Prenatal care in the perception of postpartum women from different health services

Abstracts

OBJETIVO: conhecer a percepção de puérperas acerca da assistência pré-natal. MÉTODO: foram entrevistadas em até 48 horas após o parto, 150 puérperas, provenientes de diferentes serviços de saúde que acessaram o Hospital Universitário de Santa Maria/RS, no período de dezembro de 2010 a fevereiro de 2011. RESULTADOS: das 150 puérperas, 91,33% realizaram consultas de pré-natal em algum serviço de saúde do município e 8,67% não realizaram nenhuma consulta. 56,67% das puérperas entrevistadas consideraram que fazer o pré-natal é importante tanto para a mãe quanto para o bebê; quanto à assistência pré-natal realizada no município 84,67% das puérperas julga que não há necessidade de mudanças. CONCLUSÃO: apesar das usuárias considerarem a assistência como adequada, as autoras avaliam que existem carências na atenção pré-natal nos diferentes serviços e que poderiam ser supridas com a realização de um trabalho multiprofissional e interdisciplinar. Nesse sentido, intensificar o processo educativo entre as gestantes pode melhorar a qualidade da atenção, eliminar a falta de realização de pré-natal e diminuir a morbi-mortalidade materno-infantil no município.

Cuidado Pré-Natal; Saúde Materno-Infantil; Educação em Saúde; Pesquisa Interdisciplinar

Prenatal care in the perception of postpartum women from different health services

Marizete Ilha Ceron^I; Ângela Barbieri^II; Letícia Machado Fonseca^III; Elenir Fedosse^IV

^ISpeech Therapist, Doctorate student in Human Communication Disorders by the Federal University of Santa Maria – UFSM, Santa Maria, RS, Brazil; Master of Science in Human Communication Disorders by the Federal University of Santa Maria – UFSM

^IIPsychologist; Graduation in Multiprofessional Residency in Health Care System by the Federal University of Santa Maria – UFSM

^IIIPhysiotherapist; Graduation in Multiprofessional Residency in Health Care System by the Federal University of Santa Maria – UFSM

^IVSpeech Therapist; Professor of the Undergraduation course of Speech Therapy of the Federal University of Santa Maria and of the in Multiprofessional Residency in Health Care System by the Federal University of Santa Maria – UFSM, Santa Maria-RS, Brazil; PhD in Linguistics by the State University of Campinas – UNICAMP

Mailing Address

ABSTRACT

PURPOSE: to know the mothers perception about the prenatal care.

METHOD: there were interviewed within 48 hours after the delivery, 150 postpartum women, from various health services that accessed the Hospital Universitário de Santa Maria / RS, from December 2010 to February 2011.

RESULTS: from the 150 postpartum women, 91,33% attended prenatal consultation in a health system from the town and 8,67% did not attend any consultation. 56,67% of postpartum women considered that prenatal care is important both for the mother and for the baby; regarding prenatal care held in the city, 84.67% of postpartum women judges that there is no need for change.

CONCLUSION:despite of the users consider the assistance appropriate, the authors estimate that there are deficiencies in prenatal care in the different services that could be assisted by conducting a multi-professional and interdisciplinary work. In this sense, intensify the educational process among the pregnant women may improve the care quality, eliminate the lack of prenatal and decrease maternal and infant morbimortality rates in the municipality.

KEYWORDS: Prenatal Care; Maternal and Child Health; Health Education; Interdisciplinary Research

INTRODUCTION

In Brazil, the prenatal care has been a concerning Public Health issue and has been outstanding regarding the care of the mother's and child's health since 2000. This issue has raised important discussions and has led people to seek for solutions for the morbimortality of women and children due to complications from the pregnancy and the birth¹. These complications are among the ten main causes of death of women, and the majority, approximately 92%, could have been avoided by a proper assistance².

In 2005, the maternal mortality rate in Brazil was 74.7/100 thousand children born alive; in 2008, this rate decreased to 68.7/100 thousand. In the southern region of Brazil, in 2005, the rate was 55.1/100 thousand children born alive, which decreased to 54.4/100 thousand in 2008. These maternal mortality rates are considered rather high in comparison to the ones of developed countries, such as the United States of America and Canada, where the rates are below nine deaths per 100 thousand children born alive³.

Another important fact that has to be highlighted is the neonatal mortality rate in Brazil, as it was 8.27 deaths per 1000 births in 2007 and turned to 7.4/1000 in 2010⁴.

Considering this reality, at an attempt reduce this issue, the Department of Health released the National Pact for the Reduction of the Neonatal and Maternal Mortality Rates in 2004. It aims to qualify and humanize the assistance to pregnant women, as well as to reduce the maternal mortality ratio and neonatal mortality rate in 75% until 2015, in order to meet the goals of the Objective of Development of the Millennium, established by the United Nations².

Due to the awareness of the necessity to guarantee prenatal care assistance and to reduce the high maternal and perinatal morbimortality rates, the Department of Health created the Prenatal Care Humanization Program (PHPN/2000) through the Ministerial Order #560 (Portaria/GM nº 569). This Ministerial Order aims to ensure the improvement of the access, coverage and quality of the prenatal care, as well as the assistance during the childbirth and the puerperium (for both the mother and the child), seeking an integrated, qualified and humanizing obstetric assistance. This program establishes some criteria, such as having the first prenatal consultation until the fourth month of the pregnancy, and at least six prenatal consultations and one consultation during the puerperium⁵.

After the implementation of the Prenatal Care Humanization Program, it was possible to observe a dramatic increase on the number of national prenatal consultations⁶. In 2003, there were 8.6 million consultations, whereas in 2009 there were 19.4 million consultations. This represents an increase of 125% in a few years, what can be attributed to the expansion of the access to the prenatal care, what was possible because of the work of Community Health Agents. This program encourages the states and cities towards an early collection, register and complete prenatal monitoring of the pregnant woman⁷.

In Rio Grande do Sul (RS), according to the data from the State Center of Health Surveillance, in 2000 the health care assistance exceeded 50% of pregnant women who were assisted with seven or more consultations during the prenatal period. In 2009, the percentage increased to 71.2%. In the city of Santa Maria/RS, the percentage of pregnant women who had seven or more consultations during the prenatal period was 63.61% for 3218 children born alive in 2009 and 66.80% for 3299 children born alive in 2010⁴.

Promoting the maternal health implies to follow the recommendation about the ideal number and quality of the prenatal consultations, the establishment of a maternal immunization program and the prevention, diagnosis and treatment of the diseases intercurrent to pregnancy⁸. The characteristics of an adequate prenatal care are a welcoming work conduct, no unnecessary interventions, accessibility for the users and support to all levels of attention, promotion and assistance to the health of the pregnant woman and of the newborn⁹.

This research aims to know the perception of the women who have just given birth, from different health services, regarding the prenatal assistance.

METHOD

The research is a cross-sectional study and was developed from December 2010 to February 2011, using a qualitative and quantitative approach. It was held in the maternity ward of the University Hospital of Santa Maria (UHSM), which is a reference for the city and for the region regarding high risk pregnancy. This hospital provides care for parturient women from several cities of the region, attending 260 births per month. However, this article highlights the perception of the users who received prenatal assistance on different health services in Santa Maria/RS.

The data analyzed consider 150 pregnant women who reside in Santa Maria/RS. The following aspects are regarded as the criteria for participating on the research: i) having prenatal care exclusively in Santa Maria; ii) giving birth at the UHSM; iii) having conditions to answer the instrument of data collection.

The postpartum women were invited to participate on the research and were informed about its objectives. In case the mother showed interest in participating, they would read and sign the Term of Informed Consent.

The interviews were made individually, either on the hospital bed or in a reserved room, according to the mother's preference, in a maximum period of 48 hours after the childbirth. The interview would last 25 minutes in average and the interviewer would not manifest any kind of personal point of view.

Each interview started with questions about whether the prenatal care was taken or not. In affirmative cases, the mothers would answer the following questions: 1) "How many prenatal care consultations have you had?" 2) "Where have you had these consultations?" 3) "Why was it important for you to have the prenatal care assistance?" 4) "Which were the subjects approached during the prenatal care?" 5) "Which subjects do you think should have been approached during the prenatal care?" 6) "What would you change in the prenatal consultations?" 7) "Which professionals attended you or were necessary for you during the prenatal care?" The following questions were answered by mothers who have not had any prenatal care: 1) "Why have not you done the prenatal care?" 2) "Do you think that not having done the prenatal care may have affected your pregnancy or your baby in any manner?".

The collection of data was concluded when the answers began to be considered repetitive, not adding significant information to the objectives of the research.

The prenatal care in Santa Maria is done in Public Units of Health – Family Health Strategy (Estratégias de Saúde da Família – ESF) or Basic Unit of Health (Unidade Básica de Saúde – UBS), in private doctors' offices and also at UHSM in case of high risk pregnancies, that is, the treatment of pregnant women who present some kinds of previous health complications or health complications due to the pregnancy. In fact, for a better understanding and discussion of the results, they have been divided according to the prenatal care location.

This research has been approved by the Research Ethics Committee (REC) under Certificate of Presentation for Ethical Appreciation number 0309.0.243.000-10.

In order to have knowledge about the perception of the postpartum women regarding the prenatal care, the answers to the questions have been organized in tables and, afterwards, have been analyzed qualitative and quantitatively. The quantitative criteria have been analyzed according to the frequency of the answers obtained to each questions, while the qualitative criteria have analyzed the answers which indicate the quality of the prenatal care.

RESULTS

Table 1 shows the total number of realized and not realized prenatal consultations in the different services of health assistance.

It is possible to observe that among the 150 women who had just given birth who have been interviewed, 137 (91.33%) have realized prenatal consultation in some health service (Hospital, Basic Assistance, Private Doctor's Office) and 13 (8.67%) have not realized any consultation. Among the mothers who have not done the prenatal care, 27 (18%) have sought a hospital; 92 (61.33%) have sought a Basic Unit of Health, 29 (31.52%) a Family Health Strategy and 18 (12%) have done the prenatal care at a private doctor's office.

This table also highlights that 36 (24%) of the mothers have not had sufficient consultations (1 to 5 consultations), and the majority was from the Basic Health Assistance (28 mothers = 30.43%). Among the 18 mothers who have done the prenatal care at private doctors' offices, only one (5.66%) has not realized the number of consultations that is considered effective. Regarding the hospital, seven mothers (25.92%) have attended less than six consultations. This inferior rate of mothers who have gone to few prenatal consultations at the hospital can be attributed to the fact that it is characterized by assisting high risk prenatal care and, consequently, some pregnant women have more consultations according to their necessities.

Table 2 presents the answers given by the mothers in relation to the importance of realizing the prenatal consultations.

It is possible to verify that the majority of the mothers – not only the ones who have realized the consultations (56.20%,) but also the ones who have not (61.54%) – considered that doing the prenatal care would be important for the care of the binomial mother and baby. Another significant segment of the total sample (34%) reported that the prenatal care was important only for the health of the baby. An interesting fact was that two mothers stated that they considered the prenatal care important, but not in the manner it had been done. Another woman reported that, although she had had the prenatal care, she did not know the reason why it was necessary.

Moreover, the mothers have also been questioned about the issues that were approached during the prenatal care, as well as which issues they wish had been approached. Table 3 presents the relation of the issues that have been discussed during the prenatal care and the ones which the mothers wish they had discussed.

It was noticeable that a great percentage of pregnant women (70%) have done basic consultations, followed by requests of medical examinations, not depending on the service in which the prenatal care was realized. The mothers who had the opportunity to receive information, that is, who experienced the action of health promotion, report the breast-feeding period and the necessity of healthy habits and alimentation as the most frequent subjects during the prenatal care.

Having that considered, the mothers have also been asked about what could be changed during the prenatal care. Table 4 shows the answers obtained.

As it is possible to observe, 84.67% of the pregnant women do not consider that the prenatal care needs any change, such as, for example, providing information/ orientation regarding the motherhood feelings, routine care, continuity and quality of the assistance.

On table 5, there are the professional cores which assisted the mothers on the different services in which they have received the prenatal care.

It is possible to observe that the prenatal is generally realized only by the doctor (62.04%). The users who have received the prenatal care at the hospital were the ones who related that there were different professional cores, and only five (5) users reported that they had been attended only by doctors. Such condition can be justified by the fact that there is a Group of Multiprofessional Assistance to the Expecting Woman, always before the consultations, which aims to follow the pregnant woman during the prenatal care.

DISCUSSION

The prenatal care, still nowadays, has been subject of many researches^1,8,10-20 due to its importance for the health of the postpartum woman and of the newborn, since its objective is to diminish the maternal mortality ratio and the infant mortality rate. The prenatal care has become a routine precaution to pregnant women in developed countries and it has become more and more frequent in developing countries²⁰.

Some researches^1,18 report that, in order to be effective, the assistance has to comprise promotion, prevention, diagnosis and adequate treatment for the problems that may emerge during the pregnancy. Thus, the recommendation that the prenatal care begins as soon as pregnancy is diagnosed aims to reinforce the adherence of the mothers to the prenatal care and to diagnose potential risk factors¹¹.

Considering the facts mentioned above, it is possible to highlight that the majority of the mothers (137) from this study has had prenatal consultations: 27 (18%) sought the hospital; 92 (61.33%) the Basic Health Assistance; and 18 (12%) private doctor's offices. Similar results are pointed in a study¹⁴ from São Luiz/MA in which the Health Care System (HCS) was in charge of 84.2% of the health care. Only 3.8% of the health care was private and 12% was through health insurance companies.

Among the users who had the childbirth at UHSM, the majority was from the Basic Health Assistance located close to their residences. A study¹⁵ points that the access shows as a fundamental aspect to be considered as a strategy to qualify the prenatal care assistance. Another study¹⁶ shows that the accessibility, while component of the prenatal assistance, results from factors of diverse dimensions, classified as geographical, organizational, socio-cultural and economical.

Not considering the location where the mother has had their prenatal consultations, 101 (67.33%) users have had six or more consultations, condition considered satisfactory for the Brazilian population. The lack of egalitarianism regarding health in Brazil presents, among the indicators of quality selected, the percentage of women who have received at least six prenatal consultations¹⁵.

Some authors¹⁰, in research about the prenatal assistance among the users of HCS in Caxias do Sul/RS, report that the average number of consultations was 6.2 (SD=5,3), and 90.3% (n=605) of the researched users confirm that they have undergone six or more consultations during their pregnancy. On the other hand, another study¹⁴ reveals alarming results, as it identifies factors associated to the lack of adequacy concerning the use of the prenatal assistance in São Luiz/MA. These authors point that only 49.5% of the mothers have had an appropriate prenatal care, that is, a prenatal care which begins until the fourth month, with a minimum of six consultations for a healthy pregnancy.

Among the users of the research who have not done the prenatal care, the motives were: rebooking of the consultations without previous notice from the professional of the service (7.7%); not being able to leave their jobs for the consultations (15.38%); not wanting to do the prenatal care (30.76%); not knowing that they were pregnant (46.15%). A study¹⁰ about the profile of the prenatal assistance identified that 4.6% (n=32) of the women denied having received any kind of medical assistance during the pregnancy. It is possible to observe that this data is also present in this study in a significant percentage (30.76%).

Another question, which was only asked to the postpartum women who have not done the prenatal care, was whether not having done the prenatal care had caused any damage for the pregnancy or the baby. Among the 13 mothers who have not done the prenatal care, only 4 (30.77%) reported that there was damage, justifying that they may have not had a preterm birth had they attended the prenatal assistance.

It is known that the preterm birth is not a condition which puts the health of the infant at risk. As a cause of infant mortality, it has been studied in several countries^17,21-23 and the lack of prenatal assistance is associated to a superior perinatal mortality rate¹⁰. In Brazil, the greatest causes of infant mortality are the perinatal conditions, associated to preterm birth in most cases. These rates are superior in the North and Northeast regions of Brazil, and inferior in the South and Southeast regions¹⁷. In Portugal, the preterm births have been the cause of 73% of the neonatal mortality in 2005, and most of the mortality corresponds to the newborn with gestational age inferior to 32 weeks and/or weighing less than 1500g²¹.

Researches^10,24 about the prenatal care indicate that the quality of the assistance represents a significant issue, since it is a permanent issue of concern and discussion by health professionals. A qualified prenatal care comprises an integral reception to the needs of the pregnant woman, that is, the realization of medical and/or nursing consultations in order to follow the organic/physiological aspects of the pregnancy. In addition, it is also important to have discussions/conversations regarding the psycho-affective changes that occur during the pregnancy, the birth, the perperium, healthy alimentation, changes in the routine due to the arrival of the newborn and also the role of the woman on the process of development of the infant.

Some authors^10,11 utilize the beginning date of the prenatal and also the number of consultations as indicators for the assessment of the prenatal care. Nevertheless, information regarding the participants approached during the prenatal, its continuity and the quality of the assistance is not provided, what is considered important¹⁴ by the literature.

Thus, the postpartum women from this study have been questioned not only about the subjects approached during the prenatal care, but also about the ones that should have been approached according to their point of view. On the study, it was observed that little importance was given to the promotion of health, assertion that can be confirmed by the fact that 91.79% of the mothers have not mentioned any subject to be approached during the prenatal care. Such finding refers to the importance for health professionals to consolidate educational activities during the prenatal care, as recommended by the Health Department⁷.

The actions for orientation regarding the breastfeeding and/or the realization of breast examinations during the prenatal consultations seem to have been consolidated, as it was demonstrated by a research¹⁰, which demonstrated that the rates of these actions reached 74% of the routine during the prenatal care. The same research pointed that 86.1% of the patients interviewed confirmed to have received some orientation in regards to the childbirth and to the situations that could be faced during the pregnancy. These orientation actions should motivate the pregnant woman to seek the nearest hospital. However, the reception of other pieces of educative information was denied by 57% of the pregnant women interviewed.

Another study¹³ about the importance of the prenatal care demonstrates that, even though the pregnant women have had the consultations, they confirm their lack of satisfaction with the orientation about the birth, the puerperium and the care with the newborn. They considered it important to have more information about health promotion during the pregnancy, either in groups or individually²⁰. This dissatisfaction concerning the orientation provided can explain the fact that one of the mothers of this study did not know the reasons why she had done the prenatal care.

In regards to the subjects which the mothers would like to have been approached during the prenatal care, it is possible to verify that the majority (91.79%) does not mention the necessity of any subject besides the ones which have already been approached during the prenatal care. For the users who have done the prenatal care at the hospital, 100% does not feel the necessity to discuss any other issue, perhaps due to the fact that the prenatal care is not performed by a multiprofessional group (Physician, Social Worker, Nurse, Physioterapist, Speech Therapist, Nutritionist, Psychologist) at the hospital. This multiprofessional and interdisciplinary work was initiated by specialists of the Integrated Multiprofessional Residence Program, which began in the second semester of 2009. Before the multiprofessional residence, the prenatal care used to comprise only medical and nursing assistance. The interdisciplinary attendance approaches several subjects such as breatfeeding, birth, after childbirth, as well as subjects brought up by the pregnant women. This way, they have the opportunity to clear up doubts and share experiences, as long as each woman can participate on more than one meeting of the group.

For this interdisciplinary attendance to occur, it is necessary to perceive that several professionals work in the health field and that the health field is not private to only one professional. It is important to highlight that taking care of people consists of a space for hearing, reception, dialog and an ethical and dialogical relation among the actors involved in the production of care²⁵. Authors²⁶ reinforce that the professionals need an integrated and shared know-how in order to act in the health practices in the field of integral assistance. The teamwork favors the emphasis on the actions of health education as an instrument of care.

The prenatal assistance should not focus only on the medical aspects¹³. According to these authors' reckoning, it is fundamental to organize the assistance from social and environmental necessities and circumstances of the pregnant women. Therefore, health professionals need to be prepared to listen to complaints and clear up doubts from the pregnant women and, thus, get the women to participate and provide an opportunity for them to learn about health education.

In addition, the health care is not efficient in a fragmented action, in which the questionings from users are not valued on the perspective of the actions of health education²⁷.

Consequently, another question asked to the mothers was about what could be changed on the prenatal care, and many of them considered that there were not necessary changes to be made. Such perception was also confirmed in a study²⁸ that assessed the knowledge of the pregnant women of a low socio-economic level about the prenatal care. It was identified little knowledge regarding the examinations and procedures to be undergone by them. This fact is intensified when the equality existing on the prenatal care offered by the health services is analyzed.

On a research²⁸, the findings evidenced the necessity to intensify the educational process among the pregnant women, permitting that the knowledge about the prenatal assistance becomes more adequate and widely known. According to this study, the educational actions would lower the asymmetry on the relation between the pregnant woman and the health service and improve the quality of the assistance, causing a consequent impact on the maternal and infant morbimortality rates, especially during the perinatal period.

This study reveals that the pregnant women from the basic assistance units perceive the lack of elucidation during the prenatal care, whereas the women who have done the prenatal care at the hospital relate enough clarifications. Such difference may be explained by the fact that the prenatal care of the hospital comprises a multiprofessional and interdisciplinary staff (which favors a significant exchange among the professionals and the future mothers). In spite of that, the prenatal care of the majority of women from the Basic Health Units or Family Health Strategies of the city has counted with the doctor only (who tends to draw his attention towards the physical/organic aspects, due to the traditional formation and routine, as well as to the demand of the users of clinic-biological services). It is relevant to mention that during this research the Basic Assistance of the city was in a precarious situation of minimal professional staff, and it was even worse for the specialist staff (it still does not possess a Family Health Assistance Center – FHAC).

That finding demonstrates the necessity to complete the minimal professional staff. In addition, it is convenient to expand the staff with specialized health professionals, what would certainly improve the assistance to the pregnant women, since the different types of knowledge complement themselves on the health assistance. Despite the fact that almost 90% of the women do the prenatal care with formally qualified health professionals, nurses and doctors, and that the average number of consultations on the HCS is above four consultations per women¹⁵, it is known that the prenatal and puerperal care should be done by a multiprofessional and interdisciplinary health team¹, what contributes to put one of the principles of the HCS into practice: the integrality of the assistance.

It is fundamental to highlight the role of the different health professionals (Speech Therapists, Psychologists, Occupational Therapists, Physiotherapists, Nutritionists, Physical Educators, Social Workers, among others) on the basic assistance, maximized, for example, by the FHACs²⁹. It is known that the integrality of the care can be obtained through focal actions established from the local necessities, using the interdisciplinary and intersetorial resources available. Based on the articulation of these factors it is possible to achieve popular education, social control, that is, the promotion and humanization of the health care²⁹. The formation of the professionals of health previously indicated, naturally educational and therapeutic, enables the group work and, consequently, the change in attitude of its participants. Such professionals, as well as the doctors, nurses and community agents, can focus on the multiple aspects that constitute the pregnancy and the puerperium. This means that it is possible to approach the breastfeeding, for example, focusing on the medicine, the psychology, the speech therapy, the occupational therapy and the popular knowledge, producing information that makes the mother choose to breastfeed the baby or not.

Therefore, educational actions on the care process can be developed in a context in which several professional are inserted, that is, the interdisciplinary articulation may provide a superior quality of health assistance¹. The necessity for a welcoming and differentiated care is evident on the processes of health education; the professionals find a more integrative assistance on the health education (besides the conventional clinic)³⁰.

It is noticeable that, since the implementation of the HCS, and especially after the Program for Humanization of Prenatal and Childbirth Care (PHPN), the Expanded Clinic is regarded as an instrument to achieve the expected quality in health services, as it proposes a revision on the structure of the practices of health production to beyond the expressions of the illnesses, the realization of diagnoses, the medicine prescription and the doctor-centered model. The Expanded Clinic discusses the fragmentation of the processes of work, resulting from traditional models of clinic management in public services, and proposes the incorporation of new technologies, knowledge and practices³¹.

Therefore, it is challenging to promote a formation which endeavors creative postures regarding the building of knowledge on health care, in which the professionals expand their conceptions, understanding the dimension of the necessities of the people. Additionally, it is important to transform the health assistance in an expanded care, focusing on education actions as intrinsic to the professional practices³². It is relevant to disrupt with view of the body based on welfare and mechanism, as well as to include the dialog and the socialization of knowledge and practices among professionals and users as potential alternatives¹³.

CONCLUSIONS

Based on the perception of the postpartum women, who were prevenient from different health services, concerning the prenatal care, it was possible to verify some insufficiencies on the prenatal assistance, such as the fact that some pregnant women have not done the prenatal care; others have not had the minimum number of prenatal consultations; the lack of educational practices among the women, aiming to give support on the pregnancy, the childbirth and the puerperium; the lack of knowledge about the importance of the prenatal care.

These data point towards the necessity to intensify the educational process among the pregnant women, disregarded of the social, economic or cultural level, thus, enhancing the quality of the assistance and diminishing the maternal and infant morbimortality in Brazil.

The data observed, it is believed, will also contribute to future discussions and adaptations of the prenatal services, reflecting in concrete improvements on the actions from the perspective of welfare and education. In addition to that, the participation and opinion of the mothers on this process enriches the analysis of what needs to be improved in the quality of the services and of the professional practice.

REFERENCES

20 Wu Z, Viisainen K, Wang Y, Hemminki E. Evaluation of a community-based randomized controlled prenatal care trial in rural China. BMC Healt Serv Res. 2011;11:92.

• 1. Figueiredo PP, Rossoni E. O acesso à assistência pré-natal na Atenção Básica à Saúde sob a ótica das gestantes. Rev Gaúcha Enferm. 2008; 29(2):238-45.
• ²
  Brasil. Ministério da Saúde. Seminário de Avaliação Final – Mortalidade Materna e Morbimortalidade Neonatal. [acessado 2011 jun 25] Disponível em: http://bvsms.saude.gov.br/bvs/periodicos/boletim_mortalidade_materna.pdf
• 3. Ministério da Saúde. Indicadores da mortalidade [acessado em 2011 set 07] Disponível em: http://tabnet.datasus.gov.br/cgi/idb2009/C03b.htm
• ⁴
  CEVS – Centro Estadual de Vigilância em Saúde [acessado 2011 mai 26]. Disponível em: http://www.saude.rs.gov.br/wsa/portal/index.jsp?menu=organograma&cod=746
• 5. Brasil. Ministério da Saúde. Secretaria de Políticas de Saúde. Programa de Humanização no Pré-natal e Nascimento (PHPN). Brasília: Ministério da saúde; 2000.
• 6. Brasil. Ministério da Saúde. [acessado 2011 mar 20]. Disponível em: http://portal.saude.gov.br/portal/saude/visualizar_texto.cfm?idtxt=33959&janela=1
• 7. Brasil. Ministério da Saúde. [acessado 2011 mar 20]. Assistência Pré-Natal: normas e manuais técnicos. 3. ed. Brasília: Secretaria de Políticas de Saúde, 2000b.
• 8. Calderon IMP, Cecatti JG, Vega CEP. Intervenções benéficas no pré-natal para prevenção da mortalidade materna. Rev Bras Ginecol Obstet. 2006; 28(5): 310-5.
• ⁹
  Brasil. Ministério da Saúde. Acolhimento nas práticas de produção de saúde. 2. ed. Brasília: Secretaria de Atenção à Saúde. Núcleo Técnico da Política Nacional de Humanização, 2006.
• 10. Trevisan MR, De Lorenzi DRS, Araújo NM, Ésber k. Perfil da Assistência Pré-Natal entre Usuárias do Sistema Único de Saúde em Caxias do Sul. Rev Bras Ginecol Obstet. 2002; 25(5):293-9.
• 11. Serruya SJ, Lago TG, Cecatti JG. O panorama da atenção pré-natal no Brasil e o Programa de Humanização do Pré-Natal e Nascimento. Rev Bras Saúde Matern Infant. 2004a; 4 (3): 269-79.
• 12. Xiaoning L, Zhoua X, Yana H, Wangc D. Use of maternal healthcare services in 10 province of rural western China. Int J Gynaecol Obstet. 2011;114(3):260-4.
• 13. Rios CTF, Vieira NFC. Ações educativas no pré-natal: reflexão sobre a consulta de enfermagem como um espaço para educação em saúde. Cien Saude Colet. 2007; 12(2):477-86.
• 14. Coimbra LC, Silva AAM, Mochel EG, Alves MTSSB, Riveiro VS, Aragão VMF, Bettiol, H. Fatores associados à inadequação do pré-natal. Rev Saúde Pública. 2003; 37(4):456-62.
• 15. Serruya, SJ, Lago TG, Cecatti JG. O Programa de Humanização no Pré-natal e Nascimento do Ministério da Saúde no Brasil: resultados iniciais. Cad Saúde Pública. 2004b; 20(5):1281-9.
• 16. Nagahama EEI, Santiago SM. O cuidado pré-natal em hospital universitário: uma avaliação de processo. Cad Saúde Pública. 2006; 22(1):173-9.
• 17. Silveira, MF, Santos IS, Barros AJD, Matijasevich A, Barros FC, Victora CG. O aumento da prematuridade no Brasil: revisão de estudos de base populacional. Rev Saúde Pública. 2008; 42(5):957-64.
• 18. Reis DM, Pitta DR, Ferreira HMB, Jesus MCP et al. Educação em Saúde como estratégia de promoção de saúde bucal em gestantes. Cien Saude Colet. 2010; 15(1):269-76.
• 19. Van Dijk JAW, Anderko L, Stetzer F. The impact of prenatal care coordination on birth outcomes. J Obstetric Gynecol Neonatal Nur. 2011; 40(1):98-108.
• 21. Sem autor. Nascer prematuro em Portugal. [acessado 2011 out 01]. Disponível em: www.lusoneonatologia.net/.../d5be427979a647e615755a1d04f4fa13
• 22. Moreira L, Casqueiro J, Jesuíno F, Ada LF. Recém-nascido de baixo peso: percentual de prematuridade e de restrição de crescimento intra-uterino em duas maternidades de Salvador: Maternidade Climatério de Oliveira e Hospital Santa Amaro. Gaz Méd Bahia. 2007;77(1):S93-S7. Disponível em http://www.gmbahia.ufba.br/index.php/gmbahia/article/viewFile/294/284
• 23. Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejp JH et al. The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bull World Health Organ. 2010;88:31-8. Disponível em: http://www.who.int/bulletin/volumes/88/1/08-062554.pdf
• 24. Silveira DS, Santos IS, Costa JSD. Atenção pré-natal na rede básica: uma avaliação da estrutura e do processo. Cad Saúde Pública. 2001; 17:131-9.
• 25. Lima Júnior J, Maia EMC, Alchieri JC. Avaliação de serviços hospitalares na perspectiva dos profissionais de saúde. Rev Gaúcha Enferm. 2008; 29(4):525-35.
• 26. Matos E, Pires DEP. Práticas de cuidado na perspectiva interdisciplinar: um caminho promissor. Texto Contexto Enferm. 2009; 18(2):338-46.
• 27. Costa RKS, Enders BC, Menezes RMP. Trabalho em equipe de saúde: uma análise contextual. Cienc Cuid Saude. 2008; 7(4):530-6
• 28. Mendoza-Sassi RA, Cesar JA, Ulmi EF, Mano OS, Agnol MMD, Neumann NA. Avaliando o conhecimento sobre pré-natal e situações de risco à gravidez entre gestantes residentes na periferia da cidade de Rio Grande, Rio Grande do Sul, Brasil. Cad Saúde Pública. 2007; 23(9):2157-66.
• 29. Departamento de Atenção Básica. Núcleo de Apoio à Saúde da Família – NASF. [acessado 2012 jan 03]. Disponível em: http://dab.saude.gov.br/nasf.php
• 30. Machado MFAS, Monteiro EMLM, Queiroz DT, Vieira NFC, Barroso MGT. Integralidade, formação de saúde, educação em saúde e as propostas do SUS uma revisão conceitual. Cien Saude Colet. 2007; 12(2):335-42.
• 31. Moreira MCN. A construção da clínica ampliada na atenção básica. Cad. Saúde Pública [online]. 2007;23(7): 1737-9.
• 32. Ceccim RB, Ferla AA. Educação e saúde: ensino e cidadania como travessia de fronteiras. Trab Educ Saúde. 2009; 6(3):443-56.

Publication Dates

• Publication in this collection
  18 Sept 2012
• Date of issue
  June 2013

History

• Received
  16 Oct 2011
• Accepted
  09 Jan 2012