Evaluation of the quality of Prenatal Care in Brazil

Luz, Leandro Alves da; Aquino, Rosana; Medina, Maria Guadalupe

doi:10.1590/0103-11042018S208

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

ORIGINAL ARTICLE • Saúde debate 42 (spe2) • Oct 2018 • https://doi.org/10.1590/0103-11042018S208 copy

Evaluation of the quality of Prenatal Care in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

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.

KEYWORDS
Health evaluation; Primary Health Care; Family Health Strategy; Prenatal care; Maternal and child health

Managerial dimension: Structure attributes
Sub^* * Sub-dimension.	Criterion	Pattern	Categorization of criteria
Sub-dimension Physical structure	Administrative and support environments	Adequate physical structure with reception, sanitary (normal and adapted), purge, garbage dump, waiting room for 15 to 75 people (depending on the number of FHT).	Adequate: 7 structures and adequate team number; intermediate: between 4 and 6 environments; inadequate: with more than 5 teams, or less than 3 structures.
	Structural characteristics	Structural features with air circulation (windows, exhaust fans), lighting and privacy in the offices.	Adequate: with all the characteristics; Inadequate: without at least one of the structural characteristics.
	Accessibility: wheelchair user or with difficulty of locomotion	Suitable structural features: support bars, entrance walkway in good condition, doors adapted for wheelchair, access ramp, handrail, adapted troughs, regular floor, firm and non-slip.	Adequate: with all items; Inadequate: all other situations.
	Accessibility: visual or auditory difficulty	Suitable structural features: texts or figures, characters or figures in relief, braille and auditory resources.	Adequate: with all items; intermediate: with at least one of the resources; inadequate: all other situations.
	External signaling	External identification visible as a plaque on the facade, suitable external totem or other form of signaling.	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.	Adequate: with coordinator; inadequate: without coordinator.
Reference protocols and flows	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.	Adequate: 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.
Managerial dimension: Structure attributes
	Criterion	Pattern	Categorization of criteria
Opening 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.
Regulatory Center	Regulatory center	Regulatory Center (RC) available with referral for specialized appointment marking, examinations and beds.	Adequate: with link to RC for appointment of specialized consultation, examinations and beds; intermediate: only with RC; inadequate: all other situations.
Information system	Feeding of the SisPreNatal	SisPreNatal regularly fed by health professionals, with proof.	Adequate: regularly feeds SisPreNatal and proves it; inadequate: does not power the system or does not prove it.
Permanent education	Actions of permanent education	Existence of permanent education actions in the municipality and that has guaranteed the participation of the team in the last year in at least one of the actions.	Adequate: with permanent education actions in the municipality and has participated in at least one in the last year; intermediate: without participation in the actions; inadequate: all other situations.
Care dimension: Structure attributes
	Criterion	Pattern	Categorization of criteria
Physical structure	Clinical assistance environments	Physical structure suitable to the number of teams with: pharmacy, nursing or doctor's office, dental office (If FHT with Oral Health (OH), meeting/education rooms, procedures, vaccine, nebulization and dressing	Adequate: with 7 rooms suitable to the team number; intermediate: with 4 to 6 rooms; inadequate: with more than 5 FHT, or less than 3 rooms, or with OH without a dental office.
Material resources	Instrumental	Have: adult pressure device, adult scale of 150 kg or 200 kg, adult stethoscope, light focus and table for gynecological (or clinical) examination, sonar or stethoscope of pine, under conditions of use.	Adequate: dispose of all instruments in conditions of use; intermediate: >04 to <05 instrumental; and inadequate: <03 instrumental.
	Equipment at the pharmacy	Have a specific refrigerator and air-conditioning for pharmacy	Adequate: which have a refrigerator and air-conditioning in the pharmacy; inadequate: without one of the equipment.
	Equipment in the vaccine room	Provide room-specific refrigerator and air-conditioning	Adequate: own refrigerator and air conditioning in the vaccine room; inadequate: without at least one of the equipment.
	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.
	Essential medicines	Sufficiency of medicines by groups: analgesics, antipyretics, antidiabetics, antibacterial, antihypertensive, antiparasitic, anti-asthmatics, antacids, antiemetics, vitamins, multivitamins, minerals, contraceptives and sex hormones.	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 non-dispensed medicine at central level.
	Quick test	Existence of rapid tests syphilis, HIV, pregnancy	Adequate: with all quick tests; inadequate: without one of the tests.
	Vaccines for pregnant women	Sufficiency of dT, seasonal influenza and hepatitis B vaccines	Adequate: with all the vaccines in BHU; inadequate: without one of the vaccines.
Human Resources	Basic care team	Primary care team consisting of: 1 doctor, 1 nurse, 1 dental surgeon (if with OH), 1 technician. or aux. of nursing,> 4 CHW (Community Health Agents), 1 technician or aux. in OH (if with OH).	Adequate: with all professionals; inadequate: with at least one of the professionals or < CHW.
Functioning of BHU	Operation of the unit	Work in two shifts and have the services available: medical consultation, nursing, dental, vaccination, reception and dispensing of medicines.	Adequate: works in two shifts, with all the services; inadequate: all other situations
Instrument of registry and protocol	Material printed on the unit	Have: pregnant booklet, vaccination card, files: B-GES of the Primary Care Information System (Siab), PNC and referral.	Adequate: with all record instruments; inadequate: without at least one of the instruments.
	Record	Record with legible, identifiable handwriting, with diagnostic hypothesis, requested exams and proof.	Adequate: that complies with the requirements and verifies them; inadequate: without complying with one of the requirements or dos not prove them.
	Electronic record	Have an electronic medical record integrated with the other points of the attention network, with proof.	Adequate: with electronic medical record, integrated and proven; intermediate: with medical record, but not integrated; inadequate: no electronic medical record or unproven.
	Protocol: prenatal and essential exams.	Protocols with definition for prenatal care and essential tests (fasting blood glucose, serology for syphilis, HIV, hepatitis B and urine culture or urine summary type 1)	Adequate: with all protocols; intermediate: with 4 to 5 protocols; inadequate: with less than three protocols.
	Protocols: welcoming spontaneous demand	Protocols with definition for the reception of spontaneous demand and urgency, which considers the early capture of pregnant women and the most frequent complaints.	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
	Criterion	Pattern	Categorization of criteria
Home visit	Home care	Home care performed by a doctor or nurse with survey/mapping of the users, organization of the agenda, risk assessment and vulnerability for HV periodicity, and scheduling the visits of the CHW according to the priorities of the team.	Adequate: meets all conditions Inadequate: all other situations.
Home visit	Capture of pregnant and puerperal women	Active search of pregnant women who are absent from prenatal care (by CHW), and fetal discharge from the visit of a team member or CHW.	Adequate: meets all conditions Inadequate: does not perform at least one of the actions.
Reception	Reception	Reception on five or more days per week, in two shifts, with risk evaluation and vulnerability, performed by a higher level professional, and depending on the risk identified the response is defined.	Adequate: meets all conditions Inadequate: all other situations.
Laboratory tests	Accomplishment, collection and receipt of exams	Collect material for laboratory tests, performs syphilis tests; toxoplasmosis; anti-HIV, and hepatitis B, as well as urine culture or urine summary, hemoglobin and hematocrit, glucose test, with proof, and receive the results in a timely manner.	Adequate: meets all conditions Inadequate: all other situations.
Laboratory tests	Waiting time for specialized care	Guarantee for pregnant women at high risk: specialized waiting time of up to 15 days (gynecology and obstetrical consultations) and up to 30 days of USG exams, diagnosis of HIV and syphilis.	Adequate: meets all conditions Inadequate: all other situations.
Vaccine	Vaccine situation	Provide basic calendar vaccines, with proven and prenatal guidance on the importance of tetanus vaccine.	Adequate: meets all conditions Inadequate: all other situations.
Record	Use of the booklet and record	Use the pregnant woman's booklet with proof and have records of: responsible professional, dental consultation, collection of cytopathological examination, up to date vaccination and number of high-risk pregnant women in the territory.	Adequate: meets all conditions Inadequate: all other situations.
Schedule and offer of actions	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.
Consultation	Consultation puerperium	Carry out consultation with nurse or doctor on any day and time of the week for puerperal care of up to ten days, with proof	Adequate: complies with all actions and proves; inadequate: does not comply with actions or does not prove it.
Consultation	Referral of users	Scheduling of the consultation at the specialized level after attending the BHU: patient leaves with the scheduled appointment, consultation marked by the BHU and the date is informed later to the patient.	Adequate: guarantees appointment of the consultation or the patient leaves with scheduled appointment; Inadequate: all other situations.

STRUTCTURE	BR	N	NE	CO	SE	S
Coordinator	98,0	99,5	97,0	99,2	98,3	98,1
External Signaling	84,4	80,4	83,8	86,5	84,6	85,7
Structural characteristics	57,4	43,8	51,9	45,8	61,7	67,0
Vehicle	48,9	30,8	56,5	42,2	41,2	60,5
Computer and internet access	38,7	20,4	16,2	41,5	49,4	61,8
References and flows	33,2	24,8	27,2	23,9	41,4	32,3
Audiovisual resources	22,8	10,8	6,8	20,7	34,8	30,9
Administrative environments	5,1	2,1	2,9	4,0	6,7	7,1
Visual/hearing Accessibility	4,8	2,4	3,2	2,1	6,3	6,4
Wheelchair user accessibility	1,4	0,9	0,4	0,1	2,8	0,8
PROCESS
SisPreNatal Feeding	87,4	86,9	90,9	86,3	87,0	82,2
Operation of the unit	45,4	43,2	29,2	39,4	67,8	28,8
Link to regulatory unit	25,7	24,4	21,5	30,6	23,3	37,6
Permanent education	23,9	15,1	8,1	25,6	35,6	30,0

STRUCTURE	BR	N	NE	CO	SE	S
Minimum team	84,5	84,9	86,3	79,5	86,2	79,0
Instruments	83,3	71,2	80,6	83,9	85,0	88,6
Controlled medicines	82,5	67,1	81,3	73,3	83,5	91,3
PNC protocols and exams	71,5	61,1	64,5	60,7	80,5	72,1
Women's health supplies	67,0	61,1	55,1	71,0	68,9	85,3
Printed material	59,6	68,1	52,2	56,7	64,0	61,9
Physical record	58,7	68,6	55,0	52,5	61,3	58,7
Works with services	51,6	38,9	49,4	40,1	52,4	62,8
Equipment: vaccine	47,8	91,8	44,4	72,1	28,4	70,3
Basic vaccines	43,5	48,8	46,2	35,4	46,6	32,6
Home visit protocol	35,0	32,9	30,3	25,9	41,7	33,1
Medicines	28,3	11,6	16,5	10,3	37,0	43,7
Inputs: population	28,1	18,3	14,7	28,2	35,4	40,3
Reception protocol	28,0	14,6	17,7	15,0	41,8	26,1
Equipment: pharmacy	16,9	16,8	11,0	19,1	16,9	26,9
Electronic records	10,9	1,8	0,9	17,6	13,4	24,4
Clinical environment	8,8	2,8	3,0	9,5	13,2	11,7
Quick tests	1,6	3,7	0,9	3,1	1,9	1,2
PROCESS
Capture pregnant woman and puerperal	89,6	87,4	91,2	83,9	90,9	86,9
Vaccine situation and supply	78,6	82,4	83,2	75,6	76,6	74,2
Program, consultations and actions	73,4	70,9	76,8	69,5	72,4	71,7
Risk classification offer	67,5	64,8	64,9	64,0	71,7	65,1
Agenda/health promotion offer	51,7	48,2	47,5	48,4	57,2	49,7
Specialized assistance	46,3	45,2	48,7	42,8	46,2	42,3
Home care	42,2	31,8	36,2	30,0	49,3	18,7
User referral	39,1	34,8	23,0	35,9	51,6	44,0
Exams	37,3	29,6	19,3	45,6	52,9	36,0
Reception	34,3	22,5	20,0	25,3	48,6	36,4
Pregnant's booklet	30,6	28,7	32,1	26,3	34,2	32,5
Puerperium consultation	27,1	20,7	32,1	15,0	29,1	20,2

Centro Brasileiro de Estudos de Saúde Av. Brasil, 4036, sala 802, 21040-361 Rio de Janeiro - RJ Brasil, Tel. 55 21-3882-9140, Fax.55 21-2260-3782 - Rio de Janeiro - RJ - Brazil
E-mail: revista@saudeemdebate.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] 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.