Implementation of postpartum care for women in primary care in the South of Brazil

Baratieri, Tatiane; Natal, Sonia

doi:10.1590/1806-93042022000100004

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ORIGINAL ARTICLES • Rev. Bras. Saúde Mater. Infant. 22 (01) • Jan-Mar 2022 • https://doi.org/10.1590/1806-93042022000100004 linkcopy

Implementation of postpartum care for women in primary care in the South of Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objectives: to determine the implementation level and analyze favorable and unfavorable aspects of operationalization women’s care in postpartum period in primary care.

Methods: evaluation study of the normative type, performed through a multiple case study in three cities in the South States in Brazil, with a collection of primary and secondary data. The implementation level (classification: satisfactory, partial, incipient, and critical) was determined by the Matriz de Análise e Julgamento (Analysis and Judgment Matrix), consisted of the dimensions of management and execution, and the respective sub-dimensions. Thematic and imbricated analysis of the cases were performed.

Results: postpartum care was incipient in the management dimension for all the cases, with a higher implementation level for the “care coordination and intersectorality mechanisms” (partial) sub-dimension. In the execution dimension in case 3 was partially implemented, and the others were incipient. The breastfeeding sub-dimension had a higher implementation level for all the cases, and the longitudinality, mental health and reproductive planning sub-dimensions had a lower implementation level. Care in relation to domestic violence and mental health occurred unsystematically, and reproductive planning focused on hormonal contraceptive methods.

Conclusion: management does not provide ideal conditions for healthcare professionals’ performance; and, in the execution dimension are not incorporated as the main necessity in the health care practice in women’s health.

Key words
Primary health care; Postpartum period; Women’s health; Health evaluation

Dimension		Case 1		Case 2		Case 3
Dimension	ES (%)	OS	IL (%)	OS	IL (%)	OS	IL (%)
Management	30 (100.0)	11.5	38.3	15.0	50.0	11.0	36.7
Execution	35 (100.0)	13.8	39.6	9.9	28.4	19.9	57.0

Sub dimension	Criterion or indicator	ES	OS Case 1	OS Case 2	OS Case 3
Financial, material and physical resources (10 points)	Actions for postpartum women’s health contemplated in the Programação Anual de Saúde (Annual Health Program) and executed in the last year	2	0	0	0
	Execution of the state and federal transfer resources for PHC in the last year	2	2	0	2
	Availability of essential equipment in PHUs	1	0	1	0
	Availability of contraceptives in PHUs	1	0	0	0
	Availability of essential medications for puerperal women in PHUs	1	1	0	0
	Availability of materials for cytopathological collection and gynecological examination in puerperal women in PHUs	1	1	1	1
	Adequacy of physical space: adequate spaces for waiting, as well as for clinical and educational care	1	0	0	0
	Adequacy of physical space: adequate spaces for people with disabilities	1	0	0	0
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	40%	20%	30%
Human Resources (10 points)	Primary care coverage	2	1	2	1
	Family Health Strategy Teams	2	0	2	0
	Professional qualification: Professionals (physicians and nurses) who participated in courses/meetings/educational actions to update on women’s health in the last year	2	0	1	2
	Professional qualification: Professionals (physicians and nurses) who participated in courses/meetings/educational actions to update on postpartum care in the last year	2	0	0	0
	Protocol and/or clinical guidelines for women’s healthcare that include postpartum care formally implemented and available to be used by health professionals	2	0	1	0
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	10%	60%	30%
Mechanisms for coordination in care and intersectorality (10 points)	Existence of referral and counter-referral mechanisms among different points of healthcare	1	1	1	1
	Follow-up of indicators on postpartum care	1	1	0	0
	Scheduling the first postpartum consultation	2	1	2	1
	Access for puerperal women to other points of available and facilitated healthcare (when necessary) (Psychosocial Care Center/Hospital/Emergency Care Units) through a network and formalized flows	1	1	1	1
	Access to a referral service for sterilization and vasectomy in a timely manner (60 days)	1	0	0	0
	Specialized care: PHC teams receive support from other professionals to help or provide support in the resolution of cases considered complex	1	1	1	1
	Specialized care: Timely access to specialized psychiatrists- less than 30 days	1	0	0.5	0
	Attendance of the manager or his/her representative at meetings of the Regional Inter-Management Committee in the last year	1	1	1	1
	PHC actions coordinated with other sectors of society through a network and formalized/implemented flows	1	0.5	0.5	0
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	65%	70%	50%

Case (s)	Favorable Aspects	Unfavorable Aspects
1, 2 and 3	Availability of materials Institutionalized referral and counter-referral mechanisms Access to other healthcare points Matrix support Manager’s participation in Regional Inter-Management Committee meetings	Lack of programing actions for postpartum women Inadequacy of physical space Lack of essential equipment for obese women Lack of timely access to long-term contraceptive methods Lack of professional qualification for the postpartum issue
1 and 2	Articulation with social work for specific cases	Lack of continuing education
1 and 3	Full execution of state and federal transfer resources	Low FHS coverage Lack of clinical protocol for postpartum care Lack of timely access to psychiatrists
2 and 3		Lack of follow-ups on postpartum indicators
1	Management has good registrations, knows and works based on the follow-up of postpartum indicators; electronic medical charts integrated with the whole city network
2	Availability of essential equipment Good FHS coverage Clinical protocol for nursing postpartum care Women leave the maternity hospital with a scheduled postpartum consultation Access to psychiatrists in less than 60 days	Partial execution of state and federal transfer resources; Lack of antibiotics
3	Encouragement of professional qualification (continuing education)	Lack of medications Lack of formal articulation with social work

Sub dimension	Criterion or indicator	ES	OS 1	OS 2	OS 3
Longitudinality (5 points)	Involvement of families and/or partners in the women’s healthcare from prenatal to postpartum	1	0.25	0	1
	Establishing care over time	1	0.5	0.8	0.7
	Performing a postpartum care plan	1	0	0	0.2
	Continuity of care in the remote puerperal period	1	0.4	0	0.2
	Use of clinical protocols/guidelines for postpartum care for women	1	0	0	0
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	23%	16%	42%
Access (5 points)	Welcoming on spontaneous demand	1	1	1	1
	Pregnant women followed-up in prenatal care**	1	0	0	0
	Home visit in the first week	1	0	0	1
	Postpartum consultations	1	0.3	0.3	0.7
	Active search for women who missed postpartum consultations	1	1	1	1
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	46%	46%	74%
Physical health (5 points)	Investigation on complications/severities in prenatal care and childbirth and intervention for continuity of care when necessary	1	0.8	0.2	0.5
	Guidance, prevention, identification and intervention on common postpartum problems, as required	1	0.4	0.2	0.5
	Guidance, identification and intervention on postpartum warning signs, as required	1	0.4	0	0.4
	Advice on nutrition/hygiene/physical activity	1	0.4	0.5	0.5
	Iron supplementation 3 months of postpartum	1	1	1	1
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	60%	38%	58%
Mental health (5 points)	Investigation on family and social support during prenatal and postpartum	1	0.4	0.2	0.7
	Investigation on the history of mental illness/injury during prenatal and postpartum	1	0.8	0.4	0.6
	Investigation of emotional state during postpartum	1	0.2	0.2	0.5
	Guidance on common postpartum emotional alterations	1	0	0	0.5
	Applying PPD Diagnosis Scale when identifying warning signs	1	0	0	0
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	28%	16%	46%
Domestic violence (5 points)	Guidance on domestic violence	1.5	0.2	0.2	0.5
	Identification and attention on women in situation of domestic violence	2	0.8	0.8	1.5
	Notification on domestic violence cases	1.5	0.5	0	0.75
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	30%	20%	55%
Breastfeeding (5 points)	Recommendation and promotion of exclusive breastfeeding until 6 months	2	1	1	1.5
	Prevention, identification and treatment of problems related to breastfeeding	2	1.2	0.6	1.7
	Drug therapy (if any) is reviewed, paying attention to contraindications due to BF	1	1	1	1
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	64%	52%	84%
Reproductive planning (5 points)	Providing sexual health advice	1.7	0.3	0.3	0.6
	Recommendation and guidance on reproductive rights and planning	1.7	0.8	0.25	1
	Involvement of the partner (if any) in reproductive planning.	1.6	0.2	0	0.4
	$I L = (Σ O S / Σ {E S}^{⋆} 100)$	100%	26%	11%	40%

Case (s)	Favorable Aspects	Unfavorable Aspects
1, 2 and 3	Encouragement for breastfeeding Supplementation with ferrous sulfate	Lack of use of clinical protocol Lack of care in the remote puerperal period and postpartum care plan Low coverage of prenatal and postpartum consultations Complaint-based attention to common problems Lack of routine postpartum mental healthcare Lack of attention to domestic violence routine Reproductive planning focused on the use of hormonal contraceptive methods
1 and 2	-	Lack of routine for discussing clinical cases in a team meeting Low coverage of home visits in the first week of postpartum Lack of involvement of families/partners in healthcare
1 and 3	Institutionalization of postpartum consultation in the first 10 days	-
2 and 3	-	Difficulties in providing continuity of care in situations that occur during prenatal care and childbirth
1	Specialized physician in family health Physician takes advantage of the children’s follow-up meetings to help women in the remote puerperal period Two postpartum consultations recommended Physician shows concern with comprehensive care for women’s health. City program to encourage breastfeeding	Aspects of good quality of postpartum care are related to the physician’s profile on care, not a practice of the entire team
2	The team is always available for women to be welcomed on spontaneous demands Breastfeeding space CHWs have a form for postpartum home visits	First consultation usually occurs after 30 days of postpartum Lack of postpartum nursing consultation
3	Health unit with advanced welcoming access Alignment among the services provided by different professionals Team meeting for case discussion Continuing education The team seeks to involve families/partners in healthcare Group of pregnant women Physicians and nurses specialized in family health Physicians and nurses show concern for comprehensive healthcare for women according to their needs	-

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[1] PPD = Postpartum Depression; ES = Expected score; OS = Observed score; IL = Implementation level (Satisfactory implementation: 76% to 100%; partial implementation: 51% to 75%; incipient implementation: 26% to 50%; and critical implementation: below 26%);¹⁹

[TFN1] ^**
Indicator calculation data not available in PHUs. City data used.