Implementation of postpartum care for women in primary care in the South of Brazil

Tatiane Baratieri Sonia Natal About the authors

Abstract

Objectives:

to determine the implementation level and analyze favorable and unfavorable aspects of operationalization women’s care in postpartum period in primary care.

Methods:

evaluation study of the normative type, performed through a multiple case study in three cities in the South States in Brazil, with a collection of primary and secondary data. The implementation level (classification: satisfactory, partial, incipient, and critical) was determined by the Matriz de Análise e Julgamento (Analysis and Judgment Matrix), consisted of the dimensions of management and execution, and the respective sub-dimensions. Thematic and imbricated analysis of the cases were performed.

Results:

postpartum care was incipient in the management dimension for all the cases, with a higher implementation level for the “care coordination and intersectorality mechanisms” (partial) sub-dimension. In the execution dimension in case 3 was partially implemented, and the others were incipient. The breastfeeding sub-dimension had a higher implementation level for all the cases, and the longitudinality, mental health and reproductive planning sub-dimensions had a lower implementation level. Care in relation to domestic violence and mental health occurred unsystematically, and reproductive planning focused on hormonal contraceptive methods.

Conclusion:

management does not provide ideal conditions for healthcare professionals’ performance; and, in the execution dimension are not incorporated as the main necessity in the health care practice in women’s health.

Key words
Primary health care; Postpartum period; Women’s health; Health evaluation

Resumo

Objetivos:

determinar o grau de implantação e analisar aspectos favoráveis e desfavoráveis à operacionalização da assistência às mulheres no pós-parto na atenção primária.

Métodos:

estudo avaliativo do tipo normativo, realizado por estudo de casos múltiplos em três municípios dos Estados do Sul/Brasil, com coleta de dados primários e secundários. O grau de implantação (classificação: satisfatório, parcial, incipiente e crítico) foi determinado pela Matriz de Análise e Julgamento composta pelas dimensões gestão e execução, e respectivas subdimensões. Realizou-se análise temática e imbricada dos Casos.

Resultados:

a assistência pós-parto estava com implantação incipiente na dimensão gestão para todos os Casos, com maior grau de implantação para a subdimensão “mecanismos para coordenação do cuidado e intersetorialidade” (parcial). Na dimensão execução o Caso 3 teve implantação parcial, e os demais incipiente. A subdimensão aleitamento materno teve maior grau de implantação para todos os Casos, e as subdimensões longitudinalidade, saúde mental e planejamento reprodutivo tiveram menor grau de implantação. A assistência a violência doméstica e saúde mental ocorreram de forma assistemática, e o planejamento reprodutivo focou em métodos contraceptivos hormonais.

Conclusão:

a gestão não oportuniza condições ideais para atuação dos profissionais da assistência, e na dimensão execução não são incorporadas as principais necessidades de saúde das mulheres na prática assistencial.

Palavras-chave
Atenção primária à saúde; Período pós-parto; Saúde das mulheres; Avaliação em saúde

Introduction

There were 295,000 maternal deaths in 2017, worldwide, corresponding to 211 deaths per 100,000 live births, 57 was the rate in the Americas, and 60 deaths per 100,000 live births in Brazil, of these, the majority occurred in the first 42 days after childbirth.11 WHO (World Health Organization). The global health observatory [Internet]. Geneva: WHO; 2017; [access in 2020 Jan 31]. Available from: https://www.who.int/data/gho
https://www.who.int/data/gho...

Besides mortality, postpartum is a critical period in women’s lives, as they variously experience physical, emotional and social alterations, and the most undergo some kind of situation, such as bleeding, infection, pain (abdominal, perineal and back), headache, thromboembolism, urinary tract complications, breastfeeding difficulties, family conflicts, domestic violence, sexual and mental health problems.22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...

3 O’Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth. 2018 May; 18 (1): 196.
-44 Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13. These problems can be a short transition or persist for years after childbirth, the sooner the women’s necessities are met, the better the prevention and resolution of these problems will be.55 Giallo R, Pilkington P, McDonald E, Gartland D, Woolhouse H, Brown S. Physical, sexual and social health factors associated with the trajectories of maternal depressive symptoms from pregnancy to 4 years postpartum. Soc Psychiatry Psychiatr Epidemiol. 2017 Jul; 52 (7): 815-28.,66 Henderson V, Stumbras K, Caskey R, Haider S, Rankin K, Handler A. Understanding factors associated with postpartum visit attendance and contraception choices: listening to low-income postpartum women and health care providers. Matern Child Health J. 2016 Nov; 20 (Suppl 1): S132-S43.

Reducing maternal morbidity and mortality depends on ensuring access to quality care during prenatal, childbirth and postpartum;11 WHO (World Health Organization). The global health observatory [Internet]. Geneva: WHO; 2017; [access in 2020 Jan 31]. Available from: https://www.who.int/data/gho
https://www.who.int/data/gho...
however, in general, postpartum care is neglected by health professionals and institutions.77 WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013. Accordingly, Primary HealthCare (PHC), is due to the fact of being responsible for postpartum follow-up, being closer to women, being the priority gateway to the health system and organizing the healthcare network, must have ideal conditions to provide this care with quality.22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...
,77 WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013.,88 Kleppel L, Suplee PD, Stuebe AM, Bingham D. National initiatives to improve systems for postpartum care. Matern Child Health J. 2016 Nov; 20 (Suppl 1): S66-S70.

Therefore, it is necessary to integrate PHC to other points in the healthcare network,9 with the city health management being the main responsible for this organization, enabling PHC professionals to provide comprehensive care.22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...
,1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016.

To understand the operation in the municipal health management and the actions developed for women in PHC, it is essential to identify how much postpartum care is operational, and this is possible through an implementation analysis.1111 Champagne F, Brousselle A, Hartz ZMA, Contandriopoulos AP, Denis JL. A Análise da implantação. In: Champagne F, Brousselle A, Hartz ZMA, Contandriopoulos AP, Denis JL, eds. Avaliação em saúde: conceitos e métodos. Rio de Janeiro: FIOCRUZ; 2011. p. 217-38. Focused on this study, which was justified by: shortage of evaluative studies besides normative and healthcare aspects, or “cut out ” program;1212 Baratieri T, Natal S. Postpartum program actions in primary health care: an integrative review. Ciênc Saúde Coletiva. 2019 Nov; 24 (11): 4227-38. being a care that is still neglected by public policies, services and health professionals;77 WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013. high morbidity and mortality of postpartum women;22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...

3 O’Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth. 2018 May; 18 (1): 196.
-44 Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13. and the necessity of identifying the operationalization in postpartum care, thus, indicating its favorable and unfavorable aspects, which allows to improve the program. The objective was to determine the implementation level and analyze favorable and unfavorable aspects of the operationalization in postpartum women’s care in the PHC context in three cities in the South region in Brazil.

Methods

This is a normative study, which addressed the implementation level of postpartum care in PHC and analyzed favorable and unfavorable aspects in the operationalization of this intervention,1111 Champagne F, Brousselle A, Hartz ZMA, Contandriopoulos AP, Denis JL. A Análise da implantação. In: Champagne F, Brousselle A, Hartz ZMA, Contandriopoulos AP, Denis JL, eds. Avaliação em saúde: conceitos e métodos. Rio de Janeiro: FIOCRUZ; 2011. p. 217-38. which was carried out from February to June 2019, in a quantitative and qualitative approach.1313 Baratieri T. Avaliação da implantação da assistência pós-parto às mulheres na atenção primária à saúde na região sul do Brasil [thesis]. Florianópolis (SC): Universidade Federal de Santa Catarina (UFSC) - Programa de Pós-Graduação em Saúde Coletiva; 2020. It was developed through a study of multiple cases1414 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2015.,1515 Stake RE. Multiple case study analysis. New York: The Guilford Press; 2006. by answering the following research question: How is postpartum women’s care implemented in PHC?

The selected cases were a city in each state in the South region in Brazil, and were called Case 1, Case 2 and Case 3, according to the following inclusion criteria: more than 100,000 inhabitants, most of them in favorable characteristics for health management;1616 Calvo MCM, Lacerda JT, Colussi CF, Schneider IJC, Rocha TAH. Estratificação de municípios brasileiros para avaliação de desempenho em saúde. Epidemiol Serv Saúde. 2016 Oct/Dec; 25 (4): 767-76. PHC coverage was greater than 80%; more than 80% of the health teams were enrolled in the Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ) (National Program for Access and Quality Improvement in Primary Care); more than 80% of the teams were evaluated as “excellent”, “very good” and “good” in the PMAQ program. When more than one city met the inclusion criteria, professionals in the PHC technical area and women’s health, from the respective Secretarias Estaduais de Saúde (State Health Departments), were asked to choose the best case.

The units of analysis were the city health management and a family health team from each city. The city health management was asked to indicate a family health team with PHC considered as exemplary, among those with “excellent” and “very good” evaluations in the PMAQ program.

The informants were professionals from the city administration, professionals from the PHC teams and puerperal women cared for by these teams. Professionals from the city management of the women’s health and PHC areas and professionals from the minimum family health team (physician, nurse, nursing technician/assistant and community health worker), were selected, those who had more than one year of experience in the same workplace.

Professionals on vacation or leave were excluded. Regarding to the puerperal women, women who had at least one puerperal consultation up to 42 days, and who were at six months postpartum were selected, in order to reduce memory bias about the received care. A survey of eligible women was carried out, followed by a random drawing, were interviewed until the occurrence of data saturation.

Six managers participated in the study (1 Case 1; 3 Case 2; 2 Case 3), 4 physicians (1 Case 1; 1 Case2; 2 Case 3), 4 nurses (1 Case 1; 1 Case 2; 2 Case 3), 2 nursing technicians (1 Case 1, 1 Case 2), 18 community health workers (6 Case 1; 9 Case 2; 3 Case 3) and 31 puerperal women (10 Case 1, 11 Case 2 and 10 Case 3). A nursing technician in Case 3 who was on vacation was excluded, six puerperal women refused to participate and three could not be contacted.

Primary and secondary data were collected. The primary data collection took place through interviews with selected informants, in each unit of analysis, with a semi-structured script. The interviews were scheduled with the professionals in their respective work environments and the women chose the health unit or their homes. Secondary data were collected through the analysis of medical records of selected puerperal women, documentary analysis (city documents: Annual Health Program, protocols, technical standards, etc.), microdata from the external evaluation of the third cycle of the PMAQ program, besides the information systems of the Departamento de Informática do SUS (Public Health Informatics Department). The instruments for collection were developed based on the theory of the postpartum care program for women in PHC.17A pilot case study was conducted in a city that was not part of this study.1414 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2015.

The Matriz de Análise e Julgamento (MAJ) (Analysis and Judgment Matrix) was designed, consisting of dimensions and sub-dimensions,1313 Baratieri T. Avaliação da implantação da assistência pós-parto às mulheres na atenção primária à saúde na região sul do Brasil [thesis]. Florianópolis (SC): Universidade Federal de Santa Catarina (UFSC) - Programa de Pós-Graduação em Saúde Coletiva; 2020. defined through the Teoria do Programa1717 Baratieri T, Natal S, Hartz ZMA. Cuidado pós-parto às mulheres na atenção primária: construção de um modelo avaliativo. Cad Saúde Pública. 2020; 36 (7): e00087319. (Theory Program) and validated by the consensus conference technique1818 Hartz ZMA, Silva LMV. Avaliação em saúde: dos modelos teóricos à prática na avaliação de programas e sistemas de saúde. Rio de Janeiro: FIOCRUZ; 2005. with experts in the field and stakeholders (interested in the evaluation), being: four women representatives for women’s movement, five professionals in PHC area and management in women’s health in Paraná, Santa Catarina and Rio Grande do Sul States, in addition to three professionals with experience in PHC.

The MAJ design was used to determine the implementation level of postpartum care and to identify the factors that explain the different implementation levels. It was composed by two dimensions of analysis, management and execution, broken down into three sub-dimensions (material and physical financial resources; human resources; and mechanisms for coordination in care and intersectorality) and seven sub-dimensions (longitudinality; access; physical health; mental health; domestic violence; breastfeeding and reproductive planning), respectively. Each sub-dimension has a maximum score, distributed among the criteria/indicators that constitute it.

The proportion of the sum of the observed scores (OS) in the dimensions/sub-dimensions in relation to the expected score (ES) determined the judgment value for the implementation level: IL (implementation level )= (Σ OS ∕ Σ ES) x 100. The proportions were stratified into quartiles for classification of the Implementation Level, namely: satisfactory implementation (76% to 100%); partial implementation (51% to 75%); incipient implementation (26% to 50%); and critical implementation (below 26%).1919 Alves CKA, Natal S, Felisberto E, Samico I. Interpretação e análise das informações: o uso de matrizes, critérios, indicadores e padrões. In: Samico I, Felisberto E, Figueiró AC, Frias PG, orgs. Avaliação em saúde: bases conceituais e operacionais. Rio de Janeiro: FIOCRUZ; 2010. p. 89-107.

The individual analysis of cases was carried out through thematic analysis2020 Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook. 3rd ed. Califórnia: SAGE Publications; 2014. with triangulation of data from different sources of evidence, using a pre-defined list of codes2020 Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook. 3rd ed. Califórnia: SAGE Publications; 2014. according to the MAJ design, with the aid of NVivo software, version 11. From the thematic analysis, a judgment value was held based on the rationale1313 Baratieri T. Avaliação da implantação da assistência pós-parto às mulheres na atenção primária à saúde na região sul do Brasil [thesis]. Florianópolis (SC): Universidade Federal de Santa Catarina (UFSC) - Programa de Pós-Graduação em Saúde Coletiva; 2020. of each criterion/indicator and discussed among the authors to attribute the score in each case. In order to perform the imbricated analysis, a thorough examination of the dimensions and sub-dimensions was carried out, verifying the convergences, divergences, favorable and unfavorable aspects among them.

This study was approved by the Ethics Committee for Research with Human Beings at the Universidade Federal de Santa Catarina (Opinion document number 3.036.173/2018).

Results

The results show that postpartum care was incipient in the management dimension for all the cases. In the execution dimension, Case 3 had partial implementation (57%), while the others had incipient implementation (Table 1).

Table 1
Implementation level on postpartum care for women in primary care in three cities in the South Region, Brazil, 2019.in bays along the Cuiabá River, Pantanal of Barão de Melgaço, Mato Grosso.

Table 2 shows MAJ design of the management dimension and its respective sub-dimensions.

Table 2
Analysis and judgment matrix of postpartum care for women in primary care: management dimension and its sub-dimensions in three cities in the South Region, Brazil, 2019.

In the “Financial, material and physical resources” sub-dimensions there was a critical implementation for Case 2 and incipient implementation for the others. The main weaknesses are reflected in the lack of proper scheduling of actions for postpartum women; unavailability of contraceptives in the health units, mainly because they do not perform insertion of intrauterine devices in the PHC area; inadequate physical space, referring to the lack of space for educational activities and adequate spaces and equipment for people with disabilities.

Case 2 was partially implemented in the “Human Resources” dimension (60%). Cases 1 and 3 had critical (10%) and incipient (30%) implementations, respectively. None of the studied cases did the professionals receive updates about postpartum care.

Postpartum care was partially implemented in the “Mechanisms for coordination in care and intersectorality” sub-dimension for all the cases which revealed referral and counter-referral mechanisms, puerperal women’s access to other health care points, specialists’ support for PHC professionals and participation of managers in meetings of the Comissão Intergestora Regional (Regional Inter-Management Committee). The main weaknesses were the timely access forsterilization and vasectomy, and to psychiatrists and intersectoral articulation.

Table 3 shows the specificities of each analyzed case in relation to the favorable and unfavorable aspects of the postpartum care implementation in the management dimension.

Table 3
Similarities and differences between favorable and unfavorable aspects for the postpartum care implementation: management dimension in three cities in the South Region, Brazil, 2019.

Regarding to the favorable aspects, it should be highlighted that Cases 1 and 2 are linked to social work; however, only for specific situations (homeless people - Case 2 and violence against women and children - Case 1), thus, indicating the necessity to improve the intersectoral action for all the cases.

Case 1 deserves to be highlighted for the quality of the registrations with electronic medical charts integrated throughout the city network, which enables the continuity in care. In addition, this case monitored the consultation indicator up to 42 days postpartum, although, this is not the indicator contained in the Programação Anual de Saúde (Annual Health Program).

Case 2 was the only one that had a clinical protocol for postpartum care; however, only for nurses’ performance, showing that the three cases needed improvement in this aspect. In addition, Case 2 had good articulation with the referred maternity hospital, which made it possible for women to leave the hospital with a scheduled postpartum consultation.

In relation to Case 3, it is important to emphasize its concern with the continuing education for professionals, since this is part of the primary care teams’ routine, with space to discuss in team meetings and with a continuing education center established in the city, which allows a constant professional improvement according to their needs.

In regard to unfavorable aspects, it should be highlighted the lack of Continuing Education (Cases 1 and 2), the low coverage of FHS, which would be essential for strengthening the PHC network, and the lack of access to psychiatrists in a timely manner, which hinders the resoluteness and continuity of care in the PHC for women with postpartum depression (Cases 1 and 3).

Table 4 shows the MAJ design of the execution dimension and its respective sub-dimensions.

Table 4
Analysis and judgment matrix of postpartum care for women in primary care: execution dimension and its sub-dimensions in three cities in the South Region, Brazil, 2019.

The “longitudinality” sub-dimension had critical implementation for Cases 1 and 2, while it was incipient for Case 3. The main weaknesses of the three cases were related to the lack of use of clinical protocols, lack of care in the remote puerperal period and postpartum care plan. Cases 1 and 2 had difficulties in involving families and/or partners to care for these women.

Regarding to “access”, Cases 1 and 2 had incipient implementation, while Case 3 had partial implementation. The main weaknesses are in terms of having six or more prenatal consultations and two postpartum consultations. Only Case 3 accomplishes the sufficient number of home visits in the first week of postpartum.

The “physical health” sub-dimension was partially implemented for Cases 1 and 3, but it was incipient for Case 2. All the cases showed weaknesses in terms of attention to common postpartum problems and warning signs, especially regarding to signs of pre-eclampsia/eclampsia, infection and thromboembolism, as well as guidelines on physical activity. Case 1 had better adequacy in the continuity of care in relation to complications in the prenatal and postpartum.

Regarding “mental health”, all the cases showed weaknesses, with critical implementation for Case 2 and incipient implementation for the others.

In the “domestic violence” sub-dimension, Case 3 was partially implemented, surpassing the others by looking at this issue in the healthcare routine of all professionals, in addition to allowing discussions among team members about compulsory notification. The main weakness of all the cases is the lack of guidance to women and the focus of attention on physical violence.

“Breastfeeding” had a satisfactory implementation for Case 3 and a partial implementation for Cases 1 and 2, with the main weaknesses of these being concentrated in the continuous support and guidance to women, in addition to pre-scheduled consultations and complaints. All the cases had weaknesses in the encouragement and preparation of women for breastfeeding since prenatal care.

The “reproductive planning” sub-dimension had critical implementation for Case 2 and incipient for the others. There was a focus in care on hormonal contraceptive methods, lack of approach to sexual health and involvement of partners in the choice of a method.

Table 5 describes the favorable and unfavorable aspects of the postpartum care implementation in relation to the execution dimension.

Table 5
Similarities and differences between favorable and unfavorable aspects for postpartum care implementation: execution dimension in three cities in the South Region, Brazil, 2019.

As for the favorable aspects, Case 3 stands out, which obtained the highest implementation level, especially for implementing the welcoming in the sense of advanced access in the health unit, holding a team specialized in family health and aligned between actions and concern with comprehensive care offered to women and involvement of families/partners in healthcare, carrying out discussions on cases, having Continuing Education present in the work routine and conduct a group of pregnant women.

In Case 1, the medical professional had a similar profile to the team in Case 3, which favored a positive evaluation of some criteria/indicators in both cases. In addition, this professional took advantage of the children’s follow-up meetings to help women in the remote puerperium. It is noteworthy that the quality of postpartum care was considered an unfavorable aspect for being centered on the profile of a single professional, and not being an institutionalized practice.

For Cases 1 and 3, it is worth to emphasize the institutionalization of postpartum consultation in the first 10 days, a period of utmost importance to identify women’s health needs in a timely manner, and this aspect was favored in both cases, a better implementation of the physical health and breastfeeding sub-dimensions.

With regard to unfavorable aspects, Case 2 stands out, which performs the first consultation only by a medical professional, generally after 30 days of postpartum.

Lack of use of clinical protocol, low coverage of prenatal and postpartum consultations, complaint-based attention to common problems, lack of mental health care routine and domestic violence in the postpartum and reproductive planning care with a focus on the use of hormonal contraceptive methods were items considered unfavorable aspects for the three cases.

Discussion

The current study showed that postpartum care for women is not satisfactorily implemented in the PHC of the three studied cases.

The management dimension is important because it offers the necessary conditions for PHC professionals in providing quality care, had an incipient implementation. The absence of action programing for postpartum women was identified, being that the Programação Anual de Saúde (Annual Health Program) of the three realities, in the women’s health category, prioritizes pregnant women and the follow-up on the child’s growth and development.

Concerning material and physical resources, the current study found data similar to the literature.2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. The nutritional care during the prenatal and postpartum: perceptions of managers of Primary Health Care. Rev Nutr. 2016 Jan/Feb; 29 (1): 109-23. The lack of timely access to long-term contraceptive methods should be highlighted. These aspects have a direct impact on the performance of PHC professionals, who are unable to offer comprehensive care and adequate reproductive planning, which could allow women and partners to choose from different options.1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016.,2222 FSRH (Faculty of Sexual and Reproductive Health). FSRH contraception after pregnancy [Internet]. London: FSRH; 2017; [access in 2019 Nov 30]. Available from: https://www.fsrh.org/documents/contraception-after-pregnancy-guideline-january-2017/
https://www.fsrh.org/documents/contracep...

Despite the movements over the years in Brazil in establishing comprehensive care for women’s health, it can be seen that the focus of the organization of actions is still on the maternal-child and reproductive component.1212 Baratieri T, Natal S. Postpartum program actions in primary health care: an integrative review. Ciênc Saúde Coletiva. 2019 Nov; 24 (11): 4227-38. In order to overcome this situation, it is essential to implement mechanisms that encourage the qualification of professionals in the routine of primary care services.99 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica. 2020; 44: e4.,2323 Campos KFC, Marques RDC, Ceccim RB, Silva KL. Educação permanente em saúde e modelo assistencial: correlações no cotidiano do serviço na Atenção Primária a Saúde. APS Rev. 2019; 1 (2): 132-40.

In Case 3, there is a constant concern with professional qualification, offering continuous spaces for continuing education; however, none of the cases promoted specific updates on postpartum issues.

Another way to qualify care is through the use of clinical guidelines based on the best available scientific evidence.99 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica. 2020; 44: e4.,2424 Mehndiratta A, Sharma S, Gupta N, Sankar M, Cluzeau F. Adapting clinical guidelines in India - a pragmatic approach. BMJ Evid Based Med. 2017 Nov; 359: j5147. Nevertheless, only Case 2 was going through a process of implementing a clinical protocol for nurses that included postpartum care.

The “mechanisms for coordination of care and intersectorality” sub-dimension had the highest implementation level for the three cases. It is noteworthy that Case 1 had as a favorable aspect on the follow-up of indicators of postpartum consultations, which can help in health planning for women.

In Case 2, it is worth underlining the good articulation between PHC and the maternity hospital, allowing women to leave the hospital with their first postpartum consultation scheduled at the health unit, a strategy indicated in the literature as an importance to increase women’s adherence to the consultations and enable continuity of care.66 Henderson V, Stumbras K, Caskey R, Haider S, Rankin K, Handler A. Understanding factors associated with postpartum visit attendance and contraception choices: listening to low-income postpartum women and health care providers. Matern Child Health J. 2016 Nov; 20 (Suppl 1): S132-S43. Accordingly, it is the responsibility of the city management to ensure communication between the maternity and the PHC teams, in addition to provide organizational conditions for the early recruitment of postpartum women by the PHC staff.1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016.

In addition to the good flow of the healthcare network, it is important that the city health management makes articulations with different sectors of the society, in order to provide comprehensive care for women and aid in the resolution of complex problems, especially with social workers. Of the analyzed cases, only two have established flows for specific cases (homeless people and violence against women and children).

As for the execution dimension, it should be highlighted that the training for professional to work in a multidisciplinary way is one of the essential requirements for the PHC staff to fulfill its objectives within the health system, in addition to the importance of having a professional training plan and paying attention to the specificities in PHC,99 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica. 2020; 44: e4. therefore, implying for a better care for postpartum women. In the current study, it was possible to evidence this aspect for Cases 1 and 3, where the implementation level was favored by the professional’s profile, consisted of specialists in family health. Moreover, in Case 3, there was the continuing education routine instituted in the team.

Another important aspect is that at least one postpartum consultation of up to 42 days is necessary,1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016. ideally at least two postpartum contacts, one in the first week and another at the end of 42 days, in order to meet the main needs of these women in this period, thus enabling health promotion, disease prevention and timely care.22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...
,77 WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013.,1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016. It was identified that only Cases 1 and 3 have institutionalized the first consultation in the first 10 days.

In addition, in order to optimize postpartum care, early guidance should begin during pregnancy, with the development of a postpartum care plan that addresses emotional health, maternity challenges and postpartum recovery, thus discussing the purpose and the importance of postpartum care, as well as the types of services and support available.2525 ACOG (American College of Obstetritians and Gynecologists). Optimizing postpartum care: ACOG committee opinion. Am Coll Obstet Gynecol. 2018; 131 (728): 35-42. In the three analyzed cases, women’s healthcare is provided by the same professionals, but longitudinality is undermined by the lack of preparation of a postpartum care plan and follow-up in the remote puerperal period.

Care must go beyond the first weeks of postpartum, where the follow-up of children’s growth and development in the first year of life is an opportunity for health professionals to assist women’s health needs,2626 Olin SS, McCord M, Stein REK, Kerker BD, Weiss D, Hoagwood KE, et al. Beyond screening: a stepped care pathway for managing postpartum depression in pediatric settings. J Womens Healh (Larchmt). 2017 Sep; 26 (9): 966-75. an opportunity that is used in some situations perceived in Case 1 by the individual initiative of the family physician.

When analyzing the “access” sub-dimension, Cases 1 and 2 did not reach the expected score for the number of postpartum consultations and home visits. Moreover, Case 2 performs the first consultation around 30 days of postpartum, which undermines timely care, especially in situations that must be managed in the first days after childbirth.22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...
,77 WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013.,1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016.,2727 Robling M, Bekkers MJ, Bell K, Butler CC, Cannings-John R, Channon S, et al. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet. 2016 Jan; 387 (10014): 146-55.

All the cases reached the maximum score in the criterion “iron supplementation 3 months of postpartum”, which is an established protocol in postpartum care; and, in general, physical health had a systematic care in all the cases. In addition, the sub-dimension with the highest implementation level f was “breastfeeding”, an issue that is constantly addressed in professional practice - through qualifications - and in health planning. These aspects reinforce the importance of adopting clinical protocols and continuing education. On the other hand, these results may be related to the normative nature of actions, as well as a focus on child’s health, in the case of breastfeeding.

Regarding to the “mental health” and “domestic violence” sub-dimensions, they were identified that they are healthcare practices that are not part of the postpartum care routine, and their approach depends on the sensitivity and individual knowledge on the professionals’ behalf f.

Emotional changes and signs of postpartum depression (PPD) are empirically identified, with insufficient knowledge on the issue and lack of use of a systematic instrument to track PPD, which corroborates in the literature.2828 Jairaj C, Fitzsimons CM, McAuliffe FM, O’Leary N, Joyce N, McCarthy A, et al. A population survey of prevalence rates of antenatal depression in the Irish obstetric services using the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health. 2019 Jun; 22 (3): 349-55. The prevalence of PPD varies from 10 to 15%, being higher in developing countries,55 Giallo R, Pilkington P, McDonald E, Gartland D, Woolhouse H, Brown S. Physical, sexual and social health factors associated with the trajectories of maternal depressive symptoms from pregnancy to 4 years postpartum. Soc Psychiatry Psychiatr Epidemiol. 2017 Jul; 52 (7): 815-28.,2828 Jairaj C, Fitzsimons CM, McAuliffe FM, O’Leary N, Joyce N, McCarthy A, et al. A population survey of prevalence rates of antenatal depression in the Irish obstetric services using the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health. 2019 Jun; 22 (3): 349-55.,2929 Stephens S, Ford E, Paudyal P, Smith H. Effectiveness of psychological interventions for postnatal depression in primary care: a meta-analysis. Ann Fam Med. 2016 Sep; 14 (5): 463-72. and approximately 90% of the cases can be managed in PHC,2929 Stephens S, Ford E, Paudyal P, Smith H. Effectiveness of psychological interventions for postnatal depression in primary care: a meta-analysis. Ann Fam Med. 2016 Sep; 14 (5): 463-72. which indicates the urgency of qualifying professionals to deal with this kind of problem.

As for domestic violence, this study found that there is greater attention to the physical dimension; and, in all the cases, professionals do not address this issue in the postpartum care plan. A Brazilian study identified that 30% of the surveyed women suffered some form of physical violence with an intimate partner in the first months after childbirth.44 Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13. This data highlights the magnitude of the issue and the need to fight the problem,44 Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13. in regard to all types of violence, since this constitutes a risk factor for PPD44 Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13.,55 Giallo R, Pilkington P, McDonald E, Gartland D, Woolhouse H, Brown S. Physical, sexual and social health factors associated with the trajectories of maternal depressive symptoms from pregnancy to 4 years postpartum. Soc Psychiatry Psychiatr Epidemiol. 2017 Jul; 52 (7): 815-28. and also for the onset of problems during the follow-up of a child’s growth/development.44 Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13.

Regarding reproductive planning, it is fundamental that professionals minimally advise on the resumption of sexual activity, libido alterations, dyspareunia, prevention and diagnosis of sexually transmitted infections, and on the free exercise of sexuality and pleasure,22 NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
https://www.nice.org.uk/guidance/ng194...
,77 WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013.,1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016. in addition to providing guidance on reproductive rights, including access and the right to choose different contraceptives according to clinical conditions, and involving partners in the decision-making process.1010 Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016.,2222 FSRH (Faculty of Sexual and Reproductive Health). FSRH contraception after pregnancy [Internet]. London: FSRH; 2017; [access in 2019 Nov 30]. Available from: https://www.fsrh.org/documents/contraception-after-pregnancy-guideline-january-2017/
https://www.fsrh.org/documents/contracep...
Due to therespect on this issue, this study identified that, in all the cases, care is directed in the definition of contraceptive method, with a focus on hormonal methods.

Studies have found a 40% prevalence of women with sexual health problems up to oneyear of postpartum33 O’Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth. 2018 May; 18 (1): 196. and a 27.2% prevalence of rapid repeat pregnancy, which is less likely to occur with long-term contraceptive use,3030 Sackeim MG, Sammel M, Gurney EP, Schreiber CA. Rapid repeat pregnancy: prevalence and risk factors in an urban population. Am J Obstet Gynecol. 2018; 218 (1 Suppl 1): S560-S1. issues that were neglected in the studied cases.

As limitations of this study, the lack of generalization of the data should be highlighted, but the case study allows theoretical generalization, while the replication to other units of analysis leads to the external validity of the study.1414 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2015. Furthermore, the study analyzed broad and complex dimensions and sub-dimensions, having as a limitation of the impossibility to deepen the analysis and discussion of each one of them, but the triangulation of the gathered data helped in the elaboration of the judgment value, in order to ensure that the main results were not neglected.1515 Stake RE. Multiple case study analysis. New York: The Guilford Press; 2006.

In order to strengthen the internal validity of the study, the following items were used: consensus conference for MAJ validation;1818 Hartz ZMA, Silva LMV. Avaliação em saúde: dos modelos teóricos à prática na avaliação de programas e sistemas de saúde. Rio de Janeiro: FIOCRUZ; 2005. triangulation of data from different sources of evidence, allowing verification of the reliability and interpretation of the collected data;1414 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2015.,1515 Stake RE. Multiple case study analysis. New York: The Guilford Press; 2006. pilot testing of data collection instruments; and rigor in the analysis according to the theory program.1717 Baratieri T, Natal S, Hartz ZMA. Cuidado pós-parto às mulheres na atenção primária: construção de um modelo avaliativo. Cad Saúde Pública. 2020; 36 (7): e00087319.

As the final considerations, it was found that there was incipient implementation of postpartum care for the management dimension, as well as incipient (Cases 1 and 2) and partial implementation (Case 3) for the execution dimension in the three analyzed cases, making it possible to identify the main gaps in the program, which, being ideally implemented, has the potential to reduce maternal morbidity and mortality and help women from the perspective of comprehensive care, with a focus on their health needs.

It was identified that management does not provide the ideal conditions for PHC in most of the analyzed criteria/indicators, and the dimension “execution” does not incorporate the main women’s health needs.

As the main recommendations, this study indicates that there should be: follow-ups for indicators and action planning on postpartum care; implementation of clinical guidelines; continuing qualification of health professionals, with a view in providing comprehensive care for women, especially in order to overcome the focus on physical health and maternal-child care; and timely supply of long-acting contraceptive methods. These aspects are directly related to the performance of the city health management, which is responsible for providing the ideal healthcare conditions.

This study showed that the proposed theoretical model1717 Baratieri T, Natal S, Hartz ZMA. Cuidado pós-parto às mulheres na atenção primária: construção de um modelo avaliativo. Cad Saúde Pública. 2020; 36 (7): e00087319. has the potential to be replicated in other places, both in Brazil and in other countries, as health necessities for postpartum women are common in different realities, there are specificities.

References

  • 1
    WHO (World Health Organization). The global health observatory [Internet]. Geneva: WHO; 2017; [access in 2020 Jan 31]. Available from: https://www.who.int/data/gho
    » https://www.who.int/data/gho
  • 2
    NICE (National Institute for Health and Care Excellence). Postnatal care up to 8 weeks after birth [Internet]. London: NICE; 2015; [access in 2020 Jan 31]. Available from: https://www.nice.org.uk/guidance/ng194
    » https://www.nice.org.uk/guidance/ng194
  • 3
    O’Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth. 2018 May; 18 (1): 196.
  • 4
    Moraes CL, Oliveira AGS, Reichenheim ME, Gama SGN, Leal MC. Prevalência de violência física entre parceiros íntimos nos primeiros seis meses após o parto no município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2017; 33 (8): 1-13.
  • 5
    Giallo R, Pilkington P, McDonald E, Gartland D, Woolhouse H, Brown S. Physical, sexual and social health factors associated with the trajectories of maternal depressive symptoms from pregnancy to 4 years postpartum. Soc Psychiatry Psychiatr Epidemiol. 2017 Jul; 52 (7): 815-28.
  • 6
    Henderson V, Stumbras K, Caskey R, Haider S, Rankin K, Handler A. Understanding factors associated with postpartum visit attendance and contraception choices: listening to low-income postpartum women and health care providers. Matern Child Health J. 2016 Nov; 20 (Suppl 1): S132-S43.
  • 7
    WHO (World Health Organization). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO; 2013.
  • 8
    Kleppel L, Suplee PD, Stuebe AM, Bingham D. National initiatives to improve systems for postpartum care. Matern Child Health J. 2016 Nov; 20 (Suppl 1): S66-S70.
  • 9
    Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica. 2020; 44: e4.
  • 10
    Ministério da Saúde (BR). Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016.
  • 11
    Champagne F, Brousselle A, Hartz ZMA, Contandriopoulos AP, Denis JL. A Análise da implantação. In: Champagne F, Brousselle A, Hartz ZMA, Contandriopoulos AP, Denis JL, eds. Avaliação em saúde: conceitos e métodos. Rio de Janeiro: FIOCRUZ; 2011. p. 217-38.
  • 12
    Baratieri T, Natal S. Postpartum program actions in primary health care: an integrative review. Ciênc Saúde Coletiva. 2019 Nov; 24 (11): 4227-38.
  • 13
    Baratieri T. Avaliação da implantação da assistência pós-parto às mulheres na atenção primária à saúde na região sul do Brasil [thesis]. Florianópolis (SC): Universidade Federal de Santa Catarina (UFSC) - Programa de Pós-Graduação em Saúde Coletiva; 2020.
  • 14
    Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2015.
  • 15
    Stake RE. Multiple case study analysis. New York: The Guilford Press; 2006.
  • 16
    Calvo MCM, Lacerda JT, Colussi CF, Schneider IJC, Rocha TAH. Estratificação de municípios brasileiros para avaliação de desempenho em saúde. Epidemiol Serv Saúde. 2016 Oct/Dec; 25 (4): 767-76.
  • 17
    Baratieri T, Natal S, Hartz ZMA. Cuidado pós-parto às mulheres na atenção primária: construção de um modelo avaliativo. Cad Saúde Pública. 2020; 36 (7): e00087319.
  • 18
    Hartz ZMA, Silva LMV. Avaliação em saúde: dos modelos teóricos à prática na avaliação de programas e sistemas de saúde. Rio de Janeiro: FIOCRUZ; 2005.
  • 19
    Alves CKA, Natal S, Felisberto E, Samico I. Interpretação e análise das informações: o uso de matrizes, critérios, indicadores e padrões. In: Samico I, Felisberto E, Figueiró AC, Frias PG, orgs. Avaliação em saúde: bases conceituais e operacionais. Rio de Janeiro: FIOCRUZ; 2010. p. 89-107.
  • 20
    Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook. 3rd ed. Califórnia: SAGE Publications; 2014.
  • 21
    Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. The nutritional care during the prenatal and postpartum: perceptions of managers of Primary Health Care. Rev Nutr. 2016 Jan/Feb; 29 (1): 109-23.
  • 22
    FSRH (Faculty of Sexual and Reproductive Health). FSRH contraception after pregnancy [Internet]. London: FSRH; 2017; [access in 2019 Nov 30]. Available from: https://www.fsrh.org/documents/contraception-after-pregnancy-guideline-january-2017/
    » https://www.fsrh.org/documents/contraception-after-pregnancy-guideline-january-2017/
  • 23
    Campos KFC, Marques RDC, Ceccim RB, Silva KL. Educação permanente em saúde e modelo assistencial: correlações no cotidiano do serviço na Atenção Primária a Saúde. APS Rev. 2019; 1 (2): 132-40.
  • 24
    Mehndiratta A, Sharma S, Gupta N, Sankar M, Cluzeau F. Adapting clinical guidelines in India - a pragmatic approach. BMJ Evid Based Med. 2017 Nov; 359: j5147.
  • 25
    ACOG (American College of Obstetritians and Gynecologists). Optimizing postpartum care: ACOG committee opinion. Am Coll Obstet Gynecol. 2018; 131 (728): 35-42.
  • 26
    Olin SS, McCord M, Stein REK, Kerker BD, Weiss D, Hoagwood KE, et al. Beyond screening: a stepped care pathway for managing postpartum depression in pediatric settings. J Womens Healh (Larchmt). 2017 Sep; 26 (9): 966-75.
  • 27
    Robling M, Bekkers MJ, Bell K, Butler CC, Cannings-John R, Channon S, et al. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet. 2016 Jan; 387 (10014): 146-55.
  • 28
    Jairaj C, Fitzsimons CM, McAuliffe FM, O’Leary N, Joyce N, McCarthy A, et al. A population survey of prevalence rates of antenatal depression in the Irish obstetric services using the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health. 2019 Jun; 22 (3): 349-55.
  • 29
    Stephens S, Ford E, Paudyal P, Smith H. Effectiveness of psychological interventions for postnatal depression in primary care: a meta-analysis. Ann Fam Med. 2016 Sep; 14 (5): 463-72.
  • 30
    Sackeim MG, Sammel M, Gurney EP, Schreiber CA. Rapid repeat pregnancy: prevalence and risk factors in an urban population. Am J Obstet Gynecol. 2018; 218 (1 Suppl 1): S560-S1.

Publication Dates

  • Publication in this collection
    09 May 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    13 July 2020
  • Reviewed
    01 Nov 2021
  • Accepted
    05 Nov 2021
Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br
Accessibility / Report Error