Assessment of the completeness of the pregnant woman’s bookletABSTRACT
Objective: To evaluate the quality of the Records in the Pregnant Woman’s Booklet in Boa Vista- Roraima, with an emphasis on the legibility and completeness of prenatal information.
Method: Cross-sectional descriptive study, with a quantitative and evaluative approach, conducted in a maternal and child hospital in the municipality of Boa Vista, Roraima, between November and December 2024. 71 Pregnant Woman’s Booklets were evaluated based on legibility and completeness parameters. The data were entered and analyzed in Microsoft Excel, with double-checking for correction of inconsistencies, and the overall completeness of each booklet was obtained by the simple arithmetic mean of the filling proportions of the sections, applying proportional weighting to the number of variables when necessary.
Results: All booklets had legible records. Regarding completeness, 7.04% were classified as very poor filling, 81.06% as poor, and 11.26% as fair, with none considered good or excellent. The Routine Complementary Exams section achieved the best results, while Complementary Activities showed the worst rates.
Conclusion: Most records were found to be unsatisfactory, revealing low appreciation for the Pregnant Woman’s Booklet and suggesting non-compliance with filling guidelines.
DESCRIPTORS:
Immunization Programs; Health Records, Personal; Pregnancy; Prenatal Care; Health Evaluation
HIGHLIGHTS
1. No booklet was classified with a good or excellent record.
2. Significant fragility in the use of the booklet during prenatal care.
3. 100% of the booklets were considered to have legible records.
4. The Routine Complementary Exams section showed the best results.
RESUMO
Objetivo: Avaliar a qualidade dos registros na Caderneta da Gestante em Boa Vista-Roraima, com ênfase na legibilidade e completude das informações do pré-natal.
Método: Estudo descritivo transversal, de abordagem quantitativa e avaliativa, realizado em um hospital materno-infantil, no município de Boa Vista, Roraima, entre novembro e dezembro de 2024. Foram avaliadas 71 Cadernetas da Gestante pelos parâmetros de legibilidade e completude. Os dados foram digitados e analisados no Microsoft Excel, com dupla conferência para correção de inconsistências, e a completude geral de cada caderneta foi obtida pela média aritmética simples das proporções de preenchimento das seções, aplicando-se ponderação proporcional ao número de variáveis quando necessário.
Resultados: Todas as cadernetas apresentaram registros legíveis. Quanto à completude, 7,04% foram classificadas como de preenchimento muito ruim, 81,06% como ruim e 11,26% como regular, não havendo nenhuma considerada boa ou excelente. A seção Exames Complementares de Rotina obteve os melhores resultados, enquanto Atividades Complementares apresentou os piores índices.
Conclusão: A maioria dos registros mostrou-se insatisfatória, revelando baixa valorização da Caderneta da Gestante e sugerindo descumprimento das orientações de preenchimento.
DESCRITORES:
Programas de Imunização; Registros de Saúde Pessoal; Gravidez; Cuidado Pré-Natal; Avaliação em Saúde
HIGHLIGHTS
1. Nenhuma caderneta foi classificada com registro bom ou excelente.
2. Significativa fragilidade na utilização da caderneta no pré-natal.
3. 100% das cadernetas foram consideradas com registros legíveis.
4. Seção de Exames Complementares de Rotina apresentou os melhores resultados.
RESUMEN
Objetivo: Evaluar la calidad de los Registros en la Libreta de la Gestante en Boa Vista-Roraima, con énfasis en la legibilidad y completitud de la información del prenatal.
Método: Estudio descriptivo transversal, de enfoque cuantitativo y evaluativo, realizado en un hospital materno-infantil, en el municipio de Boa Vista, Roraima, entre noviembre y diciembre de 2024. Se evaluaron 71 Libretas de la Gestante por los parámetros de legibilidad y completitud. Los datos fueron digitados y analizados en Microsoft Excel, con doble verificación para corrección de inconsistencias, y la completitud general de cada libreta fue obtenida por la media aritmética simple de las proporciones de llenado de las secciones, aplicando ponderación proporcional al número de variables cuando fue necesario.
Resultados: Todas las libretas presentaron registros legibles. En cuanto a la completitud, 7,04% fueron clasificadas como de llenado muy malo, 81,06% como malo y 11,26% como regular, no habiendo ninguna considerada buena o excelente. La sección Exámenes Complementarios de Rutina obtuvo los mejores resultados, mientras que Actividades Complementarias presentó los peores índices.
Conclusión: La mayoría de los registros resultaron insatisfactorios, revelando baja valoración de la Libreta de la Gestante y sugiriendo incumplimiento de las orientaciones de llenado.
DESCRIPTORES:
Programas de Inmunización; Registros de Salud Personal; Embarazo; Atención Prenatal; Evaluación en Salud
HIGHLIGHTS
1. Ninguna libreta fue clasificada con registro bueno o excelente.
2. Significativa fragilidad en la utilización de la libreta en el prenatal.
3. 100% de las libretas fueron consideradas con registros legibles.
4. La sección de Exámenes Complementarios de Rutina presentó los mejores resultados.
INTRODUCTION
Prenatal care comprises a set of actions directed at the care of women during pregnancy and the postpartum period, as well as the protection of fetal health. Its purpose is to early identify risk factors, prevent complications, and contribute to the reduction of maternal and infant morbidity and mortality1. To ensure continuous and integrated monitoring among different levels of care, the Pregnant Woman’s Booklet is a fundamental tool1.
Created in Brazil in 1988, initially under the name of Pregnancy Card, this tool was designed to ensure the flow of information between prenatal professionals and those responsible for childbirth assistance2. Since then, it has consolidated as a strategic resource in the public network, strengthening communication between primary care and hospital services, especially in obstetric emergency situations3.
In addition to favoring the integration of care, the notebook provides the pregnant woman access to information about her health and the procedures performed4. When properly filled out, it allows for the monitoring of clinical parameters - such as weight, blood pressure, uterine height, and laboratory tests - helps in monitoring the evolution of pregnancy, guides the definition of conduct for childbirth and postpartum, and feeds information systems, such as the Live Birth Information System (SINASC), essential for epidemiological research and the formulation of public policies4.
The quality of the record in this instrument depends on both legibility and completeness, as recommended by the Ministry of Health3. Incomplete or gapfilled records can compromise the continuity of care and indicate failures in valuing the notebook or in complying with offcial guidelines3,5. Although its distribution is widespread, studies show that, even with high coverage, the filling out still presents deficiencies, often being incomplete or difficult to interpret 3,5.
The literature indicates that the scarcity of information in this document negatively impacts gestational outcomes and the quality-of-care provided6. It is therefore essential that health professionals make proper use of the notebook, recording consistent data that allow for reliable monitoring of maternal condition and providing effective care3. Thus, all professionals involved in the care process have access to the necessary information, which facilitates communication and coordination of care5.
Despite the widespread distribution, challenges related to the quality and completeness of filling out still persist 3,6. Even with over 90% coverage among pregnant women in Brazil, the records remain, for the most part, incomplete or illegible3.
Thus, quality prenatal care depends not only on the performance of consultations but also on the proper documentation of the conducts and requested exams6. The notebook, together with the clinical record, constitutes an essential tool for planning care, ensuring continuity of care at all stages of pregnancy 2,5,7.
Located in the northern region of Brazil, the state of Roraima borders Guyana and Venezuela, configuring itself as an important migratory route. The increase in demand for services in the SUS, especially in maternal and child health, has generated challenges for management and the quality of care. In this context, the Pregnant Woman’s Booklet stands out as an essential tool to ensure continuity of care and the effectiveness of prenatal monitoring.
The latest census from the Brazilian Institute of Geography and Statistics (IBGE) indicated that Boa Vista recorded a population increase of over 14% in recent years. In this context, Primary Care has been consolidating as the main access point to health in the municipality. The municipal network is organized into eight health macro-areas, covering the entire urban territory, and has 149 Family Health Strategy (ESF) teams distributed across 38 Basic Health Units (UBS), responsible for resolving about 80% of cases directly within primary care.
Given this scenario, the present study aims to evaluate the quality of records in the Pregnant Woman’s Booklet in the municipality of Boa Vista-RR, with an emphasis on the legibility and completeness of information regarding prenatal monitoring.
METHOD
This is a descriptive, cross-sectional study with a quantitative and evaluative approach, conducted at the Maternal and Child Hospital Nossa Senhora de Nazaré (HMINSN), located in Boa Vista, Roraima, between November and December 2024.
HMINSN is a state reference in maternal and child care, providing obstetric and neonatal assistance. According to the Health Department of Roraima (SESAU/RR), the unit performs an average of between 9,000 and 10,000 births per year. Due to its location in a border region with Venezuela and Guyana, marked by the presence of indigenous peoples and a high migratory flow, the hospital serves a diverse population of pregnant women, establishing itself as the main obstetric reference center in the state.
The sample was non-probabilistic, by convenience, composed of 71 women who met the following inclusion criteria: pregnant women from the 30th week or postpartum women, over 18 years old, not belonging to vulnerable groups, with communication capacity, who had attended at least three prenatal consultations in Boa Vista-RR and presented the Pregnant Woman’s Booklet at the time of data collection.
Eligible participants were informed about the objectives and procedures of the study and invited to participate. Those who agreed to participate in the study signed the Informed Consent Form and handed over the notebook for evaluation. Each participant was approached only once, and the name was recorded in a checklist to avoid duplications. The collection team was composed of two undergraduate students from the Dentistry course, previously trained through theoretical-practical training conducted by the responsible researcher.
The collection used a structured instrument in the form of checklist, based on the current model of the Pregnant Woman’s Booklet standardized by the Ministry of Health8. Each field was classified as “yes” (fully filled), “no” (absent) or “partial” (incomplete). The record was considered complete when all mandatory fields were filled in legibly, without erasures or abbreviations; partial when it had incomplete, illegible, or ambiguous fields; and unfilled when the information was absent.
The analysis was based on the framework of information quality in health, as described in the literature9,10, which defines completeness as the proportion of fields properly filled, without null or ignored values. Seven sections of the notebook were evaluated: Identification; Risk Classification of Pregnancy; Monitoring Charts and Vitamin Supplementation; Gyneco-Obstetric Procedures; Complementary Exams; Immunization and Complementary Activities.
The data was entered and analyzed in Microsoft Excel, with double-checking to correct inconsistencies. The overall completeness of each booklet was obtained by the simple arithmetic mean of the filling proportions of the sections, applying proportional weighting to the number of variables when necessary. The degree of completeness was classified according to literature10 as: excellent (<5% incompleteness), good (5–10%), fair (10–20%), poor (20–50%), and very poor (>50%).
The results were expressed in absolute and relative frequencies, organized by section and quality category, which allowed for the identification of general completeness patterns. Only a general description of the filling percentages was made. In the table, the “Yes” column indicates the items properly recorded, while the “No” column corresponds to the missing or unfilled fields.
The study adhered to the ethical principles of Resolutions No. 466/2012, No. 510/2016, and No. 580/2018 of the National Health Council, being approved by the Ethics Committee in Research with Human Beings of Cathedral College, opinion No. 7.064.588.
RESULTS
It was found that 100% of the analyzed booklets had legible records. In the Identification section, completeness varied from 2.81% (very poor), regarding the number of the Monitoring System of the Humanization Program in Prenatal and Birth of Pregnant Women (Sisprenatal), to 98.59% (excellent), corresponding to the field “name”. A predominance of items with records classified as poor or very poor was observed (Table 1).
Completeness of identification records in the Pregnant Women’s Booklets. Boa Vista, RR, Brazil, 2024
In the Gestational Risk Classification section, the section intended for recording variables associated with gestational risk classification, significant proportions of incompleteness were observed, with instruction (50.70%), type of pregnancy (66.19%), and planned pregnancy (54.92%) classified as poor performance. The field related to risk classification showed the lowest completion (45.07%), being classified as very poor, while biometric and historical information - such as previous weight (88.73%) and number of pregnancies (87.32%) - achieved better performance (Table 2).
Completeness of gestational risk classification records in the pregnant women’s notebooks. Boa Vista, RR, Brazil, 2024
The records from the Gyneco-Obstetric Procedures section mostly showed completeness classified between good and excellent, with a variation from 83.09% to 95.77%. The field “weight” showed the best performance (95.77%), followed by gestational age, blood pressure, fetal heartbeats, and movements (92.95%), all classified as good. The fields related to the complaint, body mass index, and edema showed the lowest completion percentages (83.09%), being classified as fair (Table 3).
Completeness of records of gynecological-obstetric procedures in the pregnant women’s notebooks. Boa Vista, RR, Brazil, 2024
In the Routine Complementary Exams section, a predominance of records classified as good and excellent was observed, indicating a high level of completeness. The best results were observed in the HIV/anti-HIV and hepatitis B tests (95.77%), followed by fasting blood glucose and syphilis/VDRL (94.36%), all with excellent classification. Blood typing, toxoplasmosis, hemoglobin/hematocrit, urinalysis type I, and ultrasound tests showed good completeness, ranging from 90.14% to 92.95%. The urine culture test showed the lowest percentage (77.46%) and was classified as fair (Table 4).
Completeness of records of routine complementary exams in the pregnant women’s notebooks. Boa Vista, RR, Brazil, 2024
On the other hand, the section on Complementary Activities showed the opposite performance: all items were classified as very poor, representing the worst evaluation among the sections (Table 5).
Completeness of records of complementary activities in the pregnant women’s notebooks. Boa Vista, RR, Brazil, 2024
In the analysis of the overall completeness of the notebooks, it was found that 7.04% were classified as very poor, 81.06% as poor, and 11.26% as fair. It is noteworthy that no notebook achieved all records classified as good or excellent.
DISCUSSION
In this study, it was found that all analyzed notebooks had legible but incomplete records. The incompleteness was also observed in other studies. A study conducted in the municipality of São Luís (MA)3 with 105 notebooks of pregnant women identified that 72.4% of the records had low completeness. In another investigation, conducted with 72 cards and notebooks of pregnant women, only nine documents showed adequate filling in at least half of the variables, reinforcing the insufficient use of this monitoring tool11.
In a national analysis of the quality of filling out the standardized pregnancy card by the Ministry of Health, using qualitative and quantitative criteria, it was found that, in general, Brazil and its macro-regions showed completeness considered “poor”, except for the South region12. National results indicated better filling in obstetric history, fair in personal history, and poor in fields related to the current pregnancy. In the present study, the findings showed a similar pattern, with only partial regularity in the history and records of the ongoing pregnancy.
The field with the best performance was the record of the pregnant woman’s name, classified as excellent. However, the item “how she likes to be called” showed very low filling, also identified by other authors in the literature 3. It is emphasized that this aspect is essential for building the bond between the health team and the pregnant woman, favoring adherence and effectiveness of prenatal care13.
In the section on Gestational Risk Classification, a low level of filling in information about risk was observed. This data is extremely important as it allows for the early identification of pregnancies with a higher likelihood of complications, ensuring adequate assistance to the woman and the fetus14,15. The low adherence to registration may be related to the recommendation of the Ministry of Health, according to which the definitive classification of risk should be made only after childbirth and the puerperium, as it may change throughout the pregnancy1.
It is estimated that about 10% of pregnancies present high-risk criteria, with a higher likelihood of severe outcomes, including maternal and fetal deaths1. In this context, the correct filling of the field related to risk is fundamental to guide care, improve the direction of assistance, and favor communication between different levels of care16.
The section dedicated to Routine Complementary Exams was the one that obtained the best results. Such exams are recommended from the first consultation and should be repeated at specific times during pregnancy1. In another study, however, it was found that the recording of laboratory tests varied from “fair”, such as blood glucose, syphilis serology, and urinalysis, to “poor”, such as HIV serology3. These tests are essential for screening and preventing common complications during pregnancy, such as anemias, sexually transmitted infections, and metabolic changes, which have a direct impact on maternal and fetal health1.
The section on Complementary Activities showed the worst results, with incompleteness exceeding 50%. The field related to educational actions was the least filled out. A similar result was identified in São Luís (MA), where all records in this section were classified as “very poor”³. Educational activities are fundamental guidelines for prenatal care, promoting the autonomy and leadership of the pregnant woman and favoring informed decisions16. The absence of records may reflect anything from the non-use of the booklet for this purpose to the non-performance of activities, as well as the low value placed by pregnant women or insufficient encouragement from the health team³.
The field designated for dental consultation was classified as “very poor”, with only 29.77% of records filled out. A similar situation was observed by other authors in the literature7,17 who pointed out recurring failures in this item, revealing a gap between what is recommended and practice. The Ministry of Health recommends at least one dental consultation during pregnancy, in addition to group educational actions on oral health, nutrition, breastfeeding, and prevention of transmissible oral diseases15. The absence of these records compromises the monitoring of relevant oral health issues, such as gingivitis and periodontitis, which may be related to complications such as premature birth, pre-eclampsia, and low birth weight18,19.
Authors also highlight the uncertainty about whether the failure lies in the absence of effective assistance or merely in incomplete recording, since some procedures may be performed but not documented³. The correct filling out of the Pregnant Woman’s Booklet is an essential condition to ensure the quality of prenatal care12.
The low completeness observed in the records of the Pregnant Woman’s Booklet may be related to structural and organizational factors that influence the work process of health teams. Among them, the absence of clear protocols stands out20, poor leadership and management20, lack of ongoing training for the team regarding the use of the instrument as a tool for monitoring and clinical communication21, inadequate infrastructure21, and systemic barriers21.
These gaps negatively impact the continuity of care and the effectiveness of health surveillance, as incomplete records hinder the longitudinal monitoring of the pregnant woman, early identification of risks, and planning of preventive actions. Improvement strategies should include ongoing education for teams, systematic monitoring of record quality, integration between information systems, and strengthening care coordination within Primary Health Care.
In general, it was found that 7.04% of the analyzed booklets were classified as having very poor records, 81.06% poor, and 11.26% fair. None were considered good or excellent, a finding that resembles what has been reported by other authors in the literature 3.The findings indicate weaknesses in the completeness of the records of the Pregnant Woman’s Booklet, reflecting the need to strengthen the recording and monitoring process of prenatal care.
For professional practice, the importance of adequately filling out the Pregnant Woman’s Booklet as a communication tool and for continuity of care is evident¹. In the context of management, it is recommended to invest in ongoing training²¹, standardization of records, and monitoring of the quality of information20, in order to improve health surveillance and coordination of care for pregnant women in the municipality of Boa Vista. The strengthening of the qualified use of the booklet represents, therefore, a strategic path to consolidate more comprehensive, safe, and effective practices in maternal and child care.
Public health in Roraima faces challenges arising from its sociocultural diversity and its geographical position as a border state, marked by the presence of indigenous peoples and migratory flows from Venezuela and Guyana. This reality imposes specific demands on health services, reinforcing the need for research focused on indigenous populations, considering their cultural particularities and care needs. Such studies are essential to support strategies for comprehensive, equitable, and culturally sensitive care for pregnant women and their communities.
In this context, the results also point to relevant implications for health education and research, reinforcing the need to align professional training with the demands of care practice. It is recommended to include content on the proper completion of the Pregnant Woman’s Booklet, the use of health information, and multiprofessional communication in curricula and ongoing education programs. In addition, conducting multicenter and qualitative studies that explore the factors associated with low completeness and evaluate the impact of educational and technological interventions on improving the quality of records and the effectiveness of maternal and child care.
CONCLUSION
A high number of incomplete fields was observed, especially in the sections of personal history, current pregnancy, gestational risk classification, and complementary activities, with a negative highlight for the fields “how you like to be called” and “dental consultation.”
Although some sections, such as complementary exams, showed better performance, no booklet achieved a classification of “good” or “excellent.” The scenario of underutilization of the Pregnant Woman’s Booklet compromises the surveillance of health issues and the continuity of care at different levels of the SUS. In light of this, the importance of implementing audit strategies and periodic training of health teams is emphasized, aimed at raising awareness and improving records, which are essential to ensure more humanized, effective, and comprehensive prenatal care.
In addition, the results of this study can support management actions and public policies aimed at improving prenatal care in the municipality of Boa Vista-RR, by highlighting the need to strengthen the continuous training of teams, adopt routines for monitoring the quality of records, and standardize the protocols for completing the Pregnant Woman’s Booklet. Such measures can support managerial decisionmaking, optimize care flows, and consolidate the role of Primary Health Care as the coordinator of care, contributing to the improvement of the quality of information and the effectiveness of maternal and child care.
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HOW TO REFERENCE THIS ARTICLE:
Gomes CSB, Bueno AC, Alves VH, Neves GASS, dos Santos ACF. Assessment of the completeness of the pregnant woman’s booklet. Cogitare Enferm [Internet]. 2026 [cited “insert year, month and day”];31:e100664en. Available from: https://doi.org/10.1590/ce.v31i0.100664en
Data availability:
The authors declare that all data are fully available within the article.
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Edited by
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Associate editor:
Dr. Gilberto Tadeu Reis da Silva
