Prenatal evaluation in primary care in Northeast Brazil: factors associated with its adequacy

Esther Pereira da Silva Antônio Flaudiano Bem Leite Roberto Teixeira Lima Mônica Maria Osório About the authors

ABSTRACT

OBJECTIVE

To characterize prenatal care and verify possible factors associated with its adequacy.

METHODS

This is a cross-sectional study based on interviews with health care professionals and consultations on official documents of women attending prenatal of the primary health care in the city of João Pessoa, capital of Paraíba, in the Northeast region of Brazil. Prenatal care was evaluated by an index with criteria referring to aspects of structure, process and outcome, denominated IPR/Prenatal. The multivariate logistic regression method revealed that demographic, socioeconomic, reproductive and maternal morbidity variables were possible determinants for prenatal adequacy.

RESULTS

The survey involved 130 services and 1,625 primary health care patients. Prenatal care was adequate in approximately 23% of the cases. Low prevalence of referral to maternity, educational strategies and examinations were observed. The analysis showed that non-adolescent women (OR = 1,390), with a longer period of schooling (OR = 1.750), higher per capita income (OR = 1,870) and primiparous women (OR = 1,230) were more likely to have an adequate prenatal.

CONCLUSIONS

Prenatal care, when evaluated by broader criteria, showed a low percentage of adequacy. Strategies should be developed to ensure the referral to the maternity where the birth will take place and health education activities and examinations to provide adequate prenatal care in the municipality under study. In addition, factors associated with adequacy must be considered by managers and health professionals.

Prenatal Care, organization & administration; Health Services Coverage; Outcome and Process Assessment (Health Care); Health Status Disparities

INTRODUCTION

Health evaluation has become an important and indispensable tool for the planning and management of services. Specifically in prenatal care, it should be emphasized that the results obtained by the evaluation may support both the maintenance of the strategies and their modification, with a view to improving the quality of care1–3.

In the specialized literature, we find the use of some procedures to evaluate prenatal care. Among these, the Kessner index44. Kessner DM. Infant death: an analysis of maternal risk and health care. Washington, DC: National Academy of Sciences, Institute of Medicine; 1973. and the Adequacy of Prenatal Care Utilization (APNCU), proposed by Kotelchuck55. Kotelchuck M. Evaluation of the Kessner Adequacy of Prenatal Care Index and proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health. 1994;84(9):1414-20. https://doi.org/10.2105/AJPH.84.9.1414
https://doi.org/10.2105/AJPH.84.9.1414...
, stand out, which use as evaluative criteria the onset gestational age and the number of prenatal consultations4–7.

However, it is already known that these methods are insufficient to evaluate prenatal care, since they analyze only two aspects, preventing the visualization of relevant impacts on the quality of care. Therefore, it is necessary to insert new components that measure it integrally8–10.

In Brazil, the Ministry of Health, through the institution of the Prenatal and Birth Humanization Program (PHPN) and the Rede Cegonha Initiative, establishes guidelines for prenatal follow-up, guaranteeing the quality of care provided to pregnant women served in the public care network. In addition to the onset of prenatal care in the first trimester and the minimum number of seven appointments, laboratory tests and clinical-obstetric procedures are recommended, in addition to educational activities, immunization, multiprofessional care and guidelines on breastfeeding and childbirth3,11–16.

Despite the increase in prenatal coverage in the country, regional inequalities still persist. Specifically in the Northeast region, in recent national studies, there were lower coverage percentages, late prenatal onset, more difficulties in access and less examinations, as well as higher rates of maternal and neonatal deaths, which are related to low quality prenatal care1717. Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML, et al. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saude Publica. 2014;30 Supl 1:S192-207. https://doi.org/10.1590/0102-311X00133213
https://doi.org/10.1590/0102-311X0013321...
,1818. Viellas EF, Domingues RMSM, Dias MAB, Gama SGN, Theme-Filha MM, Costa JV, et al. Assistência pré-natal no Brasil. Cad Saude Publica. 2014;30 Supl 1:S85-100. https://doi.org/10.1590/0102-311X00126013
https://doi.org/10.1590/0102-311X0012601...
.

In the execution of prenatal care, Brazilian municipalities are responsible for coordinating the primary health care network. It presents itself as a gateway to the attention system for pregnant women and plays a fundamental role in the integral care of the mother-child binomial, providing better birth outcomes1313. Ministério da Saúde (BR). Portaria consolidada Rede Cegonha Brasil. Brasília, DF; 2011 [cited 2017 Jan 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011.html
http://bvsms.saude.gov.br/bvs/saudelegis...
.

In this sense, considering the importance of evaluation as starting point for possible interventions in health practices and the municipality as manager of primary health care, this study aimed to evaluate prenatal care in a northeastern capital from elements the structure, work process and results of the assistance. In addition, it aimed to verify demographic, socioeconomic, reproductive and maternal morbidity variables as possible factors associated with prenatal adequacy.

METHODS

This is a transversal epidemiological study, developed in the city of João Pessoa, capital of the state of Paraíba, located in the Northeast region of Brazil. This municipality has 192 primary health care units, distributed in five health districts (HD): HD-I (49 units), HD-II (40), HD-III (50), HD-IV (29) and HD-V (24). HD concentrates neighborhoods by location proximity.

Participants in the study were professionals from the primary care services and puerperal who had prenatal care at these units. Specific forms with structure, work process, socioeconomic, demographic data and prenatal care questions were used. The information was obtained from November 2015 to August 2016.

The data related to the structure and work process were collected by interview with the nursing professionals of the units, chosen for having the greatest technical-administrative knowledge about how the services work. In each unit, the nurse responsible for prenatal care was selected, totaling 130 professionals. There was no refusal of interview by the nurses.

The sample calculation for the inclusion of primary health services and users was based on the formula1919. Arango HG. Bioestatística: teórica e computacional. Rio de Janeiro: Guanabara Koogan; 2011.,2020. Calculadora OpenEpi versão 3: calculadora de código aberto - SSP. [cited 2017 Jan 10]. Available from: www.openepi.com/samplesize/SSpropor.htm
www.openepi.com/samplesize/SSpropor.htm...
:

n=z2.p.q.Ne2(N1)+z2.p.q

For services, z is the standard normal distribution score (1.96) for a significance of 5% (or a 95% confidence); p refers to the proportion of health units with adequate care (as there is no reference parameter to estimate the comparability of representation of the target population, 50% was considered); q is the complement of the probability of occurrence of p (q = 1 - p), and it is the margin of error (0.05); and N, the universe of units (192). With this calculation, the sample resulted in 130 units, distributed according to the proportion of the number of services of each health district in relation to the total units of the municipality: HD-I (32), HD-II (27), HD-III (34), HD-IV (19) and HD-V (18). The choice of units was performed randomly, using the statistical software R (version 2.10.1).

For the sample of users, the total population of live births of the municipality in the previous year in each health district was considered as N (HD-I: 2,557; HD-II: 2,011; HD-III: 3,319; HD-IV: 1,654; and HD-V: 2,330). This calculation resulted in the following sample: HD-I (340), HD-II (328), HD-III (352), HD-IV (317) and HD-V (336) with a total of 1,673 women. It should be noted that a safety margin of 20% was added to the calculation.

Patient data were collected from the municipal maternity hospital, Cândida Vargas, which accounts for the highest number of live births in the municipality, representing a percentage of 60.3% of all births in the capital in the year prior to the survey. The following were excluded from the study: women who did not had prenatal visits in João Pessoa, PB, or did not perform care in primary health care.

The collections occurred within 24 to 48 hours after birth. The women, from the sample units visited, were randomly selected to complete the sample from each health district. At that moment, to minimize the recall bias, the data were collected from the pregnant woman’s card (official document considered a valid and safe source of information for scientific research2121. Polgliani RBS, Santos Neto ET, Zandonade E. Informações dos cartões de gestantes e dos prontuários da atenção básica sobre assistência pré-natal. Rev Bras Ginecol Obstet. 2014;36(6):269-75. https://doi.org/10.1590/S0100-720320140004907
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).

The 48 users (2.9% of the sample) who did not present the pregnant woman’s card at the time of admission were considered as losses. Information from these women was collected through interviews; however, to avoid bias in the survey, they were not counted in the analyzes, resulting in a final sample of 1,625 users, which did not affect the representativeness of the municipality.

The research team was attended by nutrition students from the Federal University of Paraíba pre-selected by interviews and curricular analysis. All of them the were trained by the technical coordination of the research, through a previous training addressing the topics related to the study and the instruments used.

A pilot study was carried out, aiming to know the routine of the service, to test the instruments of collection and to experience the flow of the practice. After the collections, the questionnaires were reviewed and coded, with data entered into the Excel® computer program with double entry for concordance evaluation and error checking. The errors, when detected, were solved by returning to the questionnaire or to the interviewer for correction of the database.

Prenatal care was classified by the IPR/Prenatal instrument regarding the aspects of infrastructure, process and results, as shown in the Box. This index is based on the Donabedian theoretical reference77. Silva EP, Lima RT, Costa MJC, Batista Filho M. Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal. Rev Panam Salud Publica. 2013;33(5):356-62.,2222. Donabedian A. An introduction to quality assurance in health care. New York: Oxford University Press; 2003. and has as evaluation criteria the recommendations of the national health authorities11–13. For it, for each of the questions of infrastructure, process and result analysis is assigned the value 1, when in accordance with the established recommendations, and 2 when not. Prenatal care is classified based on the percentage of the number of appropriate items in all components in relation to the total number of questions. Thus, prenatal care is classified according to the adequacy percentage obtained: adequate superior, when 100% of the items were adequate; adequate, when 75% or more were adequate; intermediary, when 51% to 74% of the answers were adequate; and inadequate, when it presented 50% or less of the criteria evaluated in accordance with the proposed recommendations.

Box
Classification of prenatal care by IPR/Prenatal. João Pessoa, state of Paraíba, Brasil, 2016.

For this study, two evaluative criteria of the original instrument were not included, the gestational weight gain and puerperal consultation, since the data were obtained in a single moment in the postpartum period, without accompanying the woman during the prenatal and puerperium period.

The characteristics of the study population and prenatal care were presented in absolute and relative frequency distribution. The independent variables of the analysis included socio-demographic and economic characteristics: health district where the woman was assisted, age (≤ 18, 19–29 and ≥ 30 years old), living with the partner, per capita family income (considered as continuous variable), schooling (0–9 and ≥ 10 years), to be a beneficiary of the Bolsa Família program, and not be working during pregnancy.

The categorization of the age followed the parameters of the Child and Adolescent Statute, which considers the adult age group above 18 years old2323. Martinelli KG, Santos Neto ET, Gama SGN, Oliveira AE. Adequação do processo da assistência pré-natal segundo os critérios do Programa de Humanização do Pré-natal e Nascimento e Rede Cegonha. Rev Bras Ginecol Obstet. 2014;36(2):56-64. https://doi.org/10.1590/S0100-72032014000200003
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. Schooling, in turn, followed the criteria adopted by the Basic Guidelines Law, which defines Brazilian education at levels: fundamental education, lasting nine years, and secondary and higher education, with 10 years or more of study. The categorization follows authors specialized in the theme, nationally and internationally1414. Bernardes ACF, Silva RA, Coimbra LC, Alves MTSS, Queiroz RCS, Batista RFL, et al. Inadequate prenatal care utilization and associated factors in São Luís, Brazil. BMC Pregnancy Childbirth. 2014;14:266. https://doi.org/10.1186/1471-2393-14-266
https://doi.org/10.1186/1471-2393-14-266...
. For the categorical variables (health district, age and schooling), HD-I, the largest age range (≥ 30 years) and the lowest level of schooling (primary or primary education) were respectively considered as reference for the analyzes1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
,2323. Martinelli KG, Santos Neto ET, Gama SGN, Oliveira AE. Adequação do processo da assistência pré-natal segundo os critérios do Programa de Humanização do Pré-natal e Nascimento e Rede Cegonha. Rev Bras Ginecol Obstet. 2014;36(2):56-64. https://doi.org/10.1590/S0100-72032014000200003
https://doi.org/10.1590/S0100-7203201400...
,2424. Carvalho RAS, Santos VS, Melo CM, Gurgel RQ, Oliveira CCC. Avaliação da adequação do cuidado pré-natal segundo a renda familiar em Aracaju, 2011. Epidemiol Serv Saude. 2016;25(2):271-80. https://doi.org/10.5123/s1679-49742016000200006
https://doi.org/10.5123/s1679-4974201600...
. Reproductive (being primiparous and no abortions and premature births) and morbidities (diabetes, arterial hypertension, non-use of cigarettes and non-use of alcohol) characteristics were still considered.

Then, to verify the association of the independent variables with the prenatal adequacy, the logistic regression method was used based on the odds ratio, considering their respective confidence intervals (95%CI). For the analysis of the logistic regression, the prenatal classification was coded as “0” for “inadequate prenatal” (when classified as intermediate or inadequate), or “1” for “adequate prenatal” (adequate superior and adequate). The dependent variable considered for the study analyzes was “adequate prenatal.” Logistic regression was performed considering only the adequacy of the item “Results” due to the association with the independent variables used.

For the general model, all independent variables were analyzed with the dependent variable. From the stepwise technique, the inclusion and elimination of the independent variables were tested according to the significance power of each one in the analyzed outcome. The variables with the highest level of significance (p < 0.20) were inserted in the final model. To better explain the studied relationship, the quality-of-fit tests of the Nagelkerke R2 and Hosmer-Lemeshow final models2525. Hosmer DW Jr, Lemeshow S. Applied logistic regression. New York: John Wiley; 1989.,2626. Landau S, Everitt BS. A handbook of statistical analyses using SPSS. Boca Raton, FL: CRC Press; 2004. Chapter 9. were analyzed. In this model, the results were considered statistically significant at p < 0.05. Data were exported and analyzed in the SPSS application, version 20.0 (SPSS Inc., Chicago, IL, 2011)

Regarding the ethical aspects, the health and maternity units participated in the study by signing the letter of agreement of the Municipal Health Department. The professionals and users participated after signing the free and informed consent form and the free and informed consent term. The research was approved by the Ethics and Research Committee of the Lauro Wanderley University Hospital of the Federal University of Paraíba under the number 381335414.7.0000.5183.

RESULTS

Regarding the characteristics of the health services (Table 1), it can be observed that most of the units were located in places specifically built for this purpose and had visible days, shifts and professionals who carried out the prenatal care. The equipment was in operation and there were vaccines, medicines and important supplements for prenatal care in about 70% of the services. The presence of reference laboratory support was reported by 100% of the professionals, while the minimum primary care team was observed in almost 90% of the units.

Table 1
Characterization of prenatal services and users of primary care in João Pessoa, state of Paraíba, Brazil, 2016.

Regarding the characterization of the work process, there was a high coverage of pregnant women followed up by the units. However, when the number of women who started prenatal care in the first trimester, with more than seven visits and who performed the recommended exams, was analyzed, a small part of the prenatal services were able to meet these parameters.

In most services, more than one professional of higher level (at least one doctor and one nurse) was present in prenatal care. The total number of professionals reported the presence of the clinical records of pregnant women, referred to perform all the recommended clinical-obstetric procedures and prescribe the clinical exams.

Regarding the characteristics of the users, in relation to prenatal care (Table 1), less than half of the women were guided on the type and symptoms of childbirth and on breastfeeding. Only 25% participated in prenatal educational activities.

The number of women who used iron and folic acid supplements during pregnancy, who had seven or more visits, and had prenatal care in the first trimester increased. Regarding immunization, there was a coverage of 71% for the complete vaccination scheme for gestation. It stands out the low percentage of women who underwent the recommended examinations (13.4%) and women who received the referral to the maternity hospital (27.3%). When classifying prenatal care using the IPR/Prenatal care criteria, the municipality of João Pessoa showed adequacy in only 22.6% of cases (Table 2).

Table 2
Qualification of prenatal care according to aspects of structure, process and results in primary care.

Table 3 shows the characteristics of the users regarding the adequacy of prenatal care, which was higher in women between 19 and 29 years old, with 10 years of schooling or more, with a family income greater than a minimum wage, who did not work during pregnancy and living with a partner. It was also observed that beneficiaries of Bolsa Família program, primiparous women, who did not have previous abortions and preterm infants, did not drink alcohol, did not smoke and did not have diabetes, hypertension and edema during pregnancy presented a higher percentage of adequate prenatal care.

Table 3
Characterization of the users according to the prenatal classification by IPR/Prenatal. João Pessoa, state of Paraíba, Brasil, 2016.

Table 4 shows the analyzes of the independent variables with prenatal adequacy. After the adjusted model, it was seen that women between 19 and 29 years old, with more years of study, higher family income and primiparous had more chance of adequate prenatal care. Not having previous abortions did not show statistical significance in the adjusted model. It stands out the increase of the R22. Leal MC, Theme-Filha MM, Moura EC, Cecati JG, Santos LMP. Atenção ao pré-natal e parto em mulheres usuárias do sistema público de saúde residentes na Amazônia Legal e no Nordeste, Brasil 2010. Rev Bras Saude Mater Infant. 2015;15(1):91-104. https://doi.org/10.1590/S1519-38292015000100008
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measure of the models from 0.425 to 0.708, indicating that the adjusted model is approximately 71% sure that these factors are related to the prenatal adequacy, guaranteeing the confidence of the analyzes.

Table 4
Adjusted logistic regression of the variables with the adequacy of prenatal care in primary care.

DISCUSSION

The evaluation of prenatal care from the triad structure, work process and result allows to identify more accurately factors that contribute to the improvement of health practices, seeking the qualification of care55. Kotelchuck M. Evaluation of the Kessner Adequacy of Prenatal Care Index and proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health. 1994;84(9):1414-20. https://doi.org/10.2105/AJPH.84.9.1414
https://doi.org/10.2105/AJPH.84.9.1414...
,77. Silva EP, Lima RT, Costa MJC, Batista Filho M. Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal. Rev Panam Salud Publica. 2013;33(5):356-62.,99. Beeckman K, Louckx F, Masuy-Stroobant G, Downe S, Purman K. The development and application of a new tool to assess the adequacy of the content and timing of antenatal care. BMC Health Serv Res. 2011;11(2):213-23. https://doi.org/10.1186/1472-6963-11-213
https://doi.org/10.1186/1472-6963-11-213...
,2222. Donabedian A. An introduction to quality assurance in health care. New York: Oxford University Press; 2003.. In this context, regarding the aspects related to the structure and the work process, it was observed a frequency below what was considered adequate (75%) for the presence of equipment, therapeutic supplies and coverage according to the goals proposed by the Ministry of Health. The presence of equipment, therapeutic supplies and laboratory support enoough to meet the demand favors the performance of prenatal care, since it guarantees the necessary procedures and interventions with resolutive actions1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
.

Regarding the prenatal care of the studied municipality, low prevalences for educational strategies and guidance throughout care were observed. When developed in a continuous and participative way throughout the prenatal period, from the team’s dialogue with the user, they contribute to better obstetric outcomes. The sensitivity of breastfeeding practice to educational actions stands out: mothers who participated in health education strategies had a longer breastfeeding period2727. Silva EP, Lima RT, Osório MM. Impacto de estratégias educacionais no pré-natal de baixo risco: revisão sistemática de ensaios clínicos randomizados. Cienc Saude Coletiva. 2016;21(9):2935-48. https://doi.org/10.1590/1413-81232015219.01602015
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.

Regarding the onset of prenatal care and number of consultations, although the studied municipality showed a greater number of women with onset in the first trimester and with seven or more visits, the prevalence was below the adequate. Prenatal care in early pregnancy has as a great advantage the early detection of possible complications during pregnancy and the guarantee of timely interventions1313. Ministério da Saúde (BR). Portaria consolidada Rede Cegonha Brasil. Brasília, DF; 2011 [cited 2017 Jan 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011.html
http://bvsms.saude.gov.br/bvs/saudelegis...
. On the other hand, the lower number of consultations is associated with less adequacy of exams, vaccination and guidance on breastfeeding and childbirth1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
.

One finding that deserves attention is the small number of women who underwent laboratory tests, as observed in other studies33. Polgliane RBS, Leal MC, Amorim MHC, Zandonade E, Santos Neto ET. Adequação do processo de assistência pré-natal segundo critérios do Programa de Humanização do Pré-natal e Nascimento e da Organização Mundial de Saúde. Cienc Saude Coletiva. 2014;19(7):1999-2010. https://doi.org/10.1590/1413-81232014197.08622013
https://doi.org/10.1590/1413-81232014197...
,77. Silva EP, Lima RT, Costa MJC, Batista Filho M. Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal. Rev Panam Salud Publica. 2013;33(5):356-62.,1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
. Performing the exams during the gestational period is important to prevent possible problems that can be previously solved in prenatal care. Polgliane et al.33. Polgliane RBS, Leal MC, Amorim MHC, Zandonade E, Santos Neto ET. Adequação do processo de assistência pré-natal segundo critérios do Programa de Humanização do Pré-natal e Nascimento e da Organização Mundial de Saúde. Cienc Saude Coletiva. 2014;19(7):1999-2010. https://doi.org/10.1590/1413-81232014197.08622013
https://doi.org/10.1590/1413-81232014197...
point to several potential difficulties that justify this low prevalence, mainly due to the organization of the health services, including difficulties in scheduling exams, lack of inputs for its performance and malfunctioning equipment. These complications hamper adequate time to return the results to necessary interventions.

Only a small percentage of women were referred to maternity care by primary care services. In Brazil, pregnant women attending the Unified Health System have the right to be linked to the maternity hospital where they will receive childbirth care, which must be guaranteed from the beginning of prenatal care. The omission may lead to a pilgrimage by the health facilities at the time of birth, which may favor the occurrence of maternal and child morbidity and mortality in the country22. Leal MC, Theme-Filha MM, Moura EC, Cecati JG, Santos LMP. Atenção ao pré-natal e parto em mulheres usuárias do sistema público de saúde residentes na Amazônia Legal e no Nordeste, Brasil 2010. Rev Bras Saude Mater Infant. 2015;15(1):91-104. https://doi.org/10.1590/S1519-38292015000100008
https://doi.org/10.1590/S1519-3829201500...
.

Regarding the evaluation of care, as well as in other studies that used the same instrument as this research, a low prevalence of adequacy was observed77. Silva EP, Lima RT, Costa MJC, Batista Filho M. Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal. Rev Panam Salud Publica. 2013;33(5):356-62.,2828. Nogueira CMCS, Justino JMR, Tavares MIPL, Morais FRR. Caracterização da infraestrutura e do processo de trabalho na assistência ao pré-natal. Cogitare Enferm. 2016;21(4):1-10. https://doi.org/10.5380/ce.v21i4.45886
https://doi.org/10.5380/ce.v21i4.45886...
. The adequacy is the result of the satisfactory result of several components that need to be considered in the evaluation process, such as: structure and access to services, presence of equipment and supplies in the units, available human resources, assurance of exams and education activities in health, among other aspects77. Silva EP, Lima RT, Costa MJC, Batista Filho M. Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal. Rev Panam Salud Publica. 2013;33(5):356-62.,1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
.

Women with favorable socioeconomic, reproductive and morbidity conditions had a higher percentage of prenatal adequacy. These findings are corroborated by other researchers who identified a lower percentage of adequate prenatal care in more vulnerable populations1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
,2424. Carvalho RAS, Santos VS, Melo CM, Gurgel RQ, Oliveira CCC. Avaliação da adequação do cuidado pré-natal segundo a renda familiar em Aracaju, 2011. Epidemiol Serv Saude. 2016;25(2):271-80. https://doi.org/10.5123/s1679-49742016000200006
https://doi.org/10.5123/s1679-4974201600...
. The analyzes confirmed the presence of these social inequities during prenatal care, specifically regarding socioeconomic conditions. It was observed that being an adult, with more years of study and higher per capita income were factors associated with prenatal adequacy. The studies warn that managers and prenatal care teams need to be prepared to work to alleviate this difference, putting into practice the principle of social equity1515. Domingues RMSM, Hartz ZMA, Dias MAB, Leal MC. Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil. Cad Saude Publica. 2012;28(3):425-37. https://doi.org/10.1590/S0102-311X2012000300003
https://doi.org/10.1590/S0102-311X201200...
,1616. Reis PAGD, Pereira CCA, Leite IC, Theme-Filha MM. Fatores associados à adequação do cuidado pré-natal e à assistência ao parto em São Tomé e Príncipe, 2008-2009. Cad Saude Publica. 2015;31(9):1929-40. https://doi.org/10.1590/0102-311X00115914
https://doi.org/10.1590/0102-311X0011591...
,2323. Martinelli KG, Santos Neto ET, Gama SGN, Oliveira AE. Adequação do processo da assistência pré-natal segundo os critérios do Programa de Humanização do Pré-natal e Nascimento e Rede Cegonha. Rev Bras Ginecol Obstet. 2014;36(2):56-64. https://doi.org/10.1590/S0100-72032014000200003
https://doi.org/10.1590/S0100-7203201400...
,2424. Carvalho RAS, Santos VS, Melo CM, Gurgel RQ, Oliveira CCC. Avaliação da adequação do cuidado pré-natal segundo a renda familiar em Aracaju, 2011. Epidemiol Serv Saude. 2016;25(2):271-80. https://doi.org/10.5123/s1679-49742016000200006
https://doi.org/10.5123/s1679-4974201600...
,2929. Goudard MJF, Simões VMF, Batista RFL, Queiroz RCS, Brito e Alves MTSS, et al. Inadequação do conteúdo da assistência pré-natal e fatores associados em uma coorte no nordeste brasileiro. Cienc Saude Coletiva. 2016;21(4):1227-38. https://doi.org/10.1590/1413-81232015214.12512015
https://doi.org/10.1590/1413-81232015214...
.

The adequacy of prenatal care was also determined by reproductive variables such as parity. In this sense, researchers affirm that primiparity may favor the qualification of prenatal care, once multiparous women tend not to perform prenatal care in a regular way, since, from previous experience, they believe they already know about the course of gestation, its intercurrences and the breastfeeding practice3030. Rosa CQ, Silveira DS, Costa JSD. Fatores associados à não realização de pré-natal em município de grande porte. Rev Saude Publica. 2014;48(6):977-84. https://doi.org/10.1590/S0034-8910.2014048005283
https://doi.org/10.1590/S0034-8910.20140...
.

Based on the diagnosis made, the prenatal evaluation by an instrument that incorporates broader criteria in its analysis – with aspects of infrastructure, work process and result – allowed to verify more appropriately the actual situation of assistance. With the application of this index, the municipality studied presented low percentage of adequacy, determined by factors that should be discussed by the family health teams during the development of care.

From this perspective, regarding socioeconomic conditions, the construction of public policies aimed at reducing the inequities that also guide prenatal care should be strengthened. As for the reproductive aspects, the health team should increase the intake of pregnant women, making consultation schedules more flexible so that mothers with more children also have adequate prenatal care.

It is higlighted that the small number of women who were referred to the maternity hospital participated in health education activities and performed the exams recommended for prenatal care. It is worth noting that the number of women who started prenatal care in the first trimester and the highest number of consultations, although corresponding to more than half of the women, also remained below expectations. Therefore, strategies that ensure and stimulate these procedures should be considered by managers and health teams during prenatal care, to ensure adequate and resolute care.

As a possible limitation of the study, there is the non inclusion of women attended in other hospitals. However, it is worth mentioning that the analyzed maternity hospital is the highest reference for childbirth in the municipality, with the highest number of visits.

For the next studies, it is recommended to include the users in the observations of the work process and the reproduction of the instrument in other places, contributing to the knowledge of the prenatal care reality and to the elaboration of possible interventions in case of non-compliance with the recommended guidelines.

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History

  • Received
    23 June 2018
  • Accepted
    24 Aug 2018
  • Online publication
    06 May 2019
  • Issue publication
    2019
Faculdade de Saúde Pública da Universidade de São Paulo São Paulo - SP - Brazil
E-mail: revsp@org.usp.br