Evaluation of postpartum programs in Brazil: bibliometric profile of scientific production (2000-2019)

ABSTRACT

Postpartum care is a component of women’s health care, included in programs developed in Brazil, with the objective of improving maternal and child health indicators. The study aimed to analyze the state of the art of evaluative studies on programs related to puerperal care in Brazil from 2000 to 2019. The research was limited to the identification and analysis of articles published in peer-reviewed journals. The review was carried out based on research of the descriptors evaluation, programs and postpartum in the BVS, SciELO and Scopus portals, complemented by the verification of the references cited in the articles to include relevant studies. In total, 42 articles were identified, which were analyzed according to previously established criteria. The results of the bibliometric profile of intellectual production identified: absence of authors/research centers specialized in the evaluation interface and postpartum care programs, regional disparities in the production of knowledge, more articles on the Prenatal and Birth Humanization Program and the Baby Friendly Hospital Initiative, with scarce use of theoretical and methodological references in the field of Evaluation. The discussion carried out seeks to contextualize the scientific production analyzed in relation to the constitution of the space of health Evaluation in Brazil.

KEYWORDS
Health evaluation; Women’s health; Postpartum period; Bibliometrics

RESUMO

A assistência puerperal constitui um componente da atenção à saúde das mulheres, contemplado em programas desenvolvidos no Brasil, que visam à melhoria dos indicadores de saúde materno-infantil. O estudo objetivou analisar o estado da arte dos estudos avaliativos sobre programas relacionados à atenção puerperal no Brasil, no período de 2000 a 2019. A pesquisa limitou-se à identificação e análise de artigos publicados em periódicos revisados por pares. A revisão foi realizada a partir de pesquisa dos descritores Avaliação, Programas e pós-parto nos portais da BVS, SciELO e Scopus, complementada pela verificação das referências citadas nos artigos para inclusão de estudos pertinentes. Ao total, foram identificados 42 artigos, os quais foram analisados segundo critérios previamente estabelecidos. Os resultados do perfil bibliométrico da produção intelectual identificaram: ausência de autores/centros de pesquisa especializados na interface Avaliação e Programas de atenção pós-parto, disparidades regionais na produção do conhecimento, maior quantidade de artigos sobre o Programa de Humanização no Pré-Natal e Nascimento e a Iniciativa Hospital Amigo da Criança, escassa utilização de referências teórico-metodológicas da área de avaliação. A discussão realizada procura contextualizar a produção científica analisada em relação à constituição do espaço da avaliação em saúde no Brasil.

PALAVRAS-CHAVE
Avaliação em saúde; Saúde da mulher; Período pós-parto; Bibliometria

Introduction

The constitution and development of the health evaluation space in Brazil stems from three concomitant social processes: the creation of the Unified Health System (SUS) - which, by demanding the elaboration and implementation of policies for the sector, aroused interest in the evaluation of the effects of governmental actions carried out; the formation of the Public Health area as a space for bringing together researchers and health managers; the financing obtained from international organizations that demanded, in return, the evaluation of interventions, especially in primary care¹. Thus, in the 1990s, there was not only a process for the institutionalization of evaluation practices in the SUS - such as the Reinforcement and Organization of the SUS (Reforsus) program created in 1996 to promote the quality of care and management - but also a growth of academic interest in health assessment¹.

For Furtado and Vieira-da-Silva¹, the health assessment space in Brazil is developed in the intertwining between the ‘bureaucratic field’, represented by the governmental sphere, and the ‘scientific field’, constituted by the universities. Starting in 2000, the authors identified a significant increase in the number of articles published in national journals and communications in scientific events. The search for autonomy of evaluation in relation to other sub-areas of Public Health can be illustrated by the creation, in 2006, of the ‘Thematic Group for Monitoring and Evaluation of Health Programs, Services, Systems and Policies’ - Evaluation TG of the Brazilian Association of Public Health (Abrasco).

The bibliometric research elaborated by Furtado et al.² on the production in the Public Health area from 1980 to 2016, confirms the growth trend of health evaluation after the 2000s, compared to the planning subarea. Although planning and evaluation are stages of the public policy cycle, within the scope of planning, theoretical and methodological studies focus on the analysis of problem situations and the elaboration of interventions - such as plans, programs, projects - for systems and health services. In the evaluation subarea, the investigations carried out are dedicated to judging the value of an intervention or one of its components, in order to understand the relationships between resources, processes and results, aiming to identify how the elaborated intervention changes the problem-situation that demanded it. Studies with this focus expanded from the 2000s onwards, including the increase in the number of research groups on Evaluation, a phenomenon that coincided with the institutionalization of evaluation practices in the SUS³.

This context was also favorable to the expansion of studies dedicated to maternal and child health, especially on the model of humanization of obstetric and neonatal care. The debate on the conditions of pregnancy, giving birth and being born in Brazil involved a set of factors, among which the following stand out: organization and strengthening of social movements for women’s rights, recognition of sexual and reproductive rights as human rights within the scope international conferences, recommendations from supranational organizations for evidence-based obstetric and neonatal care, development of health programs and government actions aimed at reducing maternal and neonatal morbidity and mortality⁴,⁵.

Especially from the 2000s onwards, the Ministry of Health developed a series of interventions aimed at improving obstetric and neonatal care, such as the Prenatal and Birth Humanization Program - PHPN (2000), the Pact for the Reduction of Maternal Mortality and Neonatal (2004) and the Stork Network (2011). As interventions were organized by the federal government, in partnership with states and municipalities, to improve maternal and child health indicators, national scientific production on the subject also expanded significantly. Data on the production of theses and dissertations in Brazilian graduate programs on the humanization of labor and birth, from 1987 to 2012, show that 96% of a total of 379 papers were presented from the year 2000, with a peak in the year 2012⁵.

The quantitative increase in scientific works, from the first decade of the 21st century, is also linked to the expansion of stricto sensu postgraduate courses, mainly through inducing policies managed by the Coordination for the Improvement of Higher Education Personnel (Capes), by the National Council of Technological and Scientific Development (CNPq) and states research support foundations, in partnership with universities. According to Nobre and Freitas⁶, while in 1990 there were 1,462 postgraduate programs, including masters and doctorates, in 2016 there were 6,131 programs. The national scientific production has historically developed centered on postgraduate programs linked to universities⁷.

Although the expansion of scientific production is evidenced, the study of theses and dissertations on the humanization of obstetric and neonatal care also concluded that childbirth and prenatal care were more studied than the puerperal period⁸. Postpartum or puerperium is defined as the period that begins with the delivery of the placenta and ends when the woman starts menstruating again, which can vary from woman to woman and whose duration depends directly on the practice of breastfeeding. However, the changes that affect postpartum women involve, in addition to biological changes, intense psychological and social changes⁹. Thus, the health needs of postpartum women are multidimensional and influenced by the social construction of motherhood.

Care after childbirth is a component of comprehensive health care for women¹⁰, configured through actions such as postpartum consultation, breastfeeding support, guidance on reproductive planning and home visits in the first week after childbirth. The Ministry of Health in Brazil recommends that health services guide pregnant women about returning for a postpartum consultation - also known as a childbirth review consultation - from seven to ten days postpartum¹¹. It also recommends that at least one postpartum consultation take place in the first weeks of birth, so that a qualified professional can assess both the clinical-gynecological aspects and the emotional and social state in which the postpartum woman is¹².

Researches, however, indicate that there are gaps and inequalities in the coverage of puerperal care, as well as difficulties of services in recognizing the health needs of postpartum women. Qualitative approaches on the perceptions of postpartum women in relation to professional care after childbirth show that baby-centered care occurs to the detriment of welcoming women’s health needs¹³,¹⁴. According to the World Health Organization (WHO)¹⁵, the puerperal period receives less specialized attention compared to pregnancy and childbirth. The study by Langlois et al.¹⁶ also concluded that inequalities in the use of postpartum care services in low- and middle-income countries are due to factors related to the educational level, socioeconomic status and women’s difficulties in accessing health facilities.

Given the above panorama, this article aimed to analyze the state of the art, in the field of evaluation, on puerperal care in Brazil, from 2000 to 2019. For this purpose, we outline the bibliometric profile of published studies contextualizing the scientific production analyzed in relation to the constitution of the health evaluation space in Brazil.

Methodology

This study adapted the scoping review methodology, proposed by Arksey and O’Malley¹⁷, for the review of evaluative studies on programs developed in Brazil, related to the provision of health care in the postpartum period. The development of the research comprised six stages: elaboration of the research questions; definition of search descriptors and criteria; selection of studies in academic journals indexing databases; extraction and organization of data in spreadsheets and cards; verification of cited references for inclusion of relevant studies not previously selected; synthesis and report of the research.

The literature review presented here sought to answer the following question: What are and how are the studies that evaluate programs related to postpartum care in Brazil? As a methodological strategy to cover the largest possible number of studies, the search for descriptors - registered in the controlled vocabulary of health sciences terminology present in the Portal of the Virtual Health Library (VHL) - took place in four languages and with a combination of operators ‘and’ and ‘or’ in the following disposition: “(avaliação and ‘pós-parto’ and programa) or (evaluation and postpartum and program) or (evaluación and posparto and programa) or (évaluation and ‘post-partum’ and programme)”. The research took place in January 2020, in the scientific article indexing databases of the BVS, SciELO - Scientific Electronic Library Online and Scopus.

Previously, criteria for inclusion of texts were outlined: Brazil as a subject; full text available; publication year range from 2000 to 2019; type of document restricted to peer-reviewed article; text languages in Portuguese, English, Spanish or French. Texts that did not address the woman’s postpartum period were excluded, as well as those that did not conduct evaluation of a program or other health intervention. Thus, researches that were carried out with postpartum women, but that had an interest in prenatal care and childbirth were not selected. Studies on problems associated with the puerperium and that did not assess health care programs or practices were also not included, as is the case with several studies on the prevalence of postpartum depression.

The search in the VHL, a library that provides access to various scientific databases, resulted in the selection of 13 articles, of which 10 were linked to the collection of Latin American and Caribbean Literature on Health Sciences (Lilacs) and three to the Medline database. In turn, searches on the SciELO and Scopus portals resulted in the identification of seven and 15 articles, respectively. The lists from each database were compared to check for duplicates, thus making up 28 studies. To determine the corpus of analysis, a complementary step was performed, with the reading of the titles of the references cited in the selected articles. This stage added 14 works, which generated a total of 42 studies analyzed. The synthesis of the entire process is shown in figure 1.

Figure 1
Synthesis of the analysis corpus composition process

For the collection and organization of the data extracted from the texts, a spreadsheet was built based on a previously prepared script, containing the following analysis categories: a) genera l aspects of identification of the study: title, authors, institutions involved, keywords, year of publication, journal, article indexing base; b) study characteristics: study object program, territorial unit of the evaluated program, research method and techniques, documents and cited references. The collected data made it possible to characterize the bibliometric profile of intellectual production.

Bibliometric review is a technique for quantitative analysis of the literature, which seeks to measure the production and dissemination of scientific knowledge. The technique is useful for mapping and monitoring the development of a particular field or theme of studies, verifying the volume and geographic and institutional distribution of works; authorship and publication patterns; uses of results; as well as other elements relevant to the interest of the research. Literature review works can use bibliometric data to contextualize the socio-historical aspects of scientific production¹⁸-²⁰.

To analyze the keywords of the articles, we used the Iramuteq software (Interface de R pour les Multidimensional Analyzes by Textes et de Questionnaires, Laboratorie Lerass, Université de Toulouse), created by Pierre Ratinaud. According to Camargo and Justo²¹, the free program is a useful tool to organize vocabulary in visually clear formats. The word cloud is a feature that considers the frequency of words to distribute them in a visual scheme, while similarity analysis indicates the connections between words. Both resources were used to present the results of the mapping and analysis of scientific production on the evaluation of postpartum care programs in Brazil.

Results

In twenty years, the number of articles found can be considered low. The first two publications of the period date from 2003 and both carried out evaluations of the Baby-Friendly Hospital Initiative²²,²³. In graph 1, the temporal distribution of the studies is observed, with a greater concentration in the period from 2010 to 2015, with 17 articles.

Graph 1
Time distribution graph of evaluative studies of programs on postpartum care in Brazil (2000-2019)

The 42 articles are published in 30 different journals, mostly national. The following journals have published more than one article: Cadernos de Saúde Pública (4)²⁴-²⁸, Revista Brasileira de Saúde Materno Infantil (4)²³,²⁸-³⁰, Jornal de Pediatria (3)³¹-³³, Revista de Saúde Pública (3)³⁴-³⁶, Escola Anna Nery - Revista de Enfermagem (2)³⁷,³⁸, Pan American Journal of Public Health (2)³⁹,⁴⁰. The latter, together with the American Journal of Public Health²², Journal of Human Lactation⁴¹ and Scientific World Journal⁴², make up the four international journals where analyzed articles were published. All journals are classified in Capes’ Qualis Periodicals (2013-2016 quadrennium), distributed in the following strata: A1 - 1, A2 -10, B1 - 17, B2 - 9, B3 - 3, B4 - 2. Of the 26 national journals, 16 are ranked among Google Scholar’s top 100 Portuguese-language publications. Although the search for articles covered descriptors in four different languages, studies published in Portuguese, English and Spanish were identified. As for the language, 19 publications are only in Portuguese, 12 are simultaneously in Portuguese and English, nine are in English only, and one has translation into the three languages.

About three quarters of authors are female. A total of 165 authors were identified, with an average of four per publication, and one of the texts had ten. It is not possible to perceive authors or specialized centers in the postpartum care and program evaluation interface, since there is great dispersion in the productions with regard to authorship. However, it is possible to affirm that the eight authors with more than one work have in common the production of research in the stricto sensu post-graduate course on women’s health, based on information available in their respective lattes curricula (CNPq).

The authors with more than one article are: Bethsáida de Abreu Soares Schmitz²³,⁴¹ (professor with a PhD linked to the University of Brasília, has a production on the theme of evaluation of public policies and food and nutrition programs); Carla Betina Andreucci²⁶,³⁵ (professor with a PhD at the Federal University of São Carlos, has experience in the area of medicine, with an emphasis on maternal and child health and epidemiology, and was supervised in her master’s and doctoral studies by José Guilherme Cecatti); Cristina Maria Garcia de Lima Parada²⁹,⁴³ (professor with a PhD at the São Paulo State University Júlio de Mesquita Filho - Botucatu, works in the area of Obstetric Nursing, having experience in health services evaluation); Escolástica Rejane Carneiro Moura (professor with a PhD at the Federal University of Ceará, develops research in the area of sexual and reproductive health, with production linked to the research line ‘Nursing and Health Policies and Practices’)²⁵,⁴⁴; José Guilherme Cecatti²⁴,²⁶,²⁸,³⁵,³⁹,⁴⁵ (professor with a PhD at the State University of Campinas in the area of Medicine, in the area of Obstetrics, has a production on epidemiology with a focus on maternal and reproductive health); Maria de Fátima Moura de Araújo²³,⁴¹ (With a masters degree from the Human Nutrition program at the University of Brasília, had Bethsáida Schmitz as the supervisor of her dissertation on the evaluation of the Baby Friendly Hospital Initiative, a public servant linked to the Ministry of Health, where she acted as nutritionist in the Technical Area of Women’s Health); Suzanne Jacob Serruya²⁴,²⁸,⁴⁵ (graduated in medicine, she was a professor at the State University of Pará and consultant to the Ministry of Health, currently holds the position of Regional Advisor on Sexual and Reproductive Health for the Americas at WHO/Paho, at Latin American Center in Perinatology, her doctoral thesis on PHPN was supervised by Cecatti); Tânia Di Giacomo do Lago²⁴,²⁸,⁴⁵ (professor at the Faculty of Medical Sciences of Santa Casa de São Paulo, was coordinator of the Technical Area for Women’s Health at the Ministry of Health, during the development period of the PHPN; she was also a member of the State Secretary Health of São Paulo). With the greatest number of works, Cecatti subscribed six articles as co-author, three of which in partnership with Serruya and Lago. So the three are the authors with the highest number of publications. It should be noted that five of the six articles signed by Cecatti deal with PHPN.

Considering that Furtado and Vieira-da-Silva¹ point to the formation of the Abrasco Assessment TG as an element in the constitution of the health assessment space in Brazil, we sought to identify which of the authors of the analyzed studies make up the aforementioned TG. Of the total, only four researchers appear in the list provided on the Abrasco portal⁴⁶ as linked to the thematic group. The Evaluation TG was constituted as an official forum for meeting researchers and those interested in the development of the field of monitoring and evaluation in health in the country, although its formation was not peaceful, due to the opposite position of those who understood evaluation as transversal¹.

From the connection between authors, declared in the articles, 54 different institutions were counted. Of these, 42 are referred to in just one article each. The most mentioned are: the State University of Campinas - Unicamp (8 articles)²⁴,²⁶,²⁸,³⁵,³⁷,³⁹,⁴⁵,⁴⁷, Ministry of Health of Brazil (5)²³,²⁴,²⁸,⁴⁵,⁴⁸, Oswaldo Cruz Foundation - Fiocruz (4)²⁷,³³,⁴⁸,⁵⁰, Federal University of São Paulo (4)⁴⁰,⁵⁰,⁵¹,⁵² and University of Brasília (3)²³,⁴¹,⁵³.

From the institutional verification of the authors, partnerships between universities and government management bodies were identified in the making of 12 studies²²,²³, ²⁴,²⁸,³⁶,⁴⁰,⁴⁴,⁴⁵,⁴⁷,⁵⁰,⁵⁴; in four there was partnership with entities that provide health services²²,³⁵,⁵⁰,⁵³ and in two, partnerships with non-governmental organizations³⁵,⁴⁰. The other institutions mentioned correspond to universities, colleges and research institutes, almost all of them Brazilian, except for two. Not counting the Ministry of Health and foreign universities, it was found that 17 institutions are located in the Southeast (34.7%), 12 in the Northeast (24.5%), nine in the Midwest (18.4%), eight in the South (16.3%) and only three in the North (6.1%) of Brazil.

As for the territorial unit, 26 articles assess programs located in municipalities, 10 present assessments at the national level, three at the state level (Ceará, Tocantins and Goiás) and three regional (of these, two refer to the Botucatu Health Region and one to Baixada Fluminense). The distribution of the evaluated programs by region of the country - disregarding articles of national scope - maintains a similar proportion to that of the universities to which the authors are affiliated, because in the Southeast region there were 13 evaluated programs (40.6%), nine in the Northeast region (28.1%), five programs in the Center-West (15.6%), three in the South (9.4%) and two in the North (6.3%).

Quantitative type surveys represent 69.0% of the corpus (29), qualitative surveys 26.2% (11), and those that used a mixed approach 4.8% (2). Among the diversity of research techniques used, the use of interviews (20), document analysis (13) - records of health services, medical records and the pregnant woman’s portfolio - and the use of databases (11) stand out. It should be noted that half of the articles combine different data collection techniques.

The analysis of the articles’ keywords allowed the identification of the themes that stand out. The words were analyzed in English, as this is the common language for all article abstracts. Figure 2 presents, in visual format, the descriptors present in at least two studies. The bigger the word appears represented in the cloud, the more frequent its use. Prenatal care and pregnancy together add up to 24 occurrences, followed by postpartum (10), breastfeeding (10), program evaluation (9), childbirth (8), humanizing (8), women’s health (8) and maternal and child health (6).

Figure 2
Word cloud formed by article descriptors (2000-2019)

When presented in the form of a similarity tree, it is possible to see how the keywords are similar in the articles, forming five thematic axes, as shown in figure 3. Prenatal care appears as a central link between all axes, weaving the connections between pregnancy, childbirth and postpartum. The axis of studies on vertical transmission, with emphasis on HIV, is linked to pregnancy, considering that, at this stage, diagnostic tests are essential for the prevention of diseases in children. Maternal and child health, related to the problem of mortality, is connected to the axis related to the postpartum period. It is interesting to note how the axis formed by the postpartum period is linked to primary health care, home visits and nurses. Evaluation appears under three names with distinct connections: health evaluation, comprising the prenatal axis; program evaluation, linked to humanization; and simply evaluation, in the breastfeeding axis.

Figure 3
Similarity tree of article descriptors

In view of the centrality occupied by prenatal care, the Prenatal and Birth Humanization Program is the most evaluated, with 14 studies²⁴-²⁶,²⁸,²⁹,³⁴,³⁵,³⁷,³⁸,⁴³-⁴⁵,⁵⁰,⁵⁵. The program that accredits the Child Friendly Hospital seal is covered in nine articles²²,²³,³⁰,³¹,³²,³³,⁴¹,⁵⁶,⁵⁷. Vertical transmission from mother to child is the subject of three articles focusing on HIV prevention³⁹,⁴⁹,⁵⁸ and one on Hepatitis B⁵⁴. Three studies analyze the Stork Network³⁶,⁴⁸,⁵⁹; three the postpartum home visit⁵¹,⁶⁰,⁶¹, two address psychoeducational programs for parenting⁵³,⁶². One article was also registered for each of the respective themes: the SUS Hospital Information System (SIH-SUS)²⁷; the Neonatal Hearing Screening Program (TAN)⁵²; the Working with Traditional Midwives Program⁴⁰; the Program for Integral Support for Pregnant Adolescents⁴²; Nutritional Care in Prenatal and Puerperium⁶³; Waiting Room Group with Pregnant Women for the prevention of puerperal depression⁴⁷. There is also a literature review article on postpartum programs in primary care, which included studies from Brazil and other countries⁶⁴.

All documents from the Ministry of Health mentioned in the articles were compiled in a separate file, as a strategy to verify the referenced policies, programs, guidelines, manuals and bulletins. The table 1 below shows the result of the organization of the cited documents strictly related to policies and programs. Among those listed in the table, the PHPN stood out in terms of the number of times it appeared in the article references (16). Of the complementary documents of the Ministry of Health referenced, the manuals ‘Pré-natal e puerpério: atenção qualificada e humanizada’ (2006) stand out, with 11 mentions; ‘Parto, aborto e puerpério: assistência humanizada à mulher’ (2001), with five; and ‘Atenção ao pré-natal de baixo risco’ (2012), with four.

Table 1
Brazilian Ministry of Health policies and programs cited in the references of the analyzed articles (2000-2019)

Year	Name
1973	National Immunization Program
1984	Comprehensive Women's Health Care Program
1992	Baby-Friendly Hospital Initiative
1994	Family Health Program
2000	Prenatal and Birth Humanization Program
2000	Working with Traditional Midwives Program
2003	National Humanization Policy
2004	National Policy for Comprehensive Attention to Women's Health
2006	National Primary Care Policy
2008	National Policy for Comprehensive Men's Health Care
2009	National STD and AIDS Program
2011	Stork Network
2001	National Primary Care Policy
2011	National Food and Nutrition Policy
2013	More Doctors Program
2017	National Policy for the Promotion, Protection and Support of Breastfeeding

Source: Own elaboration.

When grouping all the documents from international organizations mentioned, the two main institutions mentioned were the WHO and the United Nations Children’s Fund (Unicef). The most mentioned document, cited in five articles, was published by the WHO in 1998 and is entitled ‘Evidence for the ten steps to successful breastfeeding’, which the translation into Portuguese was published in 2001. The Unicef texts cited also deal, above all, about the Baby-Friendly Hospital Initiative (BFHI).

The analysis of the references also sought to verify the conceptual and methodological texts in the field of program evaluation. There was a multiplicity of Brazilian and international texts cited, with a primacy of these. The author with the highest number of references was Avedis Donabedian, with five mentions of different texts. Among Brazilians, there were no texts or authors present in more than one article.

Discussion

Among the 42 articles analyzed, 25 studies were published from 2010 to 2019. The temporal distribution of the articles is consistent with the formation of health valuation research groups described by Cruz, Oliveira and Campos³. The authors identified the constitution of 355 research groups in the period 1976 to 2017. Of these, 42 groups were formed by 1999 and 313 from 2000 onwards. The years of 2013 and 2014 were the ones in which there were a greater number of groups created, 32 and 40 respectively.

The health evaluation research groups are mostly linked to the large area of Health Sciences (83.1%) and, to a lesser extent, to the Human Sciences (8.7%) and Applied Social Sciences (3.7%)³. Although the evaluation is transversal to several areas of knowledge, the predominance of research groups in the Health Sciences is related to the fact that health evaluation in Brazil is linked to the development of the field of Public Health¹,³. This situation was also verified in the journals responsible for publishing the 42 articles analyzed in this research, all dedicated to the production of knowledge about health.

Of the journals that had the most articles published on postpartum care programs, ‘Cadernos de Saúde Pública’ and ‘Revista de Saúde Pública’ are also highlighted by Furtado and Vieira-da-Silva¹. The authors indicate that the two journals, together with ‘Ciência e Saúde Coletiva’, published 287 of the 835 articles on health assessment published from 1990 to 2006. With four publications that assess postpartum care programs, the ‘Revista Brasileira de Saúde Maternal Infantil’ has a particular history with regard to health evaluation. According to Felisberto and Samico⁶⁵, the journal evolved from the ‘Revista do Instituto de Medicina Integral Professor Fernando Figueira’ (IMIP), whose first edition, entitled ‘Assessment in Maternal and Child Care’, resulted from an international cooperation project with the Inter-American Bank to o Development (IDB), with the aim of promoting the implementation of the evaluation of programs and services carried out by the institute. As for the three publications present in the ‘Jornal de Pediatria’, it is worth mentioning that the articles evaluated the impact of the BFHI.

When verifying the academic and professional trajectories of the eight authors with more than one article evaluating the programs for postpartum care, it is noted that there is in common the professional work dedicated to the theme of maternal and child health. Some of the authors have professional experience both as university professors and public policy managers. The articulation between academia and management was also identified in the trajectories of authors of theses and dissertations on the humanization of labor and birth⁶⁶. As in the studies by Furtado and Vieira-da-Silva¹, in which the approximation between ‘bureaucratic field’ and ‘scientific field’ was evidenced in the constitution of the space for health assessment in Brazil.

In the results of the distribution of researches, both regarding the institutional affiliation of the authors, and in relation to the local area of the evaluated program, there was a greater concentration in the Southeast region, with significant differences compared to other regions, especially the North of the country. Such disparities are similar to the data collected by Cruz, Oliveira and Campos³ on the health assessment research groups (SE - 42.8%, NE - 23.9%, S - 20.6%, MW - 8.5%, N - 4.2%), and by Bourguignon⁸, on the distribution of theses and dissertations on the humanization of obstetric and neonatal care (SE - 53.3%, NE - 20.6%, S - 17.9%, MW - 7.1%, N - 1.1%). The concentration of studies and research groups in the Southeast is due to the fact that the region has a greater number of postgraduate programs, according to data from the Capes⁶⁷ Georeferenced Information System - Geocapes.

The analysis of the references cited about conceptual aspects of the Evaluation demonstrates the little insertion of the theoretical debate in the area in the analyzed studies. Few articles brought a bibliography that addressed the concepts and methods of Health Evaluation. Avedis Donabedian, recognized author for works on evaluating the quality of health services, had only five mentions in a universe of 40 works. In the research by Furtado and Vieira-da-Silva¹, with 28 agents linked to the constitution of the health assessment space in Brazil, Donabedian was one of the authors cited by all 28 respondents.

Another challenge highlighted by the results is the carrying out of mixed research, which integrate qualitative and quantitative aspects of puerperal care programs. For example, investigations into how many Brazilian women, in different regional contexts, are able to carry out the childbirth review consultation and the quality of these services in meeting the multiple health needs of postpartum women. More qualitative and quantitative studies are also needed on home visits, recommended by the Ministry of Health, in the first week after birth; on the availability of professional breastfeeding support services; identification of psychological problems related to the puerperium, and referral to specialized services. For example, no evaluation studies were identified on the referral and counter-referral systems, which allow for the interaction between primary care and hospital care during childbirth, and which are important to guarantee the continuity of care for women after birth. There was also no record of a study that addressed a program to assist postpartum women who suffer from perinatal loss, although the concern with maternal and neonatal morbidity and mortality is present in the articles analyzed.

Conclusions

The results presented, therefore, offer subsidies regarding the low volume of articles published on the evaluation of programs aimed at puerperal care and the absence of authors and/or reference research centers in the Program Evaluation and puerperium interface. Postpartum as a less central theme in studies on women’s health care during the pregnancy-puerperal cycle, and health assessment, a cross-sectional and multifaceted area in search of consolidation as a field of study within Public Health.

Given the above, it can be said that there is potential to explore the theoretical-methodological framework of health assessment for the production of knowledge about puerperal care programs, especially because the transfer of knowledge is a constant challenge for scientific work and for health services in general. According to Craveiro and Hartz⁶⁸,

There is a gap in terms of mechanisms for the translation of knowledge from research to policy decision-making, namely in the area of social determinants of health and the interconnection with policies for training and equitable distribution of health professionals.

Thus, partnerships between the ‘scientific field’ and the ‘bureaucratic field’ have greater potential to translate into improvements in the health of the population⁶⁸-⁷¹. Above all, so that health services can recognize and respond with quality to the multiple health needs of women after childbirth and reduce the existing inequalities in the use of these services.

The bibliometric review made it possible to characterize studies on postpartum care programs in Brazil in interface with health assessment. However, it was limited to scientific works published in the researched databases and published in article format. It is expected that the systematization of scientific production undertaken in this study will provide an overview of the evaluations of postpartum care programs in Brazil and encourage the development of new evaluative research that can contribute to the improvement of women’s health conditions during the puerperium.

Referências

• ¹
  Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad. Saúde Pública. 2014 [acesso em 2020 jun 26]; 30(12):2643-2655. Disponível em: https://www.scielosp.org/pdf/csp/2014.v30n12/2643-2655/pt
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Publication Dates

• Publication in this collection
  18 Oct 2021
• Date of issue
  Jul-Sep 2021

History

• Received
  20 Feb 2021
• Accepted
  4 Aug 2021