The nutritional care during the prenatal and postpartum: Perceptions of managers of Primary Health Care

ABSTRACT

Objective:

To evaluate the perception of managers regarding the nutritional care to prenatal and postpartum in Primary Health Units in Southern,São Paulo, Brazil.

Methods:

It was conducted a census of 28 Primary Health Units from the insular area, using interviews with managers. The nutritional care was assessed according to infrastructure, work process and food and nutrition surveillance.

Results:

The insertion of dietitians was the main insufficient component of dimension structure, interfering negatively on nutritional care for 60% of managers. It was founded low compliance for the following variables of the process dimension: calculate the body mass index (35%), monitoring of nutritional status in body mass index/gestational week curve (46%) and conducting individualized nutritional counseling in antenatal (14%).

Conclusion:

Prenatal and postpartum nutritional care is unsatisfactory to achieve comprehensive care. It is necessary to sensitize local manager's awareness and qualify the health teams to ensure the effectiveness of such actions in Santos.

Keywords:
Health evaluation; Primary Health Care; Prenatal care; Postpartum period; Nutrition programs and policies

RESUMO

Objetivo:

Avaliar a percepção dos gestores quanto à atenção nutricional ao pré-natal e ao puerpério na rede básica de município da Baixada Santista, São Paulo, segundo estrutura e processo.

Métodos:

Realizou-se censo das 28 unidades básicas da área insular por meio de entrevistas com gestores. Avaliou-se a atenção nutricional segundo infraestrutura, processo de trabalho e vigilância alimentar e nutricional.

Resultados:

A inserção do nutricionista foi o principal componente insuficiente da dimensão estrutura, interferindo negativamente na atenção nutricional para 60% dos gestores. Encontrou-se baixa conformidade para as seguintes variáveis da dimensão processo: cálculo do índice de massa corporal (35%), acompanhamento do estado nutricional na curva índice de massa corporal/semana gestacional (46%) e realização de aconselhamento nutricional individualizado no pré-natal (14%).

Conclusão:

A atenção nutricional pré-natal e puerperal é insatisfatória para alcançar a integralidade do cuidado. Faz-se necessário sensibilizar gestores locais e capacitar equipes de saúde para assegurar a efetividade de tais ações em Santos.

Palavras-chave:
Avaliação em Saúde; Atenção Primária à Saúde; Cuidado pré-natal; Período pós-parto; Programas e políticas de nutrição e alimentação

INTRODUCTION

Prenatal care is one of the main policy concerns of the Sistema Único de Saúde (SUS, Unified Health System) in Brazil; however, despite the increase in prenatal care services¹, there are still issues related to the quality of care provided. Recent studies reveal that only a small number of pregnant women enrolled in prenatal programs follow the minimum standard recommendations^1-5, suggesting limitations of the care provided by health services, evidenced by medicalization rather than preventive and health promotion measures⁴.

The Ministry of Health provides a wide range of technical materials and guidelines to be used by health services to ensure a proper care during the prenatal and postpartum periods promoting maternal and newborn health by focusing on early follow-up, diagnosis, and adequate treatment and management of intercurrences that may occur in this period^6,7.

Nutritional care is one of the essential components for comprehensive prenatal and postpartum care. It means provision of guidance on subjects of food and nutrition focusing on protection and promotion of health and on the prevention, diagnosis, and treatment of disease complications⁸. Changes in the pregestational nutritional status and gestational weight gain are associated with increased risk for gestational hypertensive syndrome, gestational diabetes^9,10, and low birth weight^9,11. These are important public health problems that can be avoided with proper prenatal care⁷. Accordingly, food and nutrition surveillance and nutritional care in Primary Health Care enable the identification and management of risk factors¹², ensuring interventions during pregnancy, lactation, and infant growth and development and promoting nutrition and food security¹³.

The monitoring and evaluation of prenatal care are strategic approaches to decision-making processes in health services that focus on care improvement and reduction of maternal and perinatal morbidity and mortality rates^3,14. National and foreign research studies that assessed the quality of care, including nutritional care, revealed deficiencies^2,15-20. Despite the obvious relevance of this issue, few studies on the evaluation of nutritional care during the prenatal and postpartum periods^15,16 were identified. Moreover, there are no literature data on the health care system in the city of Santos (SP), where the infant mortality rate is higher than the São Paulo state average²¹.

The objective of this study is to evaluate the maternal and infant nutritional care during the prenatal and postpartum periods provided by the Primary Health Care of in the municipality of Santos (SP).

METHODS

A census study was carried out in 28 Primary Care Units in the insular area ofSantos (SP).

The city of Santos has 28 health care units, namely: 19 Basic Care Units (BCU) and 9 Family Health Units (FHU) spread in four different regions that comprise the insular area of the city (Orla[Shoreline], Centro [Downtown], Morros[Hillside area], and Zona Noroeste [Northwest Zone]), as follows: six are located in the Downtown area (5 BCU and 1 FHU); six in the along the Shoreline (only BCU); eight in the Northwest Zone (5 BCU and 3 FHU); and eight in the Hillside area (3 BCU and 5 FSU). Downtown, Hillside, and the Northwest Zone have higher socioeconomic inequalities, whereas the Shoreline area has the best infrastructure and housing conditions²². According to Instituto Brasileiro de Geografia e Estatística (IBGE, Brazilian Institute of Geography and Statistics)²², the insular region concentrates 99.32% of the population ofSantos; therefore, the mainland health care units were not included.

Despite their specificity, these two types of health care services are basically composed of doctors, nurses, nursing technicians, nursing assistants, dentists, and community health workers. The other health professionals, including dieticians, are included in the Seção de Atenção à Saúde da Comunidade (Community Health Service), a service center that provides matrix support to Primary Health Care.

Prenatal care for low risk pregnancy is provided by BCU and FSU. According to the latest data for the city of Santos, prenatal services were rendered to 5,596 pregnant women by primary health care services in 2013²³, 4,908 live births were registered in 2012 with an infant mortality rate of 13.9/1,000 live births in the same period⁷.

The nutritional care provided during the prenatal and postpartum periods was evaluated using the Donabedian Model for assessment of health services as a theoretical framework²⁴. According to this model, information about quality of care can be drawn from three categories: 1) structure, refers to the context in which care is delivered, i.e., an evaluation of the facilities' physical, organizational, and technical resources; 2) process, refers to the analysis of the transactions between providers and patients; and 3) outcomes, refers to the analysis of the final health status (individual or collective) as a result of the health care provided.

Donabedian²⁴ believes that a proper evaluation of the quality of health care should consider the dimensions structure, process, and outcomes of the services provided. According to the author, "good structure increases the likelihood of good process, and a good process increases the likelihood of a good outcome" (p.1147).

One basic assumption of the present study was that the nutritional care is an essential component for comprehensive care during the prenatal period. Nevertheless, there is a set of basic actions planned for this period of life, but nutritional care assessment has not been included in official documents. In addition, there is a lack of studies on the evaluation of the nutritional care during the prenatal and postpartum periods in the Primary Health Care^15,18. Therefore, in the present study, the authors developed a model for the evaluation of health services focusing on the nutritional care provided during the prenatal and postpartum periods (Figure 1). It was based on prenatal complications that can be managed with nutritional interventions, considering the main routine recommendations of the Ministry of Health for an effective nutritional care⁷.

Figura 1
Proposta de modelo de avaliação da atenção nutricional para a integralidade baseado nos componentes das dimensões estrutura e processo. Santos (SP), 2013. Nota: MS: Ministério da Saúde; EN: Estado Nutricional; AN: Atenção Nutricional; PA: Pressão Arterial; IMC: Índice de Massa Corporal; SG: Semana Gestacional; DMG: DiabetesMellitus Gestacional; HA: Hipertensão Arterial; AME: Aleitamento Materno Exclusivo; VD: Visita Domiciliar; RN: Recém-Nascido.

The construction of this model enabled the definition of the variables of the dimensions structure and process for nutritional care. Thus, the conformity of the parameters evaluated was perceived as the compliance of structure and process with the Ministry of Health recommendations since they are the minimum standard requirements for good quality care and are essential for a comprehensive nutritional care²⁵.

The variables of the dimension structure were: availability of anthropometric equipment, frequency of equipment maintenance, physical space for nutritional care assistance, inclusion of dieticians in the health services provided, training on anthropometric procedures, proper implementation of the Ministry of Health Manuals.

As for the dimension process in the prenatal period, the following variables were evaluated: gestational age at the beginning of the prenatal care, number of regular prenatal visits, basic lab tests requested, routine supplementation, presence of multidisciplinary care team, educational activities, identification of nutritional risk, anthropometric measurements, medical records, and routine nutritional assessment.

The variables of the dimension process in the postpartum period were: schedule of home visits for postpartum women and newborns, nutrition evaluation and counseling for postpartum women, routine supplementation, anthropometric measurements of newborns, monitoring and carrying out of actions to support and promote exclusive breastfeeding.

The evaluation consisted of the verification of compliance of the structure of the BCU and FHU studied and the nutritional care process during prenatal period according to the perception of the health service managers of local health care facilities, also known as department/sector heads. The choice of these managers as a source of information is due to their central role in decision-making for the achievement of the goals established in guidance documents for health care services of SUS. Therefore, there was no on-site evaluation by the researcher, but the managers' perception of the nutritional care provided was evaluated; they had access to internal documents, such as reports of production of different areas of service and surveillance indicators used, such as the Primary Care Information System and the Food and Nutrition Surveillance System, and they could talk to other staff professionals. The access to these sources was necessary for them to answer questions related to the beginning of the prenatal care, laboratory tests, number of visits, and nutritional monitoring.

Based on Ministry of Health protocols^6,7,26 and on the guidelines issued by the Política Na-cional de Alimentação e Nutrição (PNAN, National Food and Nutrition Security Policy)⁸, the data collection instrument consisted of closed-ended questions about the health services provided, such as infrastructure, team members, work process, and food and nutrition surveillance. The questionnaire also included questions that enabled the analysis of nutritional care management focusing on prenatal and postpartum care. The collection instrument was pre-tested.

The health service managers were interviewed by interviewers previously trained in the use of this data collection instrument. The managers of 28 health units signed the free and Informed Consent, and the interviews were then conducted at their workplace in December 2012. Each interview lasted between 60-90 minutes.

The data were analyzed with descriptive statistics using frequentist inference and measures of central tendency and dispersion to characterize the health care and the food and nutritional care services provided. The statistical analysis was conducted using the software Epi Info (Centers for Disease Control and Prevention, Atantla, Georgia, United States) version 3.5.3 and the Statistical Package for Social Sciences^(r) (SPSS Inc., Chicago, Illinois, United States) version 16.

This study was approved by the Research Ethics Committee of theUniversidade Federal de São Paulo (Protocol nº 32900).

RESULTS

A total of 28 managers of Santos' health units were interviewed (24 women and 4 men). The average age of the respondents was 41.6 years (Standard Deviation-SD=8.8), and their average length of employment was 45.3 months (SD=38.3). With regard to their professional training or background, most of the interviewees (n=20) were nurses; the others were dentists (n=3), social workers (n=2), psychologists (n=2), and pharmacists (n=1).

Table 1 shows the dimension structure data for the provision of nutritional care. With regard to the equipment for anthropometric measurements, low rate of compliance was found only for the availability of portable scale in the BCU. More than 89.0% of the units evaluated showed compliance for other types of equipment. According to the majority of respondents, the frequency of equipment maintenance was considered as low (42.8%), followed by regular (35.7%), and good (17.8%).

Tabela 1
Avaliação de conformidade da estrutura de unidades de saúde para atenção ao pré-natal e ao puerpério por tipo de serviço segundo percepção dos gestores. Santos (SP), 2013 (n=28).

• Nota: UBS: Unidade Básica de Saúde; USF: Unidade de Saúde da Família.

With respect to the physical space, the variable group educational activities showed the lowest rate of compliance. Only 26.3% of BCU and 33.3% of FHU had adequate space. As for the remaining physical space-related variables, the BCU showed higher rate of compliance than the FHU. Despite the high rate compliance of the variables related to anthropometric measurement equipment, especially in the FHU (100.0%), the compliance of the physical space to perform these measurements was 73.7% in the BCU and 55.6% in the FHU. As for the proper implementation of the Ministry of Health technical manuals, 78.9% of the BCU and 88.9% of the FHU showed compliance regarding the existence and use of the "Prenatal and Postpartum Technical Manual", and 62.3 and 77. 8% of the BCU and FHU, respectively, showed compliance regarding the "Primary Care Guidelines: infant care - infant nutrition, breastfeeding, and diet supplementation".

Table 2 shows the health service managers' perception of the inclusion of the dieticians and training on anthropometric procedures; both are variables of the dimension structure. In only 13 BCU (68.4%) and 6 FHU (66.6%) out of the 28 health units assessed, there was inclusion of dietitians, among which in 12 BCU these professionals worked only part-time and in one of them they worked full-time. Four out of these 6 FHU employed part-time dietitians and 2 had full-time dietitians. Most of the managers interviewed considered the inclusion of dietitians in the Primary Health Care units of Santos as insufficient.

Tabela 2
Avaliação de conformidade do processo de atenção ao pré-natal, por tipo de serviço, segundo percepção dos gestores Santos (SP), 2013 (n=28).

• Nota: UBS: Unidade Básica de Saúde; USF: Unidade de Saúde da Família; IMC: Índice de Massa Corporal.

The compliance of the variables of the prenatal care process is shown in Table 2. According to the health service managers, all units evaluated showed compliance of the variables beginning of prenatal care in the first trimester of pregnancy and the minimum of six visits. The other variables showed higher compliance for the FHU than for the BCU, exception for the procedures identification of nutritional risk assessment, height measurement, nutritional assistance as prenatal care routine, and routine supplementation, which showed slightly higher compliance in the UBSs evaluated.

In addition to the low percentage of health units that provide nutritional assistance in routine prenatal care, Table 2 shows the low adequacy of the BCU and FHU evaluated in terms of the procedures necessary for monitoring nutritional status, such as calculation of Body Mass Index (BMI) and monitoring and update of BMI/gestational age curve, according to official recommendation⁷.

Most of the procedures recommended by the Ministry of Health⁷ for the postpartum period are more frequently performed in the FHU (Table 3). With regard to the postpartum and newborn care provided, the following variables were observed in less than 50% of the BCU: home visit in the first week after birth for care of both postpartum women (in general) and newborns at risk; the First Week of Comprehensive Health between the 7^th and 10^th day after birth; and evaluation of social vulnerability and dietary quality of postpartum women. The variable home visit in the first week to newborns at risk showed compliance in less than 50% In the FHU evaluated.

Tabela 3
Avaliação de conformidade do processo da atenção ao puerpério, por tipo de serviço, segundo percepção dos gestores.

• Nota: UBS: Unidade Básica de Saúde; USF: Unidade de Saúde da Família.

DISCUSSION

This study aimed to evaluate the nutritional care provided during the prenatal and postpartum periods by the Primary Health Care of SUS, in the city ofSantos, in terms of its structure and process based on a census of health facilities. According to Donabedian²⁴, the dimension structure is represented by material resources, human resources, and organizational structure, which, when adequate, ensure the existence of a good process characterized by the care provided by health professionals and the care received by users in order to promote good outcomes²⁴. As a differential assessment, the present study was based on the premise that nutritional care is essential for comprehensive health care.

Recent studies addressed prenatal care quality^2,15,18,26 using the model proposed by Donabedian²⁴; however, no studies were found that examined nutritional care during prenatal and postpartum periods in the Primary Health Care considering the dimensions structure and process. It is worthy to mention that in the present study, it was proposed a model for the evaluation of health services focusing on the nutritional care provided during the prenatal and postpartum periods based on the Ministry of Health recommendations, which emphasizes its innovative character.

Overall, the compliance rates found were higher than those reported in the literature, possibly due to the methodology used. The responses to the questionnaire applied during the interviews with the health service managers might have been influenced by information bias and might have been overvalued due to their prior knowledge of the recommendations for the prenatal and postpartum periods, which is therefore a limitation of this study. Such limitation could have been reduced by using different approaches such as the direct observation, participant observation, or longitudinal study. A research conducted with similar methodology revealed that managers and other professionals tend to score this kind of services using higher points, and managers are the ones who best give their opinions about the dimensions of these services²⁷.

There is no standard for the evaluation of structure of health units. In general, official documents and ordinances of the Ministry of Health, such as the "Primary Care Manual: Prenatal care for low-risk pregnancy"⁷, the "Manual of physical structure of Primary Health Units"²⁸ and the "Primary Care National Policy"²⁹, are used. Health units should have equipment and materials adequate for implementation of these actions and recommendations, as well as meeting rooms for group meetings and health education^28,29.

During the prenatal and postpartum periods, pregnant women and infants need to have their weight and height/length measured regularly to ensure proper monitoring of nutritional status⁷. As for the necessary basic equipment for these measurements, two BCU lacked vertical height measuring anthropometers, making it impossible to measure the height of adults and to monitor nutritional status. Moreover, equipment maintenance, considered as bad by most managers interviewed, is essential to enable anthropometric assessment. With regard to the physical space for anthropometry, there is no specific recommendation; the equipment can be placed in doctors' offices. Nevertheless, according to nine managers, there was lack of adequate space for this practice.

The adequacy of physical space for meetings, educational activities, and case discussions was considered even more unsatisfactory by the managers interviewed. The Ministry of Health recommends individual or group educational activities during the entire care period. It is worthy to highlight the low percentage of adequate physical space for these activities; less than 30% of the managers considered them adequate although about 80% stated that these activities are performed in their units.

This study also evaluated the health service managers' perception of the anthropometry training provided; 85.7% of them considered it as insufficient. This result reveals the need for actions in terms of the food and nutritional care services in Primary Health Care that include the presence of dietitians, corroborating the findings of Camossa et al.³⁰, who highlighted that the presence of dietitians is important to form a fully qualified health care professional team, suggesting the use of matrix support model.

The evaluation of structure also showed low inclusion rate of dietitians in the Primary Health Care system of Santos. The city has only three dietitians working in the island and mainland areas. In the insular area, these professionals work one or two four-hour shifts per week in each one of the 19 units located in this area. Six BCU and three FHU out of the 28 HU evaluated did not have dietitians. In spite of that, the managers interviewed considered the number of dietitians as sufficient in more than half (n=11) of the units that actually have these professionals as part of their staff, perhaps because they are unaware of their potential contribution to the qualification of health team in primary care.

The recommended actions for food and nutritional care for the prenatal and postpartum periods are available to the health service managers of Primary Health Care^7,26. However, approximately 20 and 30% of the managers of the BCU and FHU evaluated, respectively, reported that they did not know about these materials or do not use them, which can indicate non-recognition of the importance of these actions to prenatal and postpartum care.

The assessment of the adequacy of the prenatal care has been addressed in recent studies. Considering the minimum standard requirements recommended by thePrograma de Humanização no Pré-natal e Nascimento (PHPN, Prenatal and Birth Humanization Program) - early prenatal care and the minimum of six visits - the results of the dimension process are higher than those reported in other studies. Domingues et al.⁵ reported that the late start of prenatal care in 25% of the pregnant women evaluated in the city of Rio de Janeiro (RJ) affected the number of visits received for those who started after 16 weeks of pregnancy. In another study, Vettore et al.³¹ found inadequacy of prenatal care in 14% of pregnant women according to the Kotelchuck index, classification used when prenatal care begins after the 4^th month or less than 50% of recommended visits were received. Anversa et al.³² also identified low adequacy (59%) of prenatal care in the municipality of Santa Maria (RS), when evaluating the beginning of prenatal care, before 20 weeks, and the minimum number of six visits. Low adequacy of prenatal care has also been reported in international scientific publications^20,33. It is important to mention that in the studies mentioned above, a documentary research was conducted based on the medical records and the maternity card, whereas in this study, in which it was found compliance of these two criteria in 100% of the cases, health service managers' perception of adequacy was evaluated. This may suggest an overestimation of the values found since these adequacy criteria are well-known by the managers and are constantly evaluated.

As for the nutritional care in this period of life, the results of in the present study for the following criteria were considered unsatisfactory: calculation of BMI, monitoring and updating of BMI/gestational age curve, and nutrition counseling in routine prenatal care. Despite these results, about 90% of the managers interviewed reported that identification of nutritional risk is made and blood pressure, weight, and height are measured at every visit. There has been increased compliance with the criteria recommended by the PHPN, according to the latest "Pesquisa Nacional de Demografia e Saúde da Mulher" (National Health and Demographic Survey of Children and Women)¹. However, inadequacies of prenatal and postpartum care have been identified in the literature with respect to the minimum actions for quality care recommended by this Program.

The high frequency of identification of nutritional risk and the low frequency of BMI calculations reported by the health service managers is a paradoxical finding of the present study. The Ministry of Health⁷ recommends monitoring maternal nutritional status during pregnancy to identify nutritional risk, which is verified by calculating BMI (weight/height²⁾. Therefore, the high adequacy of identification of nutritional risk reported by the managers may refer to the maternal weight gain measurements alone since the adequacy of this criterion was considered 100% by them.

Niquini et al.¹⁵ evaluated the nutritional care in the prenatal period in 7 FHUs inRio de Janeiro and found similar results. Among the 230 pregnant women evaluated, the number of weight measurements recorded in about 90% was the same as the number of prenatal visits attended, according to their maternity card. On the other hand, 90% of the maternity cards did not have any BMI/gestational age curve updates. These data reinforce the findings of this study about the importance given by the health professionals to the pregnancy weight gain as an isolated criterion to identify nutritional risk, regardless of nutritional status assessment, which includes BMI calculation and monitoring and updating the BMI/gestational age curve.

The lack of nutrition counseling in routine prenatal care observed in the present study reflects in the poor monitoring of nutritional status during pregnancy, hindering the necessary treatment and interventions. According to the literature, the rate of inadequate pregestational nutritional status is quite high, and it was found to be 40% in pregnant women users of SUS^31,34,35 in Brazil as well as in other countries^19,36,37; thus it is considered a public health issue since high quality prenatal care, including food and nutrition surveillance, should be provided⁷.

Inadequacies of nutritional care were identified in the present study since there is poor or no monitoring of nutritional status and lack of health-promoting actions that could improve nutrition and the well-being health of mothers and infants, making it difficult to provide a comprehensive prenatal care.

The compliance rate of the laboratory tests carried out in the beginning and end of pregnancy was higher than that of other studies that reported compliance rates below 50%^2,5,32. Results higher than those were also found the literature for iron and folic acid routine supplementation¹⁵.

With regard to postpartum care, higher compliance of newborn care was found in the present study. This seems to reinforce the dissociation between the health of new mothers and newborns by changing the focus of the health care from the maternal care to the child's care undermining the importance that should be given to women's health³⁸. The health service managers recognize the need for postpartum visits, which explains the high rate of adequacy found in this study. However, this recognition did ensure the provision of these visits, as demonstrated by Parada², who found records of postpartum visits in 58.7% of the medical records of the pregnant women evaluated.

The results of evaluation of nutritional and dietary quality in postpartum women were unsatisfactory, just like those found during the prenatal care. It is also important to mention the low rate of compliance of social vulnerability evaluation, indicating inadequate comprehensive care. The evaluation of these criteria was not reported in other studies on prenatal and postpartum care^2,39.

The variables related to newborn care in the postpartum period showed higher rate of compliance, including the nutritional status assessment. The discrepancy between the rate of compliance of weight measurements and determination of average weight gain seems to reinforce the underestimated role of this indicator in the monitoring of nutritional status at the beginning of the infant's life.

High rate of compliance was found in the present study for Exclusive Breastfeeding promotion, but less satisfactory results were found for home visits in the BCU evaluated. Systematic reviews that supported the Public Policies for Breastfeeding Encouragement showed that among the strategies with empirical evidence of effectiveness in promoting breastfeeding are: prenatal groups, home visits, mothers' groups, and individual counseling during the prenatal and postpartum periods, enabling dialogue with the patients, a central element of food and nutrition education^40,41.

As for the nutritional care in the postpartum period, although there are few studies on postpartum maternal health, these studies highlight the importance of actions for promotion and encouragement of breastfeeding, emphasizing the gap between the care for pregnant women and the care for the newborns.

Even lower rates of compliance were found for home visits to postpartum women in the first weeks following childbirth. In terms of comprehensive care, home visits are considered very important for health protection, and therefore they should be frequent in order to strengthen the link between pregnant/lactating women and health units, according to the integrated approach to women and their families in the social context⁷. For an effective support to breastfeeding, the home care visit to the nursing mother should occur up to 14 days after birth since this is a period of intensive learning and particular difficulties and challenges for the new mother, which can lead to early weaning⁴².

Although there was no great difference in the parameters evaluated between the BCU and FHU, perhaps due to the small number of units evaluated, the highest rate of compliance was found in the FHU, corroborating the results of other studies that compared the prenatal care provided in different types of Primary Health Care services^32,39. The need for early follow-up in the postpartum period is emphasized in the study of Parada⁴³, who found a significant association between the arising of difficulties at the beginning of breastfeeding and lower prevalence of exclusive breastfeeding.

In general, the structure variable most frequently mentioned as insufficient by the managers was the inclusion of dietitians in the municipal Primary Health Care system. This may negatively affect the performance of other components of the dimension process and, consequently, the food and nutrition services provided because of the limited assistance of these professionals and the probable lack of matrix support.

Camossa et al.³⁰ evaluated the social representation of different family health professional teams in a city in the state of São Paulo. They found very narrow views of the professional contribution of dietitians. They are seen as "professionals that prescribe a diet" or who "help patients to lose weight". Another relevant aspect verified by Camossa et al.³⁰ and Padua & Boog⁴⁴ was nutritional counseling done by other professionals, especially physicians, who, in most cases, do it in a restrictive and imposing manner. Both studies showed their lack of professional knowledge to address food and nutrition problems. Camossa et al.³⁰ highlights that many health professionals do not recognize the expertise and specific professional qualifications of dietitians and often see them as doctors' assistants to save time. According to the Dietitians and Nutritionists Federal Council, specialized nutritional care and nutrition education are specific duties of dietitians. Thus, public health services should not lack these professionals⁴⁵.

The present study presents innovative elements, both because it includes a census of health facilities in the city of Santos, reflecting the reality of nutritional care provided by the city's Primary Health Care system, and because it includes an evaluation of local health service managers', making it possible to infer their view of the nutritional care management in the Primary Health Care system.

The lack of knowledge of these managers about the National Food and Nutrition Security Policy and about the complexity of nutritional care in Maternal and Infant Health Care Policies was evident. The low rate of compliance of the monitoring of nutritional status of pregnant women, inadequacy of health education activities, and lack of nutritional counseling in routine prenatal care found in this study should raise awareness among the Primary Health Care mangers of Santos.

In this period of life, nutritional care is an essential component for comprehensive care since many risk factors for maternal and infant morbidity and mortality, such as low birth weight, gestational hypertensive syndrome, and gestational diabetes mellitus are directly associated to the nutritional status of pregnant women and therefore need nutritional intervention during prenatal care^9-11.

Finally, it is concluded that in order to provide comprehensive maternal and newborn health care, it is necessary to sensitize the managers of the Primary Health Care system and those of the Municipal Secretariat of Health of the other levels of health care to ensure the effectiveness of food and nutrition actions during the prenatal and postpartum periods. The results of this study can contribute to review the public policies of Santos in order to reduce infant mortality in the city.

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ACKNOWLEDGEMENTS

The authors wish to thank Conselho Nacional de Desenvolvimento Científico e Tecnológico for sponsory the study.

• 5
  Artigo baseado na dissertação de ASC LAPORTE-PINFILDI, intitulada "A estratégia de atenção nutricional no pré-natal e puerpério e a integralidade da atenção materno infantil". Universidade Federal de São Paul; 2014.
• Apoio: Conselho Nacional de Desenvolvimento Científico e Tecnológico (Processo nº 486017/2011-7).

Publication Dates

• Publication in this collection
  Jan-Feb 2016

History

• Received
  11 Nov 2014
• Reviewed
  08 Aug 2015
• Accepted
  22 Sept 2015