Teses e Dissertações

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An outcome evaluation of prenatal care at primary healthcare level in Brazil

Objectives: To assess the effect of prenatal care adequacy over birthweight.

Methodology: Cross-sectional study including service structure of 26 health facilities, care processes and outcome of 712 mothers of low socioeconomic level attending antenatal care at Primary Healthcare (PHC) facilities in Pelotas, southern Brazil was conducted. Data on process of care and on the result of the pregnancy were obtained through maternal interview, at household, and from Birth Certificates. For the structural evaluation of the health centers the “Health Center Evaluation Instrument� of the Brazilian Ministry of Health was applied. An adequacy approach was used to assess the effect of the Prenatal Program over birthweight.

Results: Mean birthweight was 3,149 g. Most women had white skin (71%), 25% were teenagers and about 11% were under 150 cm tall. Kessner/Takeda Index indicated that 58% of pregnant women received adequate antenatal care. After adding the minimal exam requirements to each of the categories of the preceding criterion, this share fell to 47%. In the adjusted analysis, by linear regression, mean birthweight was directly associated to maternal characteristics (age, height, family monthly income, history of diabetes and gestational age); and inversely associated to maternal history of hospital admission, high blood pressure, threatened miscarriage, and smoking. There were no associations with service structure. When compared to the control group, babies born from mothers who received adequate antenatal care were, in average, 110.34 g heavier.

Conclusions: This adequacy evaluation showed that the Prenatal Program delivered at PHC centers is moving in the expected direction.

Keywords: prenatal care, adequacy, assessment, birthweight, Primary Healthcare

 

Adequação do pré-natal e peso ao nascer: uma revisão sistemática

Resumo: Essa foi uma revisão sistemática da literatura de publicações em que o pré-natal foi investigado com uma das variáveis preditoras do peso ao nascer. Os bancos de dados MEDLINE, COCHRANE LIBRARY e SciELO foram rastreados usando-se a combinação dos seguintes descritores: “prenatal care�, “antenatal care�, “quality�, “adequacy�, “birthweight�, e “low birthweight�. Foram localizados vinte e cinco estudos: dezessete transversais, quatro coortes, três caso-controle e um ensaio randomizado. Os indicadores de adequação empregados foram os de utilização (quantitativos) e os de conteúdo do cuidado (de processo ou qualitativos). A maioria dos autores aplicou indicadores de utilização, principalmente o �ndice de Kessner e o APNCUI. Somente dois estudos usaram critérios qualitativos. De modo geral, os estudos transversais detectaram efeito protetor do pré-natal sobre o baixo peso ao nascer, enquanto que os resultados de investigações com outros desenhos foram conflitantes. Os achados dessa revisão evidenciam que o impacto do pré-natal sobre o peso ao nascer não é inequívoco, principalmente devido ao efeito do viés de auto-seleção. Há a necessidade de realização de ensaios randomizados para esclarecer essa relação.Descritores: pré-natal, utilização, adequação, qualidade, peso ao nascer. Abstract: This was a systematic review of the literature on publications in which prenatal care was investigated as a predictor variable of birth weight. MEDLINE, COCHRANE LIBRARY and SciELO data basis were searched using a combination of the following uniterms: “prenatal care�, “antenatal care�, “quality�, “adequacy�, “birthweight�, and “low birthweight�. Twenty five studies were found: seventeen had a cross-sectional design, four cohorts, three case-control and one randomized trial. The adequacy indicators used were those of utilization (quantitatives) and of content of prenatal care (processes or qualitatives). Most authors employed quantitative indicators, mainly Kessner Index and the APNCUI. In only two studies qualitative criteria were used. Most of the cross-sectional studies found a protective effect of prenatal care on low birthweight, whereas results of studies with other designs were conflictive. The findings of this review highlight that the impact of prenatal care over birthweight is not unequivocal, mainly due to the effect of the self-selection bias. Randomized trials are needed to clarify that relationship.Key words: prenatal acre, utilization, adequacy, quality, birthweight

 

Fatores associados à cesariana entre mulheres de baixa renda em Pelotas,RS

Resumo: O objetivo do estudo foi investigar a associação entre as características das mulheres e do cuidado pré-natal na rede de Atenção Primária à Saúde de Pelotas, com o tipo de parto. Realizou-se um estudo transversal, incluindo a estrutura dos serviços e o processo de atendimento. Foram estudados todos os centros de saúde da cidade e entrevistadas 712 mães. A taxa de cesarianas foi de 30%. Na análise ajustada, o risco de cesariana associou-se com características maternas (menor altura, menor número de gestações, gestação planejada, internações hospitalares e hipertensão arterial na gravidez). Entre as características dos serviços encontrou-se influência protetora do maior tempo de formado do médico pré-natalista e o cumprimento às normas do programa Pré-natal. As maiores taxas foram verificadas entre os hospitais universitários. Além da educação da mulher no pré-natal, o reconhecimento precoce e o manejo adequado da hipertensão arterial e das causas de hospitalização sugerem a possibilidade de abordagem pelo setor primário no sentido de reduzir a taxa de cesarianas.Descritores: cuidado pré-natal, cesariana, serviços de saúde, Atenção Primária à Saúde

Factors associated to caesarean sections among low income women in Pelotas, Brazil

Abstract: The aim of this study was to investigate the association between maternal and antenatal care characteristics and caesarean section prevalence. A cross-sectional study including variables of the structure and of the process of care was conducted at Primary Health Care facilities in Pelotas, Brazil. All health centres were selected and 712 mothers were interviewed. The observed caesarean rate was of 30%. Adjusted analyses showed that caesarean was associated to maternal characteristics (short stature, small number of pregnancies, planned pregnancy, hospitalisation and high blood pressure). Among variables related to the health services, a direct protective effect of time since graduation of the doctor providing the antenatal care and compliance to the Antenatal Care Programme guidelines was detected. Higher rates of caesarean sections were observed at university hospitals. To reduce caesarean rate, maternal education during pregnancy, early diagnosis and proper management of hypertension and of causes of hospitalisation are possible strategies for approaching the problem at the Primary Health Care sector.Key words: antenatal care, caesarean, health services, Primary Health Care