Principal investigator: Viviane Pires Ribeiro
Article title: EVALUATION OF THE PROCESS IN PRENATAL CARE FOR PREGNANT WOMEN WITH USUAL RISK
Article authors: Marianne Maia Dutra Balsells, Tyane Mayara Ferreira de Oliveira, Elizian Braga Rodrigues Bernardo, Priscila de Souza Aquino, Ana Kelve de Castro Damasceno, Régia Christina Moura Barbosa Castro, Paula Renata Amorim Lessa and Ana Karina Bezerra Pinheiro
Location of the Intervention: Fortaleza, Ceará, Brazil
Sample size: 560 medical records
Sector: Health Insurance
Type of intervention: Assessment of the quality of care regarding the process offered to pregnant women with usual risk.
Primary variable of interest: Prenatal care
Evaluation method: Evaluative research
Evaluation Context
Prenatal care aims to ensure the healthy development of the pregnancy, promoting a healthy birth with the least possible impact on maternal and fetal health, thus considering psychosocial aspects, educational and preventive activities. In this sense, Brazilian research shows that the health levels of mothers and fetuses are closely linked to the quality of prenatal care, thus having a direct correlation between adequate prenatal care and the reduction of maternal and perinatal morbidity and mortality rates.
Balsells et al. (2018) emphasize that current studies covering the quality of health services have been based on one or more categories proposed by Donabedian (1991), who defines the quality of these services as the degree to which they meet the needs, expectations, and standards of care of the population. Furthermore, the application of quality criteria to evaluate the prenatal care process is seen as one of the conditions for ensuring the effectiveness of care for pregnant women, as it makes it possible to identify the service's performance and demonstrates the quality of care.
Intervention Details
Balsells et al. (2018) evaluate the quality of care regarding the process offered to pregnant women with usual risk pregnancies. To achieve this objective, the authors used an evaluative survey, carried out from May 2015 to January 2016, at the Lígia Barros Costa Natural Birthing Center (CPN) in Fortaleza, Ceará. The data collection instrument included sociodemographic, clinical and obstetric aspects, and process indicators of prenatal care.
The evaluation consisted of analyzing all medical records from January 2011 (the period corresponding to the formulation of the Stork Network Strategy) to June 2015, resulting in 695 records. However, records of women who were undergoing prenatal care at the time of data collection (56), those referred to high-risk prenatal care (21), and those with a record of only one consultation (24) were excluded from the sample. Therefore, the total sample comprised 560 records.
Methodology Details
To evaluate the process, the authors adopted prenatal indicators, clinical and obstetric assessment indicators, and indicators from complementary examinations. Regarding prenatal indicators, care is considered adequate when it begins within 12 weeks of gestation and the woman has had seven or more consultations. It is considered inadequate when prenatal care begins after the 27th week of gestation or the woman has had two or fewer consultations. On the other hand, the quality of prenatal care is considered intermediate when it presents situations between adequate and inadequate.
Regarding indicators related to clinical and obstetric procedures, it is considered adequate when there are five or more records of uterine height (UH), gestational age (GA), weight, blood pressure (BP), and body mass index (BMI); and four or more records of fetal heart rate (FHR); and two or more records of fetal presentation and edema. It is considered inadequate when there are two or fewer records of UH, GA, BP, edema, weight, and FHR, or no record of fetal presentation. It is considered intermediate when it presents all situations intermediate between adequate and inadequate.
Regarding the indicators of complementary exams, the authors evaluated the toxoplasmosis and HBsAg tests, recommended by the Stork Network Strategy. Thus, it is considered adequate when the pregnant woman underwent ABO-Rh typing, two hematocrit tests, two hemoglobin tests, two fasting blood glucose tests, two VDRL tests, two anti-HIV tests, two urinalysis tests, one HBsAg test, and one toxoplasmosis serology test during the entire prenatal period. It is considered inadequate when there is no record of any laboratory test. And finally, any basic tests performed, regardless of type, are classified as intermediate.
Results
The average number of prenatal visits performed at the CPN between May 2015 and January 2016 was 5,83 (median of 6,00), and the majority of pregnant women, 73,8% (n=413), started prenatal care after the 12th week of gestation, with the most prevalent being the start of prenatal care in the 2nd trimester of pregnancy, 52,9% (n=296).
Regarding the quality indicators of prenatal care, the results show that 42,3% (n=237) attended the appropriate number of consultations, having seven or more consultations. Only 26,3% (n=147) started prenatal care early. Concerning the quality indicators of clinical and obstetric procedures, 55% (n=309) were found to be adequate. When analyzing the quality indicators related to laboratory tests, only 25,4% (n=142) were adequate.
Lessons in Public Policy
The study conducted by Balsells et al. (2018) highlights the low adequacy of prenatal care, regarding the start of prenatal monitoring, the number of visits during pregnancy, the performance of clinical and obstetric procedures, and laboratory tests recommended by the Ministry of Health. Thus, the late start of prenatal care and the inadequate number of visits contribute, among other factors, to an unfavorable outcome, since this procedure is essential for the early detection of situations that put maternal and fetal health at risk.
Prenatal care quality is adequate in a minority of the population analyzed. Therefore, there is a need to improve care regarding process indicators within the service, deserving greater attention from managers and health professionals, with investment in training and action planning to improve indicators related to the number of consultations, early initiation of prenatal care, clinical and obstetric procedures, and the performance of laboratory tests. Furthermore, the implementation of a prenatal care monitoring and evaluation program is necessary to ensure the effectiveness of actions and the quality of care.
Reference
BALSELLS, MMD et al. Evaluation of the process in prenatal care for pregnant women with usual risk. Acta Paulista de Enfermagem, v. 31, n. 3, p. 247-254, 2018.
