Mortalidade infantil evitável e barreiras de acesso à atenção básica no Recife , Brasil Preventable infant mortality and barriers to access to primary care in Recife , Northeastern Brazil

MÉTODOS: Estudo qualitativo crítico-construtivista de análise do acesso das crianças à atenção e à mortalidade infantil evitável por ações e serviços no Distrito Sanitário I do Recife, PE, entre fevereiro de 2007 e fevereiro de 2008. Desenhou-se amostra teórica em duas etapas: I) instituições prestadoras de serviços de saúde infantil; II) informantes: gestores (11); profi ssionais da Estratégia de Saúde da Família e do Programa de Agentes Comunitários de Saúde (48); profi ssionais das policlínicas (12), mães (20), com tamanho defi nido por saturação dos discursos. Foram realizadas entrevistas individuais semiestruturadas e estudo de caso de óbito infantil evitável. Utilizou-se análise temática de conteúdo com geração mista de categorias (emergentes e roteiro).

a These activities, together with a significant decrease in fecundity over the same period, have contributed to a decline in fi gures for infant mortality.However, the number of preventable infant deaths in the country remains considerable. 9,12,13ere is a strong link between preventable infant death and timely access to health care services, as preventable deaths, according to Rutstein et al 19 (1976), are defi ned as "deaths which could be partially or totally avoided by the presence of effective health care services".a Child health care policies, in accordance with these principles, aim to provide health care which is resolutory, welcoming, humane and accountable, provided by teams working together and with intersectoral cooperation, preferably offered by the Family Health Strategy (ESF) and the Program of Community Health Workers (PACS).The objective is to promote health and reduce infant mortality.b It is the duty of the health care team to monitor the child throughout their fi rst year, to identify at birth risk factors for illness and death (low birth weight, premature birth, hypoxia, teenage mothers and mothers with low levels of schooling and family history of death before age fi ve) and decide upon the appropriate medical care.c Also taken into consideration as risk factors are previous hospital admissions, delays in vaccination, living in risk areas, having no income and drug addiction.
In line with the national pattern, the infant mortality coeffi cient (IMC) for Recife, Northeastern Brazil, show a progressive reduction (IMC = 13 deaths/1,000 live births in 2007), similar to that seen in other, more developed, Brazilian cities such as Rio de Janeiro, São Paulo and Belo Horizonte, all located in Southeastern Brazil.However, 86% of these deaths could have been prevented by actions on the part of the health sector or partner organizations in other social sectors.This suggests the existence of barriers to access to health care services and campaigns.d

INTRODUCTION
The extensive literature which relates to infant deaths which could have been prevented through access to health care services, makes use of epidemiological or evaluative methods as the principal investigative tool.While these methods demonstrate the magnitude of the problem, 9,12,13,23 they do not deepen the perspective of the social protagonists (users, health care professionals) or contextual factors (political and characteristics of supply) which infl uence access.
The majority of qualitative studies concentrate on barriers relating to the performance of health care professionals in welcoming and connecting, 21,22 or on the maternal perspective of infant death, 10,15,20 and few analyze the infl uence of barriers to access on the ongoing occurrence of avoidable deaths, or else do not include the points of view of all the participants involved.
Access to health care refers to the possibility of obtaining health care, conveniently and easily, when they need it. 1As access is something that can only be observed when health care services are actually used by those who need them, Aday & Andersen's 2 (1974) theoretical model analyzes factors which infl uence use of health care services, defi ning the two most important dimensions of access: potential and realized.Potential access is concerned with the characteristics of supply (availability and organization of health care services) and of the users: predisposing factors (sociodemographic characteristics, beliefs and attitudes, level of information); enabling factors (personal and community) and health care needs.Realized access refers to actual use of health care services. 2e aim of this study was to analyze factors which infl uence preventable infant mortality, from the perspective of all participants involved in the phenomenon.

METHODS
This was a qualitative, descriptive-interpretive study using a critical-constructivist approach, 11,14 aiming to uncover the relationship between children's access to health care and infant death which could be prevented by actions and health care services,using Aday & Andersen's 2 (1974)  A two-stage theoretical sample was designed. 6The following institutions were selected: Health District 1 Administrative Headquarters; Primary Health Care Services (nine ESF units and one Traditional Primary Care Unit [UBT], which provide health care according to the traditional model, with basic children's health care provided by pediatricians and without being ascribed to areas); and services of medium complexity (two outpatients clinics and an Allergology Service, which offered primary health care within the traditional model, as well as specialized health care).Ninety-one interviewees were selected, aiming for the greatest possible variety of discourse in order to guarantee sample suffi ciency and saturation. 6,11,14two-part collection strategy was used to collect data: a) individual, semi-structured interviews (scripted according to the theoretical framework) with participants associated with the institutions and mother of children aged between 28 and 365 days.Ninety-one interviewees took part: 11 managers -nine district managers (M) and two unit managers (Geradm); 48 health care professionals from PACS and ESF: ten doctors (MED); 12 nurses (N); 26 Community Health Workers (ACS), 20 from ESF (PSF) and six from PACS; four outpatient clinic general managers (UB), one UBT director and seven pediatricians from outpatient clinics (PED); 20 mothers; b) a case study of a preventable, post-natal infant death.The areas of Health District 1 with the highest occurrence for post-natal infant death classifi ed as preventable were identifi ed; 18 events which occurred during the period in question were analyzed in order to select those which best exemplifi ed problems with health care access culminating in a death which could have been avoided.In order to build the case, the following methods were used: examining ante-natal care cards completed by doctors and nurses in ESF units; examining medical records for mother and child appointments in maternity and pediatric hospitals; looking at notes from ACS home visits to mother and child; examining child's growth and development and vaccination records; examining records from child's appointments and referrals by the ESF; examining child's death certifi cate from the Institute of Legal Medicine; individual, semi-structured interviews which health care professionals involved in child's care and the death (ACS, doctors and nurses from ESF); and non-structured interviews with mother.Two interviews were necessary in order to establish a satisfactory relationship conducive to dialogue.The interviews took into account the mother's wishes as to the details revealed about the events leading to her daughter's death and took place at a time and place convenient to her.
The interviews lasted between 30 and 60 minutes, and were recorded and transcribed and accompanied by the fi eld diary.
Thematic content analysis was carried out, with a topic deemed to be a unit of meaning, taken from the text according to criteria from the theoretic-conceptual framework. 4Mixed categories were produced (scripted and emerging).The quality of the data was guaranteed by triangulation between groups of interviewees, techniques and strategies of data collection and an external analysis. 6,11e categories and sub-categories for analyzing access where those which the social protagonists associated with infant mortality: a) Factors related to SUS policies: implementation; dissemination, infant health programs; inter-sectoral actions; b) Factors concerned with the structure of supply: availability of human and material resources; c) Factors concerned with the organization of supply and professional performance: preventive and curative care (location; professional providing care); aspects of care (welcoming/humane/technical quality); d) Factors concerned with social context: social conditions of the families and the environment; social support networks.
The research was approved by the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Committee of Ethical Research in Humans, process nº 892, 2006.All of the participants signed consent forms.

RESULTS
The majority of the participants were women; of the ten men interviewed, two were managers, three were health care unit directors, three were ACS and two were doctors.The interviewees from the institutions had been carrying out their work for between fi ve and ten years, with the extremes represented by ACS from PACS and health care professionals from the outpatient clinics and the UBT (traditional model), who had been working there for more than 15 years, and for a doctor and ACS from ESF, where some members of the team had been there for a year.The 21 mothers interviewed were aged between 17 and 38; nine of them lived with their child's father; 13 had not completed primary education, one had fi nished high school and two had steady employment; nine were employed informally and ten reported they were not working; monthly household income was of one minimum wage, with this being supplemented by benefi ts.
For the majority of the interviewees, clear barriers to access emerged throughout the continuous care.The basic level stands out, with important differences in the level of intensity of the discourse, depending on the group from which it came.Four groups of barriers feedback into themselves, with repercussions on the avoidance of preventable infant mortality.

Infant death and SUS policies
The majority of participants from institutions related the persistence of deaths to barriers due to the SUS care model, including policies dealing with children's health, not being properly established.However, there was disagreement among the different groups.The majority of participants from the traditional model (professionals from the UBT and the outpatient clinics) were unaware of policies aimed at infant health, emphasizing the effective absence of children's health programs in the municipality; managers and professionals from the ESF/PACS highlighted the fragility of inter-sectoral cooperation.The mothers perceived the low problem solving capabilities of the ESF to be contributing factors.However, there were narratives about the decline in deaths being utilized by ESF/PACS, especially between members of these teams (Table 1).

Infant deaths and structural and organizational factors of supply
Almost all of the interviewees perceived the overall scarcity of resources to be prejudicial to access to preventive and curative health care.The groups had different perspectives regarding the outcome of infant death.For PACS/ESF health care professionals, infant mortality was linked to the large number of families the ESF teams were responsible for, meaning the health care professionals were overstretched.This would lead to programmed activities, such as those aimed at child health, not being carried out.All of the participants emphasized the lack of doctors in the ESF, displacing curative care onto nurses, adversely affecting the ability to solve problems.For health care professionals from the PACS/ESF, the lack of doctors interferes with supervision of the ACSs on their house calls, fundamental to monitoring at risk children.
There was confl ict between the mothers' discourse, which linked infant death to the constant lack of medicines, and those of participants from institutions, who viewed the availability of medication as one of the positive points of the SUS and did not perceive any connection with the deaths (Table 2).
The great intensity with which organizational barriers emerged, and the refusal to treat serious illness in ESF units, was unanimous among the mothers, who viewed this as one of the causes of infant mortality, obliging them to make use of emergency pediatric services (Table 2).In the doctors' opinions, nurses do not have the proper professional training to provide curative health care, suggesting confl icts within the heath care team (Table 2).

Infant mortality and factors of professional performance
Almost all participants linked inadequate performance by professionals with low technical quality to preventable infant deaths.Among the interviewees from institutions, this lack of professional commitment was attributed to ESF health care teams being overworked, to specialists being poorly trained and to the perception of not being professionally valued.The mothers attributed infant mortality not only to poor technical quality but to de-humanized, unwelcoming health care at all levels of care (Table 3).

Infant death and the social context
The main determinant of preventable infant mortality was the families' social exclusion, high levels of poverty, unemployment, violence and drug use, according to almost the participants.The mothers talked of a lack of social support network.For the participants from the ESF/PACS, in concordance with the mothers, infant death was particularly associated with maternal characteristics, blaming the mothers for negligence towards their children (Table 4).

The case of preventable infant death
The case of preventable, post-natal infant death in an area assigned to the ESF permitted a deeper analysis of the actual obstacles to health care services and campaigns which had emerged from the interviews, and showed links between the main barriers to access to children's health care throughout the course of their day to day access (or lack of it) to health care.Situations which emerged in the process of interaction between the various participants involved with the child from in-utero to its death were analyzed: a) barriers to access such as the mother not having ante-natal checks, social risk and ESF doctors and nurses not monitoring at risk children.This suggests that SUS child health care policies are not completely established and a lack of professional commitment on the part of the ESF; b) the sick child not receiving care the day before their death, which demonstrates the barrier to treatment of acute illness in USF; and c) the lack of references to timely medical assistance when the USF refused treatment.Poor technical and scientifi c quality and a lack of professional commitment on the part of the ESF were reported.The events contributed to preventable infant death which could have been avoided by actions and health care services (Table 5).

DISCUSSION
In spite of the Brazilian government's directors' commitment to comprehensive child health care and a signifi cant decline in infant mortality, 25,a numerous barriers to access indicate the fragility with which the SUS has been established and of the main access point: basic health care.Ultimately, this has repercussions on the perpetuation of preventable infant deaths.There were signifi cant differences in the perception and/or intensity of the statements, probably due to the participant's position with regards to the phenomenon.
Lack of awareness of policies aimed at children's health and of the health care model 25,a on the part of health care professionals, together with professionals from both levels of health care's views that care is supplied better in the traditional model and the mothers' perceptions of poor problems solving capabilities in the ESF, are examples of the model's poor consolidation.This is worrying, especially in relation to the main point of access, where the majority of activities to avoid well-structured network, in which primary health care was provided by pediatricians, demonstrate the need for fresh adjustments to enable the new model to be understood and legitimized. 5,22e main criticisms of the new model which emerged from the mothers' statements were the lack of doctors No responsibility taken for the child throughout the course of their health care -Team does not continue to provide care after referral and return to specialist services.
[...] so she (ACS) comes to the house to go through her routine; and I said "the girl is distressed and vomiting" and she said "take her to the center".I took her to the center.in the ESF, limited curative health care, doctors being substituted for nurses and the refusal to treat acute illness.f The lack of doctors interfered in work processes and in inter--personal relationships as nurses were overworked and their roles in the ESF not clearly defi ned.This increased confl icts in the teams' work, permeating into values, attitudes and historically determined conceptions. 3,17,18,21e infant death case study revealed the ESF's failure to monitor at risk children as one of the main determinants of infant death as well as indicating the link between other lapses in the health care provided, such as diffi culties in working in teams.The fact that responsibility for the death was avoided and blame placed on the mother refl ects serious problems in communication and professional conduct as well as probable corporate issues. 3,6On the one hand, there is resistance to hierarchical change among medical professionals in the former care model and, on the other, promotion of nurses to a level equal to that of the doctors, which generates intra-team confl icts. 3,17rriers related to poor performance indicate the lack of quality health care in the ESF and no responsibility being taken for the child throughout the course of their health care.Failing to comply with government child health care directives highlight failures in the way comprehensive child health care policies are established.f These were aspects present in the statements of all participants and in the infant death case study.
The mothers' unanimous vision of the health care process as dehumanized suggests that access to health care through the means of welcoming, sympathetic interpersonal relationships between patient and health care provider 8,15 is not common practice, making this a SUS operational directive which has not become incorporated in the minds of health care professionals dealing with children's health care. 7,21aming the child's death on the mother's negligence was something which emerged mainly among the mothers and female ESF/PACS health care professionals.These health care professionals emphasized maternal factors, separating them from the context of social misery and played down inadequate access to health care.These statements implied prejudiced, probably ideological attitudes.Among the mothers, contradiction appeared in the statements, which had a note of involuntary maternal involvement, intertwined with conditions of extreme vulnerability.These data are consistent with those from the Scheper-Hughes 20 study, developed in Northeastern Brazil, but not with those of the study carried out by Nations, 16 in the same area at the same time, in which the mothers perceived failures in health care as one of the determinants of death.The results show an attitude more of resignation on the part of the mothers, towards the miserable conditions of the context which overcame the perception of obstacles to health care access. 9,12,13,20,22,24They also refl ect a position of little solidarity, based on the impersonality of the guiding question, which referred to the deaths of the children of mothers they did not know, which contributed to the development of blame in their statements.
To conclude, the existence of numerous barriers to access to child health care refl ects the way the SUS, and its main access point, the ESF, have not been fi rmly established.The participants fail to perceive the link between poor quality health care services and the continuing occurrence of preventable infant mortality which could be avoided by actions and health care services through child health care policies.
The structural (lack of medicines in the ESF), organizational (restrictions on care for acute illnesses/doctors substituted for nurses) and professional performance (poor technical quality, care that is not welcoming/ dehumanized and problems with team work) barriers prove themselves to be the main obstacles to access to primary care which takes responsibility for the child throughout the whole course of their health care.
Despite the mothers' conditions of social exclusion being linked to infant mortality, these factors can be minimized with effi cient primary care, bearing in mind the important role played by fairer and effective social policies.

Table 1 .
Opportunities and barriers to access related to SUS policies.Recife, Northeastern Brazil, 2007.
-[...] once there are guidelines for children, the program for at-risk children, they must actually make it happen[...]things are not happening as they were planned to, visits monitoring this very child [...].(M8).-[...] this clinic (referring to the outpatient clinic) should be for support [...] and here the demand has been more direct to the staff rather than referred by the doctors (referring to ESF doctors) and ACS [...] there has to be integration [...] I believe it would signifi cantly cut down on child illness and mortality.(PED4).Lack of awareness of child health care policies on the part of health care professionals (health care professionals in outpatient clinics/UBT) -With regards to pediatrics, when there is not a specifi c program [...] I believe that this still needs to be improved [...] in order for there to be better health care, be more attentive in these cases of infant mortality [...] or if this exists, I'm not aware of it, but this is not only my fault as I was not informed [...].(UB1).Fragility of inter-sectoral activities (managers/ ESF/PACS health care professionals) -[...] when discussing avoidable deaths, the fi rst aspect to be considered is the lack of effective inter-sectoral work [...].The health care sector managed to establish partnerships with other sectors, guarantee women's education, housing, income, generate employment.All of this is happening, but at a slow pace.(M1).-[...] the responsibility for infant mortality does not lie so much with health care [...] it is also a political question, of social exclusion [...] there are other factors involved here, structural, socio-economic, political, family, health care is limited to treating these problems.(N9).clinic (referring to outpatient clinics) [...] I prefer to go straight there.(Mother 1).Establishing ESF/PACS (ESF/PACS health care professionals) -[...] I don't think we're one hundred percent there yet, but we're getting there [...] infant mortality is falling [...] due to monitoring, the specifi c treatment we provide these children with [...] in the case of vaccination, diarrhea, these have been controlled.(PACS3).SUS: Brazilian Unifi ed Health System; ESF: Family Health Strategy; UBT: Traditional Primary Care Unit; PACS: Community Health Worker Program; USF: Family Health Center; N: nurse; M: district managers; UB: general managers; PED: outpatient clinics

Table 2 .
Barriers to access related to structural and organizational factors or supply.Recife, Northeastern Brazil, 2007.-Maybe lack of conditions, lack of care [...] I think lack of everything, in terms of the doctors, of medication [...].Sometimes on the part of the mother [...] there is nowhere else to turn, you're unable to buy medicine [...] the child ends up dying.
-In the center (USF) near home, you have to make an appointment (for a consultation) you have to go there early in the morning[...]there are times I don't manage to get an appointment, sometimes there is a draw to see which day you will get an appointment!(Mother12).Lack of supervision for the ACSs (ESF/ PACS health care professionals) -[...] I think nurses should accompany ACSs on home visits more often.Sometimes the ACSs are left totally alone (ACS5).-JustyesterdayIboughtthismedicinehere[...] sometimes I have to use grocery money because [...] they give you medicines that are not available at the center, then you have to buy it(Mother 11)-If I have to get an appointment for my daughter to be seen, because she's sick, she should be seen then and there, without having to wait for an appointment, without making an appointment, if it wasn't serious I would make an appointment for another day, not wait one or two months[...].Everything goes to the emergency room, when they could be seen at the center (referring to the USF) which is much closer (Mother 8).-[...] if it's an illness that I know the center (USF) won't deal with, if it's going to be a wasted journey, I'll go to the emergency room (Mother 16).-[...] at the center (USF) we have to wait for those who have an appointment to be seen [...] to be squeezed in [...] then the boy will die, right?(Mother1).-I don't like the health care at the center (USF) where I live, because it's not a doctor who sees you, it's a nurse, and she's not really as capable as a doctor is[...]. and there is only a general clinic there[...]there should be pediatrics.(Mother 18).-[...] this idea of children being treated at the clinic, I don't think it works out [...] and the mothers don't seem to like it.[...] here (referring to the outpatient clinic) it is always really busy because they (referring to the mothers) are not satisfi ed with the care provided by the general practitioner at the PSF.(PED3).

Table 3 .
Barriers to access related to factors of professional performance.Recife, Northeastern Brazil, 2007.
-I suffer a lot [...] I don´t treat the children because the other categories of the PSF keep me too busy and pediatrics ended up with no medical care.(MED9).-[...] I suffer over this because you can't do what you would like to [...] I already started a group (education and health) and I couldn't go ahead with it, we didn't have the energy for it [...] due to being overworked (N1).-Our universities don't train people to work from the perspective of promoting, preventing, comprehensive treatment, clinical responsibility.(M1).-[...] in the university they teach you that bad doctors work at the PSF, students who end up in the PSF are weak [...]because the good students are going to be specialists.(M4).-[...] being patient with the children, being conscientious and treating people with courtesy because there are a lot who [...] have already argued with the doctor here for being rude, if we ask what is wrong with the child, if it's something serious he answers " Who is the doctor here: me or you?".But I'm the mother [...] they should explain properly so that I know what's happening (Mother 4).-[...] there are doctors who are not caring, who don't even touch the child as if it made them nauseous!(Mother 5).ESF: Family Health Strategy; USF: Family Health Center; PSF: Family Health Program; M: district managers; Geradm: unit managers; N: nurse; MED: doctor; UB: general managers

Table 4 .
Barriers to access related to factors of family context.Recife, Northeastern Brazil, 2007.-[...] I think it's down to people's miserable living conditions, because the majority of these deaths are from the poor social classes [...] employment is more and more diffi cult, [...] there's not enough food, a decent living place, they live there in that swamp with all kinds of illnesses.(UB2).Infant death in areas assigned to the ESF as a result of failures in the Government Program to Reduce Infant Mortality f highlights barriers to implementing child health care policies.The confl icts between the current model and the traditional, -Lack of health care is it?I don't know[...]the mother, in my opinion, if the child has a fever you go straight to hospital, because it's ill [...] me, when mine was ill, I go straight there, and there are lots of mothers who keep the child at home "it's a daft little fever" and when they fi nally see that it's something serious it's too late and there is not time for it to be treated and the child dies.(Mother 8).Blaming mothers for negligence and poor quality care (mothers) -Poor treatment is it?It's also an emergency case [...] if the mother doesn't also care for the child, doesn't head straight to the doctor [...].In an emergency like that, you still have to wait your turn [...] the child had a high fever [...] and you have to wait, right?There are a lot of tired children there [...] lots of hospitalized children [...] (Mother 10).

Table 5 .
The course of preventable infant mortality: the diverse barriers to access.Recife, Northeastern Brazil, 2007.
The doctor saw us and sent us to the hospital, gave me a bus ticket.(Mother).
-[...] then I had a problem, phlebitis, and I was off for ten days.(Doctor).-[...] So I tried to get in touch with the ACS and they told me "she's not here, she's out", so I asked "where is the doctor?""Thedoctor has left".I took her back home, gave her Dipirona, the fever passed, I fed her, winded her, put her to sleep, she was playing, she wasn't poorly, she was alert, and so we went to sleep.(Mother).-[...] so I said: "hey!She's asleep, I'm going to get her and feed her, my breasts were really full" [...] I went up and lit a cigarette.Smoked it and turned around and she was still asleep [...] and I said to myself:" she's sleeping a lot" [...] and when I went to pick her up her clothes were all wet with milk, her nose was blocked with catarrh and she was purple [...] so I picked her up and went running into the street (Mother).-Blameplaced on the mother and on overwork caused by the death of the child.Intra-team confl icts.