Abstract

This mixed-method and sequential exploratory study aims to identify patterns related to the trajectory of pregnant and puerperal women who evolved to risk situations, from arrival in a first care service to admission to a tertiary maternity hospital. The quantitative phase analyzed 1,703 medical records and hospitalization records of women assisted in three tertiary maternity hospitals in the Metropolitan Region of Fortaleza, Ceará, from 2010 to 2019. The qualitative phase was conducted from January to September 2020 with 14 women survivors of Maternal Near Miss (MNM), using Schütze’s Autobiographical Narrative Interview. The findings reveal how delays related to professionals and the health system contributed to the pilgrimage of pregnant and postpartum women and, consequently, to the MNM cases. The peregrination of these women is associated with problems in the structures of the Care Network and the services. Thus, it becomes necessary to use tools to monitor the quality of the service provided by health professionals and to provide well-established care processes, physical structures, and the healthcare networks that support the follow-up of these processes.

Keywords:
Maternal Near Miss; Women’s Health; Comprehensive Health Care; Obstetrics; Public Health

Introduction

Since 2011, the World Health Organization (WHO) has recommended the use of Maternal Near Miss (MNM) as an indicator of the quality of obstetric care (Souza et al., 2011SOUZA, J. P. et al. The world health organization multicountry survey on maternal and newborn health: study protocol. BMC health services research, London, v. 11, p. 286, 2011. DOI: 10.1186/1472-6963-11-286.
https://doi.org/10.1186/1472-6963-11-286... ) in an institution. MNM occurs when a woman survives, due to adequate healthcare services, after serious clinical complications that put her life at risk during pregnancy, childbirth, or the postpartum period (Pattinson; Hall, 2003PATTINSON, R. C.; HALL, M. Near misses: a useful adjunct to maternal death enquiries. British Medical Bulletin, Oxford, v. 67, n. 1, p. 231-243, 2003. DOI: 10.1093/bmb/ldg007.
https://doi.org/10.1093/bmb/ldg007... ). The extension of the “three delays model” (Thaddeus; Maine, 1994THADDEUS, S.; MAINE, D. Too far to walk: maternal mortality in context. Social Science & Medicine, Oxford, v. 38, n. 8, p. 1091-1110, 1994. DOI: 10.1016/0277-9536(94)90226-7.
https://doi.org/10.1016/0277-9536(94)902... ), initially associated with maternal mortality, introduces to the MNM universe (Pacagnella et al., 2014PACAGNELLA, R. C. et al. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC pregnancy and childbirth , London, v. 14, p. 159, 2014. DOI: 10.1186/1471-2393-14-159.
https://doi.org/10.1186/1471-2393-14-159... ) the debate on pregnant women’s peregrination as a factor associated with unfavorable outcomes.

The three delays model proposes a structured sequence for delays in care, in three phases: delay related to patients; delay related to accessibility to the reference service; delay related to medical care (Thaddeus; Maine, 1994THADDEUS, S.; MAINE, D. Too far to walk: maternal mortality in context. Social Science & Medicine, Oxford, v. 38, n. 8, p. 1091-1110, 1994. DOI: 10.1016/0277-9536(94)90226-7.
https://doi.org/10.1016/0277-9536(94)902... ). The peregrination of pregnant women in search of birth assistance is one of the components of the second delay in exchange with the third, because diagnosis and initiation of appropriate therapy in a smaller institution are crucial for timely referral to the reference unit in cases of need (Combs Thorsen; Sundby; Malata, 2012COMBS THORSEN, V.; SUNDBY, J.; MALATA, A. Piecing together the maternal death puzzle through narratives: the three delays model revisited. PloS One, San Francisco, v. 7, n. 12, e52090, 2012. DOI: 10.1371/journal.pone.0052090.
https://doi.org/10.1371/journal.pone.005... ; Echoka et al., 2014ECHOKA, E. et al. Barriers to emergency obstetric care services: accounts of survivors of life threatening obstetric complications in Malindi District, Kenya. The Pan African medical journal, Kampala, v. 17, n. suppl 1, 2014. DOI: 10.11694/pamj.supp.2014.17.1.3042.
https://doi.org/10.11694/pamj.supp.2014.... ; Lire et al., 2017LIRE, A. et al. Delays for utilizing institutional delivery and associated factors among mothers attending public health facility in Hadiya Zone, Southern Ethiopia. Science Journal of Public Health, [s. l.], v. 5, n. 6, p. 419-427, 2017. DOI: 10.11648/j.sjph.20170506.13.
https://doi.org/10.11648/j.sjph.20170506... ; Mgawadere et al., 2017MGAWADERE, F. et al. Factors associated with maternal mortality in Malawi: application of the three delays model. BMC pregnancy and childbirth, London, v. 17, p. 219, 2017. DOI: 10.1186/s12884-017-1406-5.
https://doi.org/10.1186/s12884-017-1406-... ). Peregrination is understood as the flow of pregnant women through at least two services in search of adequate obstetric care at the time of birth (Menezes et al., 2006MENEZES, D. C. S. et al. Avaliação da peregrinação anteparto numa amostra de puérperas no município do Rio de Janeiro, Brasil, 1999/2001. Cadernos de Saúde Pública , Rio de Janeiro, v. 22, n. 3, p. 553-559, 2006. DOI: 10.1590/S0102-311X2006000300010.
https://doi.org/10.1590/S0102-311X200600... ; Mgawadere et al., 2017MGAWADERE, F. et al. Factors associated with maternal mortality in Malawi: application of the three delays model. BMC pregnancy and childbirth, London, v. 17, p. 219, 2017. DOI: 10.1186/s12884-017-1406-5.
https://doi.org/10.1186/s12884-017-1406-... ; Andrade; Vieira, 2018ANDRADE, M. S.; VIEIRA, E. M.. Itinerários terapêuticos de mulheres com morbidade materna grave. Cadernos de Saúde Pública , Rio de Janeiro, v. 34, n. 7, e00091917, 2018. DOI: 10.1590/0102-311X00091917.
https://doi.org/10.1590/0102-311X0009191... ). It is important to note that, if a pregnant woman with a serious complication takes a long time to get to a hospital that is able to meet her demand, her likelihood of death increases, even if the destination facility is a tertiary level institution with adequate equipment and qualified staff (Menezes et al., 2006MENEZES, D. C. S. et al. Avaliação da peregrinação anteparto numa amostra de puérperas no município do Rio de Janeiro, Brasil, 1999/2001. Cadernos de Saúde Pública , Rio de Janeiro, v. 22, n. 3, p. 553-559, 2006. DOI: 10.1590/S0102-311X2006000300010.
https://doi.org/10.1590/S0102-311X200600... ; Lotufo et al., 2012LOTUFO, F. A. et al. Applying the new concept of maternal near-miss in an intensive care unit. Clinics, São Paulo, v. 67, n. 3, p. 225-230, 2012. DOI: 10.6061/clinics/2012(03)04.
https://doi.org/10.6061/clinics/2012(03)... ; Andrade; Vieira, 2018ANDRADE, M. S.; VIEIRA, E. M.. Itinerários terapêuticos de mulheres com morbidade materna grave. Cadernos de Saúde Pública , Rio de Janeiro, v. 34, n. 7, e00091917, 2018. DOI: 10.1590/0102-311X00091917.
https://doi.org/10.1590/0102-311X0009191... ).

In Brazil, the Rede Cegonha (RC - Stork Network) was created in ²⁰¹¹BRASIL. Portaria nº 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Brasília, DF: Ministério da Saúde, 2011. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011.html >. Acesso em: 22 jun. 2022.
https://bvsms.saude.gov.br/bvs/saudelegi... , regulated by Ordinance No. 1,459, of June 24, with the aim of expanding access and improving the quality of care assistance in prenatal, childbirth, the puerperium, and in children up to 24 months old. Its integration into the Rede de Atenção em Saúde (RAS - Healthcare Networks) aims to coordinate health services, enabling them to act cooperatively and interdependently based on their levels of complexity, increasing the efficiency of care processes (Arruda et al., 2015ARRUDA, C. et al. Redes de atenção à saúde sob a luz da teoria da complexidade. Escola Anna Nery, Rio de Janeiro, v. 19, n. 1, p. 169-173, 2015. DOI: 10.5935/1414-8145.20150023.
https://doi.org/10.5935/1414-8145.201500... ). However, despite the undeniable advances made and the importance of RAS and RC, overcoming the fragmentation of maternal and child health care is still a challenge (Freitas; Araújo, 2018FREITAS, M. A. S.; ARAÚJO, M. R. N. As redes de atenção à saúde nos 30 anos do Sistema Único de Saúde: histórias, propostas e desafios. Revista Brasileira de Políticas Públicas, Brasília, DF, v. 8, n. 3, p. 15-33, 2018. DOI: 10.5102/RBPP.V8I3.5739.
https://doi.org/10.5102/RBPP.V8I3.5739... ).

It is well established that detailed information about the problems faced is fundamental for formulating policies and improving the quality of obstetric care (Hogan et al., 2010HOGAN, M. C. et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet, London, v. 375, n. 9726, p. 1609-1623, 2010. DOI: 10.1016/S0140-6736(10)60518-1.
https://doi.org/10.1016/S0140-6736(10)60... ). Thus, based on the assumption that the trajectories of pregnant women provide body and materiality for lapses in the care networks, the following questions emerge: “what are the paths taken by pregnant and puerperal women who progressed to MNM, from seeking care to arriving at the reference health unit?”; “there is a hierarchical RAS and a regulation service to organize it, why is the peregrination of pregnant women still a reality?”

Thus, this study was designed to identify patterns related to the trajectory of women who progressed to MNM, from their arrival at a first care service until their admission to a tertiary maternity hospital. This research is justified by the need to identify lapses in the processes of the pregnant women’s care network, providing support for an effective improvement in care.

Methodology

This is a mixed-method study, which adopted an exploratory sequential design carried out in three tertiary maternity hospitals in the Metropolitan Region of Fortaleza, Ceará, from 2010 to 2019. A brief overview of the structure of maternal and child health care in the state is therefore in order.

Ceará is the eighth most populous state in Brazil, with an estimated population in 2017 of 9,020,460 inhabitants, of whom 75.5% live in urban areas and 24.9% in rural areas. In terms of regionalization, the state is organized into five macro-regions-Fortaleza, Sobral, Cariri, Sertão Central, and Litoral Leste/Jaguaribe. According to the Master Plan for the Regionalization of Health Actions and Services in Ceará - PDR (²⁰¹⁴CEARÁ. Revisão do plano diretor de regionalização das ações e serviços de saúde: PDR do estado do Ceará. Fortaleza: Secretaria da Saúde do Estado do Ceará, 2014. Disponível em: <Disponível em: https://www.saude.ce.gov.br/wp-content/uploads/sites/9/2018/06/pdr-2014.pdf >. Acesso em: 20 maio 2023.
https://www.saude.ce.gov.br/wp-content/u... ), the macro-region of Fortaleza, with its 19 municipalities, was home to a population of 4,560,149 in 2014, corresponding to 51.9% of the state’s population in the period. Figure 1 shows the macro-regions of Ceará, the regional departments of Fortaleza and the location of tertiary maternity hospitals, identified by red triangles.

Having adhered to the Rede Cegonha Regional Action Plan, the 2012-2014 State Plan included 11 municipalities in this policy, covered by 20 hospitals, 10 of which were in Fortaleza. All municipalities have committed to carrying out normal-risk births. Although two have committed to supporting high-risk births, which still carried out today in only three hospitals in the city of Fortaleza (Ceará, 2012CEARÁ. Resolução nº 13/2012 - CIB/CE, de 3 de fevereiro de 2012. Fortaleza: Secretaria da Saúde do Estado do Ceará , 2012. Disponível em: <Disponível em: https://www.saude.ce.gov.br/wp-content/uploads/sites/9/2018/06/resolucao_13_a_20_2012_.pdf >. Acesso em: 10 jan. 2023.
https://www.saude.ce.gov.br/wp-content/u... ).

In 2015, the Government of the state of Ceará initiated the Nascer no Ceará (NC - Born in Ceará) Program, aiming to restructure the line of maternal and child care based on attention to high-risk pregnant women and guaranteeing qualified assistance to pregnant women and newborns in 184 municipalities in Ceará, with the regionalization and decentralization of health actions and services of the Brazilian National Health System (SUS). In its initial stages, the NC carried out the situational diagnosis of maternal and child health care, developed health care protocols for pregnant women that contextualized reference and regulatory services, qualified medical professionals and nurses-both in technical issues and in the dynamics of RAS-and presented a proposal for the reorganization of services based on matrix support and regionalization¹2Available from: <https://www.saude.ce.gov.br/nascer-no-ceara/>. Access on: Mar. 06, 2023.. Since 2019, however, the program has been paralyzed and its restructuring proposals have not been implemented. It is worth noting that this interruption was in the context of the health emergency linked to the Covid-19 pandemic and that in 2023 a new government began. As of the date of writing this manuscript, NC activities have not resumed, although the program has not been officially suspended.

The quantitative stage of the research consisted of a cross-sectional and analytical study of a historical series, carried out from the analysis of medical records and hospitalization records of women assisted in three tertiary maternity hospitals in the Metropolitan Region of Fortaleza, Ceará, from 2010 to 2019.

A total of 3,352 medical records were analyzed. The inclusion criterion was being a pregnant or postpartum woman admitted to participating maternity hospitals as a result of pregnancy. Medical records that were unavailable and those of women who were still hospitalized during the study period were excluded. Data were obtained by analyzing medical and hospitalization records. The specific instrument recommended by the WHO was used to identify women who met the criteria for MNM (WHO, 2011WHO - WORLD HEALTH ORGANIZATION. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. Geneva, 2011.). Sociodemographic variables (age, color/ethnicity, marital status, and education) and data on the current pregnancy, issues and complications and ways of getting to the reference maternity hospital were also collected.

Of the total analyzed, 1,703 women had been to at least one health institution before reaching one of the three tertiary services included in the survey. From their medical records, we sought to identify delays relating to three spheres: in the diagnosis at the institution of origin, in the beginning of therapy in the institution of origin (after diagnosis), and in transfer. These last data were extracted from notes or referral forms attached to the medical records, from the hospitalization summary document, from the anamnesis carried out upon admission-generally by a medical student-and from admissions carried out by nursing staff.

Data were analyzed in IBM SPSS v. 25. The exploratory analysis was described with frequencies and their respective confidence intervals (95% CI). Quantitative variables were analyzed using the non-parametric Wilcoxon test. To evaluate the association of independent variables with outcomes characterizing Near Miss (=1) and non-Near Miss (=0), the hypothesis test (Fisher’s exact test) and odds ratio (OR) were used, adopting a 95% confidence level.

In this design, quantitative data were collected and analyzed before qualitative data, which complemented and contributed to the understanding of the phenomena analyzed in the first stage ( Creswell , 2007CRESWELL, J. W. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 2. ed. Porto Alegre: Artmed, 2007.).

For the qualitative stage, 14 postpartum women participated who met criteria for MNM and were admitted to participating maternity hospitals from January to September 2020. To collect data, the autobiographical narrative interview technique proposed by sociologist Fritz Schütze (1983SCHÜTZE, F. Pesquisa biográfica e entrevista narrativa. In: WELLER, W.; PFAFF, N. (Org.). Metodologias da pesquisa qualitativa em Educação: teoria e prática. Petrópolis: ozes, 1983. p. 210-222.) was used, which can be organized into three stages. In the first stage, the participant is asked to provide a spontaneous report from a generative question (Jovchelovitch; Bauer, 2002JOVCHELOVITCH, S.; BAUER, M. W. Entrevista narrativa. In: BAUER, M.; GASKELL, G. (Ed.). Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes, 2002. p. 90-113.). In this survey, we adopted the question: “I am researching the life stories of women who had serious complications during pregnancy, childbirth or after childbirth. To do this, I ask you to tell your story however you see fit. Tell me your entire journey, from your prenatal care to your admission to the intensive care unit (ICU) and what happened after your discharge. You can take as long as you like, start and finish your story as you wish, telling your life so that I understand who you are. For you to tell your story freely, I won’t interrupt you. You must tell me when the story is over, and only then will I ask you some questions to clarify what I didn’t quite understand. All right?”. Subsequently, questions were asked to clarify ambiguities, doubts, and narrative lapses (“immanent questions”). In the third stage, the recorder was turned off and questions were asked that required the informant to rationalize and theorize about the event in question (“exmanent questions”) (Schütze, 1983SCHÜTZE, F. Pesquisa biográfica e entrevista narrativa. In: WELLER, W.; PFAFF, N. (Org.). Metodologias da pesquisa qualitativa em Educação: teoria e prática. Petrópolis: ozes, 1983. p. 210-222.; Jovchelovitch; Bauer, 2002JOVCHELOVITCH, S.; BAUER, M. W. Entrevista narrativa. In: BAUER, M.; GASKELL, G. (Ed.). Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes, 2002. p. 90-113.).

The audios were transcribed immediately after each interview, and the notes obtained from the exmanent questions were added to the material. After transcriptions, the texts were structured into narratives, which were re-presented to each participant in order to validate the information and correct lapses and inaccuracies. Concluding the construction of each narrative, data organization began by formal analysis, as proposed by Schütze (1983SCHÜTZE, F. Pesquisa biográfica e entrevista narrativa. In: WELLER, W.; PFAFF, N. (Org.). Metodologias da pesquisa qualitativa em Educação: teoria e prática. Petrópolis: ozes, 1983. p. 210-222.). The data were first divided into indexed material (rational and concrete content, which can be ordered chronologically) and non-indexed material (subjective content, such as value judgments, feelings, and reflections) (Jovchelovitch; Bauer, 2002JOVCHELOVITCH, S.; BAUER, M. W. Entrevista narrativa. In: BAUER, M.; GASKELL, G. (Ed.). Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes, 2002. p. 90-113.). The indexed content was organized in order to reconstruct individual trajectories, and the non-indexed material was incorporated into the trajectories and organized into meaning cores for saturation analysis purposes. For each narrative, the data was organized to allow comparisons between the trajectories and the emerging cores of meaning, enabling the identification of regularities and contrasts (Jovchelovitch; Bauer, 2002JOVCHELOVITCH, S.; BAUER, M. W. Entrevista narrativa. In: BAUER, M.; GASKELL, G. (Ed.). Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes, 2002. p. 90-113.). Data saturation was considered from the moment regularities became the rule.

Subsequently, the qualitative data were interpreted together with the quantitative data. In the end, a graphic scheme was constructed that summarizes the patterns found in association with the second delay and the peregrination of women in MNM situations. In order to maintain anonymity, participants were identified by fictitious names. The three reference hospitals were named H1, H2, and H3. The remaining hospitals received random identifications with other letters of the alphabet.

This research project was approved by the Ethics Committee of the Universidade de Fortaleza with number 027/2009, with the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico (FUNCAP) as sponsor, via the research program for the SUS, call 01/2017.

Results

Of the 1,703 women who had been to at least one service before arriving at the reference maternity hospital, 7.6% progressed to MNM. The majority were black (54.7%), ranging from 20 to 29 years of age (47.4%), had completed primary education (40.9%), and lived with a partner (61.7%) (Table 1).

Fourteen women participated in the qualitative stage; their characteristics are summarized in Table 2.

Table 3 shows the odds of MNM associated with delays between arrival at the first institution and arrival at the tertiary institution among women who underwent at least one transfer. Delay in diagnosis at the institution of origin increases the risk by 3.3 times in relation to timely diagnosis (95% CI 2.2-5.2), delay in starting treatment increases the risk by 3.1 times in relation to timely start (95% CI 2.0-4.8), and delay in case referral increases the risk by 3.7 times (95% CI 1.4-2.0) in relation to timely referral.

The elaboration of narratives contributed to the understanding of the events found in the quantitative stage. The delay in diagnosis at the institution of origin, for example, occurred even in cases whose risk and management are already well established in the literature, such as pre-eclampsia and postpartum hemorrhage, and cannot be justified by a lack of structure. The narratives below provide similar accounts from women treated in different services and municipalities:

The delay in diagnosis also occurs due to the transfer of responsibility for care, culminating in multiple transfers between institutions, as Suelen, a woman who works in a textile factory and lives with her husband, three children and mother-in-law, tells us:

The transfer of responsibility, however, can also occur between sectors of the same institution, in a circular pattern, as the sequence in Suelen’s account shows us:

This process of transfer to multiple services and/or intersectoral places the patient in a situation in which no professional is responsible for her care. Suelen’s comments also highlight the lack of effective communication between professionals and patients, which contributes to diagnostic delays and peregrination. Team changes during shifts mean that on each return to the previous sector, the patient is evaluated by a new professional, who reaches similar conclusions to the previous one without investigating the problem in depth:

Even after diagnosis, delays in starting treatment can still occur, as shown by the narratives of Joana (who had already experienced a delay in diagnosis) and Raquel (timely diagnosed with pre-eclampsia). Joana, 23 years old, White, single, lives with her mother, sister, and nephew, and works as a cleaner, helping her mother. Raquel (32 years old, Black, single) lives with her two children and works in a cafeteria. Both of them reported not having received intravenous or intramuscular medication, which are the routes of administration of magnesium sulfate (medication indicated for preventing eclampsia):

Cícera’s account of hemorrhagic complications corroborates the previous narrative about the delay in instituting therapy. Cícera is a 19-year-old Indigenous woman from Caucaia, single, who lives with her mother and works with her sister in an informal business:

Even after the decision to refer the patient to a hospital capable of providing the necessary assistance, this may be delayed by different factors. Following Cícera’s narrative, we highlight three of them: the difficulty of integration between precarious private assistance and the SUS, the difficulty of transportation and the distorted use of emergency services for removal:

The difficulty of transportation is also associated with attitudinal flaws that are culturally naturalized in some locations, as Clara (22 years old, White, single, from Cascavel), with no work or academic activity during the research period, tells us: “The ambulance wasn’t there. […] There, it is common for the driver to keep the ambulance at home and only come if called.”

The lack of vacancies in reference services also emerges as a factor associated with delays in transfer, as we observed in the narrative of Vera (37 years old, White, married, from Fortaleza), a telemarketing operator. Despite the timely diagnosis, the procedure was postponed due to the unavailability of places in reference institutions. In the report below, the originating institution is a secondary hospital, which had an incomplete team. According to Vera’s explanations, the hospital had only one obstetrician on the day of her admission and there was no pediatrician during part of the day:

Both Vera and Jurema had their conditions worsened by the difficulty of finding vacancies in reference services. However, not all patients reach tertiary institutions via regulation. Irregular transfers may be carried out due to lack of vacancies or delay in regulatory response, considering the urgency of the case:

This attempt at irregular transfer, however, did not reduce the risk of MNM, as shown in Table 3, which also presents the risk associated with the different ways patients arrived at the tertiary services studied. The risks faced by patients who underwent at least one service before arriving at the reference maternity hospital were calculated in relation to those who sought directly one of the three institutions participating in the research. The only method that presented an increased risk of developing MNM was exactly unscheduled intra-hospital transfer (OR=4.8; 3.1-7.4).

The sequence of Joana’s narrative contributes to understanding some of the lapses related to this unregulated transfer alternative:

Joana accumulated delay factors in her peregrinations: her diagnosis of pre-eclampsia was delayed, even though she already had high blood pressure on admission; the start of treatment after diagnosis was delayed due to lack of supplies; the regulated transfer did not occur due to unavailability of places and the peregrination was consolidated during the transfer which was not agreed with the central regulation or the other services. It is clear that factors related to delays can be cumulative, contributing to the worsening of the situation.

Unregulated referrals also come from non-hospital units, components of Primary or Secondary Healthcare. Fátima (32-year-old married woman from Fortaleza), who works as a general services assistant, for example, was having her prenatal care at the Basic Health Unit (UBS). Although she was affiliated to a hospital, she was told at the UBS, during a consultation, to go immediately to a tertiary service, carrying only a note written on a prescription form:

Sometimes, referral to the tertiary service occurs via contact between professionals, without the intermediary of central regulation, as exemplified by Elisa (15 years old, White, single, student, from Maracanaú), who lives with her grandparents and mother: “The doctor who was at the time of the bleeding called the doctor who was on duty here, and she received me even though it was full. They called it vacancy zero.”

The narratives also highlight attempts to circumvent regulation difficulties by transferring responsibility for travel to the patient, worsening the peregrination process, as we observed in Letícia’s account:

This transfer of responsibility to the patient is aggravated by conditions of social vulnerability, as we see in Cícera’s narrative, who presented bleeding in the episiotomy suture area that became a hematoma, progressed to fasciitis, and culminated in sepsis:

Figure 2 groups the patterns related to the delays found in the joint interpretation of quantitative and qualitative data.

Discussion

The results of this research show how failures in hospital care delay the arrival of women with serious conditions at reference maternity hospitals, increasing the risk of MNM. These lapses are linked to assistance issues-such as non-observance of protocols and ineffective and violent communication-as well as structural aspects, highlighting flaws in the regionalization and referral/counter-referral processes.

Notably, the delay in diagnosis and implementation of appropriate therapy occurs even in the face of conditions with well-defined clinical protocols and high epidemiological risks, such as puerperal hemorrhage and pre-eclampsia. It is worth mentioning that these are the main causes of maternal death and are considered preventable causes (Pacagnella et al., 2014PACAGNELLA, R. C. et al. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC pregnancy and childbirth , London, v. 14, p. 159, 2014. DOI: 10.1186/1471-2393-14-159.
https://doi.org/10.1186/1471-2393-14-159... ; Sheldon et al., 2014SHELDON, W. R. et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. British journal of obstetrics and gynaecology, Oxford, v. 121, n. suppl 1, p. 5-13, 2014. DOI: 10.1111/1471-0528.12636.
https://doi.org/10.1111/1471-0528.12636... ; Sotunsa et al., 2019SOTUNSA, J. O. et al. Maternal near‐miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near‐miss and Maternal Death Survey. British journal of obstetrics and gynaecology , Oxford, v. 126, n. s3, p. 19-25, 2019. DOI: 10.1111/1471-0528.15624.
https://doi.org/10.1111/1471-0528.15624... ; Zanette et al., 2014ZANETTE, E. et al. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reproductive health, London, v. 11, n. 1, p. 4, 2014. DOI: 10.1186/1742-4755-11-4.
https://doi.org/10.1186/1742-4755-11-4... ) that should not be neglected.

The narratives provided place these delays in the sphere of non-observance of established protocols and the transfer of responsibilities, subjecting the patient to multiple hospital and intersectoral transfers until diagnosis. These findings are in line with those of a study carried out in Rwanda, which found that delays at the diagnostic and therapeutic level due to human error or mismanagement were present in 65.3% of MNM cases (Benimana; Small; Rulisa, 2018BENIMANA, C.; SMALL, M.; RULISA, S. Preventability of maternal near miss and mortality in Rwanda: a case series from the University Teaching Hospital of Kigali (CHUK). PLoS One, San Francisco, v. 13, n. 6, e0195711, 2018. DOI: 10.1371/journal.pone.0195711.
https://doi.org/10.1371/journal.pone.019... ). A multicenter study carried out in Brazil, including 6,706 women with severe hypertensive disorder in 27 maternity hospitals in the country, found that most women with severe hypertension suffered some type of delay in care (55.6%) related to the health system (OR 2 .86; 1.89-4.33) or health professionals (OR 2.45; 1.53-3.92) (Zanette et al., 2014ZANETTE, E. et al. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reproductive health, London, v. 11, n. 1, p. 4, 2014. DOI: 10.1186/1742-4755-11-4.
https://doi.org/10.1186/1742-4755-11-4... ), corroborating the findings of this study. Regarding postpartum hemorrhage, it is already established that factors related to the health system and inadequate obstetric care are important determinants of survival from this condition (Ronsmans; Graham, 2006RONSMANS, C.; GRAHAM, W. J. Maternal mortality: who, when, where, and why. The Lancet , London, v. 368, n. 9542, p. 1189-1200, 2006. DOI: 10.1016/S0140-6736(06)69380-X.
https://doi.org/10.1016/S0140-6736(06)69... ). Even so, it remains one of the main causes of maternal morbidity and mortality (Hogan et al., 2010HOGAN, M. C. et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet, London, v. 375, n. 9726, p. 1609-1623, 2010. DOI: 10.1016/S0140-6736(10)60518-1.
https://doi.org/10.1016/S0140-6736(10)60... ; Umashankar et al., 2013UMASHANKAR, K. M. et al. Effect of a primary postpartum haemorrhage on the “near-miss” morbidity and mortality at a Tertiary Care Hospital in Rural Bangalore, India. Journal of clinical and diagnostic research, Deli, v. 7, n. 6, p. 1114-1119, 2013. DOI: 10.7860/JCDR/2013/5376.3066.
https://doi.org/10.7860/JCDR/2013/5376.3... ; Sheldon et al., 2014SHELDON, W. R. et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. British journal of obstetrics and gynaecology, Oxford, v. 121, n. suppl 1, p. 5-13, 2014. DOI: 10.1111/1471-0528.12636.
https://doi.org/10.1111/1471-0528.12636... ; Sotunsa et al., 2019SOTUNSA, J. O. et al. Maternal near‐miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near‐miss and Maternal Death Survey. British journal of obstetrics and gynaecology , Oxford, v. 126, n. s3, p. 19-25, 2019. DOI: 10.1111/1471-0528.15624.
https://doi.org/10.1111/1471-0528.15624... ), which correlates with lapses in care found in this study.

Non-observance of protocols in the accounts were often accompanied by violent forms of communication. Despite studies highlighting the role of interrelationships in the continuity and quality of care (Almeida et al, 2021ALMEIDA, H. B. et al. As relações comunicacionais entre os profissionais de saúde e sua influência na coordenação da atenção. Cadernos de Saúde Pública, Rio de Janeiro, v. 37, n. 2, e00022020, 2021. DOI: 10.1590/0102-311X00022020.
https://doi.org/10.1590/0102-311X0002202... ; Jesus et al 2018JESUS, R. P. F. S. et al. Health care professionals’ perceptions of coordination between levels of care in two large municipalities in the State of Pernambuco, Brazil. Interface, Botucatu, v. 22, n. 65, p. 423-434, 2018. DOI: 10.1590/1807-57622017.0026.
https://doi.org/10.1590/1807-57622017.00... ), communication problems are frequently reported in the literature, accounting for between 40% and 66% of care reports (Attanasio; Kozhimannil, 2015ATTANASIO, L.; KOZHIMANNIL, K. B. Patient-reported communication quality and perceived discrimination in maternity care. Medical care, Philadelphia, v. 53, n. 10, p. 863-871, 2015. DOI: 10.1097/MLR.0000000000000411.
https://doi.org/10.1097/MLR.000000000000... ; Domingues et al., 2016DOMINGUES, R. M. S. M. et al. Factors associated with maternal near miss in childbirth and the postpartum period: findings from the birth in Brazil National Survey, 2011-2012. Reproductive Health, London, v. 13, n. suppl 3, p. 187-197, 2016. DOI: 10.1186/s12978-016-0232-y.
https://doi.org/10.1186/s12978-016-0232-... ).

The situations narrated in this text can also be classified as obstetric violence (OV). OV is any action or omission towards a woman during prenatal care, childbirth, or e puerperium that causes unnecessary pain, harm, or suffering, carried out without her explicit consent or in disregard of her autonomy (Fundação Perseu Abramo, 2010FUNDAÇÃO PERSEU ABRAMO; SESC. Mulheres brasileiras e gênero nos espaços público e privado. São Paulo, 2010. Disponível em: <Disponível em: https://fpabramo.org.br/publicacoes/wp-content/uploads/sites/5/2017/05/pesquisaintegra_0.pdf >. Acesso em: 1 set. 2019.
https://fpabramo.org.br/publicacoes/wp-c... ). This construct therefore includes both the disrespectful and abusive treatment of patients and other elements of poor-quality care, such as non-adherence to best practices based on scientific evidence (Katz et al, 2020KATZ, L. et al. Who is afraid of obstetric violence? Revista Brasileira de Saúde Materno Infantil, Recife, v. 20, n. 2, p. 623-626, 2020. DOI: 10.1590/1806-93042020000200017.
https://doi.org/10.1590/1806-93042020000... ). Therefore, communication failures associated with different forms of obstetric violence, such as those evidenced in the narratives, can be directly related to the occurrence of MNM (Lansky et al, 2019LANSKY, S. et al. Violência obstétrica: influência da Exposição Sentidos do Nascer na vivência das gestantes. Ciência & Saúde Coletiva , Rio de Janeiro, v. 24, n. 8, p. 2811-2823, 2019. DOI: 10.1590/1413-81232018248.30102017.
https://doi.org/10.1590/1413-81232018248... ).

In addition to lapses in assistance, the results obtained in this study highlight structural problems, such as flaws in the regionalization process and regulatory systems. The organization of RAS should respond to effectiveness determinants based on an economy of scale (ES) logic. To this end, the organization of the territory, the presence of effective regulatory mechanisms and qualified regional planning are crucial in determining the ease and difficulties of access (Borsato; Carvalho, 2021BORSATO, F. G.; CARVALHO, B. G. Hospitais gerais: inserção nas redes de atenção à saúde e fatores condicionantes de sua atuação. Ciência & Saúde Coletiva, Rio de Janeiro, v. 26, n. 4, p. 1275-1288, 2021. DOI: 10.1590/1413-81232021264.10212019.
https://doi.org/10.1590/1413-81232021264... ). One of the key points in this process are the referral and counter-referral flows, which demonstrate how the dialogue between the levels of care is structured (Dubeux; Freese; Felisberto, 2013DUBEUX, L. S.; FREESE, E.; FELISBERTO, E. Acesso a hospitais regionais de urgência e emergência: abordagem aos usuários para avaliação do itinerário e dos obstáculos aos serviços de saúde. Physis, Rio de Janeiro, v. 23, n. 2, p. 345-369, 2013. DOI: 10.1590/S0103-73312013000200003.
https://doi.org/10.1590/S0103-7331201300... ). In this way, the women’s narratives in this research highlight, via regulatory failures, important lapses in the integration of the care network.

Lapses in regulatory systems are also associated with the poor distribution of services. The narratives highlight the lack of preparation of maternity hospitals in peripheral municipalities to provide adequate assistance. These smaller establishments are reported in the literature as frequently presenting low occupancy rates and lacking in structure and human resources, consequently having a poor cost-effectiveness ratio, ending up playing a role locally that is equivalent to that of primary health care (PHC) (Rocha et. al, 2017ROCHA, T. A. H. et al. Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil. International Journal for Equity in Health, London, v. 16, n. 1, p. 1-10, 2017. DOI: 10.1186/s12939-017-0645-4.
https://doi.org/10.1186/s12939-017-0645-... ). These establishments do not provide adequate ES, providing ineffective care and requiring patients to travel (Borsato, Carvalho, 2021BORSATO, F. G.; CARVALHO, B. G. Hospitais gerais: inserção nas redes de atenção à saúde e fatores condicionantes de sua atuação. Ciência & Saúde Coletiva, Rio de Janeiro, v. 26, n. 4, p. 1275-1288, 2021. DOI: 10.1590/1413-81232021264.10212019.
https://doi.org/10.1590/1413-81232021264... ). This, combined with inadequately distributed tertiary hospital care, as shown in Figure 1, and this creates a scenario that is conducive to the establishment of regionalization problems (Rocha et al, 2017ROCHA, T. A. H. et al. Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil. International Journal for Equity in Health, London, v. 16, n. 1, p. 1-10, 2017. DOI: 10.1186/s12939-017-0645-4.
https://doi.org/10.1186/s12939-017-0645-... ; Borsato; Carvalho, 2021BORSATO, F. G.; CARVALHO, B. G. Hospitais gerais: inserção nas redes de atenção à saúde e fatores condicionantes de sua atuação. Ciência & Saúde Coletiva, Rio de Janeiro, v. 26, n. 4, p. 1275-1288, 2021. DOI: 10.1590/1413-81232021264.10212019.
https://doi.org/10.1590/1413-81232021264... ).

This scenario is compounded by difficulties in traveling and accessing essential places, such as health services. Since this is a constitutional right, it is necessary to consider issues of population mobility and the provision of multiple forms of transport leading to these institutions (Feitoza; Aredes, 2015FEITOZA, J. S.; AREDES, A. Mobilidade urbana e acessibilidade aos serviços de saúde pelo uso do transporte coletivo urbano no município de Campo Grande (MS): o caso do hospital universitário. Anais do ENIC, [s. l.], n. 6, 2015. Disponível em: <Disponível em: https://anaisonline.uems.br/index.php/enic/article/view/2442 >. Acesso em: 29 maio 2023.
https://anaisonline.uems.br/index.php/en... ).

Our findings therefore corroborate those of Borsato and Carvalho (2019BORSATO, F. G.; CARVALHO, B. G. Hospitais gerais: inserção nas redes de atenção à saúde e fatores condicionantes de sua atuação. Ciência & Saúde Coletiva, Rio de Janeiro, v. 26, n. 4, p. 1275-1288, 2021. DOI: 10.1590/1413-81232021264.10212019.
https://doi.org/10.1590/1413-81232021264... ), in that, despite efforts to implement the legal framework regarding RAS, the process of health services regionalization still suffers from biases that impact on the integration and activity of the care network.

Another emerging problem is the intersection between the public and private sectors. The discussion of both issues requires considering the concomitant implementation of conflicting projects in the health area. While in the early 2000s there was a commitment to ensure advances in access to care provided by the SUS, on the other hand there was a stimulus to the growth of the private sector with a focus on the C and D income segments. The blatant underfunding-which would worsen in the following years-coupled with the progressive increase in demand-resulting from the greater longevity of the population and technological innovations in health-culminated in growing difficulties in providing care. These issues led to significant waiting times for many procedures and an insufficient supply of beds and hospitalization spaces (Cordilha; Lavinas, 2018CORDILHA, A. C.; LAVINAS, L. Transformações dos sistemas de saúde na era da financeirização. Lições da França e do Brasil. Ciência & Saúde Coletiva , Rio de Janeiro, v. 23, n. 7, p. 2147-2158, 2018. DOI: 10.1590/1413-81232018237.11422018.
https://doi.org/10.1590/1413-81232018237... ), which contributes to the difficulty of transfer as evidenced in the narratives.

As a more immediate effect of this overload, the 21st century saw the progressive expansion of medical services companies, known as “popular” companies, which focused their attention on users dissatisfied with the waiting times of the public system-the so-called SUS overflow (Godoy, 2015GODOY, C. V. A geografia dos serviços e equipamentos da saúde: a expansão das “clínicas médicas populares” no Centro em Fortaleza - CE. Dissertação (Mestrado em Geografia) - Universidade Federal do Ceará, Fortaleza, Ceará, 2015. Disponível em: <Disponível em: http://www.repositorio.ufc.br/handle/riufc/16885 >. Acesso em: 20 jul. 2022.
http://www.repositorio.ufc.br/handle/riu... ). It turns out that this expansion of the private sector, in a highly segmented way, generated potentially more limited accessibility, without planning lines of care and returning the patient to the SUS when the cost of their treatment becomes high or when care becomes difficult to be provided at the agreed value to the most vulnerable segments.

Therefore, the results show that delays in assistance to pregnant and postpartum women are multifactorial and complex. The peregrination of these women is associated with problems in the structures of RAS and services, but it is also linked to significant lapses in care, requiring greater management to have greater control over following the established protocols.

Final considerations

This study showed that the peregrinations of pregnant and postpartum women is a complex phenomenon, associated with multiple factors, including delays related to professionals (such as disregard for care protocols, communication, and obstetric violence), the health system (lapses in the regulatory system, availability of beds, referral and counter-referral flows, regionalization of the SUS, and the relationship between public and private/supplementary networks), and structural issues (such as urban mobility problems).

Improving obstetric care and reducing peregrinations requires a health system that has tools for monitoring the quality of service provided by health professionals, well-established care processes, physical structures and RAS that support the monitoring of these processes. These measures can only be achieved by strengthening the SUS and overcoming underfunding and the public-private dichotomy.

References

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