# Use of prenatal care and hospital structure according to obstetric risk in Rio de Janeiro, Brazil

## TL;DR

This study examines prenatal care and hospital structure in Rio de Janeiro, finding that high-risk pregnancies are often not matched with appropriate hospital resources.

## Contribution

The study provides insights into the mismatch between obstetric risk levels and hospital infrastructure in Brazil's public health system.

## Key findings

- High-risk pregnancies are more common in small-city hospitals and among older, obese, and less-educated women.
- Hospitals with ICU/NICU units showed better structural adequacy for maternal and neonatal care.
- A significant proportion of high-risk women are attended in hospitals lacking critical care units.

## Abstract

To estimate the use and adequacy of prenatal care services and to verify the structure of the maternity hospital to meet the needs of health care during childbirth in the Brazilian Unified Health System.

This is a cross-sectional, hospital-based study conducted in the state of Rio de Janeiro, Brazil. 1,073 puerperae were eligible, whose delivery took place in public and mixed hospitals. The interviews were conducted in the hospital, and data were extracted from the prenatal card and maternal medical records. To evaluate the hospital structure, managers were interviewed. Sociodemographic, obstetric and prenatal care characteristics of the puerperae were described according to obstetric risk. The evaluation of the structure of the maternity hospital included: human resources, medicines, emergency equipment, and support services, according to the complexity level. Moreover, the distribution of puerperae classified as at obstetric risk was analyzed according to the complexity of the hospital structure.

The highest prevalence of high obstetric risk was observed in hospitals located in small cities, among white women, aged 35 years or over, with up to 11 years of formal study, multiparous, and obese. Prenatal care adequacy, control of hypertension, diabetes, and nutritional evaluation were low, and traveling for delivery was significant. Hospitals with ICU/NICU presented better levels of adequacy in all structure dimensions evaluated. At the state level, 30.5% of women at high obstetric risk were seen in maternity hospitals without ICU/NICU; and 40.4% women at normal risk, in maternity hospitals with ICU/NICU.

We highlight the need to improve prenatal care and the implementation of an articulated network of services that integrate the Brazilian Unified Health System (SUS), centered on maternity hospitals that guarantee the structure conditions for quality and safety in obstetric and neonatal care, both in good practices at normal risk and in the management of complications at high obstetric risk, in such a way to impact the considerable outcomes of maternal and neonatal morbidity and mortality.

Estimar a utilização e adequação de serviços de pré-natal e verificar a estrutura da maternidade para atender às necessidades de cuidado de saúde durante o parto no Sistema Único de Saúde.

Estudo seccional de base hospitalar realizado no estado do Rio de Janeiro. Foram elegíveis 1.073 puérperas cujo parto ocorreu em hospitais públicos e mistos. As entrevistas foram realizadas no hospital e foram extraídos dados da caderneta de pré-natal e do prontuário materno. Para avaliar a estrutura hospitalar foram entrevistados os gestores. As características sociodemográficas, obstétricas e do cuidado pré-natal das puérperas foram descritas segundo o risco obstétrico. A avaliação da estrutura da maternidade englobou: recursos humanos, medicamentos, equipamentos de emergência e serviços de apoio, segundo o nível de complexidade. Ao final, analisou-se a distribuição das puérperas classificadas em risco obstétrico segundo a complexidade da estrutura hospitalar.

As maiores prevalências de alto risco obstétrico foram observadas nos hospitais localizados no interior, entre as mulheres brancas, com 35 ou mais de idade, com até 11 anos de estudo, multíparas e obesas. A adequação do pré-natal, o controle da hipertensão arterial, diabetes e da avaliação nutricional foram baixos e a peregrinação foi expressiva. Os hospitais com UTI/UTIN apresentaram melhores níveis de adequação em todas as dimensões de estrutura avaliadas. Ao nível estadual, 30,5% das mulheres de alto risco obstétrico foram atendidas em maternidades sem UTI/UTIN e 40,4% de risco habitual em maternidades com UTI/UTIN.

O estudo sublinha a necessidade de melhorar a assistência pré-natal e a implementação de uma rede articulada dos serviços que integram o Sistema Único de Saúde (SUS), centrada em maternidades que garantam as condições de estrutura para a qualidade e segurança no cuidado obstétrico e neonatal, tanto nas boas práticas no risco habitual quanto no manejo de intercorrências e no alto risco obstétrico, de forma a impactar os persistentes resultados elevados de morbimortalidade materna e neonatal.