Avaliação dos Impactos do Programa Avançar na Oferta de Cuidados Básicos em Saúde no Estado do Rio Grande do Sul

To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Data from cross-sectional household-based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log-linear model. Between 2002 and 2007, having no any pre-natal visit decreased from 25% to 12% (difference 13%, 95% CI 10-17%); facility-based delivery increased from 45% to 80% (difference 35%, 95% CI 29-37%); and differences in using pre-natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre-natal and delivery care in 2007. The expenditure for facility-based delivery increased over the period, but the out-of-pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low-income group. NCMS participation was found positively correlated with lower out-of-pocket expenditure for facility-based delivery (coefficient -1.14 P < 0.05) in 2007. Facility-based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility-based delivery, although NCMS participation reduced the out-of-pocket expenditure on average.

Finding a Medical Home for Perinatal Depression: How Can We Bridge the Postpartum Gap?

BackgroundDespite strong efforts to improve maternal care, its quality remains deficient in many countries of Sub-Saharan Africa as persistently high maternal mortality rates testify. The QUALMAT study seeks to improve the performance and motivation of rural health workers and ultimately quality of primary maternal health care services in three African countries Burkina Faso, Ghana, and Tanzania. One major intervention is the introduction of a computerized Clinical Decision Support System (CDSS) for rural primary health care centers to be used by health care workers of different educational levels.MethodsA stand-alone, java-based software, able to run on any standard hardware, was developed based on assessment of the health care situation in the involved countries. The software scope was defined and the final software was programmed under consideration of test experiences. Knowledge for the decision support derived from the World Health Organization (WHO) guideline “Pregnancy, Childbirth, Postpartum and Newborn Care; A Guide for Essential Practice”.ResultsThe QUALMAT CDSS provides computerized guidance and clinical decision support for antenatal care, and care during delivery and up to 24 hours post delivery. The decision support is based on WHO guidelines and designed using three principles: (1) Guidance through routine actions in maternal and perinatal care, (2) integration of clinical data to detect situations of concern by algorithms, and (3) electronic tracking of peri- and postnatal activities. In addition, the tool facilitates patient management and is a source of training material. The implementation of the software, which is embedded in a set of interventions comprising the QUALMAT study, is subject to various research projects assessing and quantifying the impact of the CDSS on quality of care, the motivation of health care staff (users) and its health economic aspects. The software will also be assessed for its usability and acceptance, as well as for its influence on workflows in the rural setting of primary health care in the three countries involved.ConclusionThe development and implementation of a CDSS in rural primary health care centres presents challenges, which may be overcome with careful planning and involvement of future users at an early stage. A tailored software with stable functionality should offer perspectives to improve maternal care in resource-poor settings.Trial registrationhttp://www.clinicaltrials.gov/NCT01409824.

BackgroundStudies on prenatal care in China have focused on the timing and frequency of prenatal care and relatively little information can be found on how maternal care has been organized and funded or on the actual content of the visits, especially in the less developed rural areas. This study explored maternal care in a rural county from Anhui province in terms of care organization, provision and utilization.MethodsA total of 699 mothers of infants under one year of age were interviewed with structured questionnaires; the county health bureau officials and managers of township hospitals (n = 10) and county level hospitals (n = 2) were interviewed; the process of the maternal care services was observed by the researchers. In addition, statistics from the local government were used.ResultsThe county level hospitals were well staffed and equipped and served as a referral centre for women with a high-risk pregnancy. Township hospitals had, on average, 1.7 midwives serving an average population of 15,000 people. Only 10–20% of the current costs in county level hospitals and township hospitals were funded by the local government, and women paid for delivery care. There was no systematic organized prenatal care and referrals were not mandatory. About half of the women had their first prenatal visit before the 13th gestational week, 36% had fewer than 5 prenatal visits, and about 9% had no prenatal visits. A major reason for not having prenatal care visits was that women considered it unnecessary. Most women (87%) gave birth in public health facilities, and the rest in a private clinic or at home. A total of 8% of births were delivered by caesarean section. Very few women had any postnatal visits. About half of the women received the recommended number of prenatal blood pressure and haemoglobin measurements.ConclusionDelivery care was better provided than both prenatal and postnatal care in the study area. Reliance on user fees gave the hospitals an incentive to put more emphasis on revenue generating activities such as delivery care instead of prenatal and postnatal care.

The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. Descriptive, cross-sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High-risk geographic areas were defined as those where women needed to travel >30 miles for maternity-related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%-60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. In Michigan's 57 rural counties, only 29 hospitals provide maternity care. Geographic high-risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. Maternity care services are limited for many rural Michigan women. Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities.

A renaissance in primary health care

Objective: This study aims at assessing maternal and child care provided from prenatal to birth, so that it can reveal the weaknesses and potentialities of prenatal program in order to guide the development of strategic plans. Methods: This is an exploratory descriptive study with a quantitative approach, conducted in the city of Santa Cruz, state of Rio Grande do Norte, Brazil, from November 2012 to February 2013. The sample consisted of 200 women, chosen by draw, mothers of children under two years old who had attended the Primary Health Care System. The study used a semi-structured questionnaire used by the Ministry of Health. Our research project was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte, under the approval No. 311.613. Results: It was found that most mothers were rated from good to very good in the quality of care during prenatal and birth. As to the performance of prenatal and birth care services, most women performed those services under the municipality’s Public Health System, and the prenatal care primarily under Basic Health Care Units. Conclusion: In this assessment study, indicators regarding maternal and child care provided during the prenatal period were found to be positive, which contributes to the reduction of maternal and child mortality. The study also shows that Primary Health Care is essential to ensuring an effective, humane and comprehensive health care.

Preconception Women’s Health and Pediatrics: An Opportunity to Address Infant Mortality and Family Health

ABSTRACTOBJECTIVE To evaluate the factors associated with HIV and syphilis testing during pregnancy in Brazil.METHODS This was an ecological study covering all Brazilian municipalities evaluated by the second cycle of the National Program for Access and Quality Improvement in Primary Care, 2013-2014. The dependent variables were based on prenatal care access: prenatal care appointments, and HIV and syphilis tests during prenatal care. The independent variables were compared with demographic and social characteristics. Bivariate analysis was performed assessing the three outcomes with the independent variables. Variables with significant associations in this bivariate analysis were fit in a Poisson multiple regression analysis with robust variance to obtain adjusted estimates.RESULT Poisson regression analysis showed a statistically significant association with the variables “less than eight years of study” [prevalence ratio (PR) = 1.31; 95%CI 1.19–1.45; p < 0.001] and “participants of the cash transfer program” (PR = 0.80; 95%CI 0.72–0.88; p < 0.001) for the outcome of “having less than six prenatal care appointments” and individual variables. A statistically significant association was found for “participants of the cash transfer program” (PR = 1.43; 95%CI 1.19–1.72; p < 0.001) regarding the outcome from the comparison between HIV testing absence during prenatal care and demographic and social characteristics. The absence of syphilis testing during prenatal care, and demographic and social characteristics presented a statistically significant association for the education level variable “less than eight years of study” (PR =1.75; 95%CI 1.56–1.96; p < 0.001) and “participants of the cash transfer program” (PR = 1.21, 95%CI 1.07–1.36; p < 0.001).CONCLUSIONS The individual factors were associated with prenatal care appointments and HIV and syphilis tests in Brazilian pregnant women. They show missed opportunities for diagnosing HIV and syphilis infection during prenatal care and indicate weaknesses in the quality of maternal health care services to eliminate mother-to-child transmission.

1. Maternal care is a major component of demographic tactics in mammals. In ungulates most work has been done on capital breeders (e.g. bighorn sheep), which rely heavily on body reserves to raise their young. Roe deer, in contrast, are close to the income breeder end of the capital–income breeder continuum, and show high levels of maternal care.2. The aim of this study was to explore the factors determining the level of maternal care in roe deer, in particular the effects of maternal body weight, mother's parity, litter size and year of birth on the amount of prenatal care (i.e. the average mass of an offspring multiplied by the number of offspring) and postnatal care (i.e. the average growth rate of the offspring multiplied by their number). The study was carried out on a captive population of roe deer fedad libitum, and in a wild population.3. In both populations prenatal care increased with increasing maternal body weight. In the population fedad libitumthis effect was found in light females only (&lt; 22 kg); in the wild population the positive relationship between maternal body weight and prenatal care was entirely accounted for by variation in litter size (i.e. heaviest females produced larger litters) and density (i.e. females were lightest in years with high population density). Parity did not affect prenatal care.4. In 14 females fedad libitumthere was no relationship between postnatal care and maternal body weight. Multiparous females had higher levels of postnatal care. In contrast, 20 wild females showed a positive relationship between postnatal care and maternal body weight, and only litter size affected the level of postnatal care.5. Even after accounting for the confounding effects of maternal body weight, parity, litter size and population density, we found no trade‐off between pre‐ and postnatal care in any of the two populations. The conditions under which the pattern of maternal care could impose trade‐offs that affect the individual offspring are discussed.

Getting along.

Introduction: Perinatal depression significantly affects maternal and child health and is often underdiagnosed in primary care. Prenatal and postnatal follow-up is essential for early detection and appropriate intervention (BRASIL, 2022). In the Tocantina Region, understanding this relationship is crucial to promoting comprehensive women's care. Objectives: This study aimed to analyze the importance of prenatal and postnatal follow-up in identifying and preventing postpartum depression (PPD) in women assisted in Primary Health Care in the Tocantina region. Theoretical Framework: The research is based on studies of maternal mental health, highlighting the influence of psychosocial, economic factors, and professional support in the development of PPD. Method: This is a qualitative study involving the analysis of medical records and semi-structured interviews with postpartum women monitored in primary health care units in the Tocantina region. The sample consisted of 101 women in the prenatal and postpartum periods. Results and Discussion: The findings revealed that continuous follow-up during prenatal care and the puerperium enables early detection of depressive symptoms. The absence of qualified listening and a strong bond with the health team emerged as aggravating factors. Women with less social support and economic hardship were the most affected. Strengthening the bond between pregnant women and the health team had a positive impact on PPD prevention. Research Implications: The results reinforce the need to train primary care professionals to address mental health during the pregnancy-puerperal cycle, promoting more effective preventive strategies. Originality/Value: This research contributes to understanding the regional reality of maternal mental health in the Tocantina region and proposes specific actions to enhance prenatal and postnatal care within Primary Health Care.

This research examines individual and area level factors associated with maternal health care utilization in Pakistan. The 2012-2013 Pakistan Demographic and Health Surveys data was used to model five outcomes: prenatal care within the first trimester, four plus prenatal visits, birth attendance by a skilled attendant, birth in a medical facility, and receipt of postnatal care. Less than half of births were to mothers receiving prenatal care in the first trimester, and approximately 57% had trained personnel at delivery. Over half were born to mothers who received postnatal care. Evidence was found to support the positive effect of individual level variables, education and wealth, on the utilization of maternal health care across all five measures. Although, this study did not find unilateral differences between women residing in rural and urban settings, rural women were found to have lower odds of utilizing prenatal services as compared to mothers in urban environments. Additionally, women who cited distance as a barrier, had lower odds of receiving postnatal health care, but still engaged in prenatal services and often had a skilled attendant present at delivery. The odds of utilizing prenatal care increased when women resided in an area where prenatal utilization was high, and this variability was found across measures across provinces. The results found in this paper highlight the uneven progress made around improving prenatal, delivery, and postnatal care in Pakistan; disparities persist which may be attributed to factors both at the individual and community level, but may be addressed through a consorted effort to change national policy around women's health which should include the promotion of evidence based interventions such as incentivizing health care workers, promoting girls' education, and improving transportation options for pregnant women and recent mothers with the intent of ultimately lowering the Maternal Mortality Rate as recommended in the U.N.'s Millennium Development Goal 5.

To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care.

Home visiting is recommended to address maternal and infant health disparities but is underused with mixed impacts on birth outcomes. Community health workers, working with nurses and social workers in a combined model, may be a strategy to reach high-risk individuals, improve care and outcomes, and address inequities. To assess the association of participation in a home visiting program provided by community health workers working with nurses and social workers (Strong Beginnings) with adverse birth outcomes and maternal care vs usual care among birthing individuals with Medicaid. This retrospective, population-based, propensity score matching cohort study used an administrative linked database, including birth records and Medicaid claims, linked to program participation. The Strong Beginnings program exposure took place in 1 county that includes the second largest metropolitan area in Michigan. Study participants included primarily non-Hispanic Black and Hispanic Strong Beginnings participants and all mother-infant dyads with a Medicaid-insured birth in the other Michigan counties (2016 through 2019) as potential matching nonparticipants. The data were analyzed between 2021 and 2023. Participation in Strong Beginnings or usual care. Preterm birth (less than 37 weeks' gestation at birth), very preterm birth (less than 32 weeks' gestation), low birth weight (less than 2500 g at birth), very low birth weight (less than 1500 g), adequate prenatal care, and postnatal care (3 weeks and 60 days). A total of 125 252 linked Medicaid-eligible mother-infant dyads (mean age [SD], 26.6 [5.6] years; 27.1% non-Hispanic Black) were included in the analytical sample (1086 in Strong Beginnings [mean age (SD), 25.5 (5.8) years]; 124 166 in usual prenatal care [mean age (SD), 26.6 (5.5) years]). Of the participants, 144 of 1086 (13.3%) in the SB group and 14 984 of 124 166 (12.1%) in the usual care group had a preterm birth. Compared with usual prenatal care, participation in the Strong Beginnings program was significantly associated with reduced risk of preterm birth (-2.2%; 95% CI, -4.1 to -0.3), very preterm birth (-1.2%; 95% CI, -2.0 to -0.4), very low birth weight (-0.8%; 95% CI, -1.3 to -0.3), and more prevalent adequate prenatal care (3.1%; 95% CI, 0.6-5.6), postpartum care in the first 3 weeks after birth (21%; 95% CI, 8.5-33.5]), and the first 60 days after birth (23.8%; 95% CI, 9.7-37.9]). Participation in a home visiting program provided by community health workers working with nurses and social workers, compared with usual care, was associated with reduced risk for adverse birth outcomes, improved prenatal and postnatal care, and reductions in disparities, among birthing individuals with Medicaid. The risk reductions in adverse birth outcomes were greater among Black individuals.