143	S n = 1,727	MW n = 993	Brazil n = 15,310	p-value^a	N n = 1,773	NE n = 4,674	SE n = 6,143	S n = 1,727	MW n = 993	Brazil n = 15,310	p-value^a	N n = 1,773	NE n = 4,674	SE n = 6,143	S n = 1,727	MW n = 993	Brazil n = 15,310	p-value^a

	%	%	%	%	%	%		%	%	%	%	%	%		%	%	%	%	%	%
Adequacy of prenatal care ^b	47.3	52.6	67.1	65.8	63.4	60.1	< 0.001	55.5	64.5	72.0	69.5	72.6	68.2	< 0.001	48.7	54.7	68.2	66.7	65.0	61.7	< 0.001
Adequacy of overall prenatal care 1 ^c	10.1	11.4	21.6	24.6	18.5	17.7	< 0.001	12.0	21.0	29.4	29.4	26.9	25.6	< 0.001	10.5	13.3	23.4	25.7	20.4	19.4	< 0.001
Adequacy of overall prenatal care 2 ^d	9.6	8.8	17.3	22.5	15.1	14.5	< 0.001	11.7	16.2	24.0	26.1	24.8	21.2	< 0.001	10.0	10.2	18.9	23.4	17.3	16.0	< 0.001
Type of birth
Vaginal	59.1	63.0	62.0	59.8	57.2	61.4	< 0.001	36.2	37.2	38.8	45.3	20.6	37.9	< 0.001	55.1	58.4	57.0	56.5	50.5	56.7	< 0.001
Intrapartum cesarean section	31.7	27.2	31.4	32.0	33.7	30.4		52.6	50.6	53.4	45.3	68.2	52.4		35.3	31.4	36.2	35.1	40.0	34.8
Antepartum cesarean section	9.3	9.8	6.6	8.2	9.1	8.2		11.1	12.2	7.8	9.4	11.2	9.7		9.6	10.2	6.8	8.5	9.5	8.5

Outcomes
Spontaneous preterm birth	8.5	9.0	6.7	7.4	8.4	7.8	< 0.001	9.8	8.1	5.8	8.4	5.8	7.2	0.023	8.8	8.9	6.5	7.6	7.9	7.7	< 0.001
Provided-initiated preterm birth	3.5	1.9	2.1	2.5	1.4	2.2	< 0.001	11.9	11.8	11.9	10.5	12.1	11.7	0.949	4.9	3.7	4.2	4.4	3.4	4.1	0.096
Low birth weight (< 2,500g)	7.9	8.9	7.6	7.7	7.8	8.1	0.124	17.9	18.7	13.5	12.7	17.6	15.4	0.001	9.6	10.7	8.9	8.9	9.6	9.5	0.001
IUGR (< 10th percentile)	5.9	7.7	7.9	7.0	8.8	7.6	< 0.001	11.6	10.3	7.1	6.3	8.1	8.4	< 0.001	6.9	8.2	7.8	6.8	8.7	7.7	< 0.001
Apgar in the 5th minute < 8	1.6	3.4	1.9	1.3	1.2	2.2	< 0.001	3.2	3.0	2.5	1.8	2.9	2.6	0.615	1.9	3.3	2.0	1.4	1.5	2.3	< 0.001
Neonatal near miss	9.2	9.1	10.4	10.5	8.9	9.8	0.100	15.9	17.6	18.9	17.2	17.9	18.0	0.670	10.3	10.6	12.2	12.0	10.6	11.4	0.061
Maternal near miss	0.5	0.3	0.3	0.6	0.2	0.4	0.318	3.4	5.5	3.3	3.3	7.6	4.1	0.004	1.0	1.2	1.0	1.2	1.6	1.1	0.333

	Spontaneous preterm birth	Provided-initiated preterm birth	LBW	IUGR	Apgar 5 min < 8	Neonatal near miss	Maternal near miss

	OR^a (95%CI)	OR^a (95%CI)	OR^a (95%CI)	OR^a (95%CI)	OR^a (95%CI)	OR^a (95%CI)	OR^a (95%CI)
Pilgrimage for birth
All women	1.61 (1.29–2.01)	1.62 (1.27–2.06)	1.56 (1.28–1.89)	1.19 (0.95–1.49)	1.56 (1.19–2.03)	1.48 (1.23–1.78)	1.38 (0.81–2.36)
Women without complications	1.60 (1.25–2.04)	1.32 (0.92–1.91)	1.52 (1.23–1.87)	1.14 (0.86–1.51)	1.41 (1.03–1.94)	1.50 (1.21–1.85)	1.34 (0.70–2.56)
Women with complications	1.67 (1.06–2.61)	1.98 (1.49–2.65)	1.69 (1.23–2.31)	1.37 (1.03–1.83)	2.19 (1.31–3.68)	1.45 (1.16–1.81)	1.39 (0.70–2.77)
Inadequate prenatal care (onset and number of appointments)
All women	1.51 (1.24–1.83)	1.06 (0.73–1.55)	1.25 (0.99–1.56)	1.11 (0.88–1.38)	0.96 (0.68–1.36)	1.14 (0.95–1.37)	0.96 (0.54–1.68)
Women without complications	1.47 (1.18–1.82)	0.95 (0.62–1.46)	1.21 (0.94–1.54)	1.19 (0.95–1.49)	1.00 (0.69–1.43)	1.08 (0.88–1.34)	0.82 (0.29–2.36)
Women with complications	1.73 (1.02–2.94)	1.14 (0.66–1.97)	1.32 (0.90–1.92)	1.14 (0.86–1.51)	0.81 (0.39–1.71)	1.28 (0.85–1.93)	0.97 (0.55–1.73)

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[1] Correspondence: Maria do Carmo Leal Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz (ENSP/Fiocruz). Rua Leopoldo Bulhões, 1480 - sala 809, Manguinhos. Rio de Janeiro, RJ, Brasil. CEP 21041-210 Email: ducaleal@gmail.com