Abstract

There are no nationwide studies characterizing accessibility for people with disabilities during delivery. This study aimed to describe the physical structure of hospital units regarding accessibility for pregnant and puerperae with motor (MD), visual (VD), or hearing (HD) disabilities in Brazil. This is an ecological, descriptive study conducted in all 606 health facilities linked to the “Rede Cegonha” where deliveries occurred, according to 2015 databases. We performed the descriptive and geospatial analysis and considered the presence of motor accessibility when the establishment had a handrail or elevator ramp, wheelchair-sized doors, and accessible bathroom with bars. We assumed visual accessibility when there was tactile signage on the floor (Braille system or embossed figures) and hearing accessibility when there was signage by texts, pictures, signs, posters, or symbols in the environments. In Brazil, only 26 (4.3%) of the facilities had accessibility for people with MD, 20 (3.3%) for people with VD, and none for HD. Motor accessibility was worse in the North and Northeast of Brazil, and hearing accessibility in the North region. Despite advances in the implementation of the “Rede Cegonha” in Brazil, the facilities’ structure is not adapted for women with MD, VD, or HD.

Key words
People with disabilities; Maternal health services; Service structure

Introduction

In the last 2010 census, 24% of the Brazilian population reported having some type of motor (MD), visual (VD), or hearing (HD) disability. More than 13 million (7.1%) had some degree of MD, of which 734,421 (0.4%) were utterly unable to walk. VD was reported by 35,774,392 (18.8%) Brazilians, and of these, 506,377 (0.3%) were completely blind. Some hearing impairment degree was reported by 9,717,318 (5.1%) Brazilians, of whom 344,206 (0.2%) were totally deaf. These disabilities were more expressive in women, especially motor and visual¹1 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico 2010: Características gerais da população, religião e pessoas com deficiência. [acessado 2019 Jun 6]. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/caracteristicas_religiao_deficiencia/caracteristicas_religiao_deficiencia_tab_gregioes_xls.shtm
http://www.ibge.gov.br/home/estatistica/... .

Women with disabilities experience multiple social, economic, and health inequalities, with greater exposure to poverty, unemployment, and low schooling²2 Mathias K, Kermode M, San Sebastian M, Davar B, Goicolea I. An asymmetric burden: Experiences of men and women as caregivers of people with psycho-social disabilities in rural North India. Transcult Psychiatry 2019; 56(1):76-102.

3 Belzunegui-Eraso A, Pastor-Gosálbez I, Puig-Andreu X, Valls-Fonayet F. Risk of Exclusion in People with Disabilities in Spain: Determinants of Health and Poverty. Int J Environ Res Public Health 2018; 15(10):2129.

4 Mitra M, Akobirshoev I, Moring NS, Long-Bellil L, Smeltzer SC, Smith LD, Iezzoni LI. Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey. J Womens Health (Larchmt) 2017; 26(12):1356-1363.

5 Boccolini PMM, Duarte CMR, Marcelino MA, Boccolini CS. Social inequalities in limitations caused by chronic diseases and disabilities in Brazil: the 2013 National Health Survey. Cien Saude Colet 2017; 22(11):3537-3546.

6 Gudlavalleti MVS, John N, Allagh K, Sagar J, Kamalakannan S, Ramachandra SS. Access to health care and employment status of people with disabilities in South India, the SIDE (South India Disability Evidence) study. BMC public health 2014; 14(1):1125.

7 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872.^-88 Devkota HR, Kett M, Groce N. Societal attitude and behaviours towards women with disabilities in rural Nepal: pregnancy, childbirth and motherhood. BMC Pregnancy Childbirth 2019; 19(1):20.. Pregnant women with disabilities are more susceptible to problems during pregnancy and delivery⁹9 Long-Bellil L, Mitra M, Iezzoni LI, Smeltzer SC, Smith L. The Impact of Physical Disability on Pregnancy and Childbirth. J Womens Health (Larchmt) 2017; 26(8):878-885.

10 Murthy GVS, John N, Sagar J. Reproductive health of women with and without disabilities in South India, the SIDE study (South India Disability Evidence) study: a case control study. BMC Women's Health 2014; 14(1):146.^-1111 Tarasoff LA, Ravindran S, Malik H, Salaeva D, Brown HK. Maternal disability and risk for pregnancy, delivery, and postpartum complications: A systematic review and meta-analysis. Am J Obstet Gynecol 2019; 222(1):27.. Even so, international studies show that these women face barriers and challenges related to access and quality of reproductive health and cancer prevention services⁴4 Mitra M, Akobirshoev I, Moring NS, Long-Bellil L, Smeltzer SC, Smith LD, Iezzoni LI. Access to and Satisfaction with Prenatal Care Among Pregnant Women with Physical Disabilities: Findings from a National Survey. J Womens Health (Larchmt) 2017; 26(12):1356-1363.^,66 Gudlavalleti MVS, John N, Allagh K, Sagar J, Kamalakannan S, Ramachandra SS. Access to health care and employment status of people with disabilities in South India, the SIDE (South India Disability Evidence) study. BMC public health 2014; 14(1):1125.^,77 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872.^,1212 Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: A systematic review. Womens Health Issues 2013; 23(14):205-214.

13 Iezzoni LI, Kilbridge K, Park ER. Physical access barriers to care for diagnosis and treatment of breast cancer among women with mobility impairments. Oncol Nurs Forum 2010; 37(6):711-717.

14 McRee A-L, Haydon AA, Halpern CT. Reproductive health of young adults with physical disabilities in the U.S. Prev Med 2010; 51(6):502-504.

15 Drainoni ML, Lee-Hood E, Tobias C, Bachman SS, Andrew J, Maisels L. Cross-disability experiences of barriers to health-care access: Consumer perspectives. J Disabil Policy Stud 2006; 17(2):101-115.

16 Read S, Heslop P, Turner S, Mason-Angelow V, Tilbury N, Miles C, Hatton C. Disabled people's experiences of accessing reasonable adjustments in hospitals: a qualitative study. BMC Health Serv Res 2018; 18(1):931.

17 Sakellariou D, Rotarou ES. The effects of neoliberal policies on access to healthcare for people with disabilities. Int J Equity Health 2017; 16(1):199.^-1818 Hunt X, Carew MT, Braathen SH, Swartz L, Chiwaula M, Rohleder P. The sexual and reproductive rights and benefit derived from sexual and reproductive health services of people with physical disabilities in South Africa: beliefs of non-disabled people. Reprod Health Matters 2017; 25(50):66-79..

In 2002, the National Health Policy for People with Disabilities¹⁹19 Brasil. Portaria nº 1.060, de 5 de junho de 2002. Institui a Política Nacional de Saúde da Pessoa Portadora de Deficiência. Diário Oficial da União 2002; 5 jun. was established to reduce the multiple vulnerabilities experienced by people with disabilities. However, it was altered in 2010 by the National Health Policy for People with Disabilities²⁰20 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde da Pessoa com Deficiência. Brasília: Editora do Ministério da Saúde; 2010. [acessado 2020 Maio 26]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_pessoa_com_deficiencia.pdf
https://bvsms.saude.gov.br/bvs/publicaco... , since understanding the concept of disability is evolving around the world. In Brazil, the Care Network for People with Disabilities, established under Ordinance N° 793, of April 24, 2012²¹21 Brasil. Portaria nº 793, de 24 de abril de 2012. Institui a Rede de Cuidados à Pessoa com Deficiência no âmbito do Sistema Único de Saúde. Diário Oficial da União 2012; 24 abr., emphasizes the need to modify the structure of health establishments within the Unified Health System (SUS), ensuring access, improved physical structure, and professional qualification of the entire Care Network, from primary care to high complexity, including funding for this purpose, to cover service users with disabilities.

Martins et al.²²22 Martins KP, Costa TFD, Medeiros TMD, Fernandes MDGM, França ISXD, Costa K. NDFM. Estrutura interna de Unidades de Saúde da Família: acesso para as pessoas com deficiência. Cien Saude Colet 2016; 21(10):3153-3160. found that the physical structure of a primary health care facility (acronym in Portuguese – UBS) in João Pessoa, Northeast Brazil, was not adapted for people with disabilities, diverging from the SUS principles of equity and universality. In an analysis of 240 UBS in 41 Brazilian municipalities with more than 100 thousand inhabitants, Siqueira et al.²³23 Siqueira FCV, Facchini LA, Silveira DSD, Piccini RX, Thumé E, Tomasi E. Barreiras arquitetônicas a idosos e portadores de deficiência física: um estudo epidemiológico da estrutura física das unidades básicas de saúde em sete estados do Brasil. Cien Saude Colet 2009; 14(1):39-44. found that about 60% of the facilities were unsuitable for access by people with disabilities. The presence of steps, the lack of handrails, ramps, restrooms adapted for wheelchair users, and waiting rooms inadequate to needs were the most identified problems.

No studies evaluating accessibility in Brazilian maternity hospitals for pregnant women/mothers with MD, VD, or HD have been identified concerning delivery care. However, some evidence shows that the adequacy of the structure in maternity hospitals affects the reduction of maternal and child mortality and adverse perinatal outcomes²⁴24 Bittencourt SDA, Domingues RMSM, Reis LGC, Ramos MM, Leal CM. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 13(3):120.^,2525 Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, Leal MDC. Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento. Cad Saude Publica 2014; 30(1):208-219..

From the perspective of greater social inclusion and the construction of full and effective citizenship of people with disabilities, in 2015, Brazil established the Brazilian Law for the Inclusion of People with Disabilities, also known as the Statute of People with Disabilities²⁶26 Brasil. Lei nº 13.146, de 06 de julho de 2015. Institui a Lei Brasileira de Inclusão da Pessoa com Deficiência (Estatuto da Pessoa com Deficiência). Diário Oficial da União 2015; 7 jul.. This Law guarantees access to health for this segment of the population²⁶26 Brasil. Lei nº 13.146, de 06 de julho de 2015. Institui a Lei Brasileira de Inclusão da Pessoa com Deficiência (Estatuto da Pessoa com Deficiência). Diário Oficial da União 2015; 7 jul.. However, despite scarce evidence, we can assume that significant challenges persist in guaranteeing universal and equitable access to health services during delivery and birth in the SUS network establishments to women with disabilities.

Taking this challenge as a reference and given the scarcity of studies addressing this topic, this study aims to describe the physical structure of hospital establishments linked to the Rede Cegonha (RC) regarding accessibility for pregnant women puerperae with motor, visual, or hearing disabilities in Brazil.

Methods

Study design, Analysis unit

This ecological, descriptive study collected data in a single moment in time from December 2016 to September 2017. The analysis units were public or SUS-affiliated hospital establishments linked to the RC.

Sample and study location

All hospitals that, in 2015, according to data from the Live Birth InformationSystem (acronym in Portuguese – SINASC), met the following criteria were included: i) Performing 500 or more deliveries and location in a health region with an RC action plan, regardless of funding release (N = 581); and ii) Performing less than 500 deliveries, located in a health region with an RC action plan and with the release of RC funding (N = 25). Thus, the study population consisted of 606 establishments, 86 in the North, 175 in the Northeast, 223 in the Southeast, 81 in the South, and 41 in the Midwest. These establishments were identified by the link between SINASC and the National Registry of Health Establishments (acronym in Portuguese – CNES).

Brazilian regions have contrasting socioeconomic and health indicators. In 2017, the North region had an illiteracy rate of 8.8%²⁷27 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2016. [acessado 2019 Jun 28]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv98965.pdf.
https://biblioteca.ibge.gov.br/visualiza... and a gross domestic product (GDP) of R$ 337.231 billion²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2010. [acessado 2019 Jun 27]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=series-historicas& utm_source=landing&utm_medium= explica&utm_campaign=pib
https://www.ibge.gov.br/estatisticas/eco... . It had the highest maternal mortality ratio (MMR) in Brazil, with 76.0 deaths per 100,000 live births²⁹29 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018. [acessado 2019 Jun 28]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2017_analise_situacao_saude_desafios_objetivos_desenvolvimento_sustetantavel.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , followed by the Northeast region. The Northeast had a GDP of R$ 898.082 billion²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2010. [acessado 2019 Jun 27]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=series-historicas& utm_source=landing&utm_medium= explica&utm_campaign=pib
https://www.ibge.gov.br/estatisticas/eco... , an illiteracy rate of 14.3%²⁷27 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2016. [acessado 2019 Jun 28]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv98965.pdf.
https://biblioteca.ibge.gov.br/visualiza... and the second highest MMR, with 75.3 per 100 thousand live births²⁹29 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018. [acessado 2019 Jun 28]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2017_analise_situacao_saude_desafios_objetivos_desenvolvimento_sustetantavel.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . The Southeast has the highest demographic and urban concentrations and the best economic indicators. It has the highest GDP in the country (R$ 3.332 trillion)²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2010. [acessado 2019 Jun 27]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=series-historicas& utm_source=landing&utm_medium= explica&utm_campaign=pib
https://www.ibge.gov.br/estatisticas/eco... , the lowest illiteracy rate (3.8%)²⁷27 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2016. [acessado 2019 Jun 28]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv98965.pdf.
https://biblioteca.ibge.gov.br/visualiza... , and the MMR was 54.3 per 100 thousand live births²⁹29 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018. [acessado 2019 Jun 28]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2017_analise_situacao_saude_desafios_objetivos_desenvolvimento_sustetantavel.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... in 2015. The South had a GDP of R$ 1.066 trillion²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2010. [acessado 2019 Jun 27]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=series-historicas& utm_source=landing&utm_medium= explica&utm_campaign=pib
https://www.ibge.gov.br/estatisticas/eco... and MMR of 43.7 per 100 thousand live births²⁹29 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018. [acessado 2019 Jun 28]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2017_analise_situacao_saude_desafios_objetivos_desenvolvimento_sustetantavel.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . The Midwest had a GDP of R$ 632.889 billion²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico: características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2010. [acessado 2019 Jun 27]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=series-historicas& utm_source=landing&utm_medium= explica&utm_campaign=pib
https://www.ibge.gov.br/estatisticas/eco... , an illiteracy rate of 6.8%²⁷27 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2016. [acessado 2019 Jun 28]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv98965.pdf.
https://biblioteca.ibge.gov.br/visualiza... , and an MMR of 65.9 per 100 thousand live births²⁹29 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018. [acessado 2019 Jun 28]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2017_analise_situacao_saude_desafios_objetivos_desenvolvimento_sustetantavel.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

Data collection

Data were collected through on-site observation using an Observation Guide especially developed for this study, and digitally, using REDCap © 2017, Vanderbilt University. This roadmap was based on the National Humanization Policy³⁰30 Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Universidade Estadual do Ceará. Brasília: 2014 [acessado 2018 Mar 29]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/parto.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , National Policy of RC³¹31 Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011., on Good Practices for Delivery and Birth Care³²32 Organização Mundial de Saúde (OMS). Maternidade Segura. Assistência ao Parto Normal: um guia prático. Genebra: OMS; 1996., Pregnant Women Care Guidelines: cesarean section³³33 Brasil. Ministério da Saúde (MS). Diretrizes de Atenção à Gestante: a operação cesariana 2015. [acessado 2019 Jul 8]. Disponível em: http://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf.
http://conitec.gov.br/images/Relatorios/... and Pregnant Women Care Guidelines: normal delivery³⁴34 Brasil. Ministério da Saúde (MS). Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: MS; 2017 [acessado 2018 Mar 29]. Disponível em: ://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf.
://bvsms.saude.gov.br/bvs/publicacoes/di... . On-site observation aimed to evaluate care processes and hospital infrastructure conditions, physical plant, equipment, materials, and supplies.

The observation of the establishment was previously scheduled with managers of the state, municipality, and the establishment itself, who were invited to participate in the process or send a representative on the day of data collection, in order to visit the hospital, together with the evaluator, during the registration of information.

Study variables

The variables related to the accessibility of pregnant women and puerperae with MD, VD or HD were extracted from the instrument and are shown in Box 1. Data related to the hospitals’ contextual variables were geopolitical region, Federative Unit (acronym in Portuguese – UF), municipality, and data from hospital geographical coordinates.

For analysis purposes, motor, visual or hearing accessibility variables were created for each hospital and each hospital establishment setting, as described in Chart 1. Motor Accessibility in the hospital was considered when, during on-site observation, accessibility was identified in all environments analyzed (Chart 1). The same applies to Visual and Hearing Accessibility. Concerning visual and hearing accessibility analysis, rooming-in was not considered due to the lack of this information in the databases we adopted for this study.

Statistical analysis

Descriptive data analysis was performed by calculating absolute and relative frequencies for each variable within the hospital. After that, the proportion of maternity hospitals in each UF was observed with the appropriate items. This information was used to produce spatial distribution analyses by UF.

The characterization of the spatial distribution of hospital establishments by the accessibility of people with MD, VD, or HD required the elaboration of maps with the spatial distribution of points in their respective municipalities from the geographical coordinates obtained through the address of the hospital establishments. Descriptive analyses were performed using Stata^® software, version 14.0 (StataCorp., College Station, United States).

Point maps were made using ArcGIS^® software, version 10.5 (Esri Inc., 2017, United States). Thematic maps were prepared with Q-GIS^® software, version 3.10.1³⁵35 Qgis Training Manual. [acessado 2019 Ago 21]. Disponível: s://docs.qgis.org/3.4/pdf/en/QGIS-3.4-QGISTrainingManual-en.pdf
s://docs.qgis.org/3.4/pdf/en/QGIS-3.4-QG... . A map was created with distance lines between these establishments vis-à-vis all the other existing Brazilian establishments to visualize the outreach area of the establishments classified with accessibility for people with MD, VD, or HD, together. Radius ranges were obtained by adopting three distance parameters (30km, 50km, and 100km) from establishments with accessibility for people with MD, VD, or HD.

Ethical considerations

The Human Research Ethics Committee of the Federal University of Maranhão and the Sérgio Arouca National School of Public Health approved the research. All participants signed an Informed Consent Form. The research was financed by resources from the National Health Fund/Ministry of Health. This paper is nested in the Evaluation research on the management of delivery and birth care in the Brazilian SUS network.

Results

The structure of hospital/maternity facilities linked to the RC in Brazil was not adapted for people with MD (Table 1, Figure 1), VD (Table 2, Figure 1), or HD (Table 3, Figure 1). Only 26 establishments (4.3%) had all four environments (reception, admission room, obstetric unit, and rooming-in) with the minimum characteristics of motor accessibility measured in this study, as described in Chart 1.

When considering the motor accessibility synthesis indicator, establishments in the Midwest (%) and Southeast (%) performed better than the other regions – South, although all have proportions of accessible environments below 10%. The states of Sergipe (22.2%), Mato Grosso do Sul (18.2%), Acre (16.7%), and Mato Grosso (16.7%) performed best. Reception – ramps with handrail or elevator, doors with appropriate sizes for wheelchairs, and accessible bathroom with bars – was the environment with the worst structure for motor accessibility (16.5%). The admission room – doors with appropriate sizes for wheelchairs – obtained the best adaptation results (65.2%) (Table 1, Figure 1).

None of the 606 establishments evaluated in Brazil had tactile signages on the floor (Braille system or figures in relief) at the reception, admission room, and obstetric unit. Tactile signaling at reception was found in three establishments in the Northeast (1.7%), four in the Southeast (1.8%), one in the South (1.2%), and one in the Midwest (2.4%). In the admission room, only two establishments in the Southeast (0.9%) had tactile signages. In the obstetric unit, only three establishments in the Northeast (1.7%) and three in the Southeast (1.4%) had a structure that would allow accessibility to pregnant/puerperae with a visual disability (Table 2, Figure 1).

Signaling through texts, figures or symbols on signs, information posters inside the reception, admission room, and obstetric unit was observed in only 20 (3.3%) hospital establishments linked to RC. According to the synthesis indicator, northern establishments had the worst performance – none of the establishments met the criteria for hearing accessibility (Table 3, Figure 1).

In the radius distance map of maternity hospitals with visual, motor, or hearing accessibility, we observed that, due to the lack of adequate maternity hospitals for the three accessibility indicators, two establishments with motor and hearing accessibility located in Bahia and Minas Gerais reached populations residing within the state located at distances of 30km and 50km. At a distance of 100km, the establishment located in Bahia reached resident populations in the South of the state of Piauí, in the east of Pernambuco, Alagoas, and Sergipe, while in the other establishment in Minas Gerais, that same distance (100km), reached the largest part of Espírito Santo and Rio de Janeiro (Figure 2).

Discussion

This study points out that the structure of hospital facilities linked to the RC in Brazil is not adapted for people with MD, VD, or HD, corroborating the findings of other studies in which inadequacies were observed in the physical structure of family health units²²22 Martins KP, Costa TFD, Medeiros TMD, Fernandes MDGM, França ISXD, Costa K. NDFM. Estrutura interna de Unidades de Saúde da Família: acesso para as pessoas com deficiência. Cien Saude Colet 2016; 21(10):3153-3160.^,2323 Siqueira FCV, Facchini LA, Silveira DSD, Piccini RX, Thumé E, Tomasi E. Barreiras arquitetônicas a idosos e portadores de deficiência física: um estudo epidemiológico da estrutura física das unidades básicas de saúde em sete estados do Brasil. Cien Saude Colet 2009; 14(1):39-44..

The National Health Policy for People with Disabilities²⁰20 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde da Pessoa com Deficiência. Brasília: Editora do Ministério da Saúde; 2010. [acessado 2020 Maio 26]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_pessoa_com_deficiencia.pdf
https://bvsms.saude.gov.br/bvs/publicaco... , the Care Network for People with Disabilities²¹21 Brasil. Portaria nº 793, de 24 de abril de 2012. Institui a Rede de Cuidados à Pessoa com Deficiência no âmbito do Sistema Único de Saúde. Diário Oficial da União 2012; 24 abr. and the Brazilian Law for Inclusion of People with Disabilities²⁶26 Brasil. Lei nº 13.146, de 06 de julho de 2015. Institui a Lei Brasileira de Inclusão da Pessoa com Deficiência (Estatuto da Pessoa com Deficiência). Diário Oficial da União 2015; 7 jul. are more current legal frameworks designed to ensure and promote similar conditions, the exercise of social rights of people with disabilities, targeting their social inclusion and citizenship. The results of this work are a counterpoint to these legal frameworks that emphasize the relevance of access and quality of services to these individuals, equity, comprehensive care, improving the physical structure of health establishments⁷7 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872., the dissemination of information, and a dynamic and global view of the health status of women with MD, VD, or HD⁷7 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872.^,2424 Bittencourt SDA, Domingues RMSM, Reis LGC, Ramos MM, Leal CM. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 13(3):120..

SUS management and financing problems may hinder the more effective implementation of public health policies aimed at people with disabilities, contributing to the low proportion of adequacy of establishments in the RC for people with disabilities³⁶36 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779):1778-1797..

The qualification of maternal and child health services, especially for the most vulnerable population, is an essential strategy for curbing health inequities and achieving internationally agreed goals. In Brazil, this theme has received greater prominence in the last decades, mainly given the persistence of high MMR, with estimates above the standards required by World Health Organization (WHO), and is the only Millennium Development Goal (MDG) that was not achieved by the country in 2015, not reaching a reduction of 70% in the 1990-2015 period³³33 Brasil. Ministério da Saúde (MS). Diretrizes de Atenção à Gestante: a operação cesariana 2015. [acessado 2019 Jul 8]. Disponível em: http://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf.
http://conitec.gov.br/images/Relatorios/... .

Women with special needs are at higher risk of problems related to pregnancy, delivery, and postpartum than the general population, such as significantly higher rates of depression¹⁰10 Murthy GVS, John N, Sagar J. Reproductive health of women with and without disabilities in South India, the SIDE study (South India Disability Evidence) study: a case control study. BMC Women's Health 2014; 14(1):146., diabetes, urinary tract infections³⁷37 Morton C, Le JT, Shahbandar L, Hammond C, Murphy EA, Kirschner KL. Pregnancy outcomes of women with physical disabilities: a matched cohort study. PM&R 2013; 5(2):90-98., and preterm birth⁹9 Long-Bellil L, Mitra M, Iezzoni LI, Smeltzer SC, Smith L. The Impact of Physical Disability on Pregnancy and Childbirth. J Womens Health (Larchmt) 2017; 26(8):878-885.^,1313 Iezzoni LI, Kilbridge K, Park ER. Physical access barriers to care for diagnosis and treatment of breast cancer among women with mobility impairments. Oncol Nurs Forum 2010; 37(6):711-717.^,3737 Morton C, Le JT, Shahbandar L, Hammond C, Murphy EA, Kirschner KL. Pregnancy outcomes of women with physical disabilities: a matched cohort study. PM&R 2013; 5(2):90-98., and low birth weight⁹9 Long-Bellil L, Mitra M, Iezzoni LI, Smeltzer SC, Smith L. The Impact of Physical Disability on Pregnancy and Childbirth. J Womens Health (Larchmt) 2017; 26(8):878-885.^,1313 Iezzoni LI, Kilbridge K, Park ER. Physical access barriers to care for diagnosis and treatment of breast cancer among women with mobility impairments. Oncol Nurs Forum 2010; 37(6):711-717.^,3737 Morton C, Le JT, Shahbandar L, Hammond C, Murphy EA, Kirschner KL. Pregnancy outcomes of women with physical disabilities: a matched cohort study. PM&R 2013; 5(2):90-98. among newborns. Therefore, there is a need to improve the physical structure of maternity hospitals linked to the RC, to make access more equitable and streamline health indicators among women with MD, VD, or HD.

The Ministry of Health also states that regional and population-based inequalities lead to different MMR and that it is necessary to build and measure reliable estimates stratified by regions and UF to subsidize the monitoring of priority areas related to women’s health, especially pregnant women, ensuring the effective implementation and evaluation of public policies aimed at this population³⁸38 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018..

Women with disabilities are found in all age groups, ethnicities, religions, economic backgrounds, and sexual orientation. It is about a segment of the population that suffers from inexpressive actions geared to their needs in health care services. They are characterized by a dual condition of vulnerability, from the perspective that being a woman and having a disability are two social disadvantages⁷7 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872..

This study highlights that maternity hospitals in the North and Northeast regions linked to the RC had more significant architectural barriers to access for pregnant women with MD, VD, or HD. Inequalities are more significant for motor accessibility, and this result suggests a reflection of regional disparities concerning access to health services in a context of low support for the care of pregnant/puerperae with physical disabilities. Also, these regions gather the worst socioeconomic and health indicators, reflecting the difficulty of achieving equity in the SUS for vulnerable populations, supporting the idea of other studies that reiterate the thought that women with MD, VD, or HD are more exposed to poverty, unemployment, and low schooling²2 Mathias K, Kermode M, San Sebastian M, Davar B, Goicolea I. An asymmetric burden: Experiences of men and women as caregivers of people with psycho-social disabilities in rural North India. Transcult Psychiatry 2019; 56(1):76-102.^,77 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872.^,88 Devkota HR, Kett M, Groce N. Societal attitude and behaviours towards women with disabilities in rural Nepal: pregnancy, childbirth and motherhood. BMC Pregnancy Childbirth 2019; 19(1):20.^,3838 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018.^,3939 Almeida WS, Szwarcwald CL. Mortalidade infantil e acesso geográfico ao parto dos municípios brasileiros. Rev Saude Publica 2012; 46(1):68-76..

The North and Northeast regions also have a more significant proportion of the population with exclusive access to SUS health establishments and significant barriers to access to high-complexity establishments⁴⁰40 Rocha TAH, Silva NC, Amaral PV, Barbosa ACQ, Rocha JVM, Alvares V, Almeida DG, Thumé E, Thomaz EBAF, Queiroz RCS, Souza MR, Lein A, Lopes DP, Staton C, Vissoci JRN, Facchini LA. Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil. Int J Equit Health 2017; 16(1):149., almost always with restricted access to mixed, lower complexity hospitals⁴¹41 Rocha TAH, Silva NC, Amaral PV, Barbosa ACQ, Rocha JVM, Alvares V, Almeida DG, Thumé E, Tomaz EBAF, Queiroz RCS, Vissoci JRN, Souza MR, Lein A, Staton C, Facchini LA. Access to emergency care services: A transversal ecological study about Brazilian emergency health care network Public Health. Public Health 2017; 153:9-15., with potential impacts on maternal and neonatal mortality. Moreover, hospital care regionalization is still a challenge, hindering referrals to places with adequate accessibility for women with disabilities⁷7 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872.^,2525 Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, Leal MDC. Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento. Cad Saude Publica 2014; 30(1):208-219.^,3838 Brasil. Ministério da Saúde (MS). Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: MS; 2018..

Hospital establishments in the South, Southeast, and Midwest regions showed, in general, better results. However, they did not achieve minimum proportions in several of the structural criteria studied. These results pointed to a significant number of pregnant/puerperae exposed to avoidable and unnecessary risks. Studies reiterate that the different patterns of the regions mentioned above can be justified by the excessive concentration of maternity hospitals in the state capitals and the difference in funding⁶6 Gudlavalleti MVS, John N, Allagh K, Sagar J, Kamalakannan S, Ramachandra SS. Access to health care and employment status of people with disabilities in South India, the SIDE (South India Disability Evidence) study. BMC public health 2014; 14(1):1125.^,77 Nicolau SM, Schraiber LB, Ayres JRDCM. Mulheres com deficiência e sua dupla vulnerabilidade: contribuições para a construção da integralidade em saúde. Cien Saude Colet 2013; 18(3):863-872.^,2424 Bittencourt SDA, Domingues RMSM, Reis LGC, Ramos MM, Leal CM. Adequacy of public maternal care services in Brazil. Reprod Health 2016; 13(3):120.^,3939 Almeida WS, Szwarcwald CL. Mortalidade infantil e acesso geográfico ao parto dos municípios brasileiros. Rev Saude Publica 2012; 46(1):68-76..

No establishment managed to show all structural items suitable for pregnant/puerperae with MD, VD, or HD in Brazil. The two establishments that guaranteed motor and hearing accessibility reach resident populations at a shorter (30km) and intermediate (50 km) distance considered in this study. These distances reach populations resident in Bahia and Minas Gerais states, where such establishments are located. This finding corroborates the regional inequalities found, mainly for the North region, whose distances are enormous until access to establishments with better structural conditions.

Despite the significant advances resulting from RC’s implantation in Brazil, especially in the good labor care practices, few maternity hospitals linked to the RC have been suitable for pregnant women and puerperae with MD, VD, or HD. This result goes against what the policy mentioned above recommends since it is based on the components of the right to pregnancy, safe and humanized delivery and puerperium, and the right to reproductive planning, transport, and accessibility³⁰30 Brasil. Ministério da Saúde (MS). Humanização do parto e do nascimento. Universidade Estadual do Ceará. Brasília: 2014 [acessado 2018 Mar 29]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/parto.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,3131 Brasil. Ministério da Saúde (MS). Manual prático para implementação da Rede Cegonha. Brasília: MS; 2011..

A limitation of this study is the impossibility to make inferences for the individual level, given the ecological design of the study, at risk of ecological fallacy. Another limitation is that the rooming-in environment was not studied for the characterization of visual and hearing accessibility, but only for motor accessibility. Despite this, the proportion of establishments with motor accessibility (suitable for all criteria analyzed in all environments studied) was higher than those with visual and hearing accessibility. The criteria used to characterize accessibility did not include all the standards recommended in NBR-9050⁴²42 Norma Brasileira Regulamentadora (NBR). Acessibilidade a edficações, mobiliário, espaços e equipamentos urbanos [recurso eletrônico]. Rio de Janeiro: 2015. [acessado 2017 Ago 7]. Disponível em: https://www.ufpb.br/cia/contents/manuais/abnt-nbr9050-edicao-2015.pdf
https://www.ufpb.br/cia/contents/manuais... . Notwithstanding this, the results were very unsatisfactory, even considering only the very minimum. Also, the standards chosen throughout this work are those reflecting the minimum accessibility parameters. The use of more complete guidelines would reveal an even more challenging setting from the viewpoint of accessibility.

This work’s strengths are the creation of maps to present the panorama of motor, visual, and hearing accessibility for pregnant women and puerperae, which allows identifying the geographic distribution of establishments in the national territory and better visualization of the barriers of access. This study also described accessibility in all facilities linked to the RC, analyzing unprecedentedly in the literature the accessibility for pregnant and puerperae women with MD, VD, or HD in hospital/maternity facilities throughout the Brazilian territory.

Conclusion

Hospital/maternity facilities linked to RC are not adapted for people with MD, VD, or HD in Brazil, especially in the North and Northeast regions. Despite the normative advances regarding the inclusion of people with disabilities in public policies, challenges remain regarding equity in the SUS for this population. Therefore, adapting the physical structure of these hospital establishments to this population’s needs can contribute to improving maternal and child health indicators.

References

Publication Dates

History