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Evaluation of prenatal care in Primary Health Care in Brazil

Abstract

Objectives:

to evaluate prenatal care in Primary Care by identifying the aspects that influence structural and operational adequacy.

Methods:

evaluation research with analysis of 4,059 municipalities that joined the 2nd cycle of the Program for Improving Access and Quality in Primary Care in 2013-2014. The evaluative model composed of 19 indicators grouped in structural aspects and operational aspects dimensions was validated in a consensus conference. Data analysis was descriptive, with the issuance of value judgment.

Results:

in structural aspects, 32.6% of the municipalities presented adequacy, whilst in operational ones, only 24.1%. In the general prenatal evaluation, less than a quarter (24.6%) of the municipalities was adequate, those with up to 10 thousand inhabitants had a higher percentage of adequacy (41.6%). The South region presented adequacy of 33.8%, considering all sizes.

Conclusions:

most municipalities presented low adequacy in prenatal care, with better performance of structural aspects. Smaller municipalities presented better results in all analyzed items. Structural aspects and general evaluation of prenatal care are highlighted in the South region. Adequate attention to prenatal care needs to be comprehensive and equitable, with the strengthening of regional networks geared towards social inclusion.

Key words
Health evaluation; Primary health care; Quality assurance; Health care

Resumo

Objetivos:

avaliar a atenção ao pré-natal na Atenção Básica identificando os aspectos que influenciam a adequação estrutural e operacional.

Métodos:

pesquisa avaliativa com análise de 4.059 municípios que aderiram ao 2° ciclo do Programa de Melhoria do Acesso e da Qualidade na Atenção Básica em 2013-2014. O modelo avaliativo composto por 19 indicadores agrupados nas dimensões aspectos estruturais e aspectos operacionais foi validado em conferência de consenso. A análise de dados foi descritiva, com emissão de juízo de valor.

Resultados:

nos aspectos estruturais 32,6% dos municípios apresentaram adequação e nos operacionais, apenas 24,1%. Na avaliação geral do pré-natal menos de um quarto (24,6%) dos municípios ficaram adequados, àqueles com até 10 mil habitantes apresentaram maior percentual de adequação (41,6%). A região Sul apresentou adequação de 33,8%, considerando todos os portes.

Conclusões:

a maior parte dos municípios apresentou baixa adequação na atenção ao pré-natal, com melhor desempenho dos aspectos estruturais. Municípios de menor porte apresentaram melhores resultados em todos os itens analisados. Destaque para a região Sul nos aspectos estruturais e na avaliação geral do pré-natal. Uma adequada atenção ao pré-natal precisa ser integral e equânime, com fortalecimento das redes regionais voltadas para a inclusão social.

Palavras-chave
Avaliação em Saúde; Atenção Primária à Saúde; Garantia da Qualidade dos Cuidados de Saúde

Introduction

Prenatal care includes health education actions, risk identification, prevention and treatment of complications and diseases, requiring planning and structuring to guarantee access and continuity of care with effective comprehensiveness of care, in order to promote mother and child health.11 World Health Organization (WHO). WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO; 2016. [acesso em 26 jan 2019]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912eng.pdf;jsessionid=18BB411AA9F40CFF591B9F90322FBA65?sequence=1
https://apps.who.int/iris/bitstream/hand...
,22 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação / Ministério da Saúde. Brasília, DF; 2018. 180 p.:il.

Low-risk prenatal care is configured as one of the main programmatic actions carried out in Primary Care (PC). The whole process of women's health care is influenced by the social, economic and cultural context of the environment in which pregnant women and concepts live. Structural and operational aspects must be guaranteed for continuous and quality monitoring, with humanized care to pregnancy. Prenatal care involves a warm relationship and the systematic follow-up of the pregnant woman contributes to the early detection of diseases and gestational risk, preparation for childbirth and establishment of a bond with motherhood.33 Sena IVA. Qualidade da Atenção Pré-Natal na Estratégia Saúde da Família: Revisão de Literatura. [internet]; 2014 [acesso em 19 jan 2019]. Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/4555.pdf.
https://www.nescon.medicina.ufmg.br/bibl...

The inadequacy of prenatal care actions is associated with negative effects such as prematurity and low birth weight, in addition to increased risk of fetal and maternal death, hospitalizations in intensive care units, postpartum depression and anxiety, and successive pregnancies in a short time.44 Tsunechiro MA, Lima MOP, Bonadio IC, Corrêa MD, Silva AVA, Donato SCT. Avaliação da assistência pré-natal conforme o Programa de Humanização do Pré-natal e Nascimento. Rev Bras Saúde Mater Infant. 2018; 18 (4): 781-90.,55 Heaman MI, Martens PJ, Brownell MD, Chartier MJ, Derksen SA, Helewa ME. The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada. J Obstet Gynaecol Can. 2019. (No prelo).

In Brazil, there has been an increase in coverage of prenatal care in the last years in most of the country,66 Luz LA, Aquino R, Medina MG. Avaliação da qualidade da Atenção Pré-Natal no Brasil. Saúde debate. 2018; 42 (n. spe2): 111-26.,77 Nunes JT, Gomes KRO, Rodrigues MTP, Mascarenhas MDM. Qualidade da assistência pré-natal no Brasil: revisão de artigos publicados de 2005 a 2015. Cad Saúde Colet. 2016; 24 (2): 252-61. coinciding with the institutionalization of actions aimed at the comprehensiveness of care, proposed from different national programs in the period from 1984 to 2011. Despite this, the challenges persist with a high level of inadequacy of actions, endangering maternal and child health.66 Luz LA, Aquino R, Medina MG. Avaliação da qualidade da Atenção Pré-Natal no Brasil. Saúde debate. 2018; 42 (n. spe2): 111-26.

High child mortality rates, with a higher concentration of deaths in the early neonatal components,22 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação / Ministério da Saúde. Brasília, DF; 2018. 180 p.:il.,88 França EB, Lansky S, Rego, MAS, Malta DC, França JS, Teixeira R. Principais causas da mortalidade na infância no Brasil, em 1990 e 2015: estimativas do estudo de Carga Global de Doença. Rev Bras Epidemiol (online). 2017; 20 (Suuppl 1): 46-60. and the still high maternal mortality rate (58 maternal deaths out of 100 thousand live births), with expressive disparities in the country,99 Brasil. Ministério da Saúde. Departamento de Informática do Sistema Único de Saúde -DATASUS. Informação sobre nascidos vivos e óbitos maternos do ano de 2016. [acesso em 13 jul 2018]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6939&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/mat10.
http://www2.datasus.gov.br/DATASUS/index...
reinforce the existence of failures in the care provided.

The institutionalization of prenatal care evaluation is a fundamental strategy for the improvement of quality with consequent reduction of maternal and infant morbimortality,1010 Guimaraes WSG, Parente RCP, Guimaraes TLF, Garnelo L. Acesso e qualidade da atenção pré-natal na Estratégia Saúde da Família: infraestrutura, cuidado e gestão. Cad Saúde Pública. 2018; 34 (5): e00110417. since it reveals and produces subsidies for awareness and confrontation with failures, reviewing public policies and managerial and procedural adaptations, in order to respond more adequately and with immediate solution the needs of this population group. Studies that evaluated prenatal care with national coverage observed inadequacies in relation to the recommended66 Luz LA, Aquino R, Medina MG. Avaliação da qualidade da Atenção Pré-Natal no Brasil. Saúde debate. 2018; 42 (n. spe2): 111-26.,1010 Guimaraes WSG, Parente RCP, Guimaraes TLF, Garnelo L. Acesso e qualidade da atenção pré-natal na Estratégia Saúde da Família: infraestrutura, cuidado e gestão. Cad Saúde Pública. 2018; 34 (5): e00110417.,1111 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SMS, Saes MO, Nunes BP, Fassa AG, Facchini, LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saúde Pública. 2017; 33 (3): e00195815. and had as a unit of analysis users1111 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SMS, Saes MO, Nunes BP, Fassa AG, Facchini, LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saúde Pública. 2017; 33 (3): e00195815. and PC66 Luz LA, Aquino R, Medina MG. Avaliação da qualidade da Atenção Pré-Natal no Brasil. Saúde debate. 2018; 42 (n. spe2): 111-26.,1010 Guimaraes WSG, Parente RCP, Guimaraes TLF, Garnelo L. Acesso e qualidade da atenção pré-natal na Estratégia Saúde da Família: infraestrutura, cuidado e gestão. Cad Saúde Pública. 2018; 34 (5): e00110417. teams, and it was necessary to advance in the aspects of municipal management responsibility.

Accordingly, the objective of this study was to evaluate prenatal care in PC by identifying the aspects that influence structural and operational adequacy, with a focus on management, having the Brazilian municipalities as a unit of analysis.

Methods

Evaluative study, of quantitative based approach of the low risk prenatal care having as analysis units the Brazilian municipalities that participated in the external evaluation of the Program for Improving Access and Quality of Primary Care (PMAQ - AB), in 2013 - 2014.

The municipalities that have joined with at least 80% of the teams in the 2nd cycle of PMAQ - AB were included, and responded to modules I and II. The sample consisted of 4,059 municipalities, 19,849 Basic Health Units (BHU) and 24,626 participants in the Family Health Strategy (FHS).

The theoretical-logical model and the matrix of analysis and judgment are based on documental and bibliographic research pertinent to the theme. The main documents used were the ordinance that established the Stork Network (2011) and the Technical Standards and Manuals of the series of Notebooks of Primary Care n° 18, n° 26 and n° 32: HIV/Aids, hepatitis and other sexually transmitted diseases (2006), Sexual health and reproductive health (2010) and Attention to low risk prenatal care (2013), respectively.

The evaluative model was validated in Consensus Conference, in two stages: distance and face-to-face meeting. A group of eight experts from the field of women's health and/or public policy evaluation participated in the two phases. The model was emailed and the experts were invited to give their full, partial agreement or disagreement within 15 days. The researchers consolidated the answers and cases of discordance were the subject of debate in the face-to-face meeting. All suggestions were included from consensus.

The analysis and judgment matrix has two dimensions, six sub-dimensions, 19 indicators and 30 measures. The "structural aspects" dimension analyzes the conditions of infrastructure, human resources and standardization of care that give the conditions for the teams to carry out their activities. The "operational aspects" dimension analyzes the activities carried out by the teams, focusing on the organization of care, promotion and prevention and follow-up (Tables 1 and 2).

Table 1
Analysis and judgment matrix of structural aspects of the evaluation of prenatal care in Primary Care. Brazil, 2017.
Table 2
Analysis and judgment matrix of the operational aspects of the evaluation of prenatal care in Primary Care. Brazil, 2017.

In addition to the PMAQ - AB database, the official sites of the Live Birth Information System (Sinasc), the National Registry of Health Establishments (CNES) and the Brazilian Institute of Geography and Statistics (IBGE) were used as sources of evidence.

The parameters for the issuing of value judgments that guided the descriptive analysis were defined based on literature review, documentary research and the fact that all actions chosen were well founded, based on scientific evidence and recommended in official documents for at least five years. (Tables 1 and 2).

In the analysis of the measures it was considered adequate when in the municipality at least 90% of the BHU or FHS teams performed the action (s); inadequate when less than 75% of the BHU or FHS teams performed the action (s); and minimally adequate, in the rest of the cases. There was an exception in four measures: for minimum adequate FHS team, FHS teams with oral health and population coverage, the parameters were defined by population size, by tertile distribution, and for extended hours of operation, they were also defined by population size, but by quartile distribution.

Data were analyzed using Microsoft Office Excel® and SPSS 22.0 software and presented in tabular form.

For indicators with more than one measure it was considered adequate when all measures were classified as adequate, inadequate when all measures were classified as inadequate and the other situations, as minimally adequate.

Initially, measures and indicators were analyzed and, in the aftermath, the conversion into scores 1.0 (adequate) 0.5 (a) and 0.0 (inadequate) was made. The analysis was guided by the sum of the scores, followed by the calculation of the percentage of points obtained compared to the maximum score expected in each of the components, as follows: (Σ obtained / Σ expected) x100. For the value judgment of dimensions, the cut-off points used were: adequate (100%-75% of the expected), inadequate (less than or equal to 50% of the expected) and the other cases were minimally adequate, received weight two, considering it with greater influence on the adequacy of attention.

The study was approved by the Human Research Ethics Committee of the Federal University of Santa Catarina (CEPSH/UFSC), Opinion n° 1.599.464. CAAE n° 53671016.1.1001.0121.

Results

The study analyzed 72.9% of the total number of Brazilian municipalities, predominantly with a population size of less than 25 thousand inhabitants (78.8%), with less than one quarter (24.6%) presenting an adequate prenatal care.

In Table 3, it is observed that the structural aspects dimension 39.1% of the municipalities was classified as minimally adequate. In the analysis of the infrastructure, the physical space presented more than half of the adequate municipalities (69.6%). Regarding human resources, a positive highlight was the specialized support with 86.4% of the municipalities offering specialist support to the PC teams and for the population coverage that showed adequacy in 53.3% of the municipalities. The standardization of care was the subdimension with the highest percentage of inadequate municipalities (62.0%), especially in the standardization of care indicator.

Table 3
Classification of municipalities in the evaluation of prenatal care in Primary Care according to components, dimensions and subdimension Brazil, 2017.

The classification in the dimension of operational aspects was minimally adequate in 49.1% of the municipalities. In the organization of the care, the appropriation of the territory (82.3%) and the early capture (56.9%) were indicators with the highest percentages of adequacy. While in the access indicator 63.9% of the municipalities were inadequate, that is, they do not have health units with an extended working period. In the analysis of promotion and prevention actions, a low percentage of municipalities (22.6%) presented adequacy in the early diagnosis of pregnancy, HIV and syphilis. In the follow-up subdimension, most municipalities (58.7%) were inadequate, especially in gestational follow-up (64.8%). In contrast, the continuity of care is within the expected level in 74.9% of the municipalities.

With regard to the population size and regional location (Tables 4 and 5), municipalities with up to 10,000 inhabitants achieved better results in structural aspects (50.8%), operational aspects (38.6%) and general prenatal evaluation (41.6%), compared to the others. Regarding location, the worst results were observed in the North region in all items analyzed. The Southeast region presented adequacy in operational aspects and the South region in structural aspects and the general prenatal evaluation.

Table 4
Evaluation of structural, operational aspects and overall evaluation of prenatal care in Primary Care, according to population size. Brazil, 2017.
Table 5
Evaluation of structural, operational aspects and overall evaluation of prenatal care in Primary Care, according to regions. Brazil, 2017.

Discussion

The analysis of this study reveals relevant data on prenatal care under the responsibility of Brazilian municipalities. Less than a quarter of the municipalities presented prenatal adequacy in PC, with worse conditions in the ones with larger population size and located in the North region.

Between the two dimensions analyzed, the structural aspects presented a greater number of municipalities classified as adequate. In the infrastructure analysis, financial incentives from the Ministry of Health offered to municipalities since 2011 for the reform, expansion and construction of BHU could have contributed to the result of adequacy of the physical space, with a view to improving working conditions, access and quality of PC.1212 Brasil. Diário Oficial. Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Brasília, DF; n.204, p.55, 24 out. 2011; Seção 1, pt1.

The high percentage of municipalities offering specialized support is another positive aspect in this dimension, since a care network must be activated in cases that exceed the competencies of the PC teams. In this network are the Family Health Support Center (NASF) and specialists who provide matrix support and care, fundamental to ensure qualified and resolutive clinical action. However, as in other studies,1111 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SMS, Saes MO, Nunes BP, Fassa AG, Facchini, LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saúde Pública. 2017; 33 (3): e00195815.,1313 Viellas EF, Domingues RM, Dias MA, Gama SG, Theme Filha MM, Costa JV, Bastos, MH, Leal, MC. Assistência pré-natal no Brasil. Cad Saúde Pública. 2014; 30 (Suppl. 1): S85-S100. problems were identified in the adequacy of personnel and population coverage. These are extremely important factors in ensuring that the demands of the population are met without increased workload and with a satisfactory team-population relationship.1414 Faria HP, Werneck MAF, Santos AS, Teixeira PF. Processo de trabalho em saúde: protocolo de cuidado à saúde e organização do serviço. 2 ed. Belo Horizonte: COOPMED; 2009.

In the subdimension of standardization of care, most municipalities were inadequate, differing from the findings of Luz et al.66 Luz LA, Aquino R, Medina MG. Avaliação da qualidade da Atenção Pré-Natal no Brasil. Saúde debate. 2018; 42 (n. spe2): 111-26.. It is worth mentioning that the authors analyzed the availability of protocols, unlike the measure adopted in this study that included the information of its use. Municipal management needs to standardize care and encourage teams with respect to the use of clinical protocols for safe decision-making and quality in the care for pregnant women in all units and health services.

Operational aspects are fundamental for the comprehensive and equitable care of the mother / baby binomial. In the organization of care, teams must provide access and adherence to health services. Teams from the municipalities studied, mostly, have information of the territory, make early capture and offer scheduled appointments, according to the gestational risk. Such strategies are fundamental for continuous follow-up with a view to reducing risks and possible complications for the pregnant woman and the fetus.1414 Faria HP, Werneck MAF, Santos AS, Teixeira PF. Processo de trabalho em saúde: protocolo de cuidado à saúde e organização do serviço. 2 ed. Belo Horizonte: COOPMED; 2009.,1515 Silva MZN, Andrade AB, Bosi MLM. Acesso e acolhimento no cuidado pré-natal à luz de experiências de gestantes na Atenção Básica. Saúde Debate. 2014; 38 (103): 805-16. However, access to the BHU was inadequate, with almost two-thirds of the municipalities without an alternative schedule of care for the pregnant worker. Similar findings were reported by Silva MZN et al.1515 Silva MZN, Andrade AB, Bosi MLM. Acesso e acolhimento no cuidado pré-natal à luz de experiências de gestantes na Atenção Básica. Saúde Debate. 2014; 38 (103): 805-16. corroborating the observation that the non-expansion of the opening hours of the units makes it difficult for pregnant women to access the service, as well as it threats their right to health.

Promotion and prevention actions ensure general health and well-being in the gestational period and include: early diagnosis, immunization, identification of diseases and health education. The findings on early diagnosis in this study deserve attention. Confirmation of pregnancy in the first months allows continuous follow-up, with more guidance and consultation, possibility of identification and appropriate treatment of diseases. Rapid tests of HIV and syphilis allow the immediate onset of follow-up as well as the prevention of vertical transmission of these diseases. The increase in the number of cases, especially syphilis in Brazil, reinforces the concern and demonstrates the importance of qualified prenatal care in PC.1616 Cruz RSBLC, Caminha MFC, Filho MB. Aspectos históricos, conceituais e organizativos do Pré-natal. Rev Bras Saúde. 2014; 18(1): 87-94.

Women should be followed throughout the gestational and puerperal cycle, at different points in the network. The ideal number of consultations is a controversial topic, but it is a frequent indicator in studies evaluating prenatal care. Some countries consider four, six, ten and can reach 15 consultations, as in Finland.1717 Silva EP, Lima RT, Costa MJC, Batista Filho M. Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal. Rev Panam Salud Pública. 2013; 33 (5): 356-62.

In 2016, the World Health Organization (WHO) expanded the number of consultations from four to eight, based on the scientific evidence that related the increase in the number of meetings with a lower probability of stillborn children.1 In Brazil, the last recommendation, defined in 2011, is at least seven prenatal consultations, and was used in this analysis. The prevalence of accomplishment of seven or more prenatal visits has increased in the country over the years, from 43.7%, in 2000, to 61.1%, in 2010.1818 César JA, Mendonza-Sassi RA, Gonzalez-Chica DA, Mano PS, Goulart Filho SM. Características sociodemográficas e de assistência à gestação e ao parto no extremo sul do Brasil. Cad Saúde Pública. 2011; 27 (5): 985-94.

19 Anversa ETR, Bastos GAN, Nunes LN, Dal Pizzol TDS. Qualidade do processo da assistência pré-natal: unidades básicas de saúde e unidades de Estratégia Saúde da Família em município no Sul do Brasil. Cad Saúde Pública. 2012; 28 (4): 789-800.

20 Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística (IBGE). Diretoria de Pesquisas. Coordenação de População e Indicadores Sociais. Estudos e Pesquisas: informação demográfica e socioeconômica número 32. Síntese de Indicadores Sociais: uma análise das condições de vida da população brasileira 2013. Rio de Janeiro: IBGE; 2013.
-2121 Anjos JC, Boing AF. Diferenças regionais e fatores associados ao número de consultas de pré-natal no Brasil: análise do Sistema de Informações sobre Nascidos Vivos em 2013. Rev Bras Epidemiol. 2016; 19 (4): 835-50. Despite advances, more than half of municipalities (64.8%) were inadequate in this indicator, considering the judgment parameter defined in this study.

Follow-up at different points in the network has been regular in most municipalities and its effects on the monitoring of high-income pregnant women and the return from maternity are a concerning issue. On the other hand, postpartum care continuity was adequate in most municipalities. Nearly three-quarters of the municipalities have at least 90% of the teams performing puerperal consultation until the 10th day following the birth, similar to what was found by other authors.2222 Oliveira RLA, Fonseca CRB, Carvalhaes MABL, Parada CMGL. Avaliação da atenção pré-natal na perspectiva dos diferentes modelos na atenção primária. Rev Latino-Am Enfermagem. 2013; 21 (2): 1-8.,2323 Corrêa MD, Tsunechiro MA, Lima MOP, Bonadio IC. Avaliação da assistência pré-natal em unidade com estratégia saúde da família. Rev Esc Enferm USP. 2014; 48 (Esp): 24-32. Concerning about the baby's health, calendar for vaccinations and early diagnosis tests, such as that of the foot, contribute to the return of puerperae to the unit during this period, and may justify the high percentage of adequacy of this indicator. Measures to improve network integration must be implemented in order to increase safety and improve outcomes in the follow-up of pregnant women.

The municipalities with larger population size showed the worst results compared to smaller ones, corroborating studies at the national level. Larger municipalities have more difficulties in equating public policy actions, while smaller ones are able to meet the basic needs of the population more easily.2424 Calvo MCM, Lacerda JT, Colussi CF, Schneider IJC, Rocha TAH. Estratificação de municípios brasileiros para avaliação de desempenho em saúde. Epidemiol Serv Saúde. 2016; 25 (4): 767-76.,2525 Domingues RMSM, Viellas, EF, Dias, MAB, Torres JÁ, Theme-Filha MM, Gama SGN, Leal, MC. Adequação da assistência pré-natal segundo as características maternas no Brasil. Rev Panam Salud Pública. 2015; 37 (3): 140- 7. As well as that found by other researchers,44 Tsunechiro MA, Lima MOP, Bonadio IC, Corrêa MD, Silva AVA, Donato SCT. Avaliação da assistência pré-natal conforme o Programa de Humanização do Pré-natal e Nascimento. Rev Bras Saúde Mater Infant. 2018; 18 (4): 781-90.,1111 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SMS, Saes MO, Nunes BP, Fassa AG, Facchini, LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saúde Pública. 2017; 33 (3): e00195815. the North region was the one that presented the worst results, requiring a development model committed to the reduction of regional inequalities and integration between levels of health care, combined with economic and social policies geared towards social inclusion.

In this study, an evaluation of prenatal care in PC was conducted with data from the PMAQ, using Brazilian municipalities as the unit of analysis. Limitations such as the use of secondary data made it difficult the deepening of the analysis. On the other hand, the exploration of data collected with public resources, in a research that adopted a qualified methodological process, is desirable. In the PMAQ, data collection is done with prior scheduling, interviewees are aware of the content of questions and it also provides financial contribution to the municipalities that meet established goals. Therefore, it would be expected to find slightly better results, which allows us to affirm that, in fact, data presented here can represent the Brazilian reality.

The reduction of maternal and child mortality rates is a global goal and it has been demanding from the managers actions that ensure equitable public policies and the strengthening of regional networks of care focused on social inclusion for decades.2626 Dourado DA, Elias PEM. Regionalização e dinâmica política do federalismo sanitário brasileiro. Rev Saude Pública. 2011; 45 (1): 204-11.

Most of municipalities in the country presented a low adequacy in prenatal care, even though the performance was better in structural aspects. It is recommended periodic prenatal evaluations to follow up and adopt measures that will improve the quality of this care.

References

  • 1
    World Health Organization (WHO). WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO; 2016. [acesso em 26 jan 2019]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912eng.pdf;jsessionid=18BB411AA9F40CFF591B9F90322FBA65?sequence=1
    » https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912eng.pdf;jsessionid=18BB411AA9F40CFF591B9F90322FBA65?sequence=1
  • 2
    Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação / Ministério da Saúde. Brasília, DF; 2018. 180 p.:il.
  • 3
    Sena IVA. Qualidade da Atenção Pré-Natal na Estratégia Saúde da Família: Revisão de Literatura. [internet]; 2014 [acesso em 19 jan 2019]. Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/4555.pdf
    » https://www.nescon.medicina.ufmg.br/biblioteca/imagem/4555.pdf
  • 4
    Tsunechiro MA, Lima MOP, Bonadio IC, Corrêa MD, Silva AVA, Donato SCT. Avaliação da assistência pré-natal conforme o Programa de Humanização do Pré-natal e Nascimento. Rev Bras Saúde Mater Infant. 2018; 18 (4): 781-90.
  • 5
    Heaman MI, Martens PJ, Brownell MD, Chartier MJ, Derksen SA, Helewa ME. The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada. J Obstet Gynaecol Can. 2019. (No prelo).
  • 6
    Luz LA, Aquino R, Medina MG. Avaliação da qualidade da Atenção Pré-Natal no Brasil. Saúde debate. 2018; 42 (n. spe2): 111-26.
  • 7
    Nunes JT, Gomes KRO, Rodrigues MTP, Mascarenhas MDM. Qualidade da assistência pré-natal no Brasil: revisão de artigos publicados de 2005 a 2015. Cad Saúde Colet. 2016; 24 (2): 252-61.
  • 8
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Publication Dates

  • Publication in this collection
    22 July 2019
  • Date of issue
    Apr-Jun 2019

History

  • Received
    15 Aug 2018
  • Reviewed
    25 Apr 2019
  • Accepted
    09 May 2019
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