Assessing the Quality of Prenatal Care: Use of the Kotelchuck Index Combined with Prenatal Care Data
by
, ,
Débora Melo de Aguiar
1,*,
Andréia Moreira de Andrade
1,
Alanderson Alves Ramalho
1,
Fernanda Andrade Martins
1,
Rosalina Jorge Koifman
2,
Simone Perufo Optiz
1 and
Ilce Ferreira da Silva
2 1
Postgraduate Program in Public Health, Federal University of Acre, Rio Branco 69920-900, AC, Brazil
2
Department of Epidemiology and Quantitative Methods in Health, National School of Public Health, Rio de Janeiro 21040-360, RJ, Brazil
*
Author to whom correspondence should be addressed.
Women 2023, 3(2), 225-236; https://doi.org/10.3390/women3020018
Submission received: 27 January 2023
/
Revised: 31 March 2023
/
Accepted: 10 April 2023
/
Published: 13 April 2023
Abstract
:The aim of the present study was to propose a quality prenatal (PN) care assessment model combining use and visit content (both adjusted for the weeks of gestation) to estimate inadequate PN care and associated factors in Rio Branco, Acre. A cross-sectional study was conducted using a population-based cohort of 1030 women in the city of Rio Branco in 2015. The use of PN care was classified according to the adapted Kotelchuck index by combining the performance of clinical-obstetric procedures adjusted for weeks of gestation. Levels of adequacy were built according to PN care use and content. Gross and adjusted odds ratios were estimated by using a logistic regression. The prevalence rates of inadequate prenatal care quality were 25.9% (Level-1), 54.8% (Level-2), 68.8% (Level-3), and 78.6% (Level-4). The factors associated with Level-1 were age ≤ 34 years (ORaj:3.74), not having a partner (ORaj:1.62), unplanned pregnancy (ORaj:1.73), and multiparity (ORaj:2.25); those for Level-2 comprised not having a partner (ORaj:1.82) and multiparity (ORaj:1.33); those for Level-3 were age ≤ 34 years (ORaj:3.31), not having a partner (Oraj:1.71), unplanned pregnancy (Oraj:1.45), PN in the private sector (Oraj:3.08), and multiparity (ORaj:2.17); those for Level 4 comprised not having a partner (ORaj:2.33), family income < 1 MW (ORaj:2.05), unplanned pregnancy (ORaj:1.41), PN in the private sector (ORaj:6.80), and multiparity (ORaj:1.49). The Kotelchuck index was proven efficient in assessing the combined effect of use and content in assessing PN care quality.
1. Introduction
Maternal and child health indicators comprise an important reflection of health and development conditions. In this context, prenatal (PN) care indicators such as the Kessner and Kotelchuck indices were developed to assess the use of PN care (by combining the number of PN visits and timing of initiation of PN care) [1,2].
The indices were developed based on these indicators and are the most commonly applied in both the Brazilian and international literature. The former allows for assessments of the combination of the number of visits with the week when prenatal care began. The second index, also known as the Adequacy Prenatal Care Utilization Index (APNCUI), allows for the analysis of the number of visits and timing of initiation of PN care both independently and/or combined in addition to adjusting the number of visits for weeks of gestation [1,2].
Although most of the proposed evaluation indices are applied to assess PN access and use, the literature has demonstrated that such criteria are not sufficient to assess the quality of the PN care because the content of the assistance PN (clinical procedures and laboratory tests) performed in a timely manner is essential for high-quality PN care [3,4]. Studies have demonstrated that insufficient or absent PN care is associated with negative outcomes that include preterm births, low birth weights (LBWs), and neonatal mortality. Thus, identifying PN care flaws and quality is paramount because high-quality PN care programs may contribute to decreasing complications during pregnancy and delivery, thereby positively affecting mother-and-child morbidity and mortality [5,6].
Prenatal care use effects on maternal, fetal, and infant outcomes have been investigated worldwide [7,8]. However, this does not necessarily reflect consultation procedures (content), which are essential in preventing hazard outcomes such as spontaneous preterm births, low birth weights, and vertical disease transmission [7,8]. In Brazil, Takeda and collaborators [3] and Anversa and collaborators [9] proposed a PN care program evaluation model that considers content criteria combined with use (PN care onset and number of appointments). However, the authors employed the Kessner index according to the Brazilian Ministry of Health recommendations [10], which does not adjust the number of visits according to weeks of gestation [3,9]. Therefore, the present study proposes a quality PN care assessment model combining use and visit content (both adjusted for weeks of gestation) to estimate the prevalence of inadequate PN care and associated factors in the city of Rio Branco, Acre. This city is located in the western Brazilian Amazon area and comprises 3.27% of Brazil’s population [11]. Despite its high PN care coverage (97.5%), this region presents the highest percentage of women without PN care (60% higher than the national average) and experiences the worst neonatal results, including spontaneous preterm births (8.5%) and LBWs (7.9%) [12].
2. Results
A total of 129 (10.7%) women were lost, 6 lacked prenatal cards at hospitalization, and 123 lacked information on the prenatal card regarding the number of visits and timing of initiation of PN care. Thus, the study population encompassed 1030 women who answered a questionnaire containing information concerning sociodemographic, current pregnancy, and PN care procedures and exams.
From 1030 women included in the study, 20.3% were inadequate for Level-1 quality, 0.0% for Level-2, 12.0% for Level-3, and 0.0% for Level-4. On the other hand, 74.1% were more than adequate/adequate for Level-1, 45.2% for Level-2, 31.2% for Level-3, and 21.4% for Level-4 (Table 1).
According to Table 2, compared to women classified as receiving adequate PN care, those classified as receiving inadequate PN care at Level-1 were more frequently aged <20 years (34.4%); self-declared as multiethnic (32.4%); had an education level <elementary school (37.6%); had no partner (38.5%); had family income up to 1 MW (42.3%); belonged to class C, D, and E (28.4%); had an unplanned pregnancy (31.1%); had no previous abortion (31.2%); used the public health service (27.9%); and were multiparous (30.7%) with statistical significance. Regarding women classified as receiving inadequate PN care in Level-2, the majority had no partner (62.1%), used private health services (53.6%), and were multiparous (58.1%) with statistical significance. Among those classified as receiving inadequate PN care in Level-3, the most frequent characteristics were having no partner (77.0%), family income up to 1 MW (77.5%), unplanned pregnancy (72.2%), using private health care service (67.1%), no previous abortions (75.3%), and multiparity (63.0%) with statistical significance. Regarding those classified as inadequate in Level-4, a greater proportion had no partner (87.6%), had family income up to 1 MW (85.9%), had an unplanned pregnancy (80.9%), used private health care service (76.5%), had no previous abortions (83.1%), and was multiparous (74.5%) with statistical significance.
In the multivariate analysis (Table 3), when considering Level-1 of PN care quality, women aged ≤ 20 years old (OR = 3.74; CI: 95%: 1.90–7.35) or 20–34 years old (OR = 1.79; CI: 95%: 1.01–3.18) with elementary school II schooling (OR = 2.53; CI: 95%: 1.41–4.53) or a high school (OR = 1.60; CI: 95%: 0.94–2.70) education level, with no partner (OR = 1.62; CI: 95%: 1.07–2.46), with an unplanned pregnancy (OR = 1.73; CI: 95%: 1.22–2.47), and were multiparous (OR = 2.25; CI: 95%: 1.50–3.35) presented a statistically increased chance of inadequate PN care. Concerning Level-2 PN care quality, women with no partner (OR = 1.82; CI: 95%: 1.27–2.61) and multiparous women (OR = 1.33; CI: 95%: 1.03–1.71) presented statistically increased chances of inadequate PN care. When assessing Level-3 of PN care quality, women aged >20 years old (OR = 3.31; CI: 95%: 1.92–5.73) or 20–34 years old (OR = 1.99; CI: 95%: 1.27–3.12) with no partner (OR = 1.71; CI: 95%: 1.12–2.59); with an unplanned pregnancy (OR = 1.45; CI: 95%: 1.09–1.93), using private health care service (OR = 3.08; CI: 95%: 1.91–4.97), and who were multiparous (OR = 2.17; CI: 95%: 1.59–2.96) presented statistically increased chances of inadequate PN care. Regarding Level-4 of PN quality, women with no partner (OR = 2.33; CI: 95%: 1.30–4.17), with family income < 1 MW (OR = 2.05; CI: 95%: 1.07–3.92), with an unplanned pregnancy (OR = 1.41; CI: 95%: 1.01–2.00); using private health care service (OR = 6.80; CI: 95%: 2.84–16.28), and who were multiparous (OR = 1.49; CI: 95%:1.06–2.11) presented statistically increased chances of inadequate PN care.
3. Discussion
Although the Kotelchuck index has been consistently employed to assess PN care use quality in the literature [13,14], many studies conducted in Brazil still use limited indices such as the Kessner index [9,15,16] because preterm births may present an adequate number of visits for weeks of gestation. Therefore, an index combining the use and recommended contents adjusted according to weeks of gestation may adequately provide accurate PN care quality assessments.
Since its development, the Kotelchuck index has revealed that an increased number of women with more than adequate PN care translates into decreased unfavorable outcomes such as low birth weights and preterm births. Thus, Kotelchuck and colleagues conducted a cross-sectional study in 1997 to evaluate the content of PN care administered to women classified as low-income individuals [17] that demonstrated the limitations of this index in assessing the adequacy of PN care when content is not considered.
In this sense, the present study provides evidence that the Kotelchuck index combined with contents adjusted for weeks of gestation may comprise a complete and accurate PN care quality assessment strategy. The findings indicated very frequent inadequate PN care (78.6%) in Rio Branco, Acre. The contents presented higher weights on the adequacy drop compared to the Kotelchuck index alone: the Level-3 inadequacy when employing this index was 68.8%; for Level-2, it was 54.8%.
The observed Level-2 adequacy decreases corroborated other studies [9,18]. In one study, for example, the same trend was noted in the city of Santa Maria in southern Brazil [9] in 2010, where the adequacy frequency when combining clinical-obstetric procedures and the Kessner index was 46.0%. However, that study applied the Kessner index adapted by Takeda, which does not adjust the number of visits for weeks of gestation, which could have underestimated PN care adequacy. In another assessment, concerning use combined with laboratory tests (Level-3), in Santa Maria in 2012, the decrease was lowered from 59.0% (Level-1) to 8.0% (Level-3) [9]. This suggested that even after the creation of national policies and programs over the years, the performance of laboratory tests remains the greatest challenge with regard to the quality of PN care in different regions; this includes Acre, which is located in a region presenting high hepatitis B endemicity. These findings reinforce the need for awareness concerning screening and potentially early morbidity detection in addition to a greater number of children and lack of a partner, which often makes the woman a household keeper, which in turn makes it impossible for her to seek health care.
The literature demonstrates that failure to perform routine examinations can be associated with several factors such as failures in health service structuring; i.e., barriers and difficulties related to scheduling and performance, which depend on often insufficient inputs for the demands in place. In addition, test scheduling, realization, and results must be performed and obtained in a timely manner [18].
The difference between the inadequacy of Level-4 PN care (78.6%) when considering all content criteria and Level-1 (25,9%) was considerable, suggesting that although women from Acre have access and utilize PN care programs, they are not provided with the full recommended procedures and laboratory tests, which was similar to that observed other studies [9,19,20,21], demonstrating failures in accessing essential services for safe pregnancy and delivery in developing countries.
In another study carried out in Santa Maria [9], the PN care adequacy for all issues (use + laboratory tests + obstetric procedures) was evaluated between 2009 and 2010 according the Brazilian recommendations [10]. The factors associated with PN care inadequacy for all issues may reflect patient barriers, the healthcare system itself, and health professionals and services. Thus, the findings reported herein stress the need for a continuous individualized care monitoring system regarding PN care with a surveillance system for users who were not submitted to recommended clinical procedures and examinations in a timely manner. Additionally, the results reported herein were similar to those observed in a study carried out in São Tomé and Príncipe between 2008 and 2009, which showed that adequate PN care was more frequent among married women who wished to become pregnant and exhibited a better economic well-being index [22].
Although the PN care provided in the private sector has often led to a higher frequency of adequacy compared to the public sector in both the international [23] and Brazilian [24] literature, performing PN care in the private sector in Rio Branco led to a 6.80-fold higher chance of inadequate care than patients who underwent PN care in the public sector. The apparent inadequacy in the private sector regarding obstetric procedures can be partly explained by the superiority of performing more expensive procedures such as ultrasounds in this sector instead of fetal heart rate and fetal movement tests, which are less expensive.
Additionally, a lack of pregnancy card standardization in the private Rio Branco system may lead professionals to miss report visits in gestational cards. Similarly, since the private system in Rio Branco usually covers long-term patients, private health professionals often skip the request of specific recommended tests such as those for syphilis, HIV, and hepatitis B and C due to the known patient health profiles; i.e., steady partners, sexually transmitted disease history, and so on. Another aspect is the difference between nurse and doctor PN care performances in each Rio Branco sector. In the private sector, PN care is performed exclusively by a medical doctor, while in the public sector, PN care for low-risk pregnancies is performed by nurses. In this sense, it is important to highlight that nurses in Brazil can only prescribe medications, requests, and perform clinical and laboratory tests officially recommended by the Ministry of Health in the scope of PN care programs. This may explain why the number of fetal movements and fetal heart rates are more frequently assessed in the public sector compared to the private sector because nurses cannot conduct ultrasounds according to Brazilian legislation [25].
Since nurses perform the PN care in low-risk pregnancies, another aspect for greater public sector PN adequacy concerns the holistic nursing care provided by these professionals and informing them of all aspects recommended in the Brazilian Ministry of Health protocols and manuals, which can contribute to compliance with established standards [14,26].
The present study contributes to the public health field by proposing a more accurate PN care quality index that allows for estimates of the frequency of PN care inadequacy according to the main components recommended by official agencies adjusted for weeks of gestation. Additionally, the proposed index may be customized to the official recommendations of any country. Finally, this analysis allows for the identification of factors associated with inadequacy, which should become targets for public health interventions, thereby prioritizing women at risk of poor PN care use and those receiving inadequate PN care content. This approach provides health managers with a standard for evaluating program quality and the main points deserving greater investment and/or strategic management interventions.
In sum, the findings reported herein demonstrate the importance of actions that contribute to timely access to obstetric and laboratory procedures during consultations responsible for identifying possible complications; such initiatives are paramount in reducing child and maternal morbidity and mortality in the western Amazon.
4. Materials and Methods
This article is an integral part of two major projects: “Use of medicine during pregnancy, childbirth and breastfeeding in pregnant women in the municipality of Rio Branco, Acre” and “Evolution of nutritional indicators of children from birth to the first year of life in Rio Branco, Acre”, both of which were approved by the Research Ethics Committee of the Federal University of Acre. All participants provided informed consent. Detailed sampling procedures were previously published elsewhere [27].
A cross-sectional, population-based study analysis was carried out on a cohort of pregnant women residents of the Rio Branco urban area who delivered at only two maternities (one public and another private) in 2015. From 1205 mothers eligible for this study, 46 were excluded because either they had twins, performed PN care in another city, or had no PN care. A total of 1159 women were included in this study. Information on the utilization and content of PN care was obtained through the records available on the PN care cards as follows: Place of PN care; last menstruation period (LMP) to define the weeks of gestation of the beginning PN care, preferably; or ultrasound (USG); number of visits, laboratory test records, weight, blood pressure, uterine height, and heartbeat and fetal movement assessments.
To assess the utilization of PN care programs (timing of initiation of PN care and number of visits), we used the Kotelchuck index adapted to the Brazilian recommendations [10], which includes six PN care visits until full-term birth, while adjusting the number of visits for preterm births. The Kotelchuck index categories were calculated while considering the weeks of gestation at PN care onset, which were categorized as 1 and 2 months, 3 and 4 months, 5 and 6 months, and 7 to 9 months; while the ratio of the number of visits was obtained by the ratio of the number of visits observed to those expected for weeks of gestation. The PN care content adequacy variable was obtained based on Brazilian [10,28] and WHO [29] recommendations and adjusted using the number of obstetric procedures according to weeks of gestation. Thus, the adequacy criteria of the PN care process used in the present study were adaptations of the proposals developed by Silveira, Santos, and Costa (2001) [30] and Anversa (2012) [9] and categorized into suitability levels as shown in Table 4.
The distributions of epidemiological and obstetrics characteristics according to adequacy levels were evaluated by using the absolute and relative frequencies of the categorical variables. Differences were assessed using the X²-test and Fisher’s exact test at a 5% significance level. Thus, the outcome (inadequacy) was classified based on the aforementioned adequacy levels (Square-1). Subsequently, adequacy levels were transformed into dichotomous variables as follows: intermediate + inadequate level in a single category (inadequate) and more than adequate + adequate in a single category (adequate).
Crude and adjusted odds ratios were obtained with their respective 95% confidence intervals. Multiple analyses were performed considering the input criteria for the model as a p-value < 0.20 of each variable in the crude analysis and their biological relevance in the causal process. The output criteria were set as a p-value < 0.05 or to maintain model parsimony. Thus, for the final model, we considered the variable significance level and biological plausibility. The goodness-of-fit model was assessed by a residual analysis. All analyses were performed using the SPSS 22.0 statistical package.
5. Conclusions
Although the literature has shown a high coverage of prenatal care in Rio Branco, the findings of this study suggest that almost 23 years after the implementation of the Humanization Program for Prenatal and Birth in the country, the established recommendations are still not widely implemented for the entire target population in the municipality of Rio Branco. Economically disadvantaged women with the lowest social support and the lowest educational level are at most risk of receiving low-quality prenatal care, pointing to the need for interventions aimed at the most vulnerable populations through a care network that takes into account the disadvantages that compromise the quality of this assistance in this municipality.
From a methodological point of view, this study proposed an accurate and sensitive approach to assess the quality of the prenatal process by combining the Kotelchuck index with prenatal care content adjusted for weeks of gestation. This strategy would allow for an adequate and accurate assessment that reveals the real process quality standard.
Author Contributions
Conceptualization, D.M.d.A. and I.F.d.S.; methodology, R.J.K., I.F.d.S. and D.M.d.A.; formal analysis, D.M.d.A.; investigation, A.A.R. and A.M.d.A.; resources, A.M.d.A., A.A.R. and F.A.M.; data curation, I.F.d.S. and D.M.d.A.; writing—original draft preparation, D.M.d.A.; writing—review and editing, I.F.d.S. and A.M.d.A. visualization, D.M.d.A., I.F.d.S., A.M.d.A., A.A.R., R.J.K., F.A.M. and S.P.O.; supervision, D.M.d.A.; project administration, A.A.R. and A.M.d.A.; funding acquisition, A.M.d.A., A.A.R. and D.M.d.A. All authors have read and agreed to the published version of the manuscript.
Funding
This research was funded by Programa de Pesquisa Para o SUS-Fundação de Amparo à Pesquisa do Estado do Acre (PPSUS/FAPAC 2013 6068-14-0000032 and PPSUS/FAPAC 2015 32888.501.20968.22032016) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES)—Finance Code 001.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of the Federal University of Acre (protocol codes 760821 and 1074982).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
References
- Kessner, D.M.; Singer, J.; Kalk, C.E.; Schlesinger, E.R. Infant Death: An Analysis by Matemal Risk and Health Care; Institute of Medicine and National Academy of Sciences: Washington, DC, USA, 1973. [Google Scholar]
- Kotelchuck, M. An Evaluation of the Kessner Adequacy of Prenatal Care Index and a Proposed Adequacy of Prenatal Care Utilization Index. Am. J. Public. Health 1994, 84, 1914–1920. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Takeda, S. Avaliação de Unidade de Atenção Primária: Modificação dos Indicadores de Saúde e Qualidade da Atenção. Ph.D. Thesis, Universidade Federal de Pelotas, Pelotas, Brazil, 1993. [Google Scholar]
- da Cruz, G.C.; Ruiz, P.C.; Junior, O.C.; de Sousa, A.D.; de Oliveira Pereira, R.M.; Barroso, C.O.; Campos, S.S.T. Métodos de avaliação da qualidade de assistência ao pré-natal no Brasil: Revisão integrativa da literatura. Rev. Eletrônica Acervo Saúde 2019, 27, e521. [Google Scholar] [CrossRef]
- Gonzaga, I.C.A.; Santos, S.L.D.; da Silva, A.R.V.; Campelo, V. Atenção pré-natal e fatores de risco associados à prematuridade e baixo peso ao nascer em capital do nordeste brasileiro. Ciência Saúde Coletiva 2016, 21, 1965–1974. [Google Scholar] [CrossRef] [Green Version]
- Veloso, F.C.S.; Kassar, L.D.M.L.; Oliveira, M.J.C.; Lima, T.H.B.D.; Bueno, N.B.; Gurgel, R.Q.; Kassar, S.B. Analysis of neonatal mortality risk factors in Brazil: A systematic review and meta-analysis of observational studies. J. Pediatr. 2019, 95, 519–530. [Google Scholar] [CrossRef]
- Heaman, M.I.; Martens, P.J.; Brownell, M.D.; Chartier, M.J.; Derksen, S.A.; Helewa, M.E. The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada. J. Obstet. Gynaecol. Can. 2019, 41, 947–959. [Google Scholar] [CrossRef] [PubMed]
- Benzaken, A.S.; Pereira, G.F.M.; da Cunha, A.R.C.; de Souza, F.M.A.; Saraceni, V. Adequacy of prenatal care, diagnosis and treatment of syphilis in pregnancy: A study with open data from Brazilian state capitals. Cad. Saúde Pública 2020, 36, e00057219. [Google Scholar] [CrossRef]
- Anversa, E.T.; Bastos, G.A.; Nunes, L.N.; Dal Pizzol, T.D. Qualidade do processo da assistência pré-natal: Unidades básicas de saúde e unidades de Estratégia Saúde da Família em município no Sul do Brasil. Cad. Saúde Pública 2012, 28, 789–800. [Google Scholar] [CrossRef] [Green Version]
- Brazil. Ministério da Saúde. Programa de Humanização no Pré-Natal e Nascimento; Ministério da Saúde: Brasília, Brazil, 2000.
- Brazil. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico. Características da População e dos Domicílios: Resultados do Universo. 2011. Available online: http://www.sidra.ibge.gov.br/cd/cd2010universo.asp?o=5&i=P (accessed on 10 June 2020).
- Leal, M.C.; Esteves-Pereira, A.P.; Viellas, E.F.; Domingues, R.M.S.M.; da Gama, S.G.N. Prenatal care in the Brazilian public health services. Rev. Saúde Pública 2020, 54, 8. [Google Scholar] [CrossRef]
- Rowe, S.; Karkhaneh, Z.; MacDonald, I.; Chambers, T.; Amjad, S.; Osornio-Vargas, A.; Chari, R.; Kumar, M.; Ospina, M.B. Systematic review of the measurement properties of indices of prenatal care utilization. BMC Pregnancy Childbirth 2020, 20, 171. [Google Scholar] [CrossRef] [Green Version]
- Nunes, J.T.; Gomes, K.R.O.; Rodrigues, M.T.P.; Mascarenhas, M.D.M. Qualidade da assistência pré-natal no Brasil: Revisão de artigos publicados de 2005 a 2015. Cad. Saúde Coletiva 2016, 24, 252–261. [Google Scholar] [CrossRef]
- Melo, E.C.; Oliveira, R.R.; Mathias, T.A. Factors associated with the quality of prenatal care: An approach to premature birth. Rev. Esc. Enferm. USP 2015, 49, 0540–0549. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Mario, D.N.; Rigo, L.; Boclin, K.D.; Malvestio, L.M.; Anziliero, D.; Horta, B.L.; Wehrmeister, F.C.; Martínez-Mesa, J. Qualidade do Pré-Natal no Brasil: Pesquisa Nacional de Saúde 2013. Ciência Saúde Coletiva 2019, 24, 1223–1232. [Google Scholar] [CrossRef] [PubMed]
- Kotelchuck, M.; Kogan, M.D.; Alexander, G.R.; Jack, B.W. The influence of site of care on the content of prenatal care for low-income women. Matern. Child Health J. 1997, 1, 25–34. [Google Scholar] [CrossRef]
- Polgliane, R.B.S.; Leal, M.C.; Amorim, M.H.C.; Zandonade, E.; dos Santos Neto, E.T. Adequação do processo de assistência pré-natal segundo critérios do Programa de Humanização do Pré-natal e Nascimento e da Organização Mundial de Saúde. Ciência Saúde Coletiva 2014, 19, 1999–2010. [Google Scholar] [CrossRef] [PubMed]
- Joshi, C.; Torvaldsen, S.; Hodgson, R.; Hayen, A. Factors associated with the use and quality of antenatal care in Nepal: A population-based study using the demographic and health survey data. BMC Pregnancy Childbirth 2014, 14, 94. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Zhou, H.; Wang, A.; Huang, X.; Guo, S.; Yang, Y.; Martin, K.; Tian, X.; Josephs-Spaulding, J.; Ma, C.; Scherpbier, R.W.; et al. Quality antenatal care protects against low birth weight in 42 poor counties of Western China. Chico RM, editor. PLoS ONE 2019, 14, e0210393. [Google Scholar]
- Ciceklioglu, M. Factors associated with the utilization and content of prenatal care in a western urban district of Turkey. Int. J. Qual. Health Care 2005, 17, 533–539. [Google Scholar] [CrossRef]
- Reis, P.; Pereira, C.; Leite, I.; Theme, M. Fatores associados à adequação do cuidado pré-natal e à assistência ao parto em São Tomé e Príncipe, 2008–2009. Cad. Saúde Pública 2015, 31, 1929–1940. [Google Scholar] [CrossRef] [Green Version]
- Correia, S.; Rodrigues, T.; Barros, H. Assessing the Effect on Outcomes of Public or Private Provision of Prenatal Care in Portugal. Matern. Child Health J. 2015, 19, 1574–1583. [Google Scholar] [CrossRef] [Green Version]
- Paris, G.F.; Pelloso, S.M.; Martins, P.M. Quality of prenatal care in public and private services. Rev. Bras. Ginecol. Obs. 2013, 35, 447–452. [Google Scholar] [CrossRef] [Green Version]
- Ferreira, G.E.; Fernandes, I.T.; Flores, P.C.; da Conceição, K.M.; Caetano, S.A.; de Souza, L.N.; dos Santos, P.O.; do Nascimento Dario, J.E.; da Silva, C.D.; do Nascimento, A.L.; et al. A atenção do enfermeiro na assistência ao pré-natal de baixo risco/Nurse’s attention in assisting low risk prenatal. Braz. J. Health Rev. 2021, 4, 2114–2127. [Google Scholar] [CrossRef]
- Brazil. Ministério da Saúde. Gestação de Alto Risco: Manual Técnico, 5th ed.; Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde: Brasília, Brazil, 2010.
- Ramalho, A.A.; Holanda, C.M.; Martins, F.A.; Rodrigues, B.T.; Aguiar, D.M.; Andrade, A.M.; Koifman, R.J. Food Insecurity during Pregnancy in a Maternal–Infant Cohort in Brazilian Western Amazon. Nutrients 2020, 12, 1578. [Google Scholar] [CrossRef] [PubMed]
- Brazil. Ministério da Saúde. Pré-Natal e Puerpério: Atenção Qualificada e Humanizada; Área Técnica de Saúde da Mulher, Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde: Brasília, Brazil, 2006; 163p.
- Villar, J.; Bergsjo, P. Antenatal Care Randomized Trial: Manual for the Implementation of the New Model; WHO: Geneva, Switzerland, 2002; 37p.
- Silveira, D.; Santos, I.; Costa, J. Atenção pré-natal na rede básica: Uma avaliação da estrutura e do processo. Cad. Saúde Pública 2001, 17, 131–139. [Google Scholar] [CrossRef] [PubMed] [Green Version]
Table 1.
Distribution of the inadequacy of PN care content according to the Kotelchuck index adapted to Brazilian Ministry of Health and WHO recommendations in a cohort of parturients in the city of Rio Branco, AC, 2015.
Table 1.
Distribution of the inadequacy of PN care content according to the Kotelchuck index adapted to Brazilian Ministry of Health and WHO recommendations in a cohort of parturients in the city of Rio Branco, AC, 2015.
| Levels a of PN Care | Analysis Adjusted for Procedure IGs | |
|---|---|---|
| N | % | |
| Level-1 (Adapted Kotelchuck) | ||
| >Adequate | 522 | (50.7) |
| Adequate | 241 | (23.4) |
| Intermediate | 58 | (5.6) |
| Inadequate | 209 | (20.3) |
| Level-2 (Level 1 + clinical-obstetric procedures) | ||
| >Adequate | 361 | (35.0) |
| Adequate | 105 | (10.2) |
| Intermediate | 564 | (54.8) |
| Inadequate | 0 | (0.0) |
| Level-3 (Level 1 + laboratory tests) | ||
| >Adequate | 243 | (23.6) |
| Adequate | 78 | (7.6) |
| Intermediate | 585 | (56.8) |
| Inadequate | 124 | (12.0) |
| Level-4 (Level 1 + clinical-obstetric procedures + laboratory tests) | ||
| >Adequate | 184 | (17.9) |
| Adequate | 36 | (3.5) |
| Intermediate | 810 | (78.6) |
| Inadequate | 0 | (0.0) |
| Total | 1030 | 100 |
a Levels established by Silveira, Santos, and Costa (2001) and Anversa et al. (2012).
Table 2.
Sociodemographic characteristics, clinical history, and PN care according to a inadequacy of PN care in a cohort of parturients in the municipality of Rio Branco, AC, 2015.
Table 2.
Sociodemographic characteristics, clinical history, and PN care according to a inadequacy of PN care in a cohort of parturients in the municipality of Rio Branco, AC, 2015.
| Level-1: | Level-2: | Level-3: | Level—4: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Variable | Total | Kotelchuck | Level-1 + Clinical-Obstetric Exams | Level-1 + Laboratory Tests | Level-1 + Level-2 + Level-3 | ||||||||
| d N (%) | b Inadequate | c Adequate | p-Value | b Inadequate | c Adequate | p-Value | b Inadequate | c Adequate | p-Value | b Inadequate | c Adequate | p-Value | |
| 1030 (100%) | 267 (100%) | 763 (100%) | 564(100%) | 466(100%) | 709 (100%) | 321 (100%) | 810 (100%) | 220 (100%) | |||||
| Age (years) | |||||||||||||
| <20 | 256 (24.8) | 88 (34.4) | 168 (65.6) | 145 (56.6) | 111 (43.4) | 185 (72.3) | 71 (27.7) | 202 (78.9) | 54 (21.1) | ||||
| 20–34 | 664 (64.5) | 160 (24.1) | 504 (75.9) | 0.001 | 362 (54.5) | 302 (45.5) | 0.682 | 456 (68.7) | 208 (31.3) | 0.140 | 527 (79.4) | 137 (20.6) | 0.395 |
| ≥35 | 110 (10.7) | 19 (17.3) | 91 (82.7) | 57 (51.8) | 53 (48.2) | 68 (61.8) | 42 (38.2) | 81 (73.6) | 29 (26.4) | ||||
| Skin color | |||||||||||||
| White | 109 (10.6) | 18 (16.5) | 91 (83.5) | 62 (56.9) | 47 (43.1) | 74 (67.9) | 35 (32.1) | 92 (84.4) | 17 (15.6) | ||||
| Brown | 853 (82.8) | 227 (26.6) | 626 (73.4) | 0.035 | 462 (54.2) | 391 (45.8) | 0.679 | 594 (69.6) | 259 (30.4) | 0.271 | 666 (78.1) | 187 (21.9) | 0.286 |
| Other | 68 (6.6) | 22 (32.4) | 46 (67.6) | 40 (58.8) | 28 (41.2) | 41 (60.3) | 27 (39.7) | 52 (76.5) | 16 (23.5) | ||||
| Schooling | |||||||||||||
| Up to elementary school II | 266 (25.9) | 100 (37.6) | 166 (62.4) | 159 (59.8) | 107 (40.2) | 196 (73.7) | 70 (26.3) | 216 (81.2) | 50 (18.8) | ||||
| High school | 533 (51.8) | 137 (25.7) | 396 (74.3) | <0.001 | 288 (54.0) | 245 (46.0) | 0.111 | 357 (67.0) | 176 (33.0) | 0.138 | 409 (76.7) | 124 (23.3) | 0.290 |
| University education | 231 (22.3) | 30 (13.0) | 201 (87.0) | 117 (50.6) | 114 (49.4) | 156 (67.5) | 75 (32.5) | 185 (80.1) | 46 (19.9) | ||||
| Marital situation | |||||||||||||
| No partner | 161 (15.6) | 62 (38.5) | 99 (61.5) | <0.001 | 100 (62.1) | 61 (37.9) | 0.025 | 124 (77.0) | 37 (23.0) | 0.015 | 141 (87.6) | 20 (12.4) | 0.003 |
| With partner | 869 (84.4) | 205 (23.6) | 664 (76.4) | 464 (53.4) | 405 (46.6) | 585 (67.3) | 284 (32.7) | 669 (77.0) | 200 (23.0) | ||||
| Family income | |||||||||||||
| Up to 1 MW e | 142 (13.7) | 60 (42.3) | 82 (57.7) | 86 (60.6) | 56 (39.4) | 0.354 | 110 (77.5) | 32 (22.5) | 122 (85.9) | 20 (14.1) | |||
| 1 to 3 MW | 506 (49.1) | 141 (27.9) | 365 (72.1) | <0.001 | 272 (53.8) | 234 (46.2) | 333 (65.8) | 173 (34.2) | 0.030 | 378 (74.7) | 128 (25.3) | 0.008 | |
| >3 MW | 237 (22.2) | 41 (17.3) | 196 (82.7) | 131 (55.3) | 106 (44.7) | 164 (69.2) | 73 (30.8) | 192 (81.0) | 45 (19.0) | ||||
| ABEP class | |||||||||||||
| A and B | 201 (19.7) | 34 (16.9) | 167 (83.1) | <0.001 | 105 (52.2) | 96 (47.8) | 0.244 | 136 (67.7) | 65 (32.3) | 0.690 | 160 (79.6) | 41 (20.4) | 0.662 |
| C, D, and E | 816 (80.3) | 232 (28.4) | 584 (71.6) | 365 (44.7) | 451 (55.3) | 564 (69.1) | 252 (30.9) | 638 (78.2) | 178 (21.8) | ||||
| Planned pregnancy | |||||||||||||
| No | 643 (62.7) | 200 (31.1) | 443 (68.9) | <0.001 | 361 (56.1) | 282 (43.9) | 0.239 | 464 (72.2) | 179 (27.8) | 0.003 | 520 (80.9) | 123 (19.1) | 0.023 |
| Yes | 382 (37.3) | 67 (17.5) | 315 (82.5) | 200 (52.4) | 182 (47.6) | 242 (63.4) | 140 (36.6) | 286 (74.9) | 96 (25.1) | ||||
| Prenatal care | |||||||||||||
| Public | 896 (87.0) | 250 (27.9) | 646 (72.1) | <0.001 | 480 (53.6) | 416 (46.4) | 0.048 | 601 (67.1) | 295 (32.9) | 0.002 | 685 (76.5) | 211 (23.5) | <0.001 |
| Private | 134 (13.0) | 17 (12.7) | 117 (87.3) | 84 (62.7) | 50 (37.3) | 108 (80.6) | 26 (19.4) | 125 (93.3) | 9 (6.7) | ||||
| Abortion | |||||||||||||
| No | 433 (67.6) | 135 (31.2) | 298 (68.8) | 0.033 | 248 (57.3) | 185 (42.7) | 0.610 | 326 (75.3) | 107 (24.7) | 0.002 | 360 (83.1) | 73 (16.9) | 0.010 |
| Yes | 208 (32.4) | 48 (23.1) | 160 (76.9) | 114 (54.8) | 94 (45.2) | 132 (63.5) | 76 (36.5) | 155 (74.5) | 53 (25.5) | ||||
| Number of births | |||||||||||||
| Primiparous | 443 (43.0) | 87 (19.6) | 356 (80.4) | <0.001 | 223 (50.3) | 220 (49.7) | 0.013 | 279 (63.0) | 164 (37.0) | <0.001 | 330 (74.5) | 113 (25.5) | 0.005 |
| Multiparous | 587 (57.0) | 180 (30.7) | 407 (69.3) | 341 (58.1) | 246 (41.9) | 430 (73.3) | 157 (26.7) | 480 (81.8) | 107 (18.2) | ||||
a Criterion based on the Kotelchuck index (repetition of exams during the third trimester was not considered); b Inadequate: Intermediate + Inadequate; c Adequate: More than adequate + Adequate; d totals may change due to missing data; e MW = 788 reais or US$ 302.
Table 3.
Factors associated with a inadequate PN care in Rio Branco, Acre, according to the adapted Kotelchuck index.
Table 3.
Factors associated with a inadequate PN care in Rio Branco, Acre, according to the adapted Kotelchuck index.
| Variable | Levels of Quality of PN Care according to the Category of Use (Kotelchuck Index) Combined with Content | |||||||
|---|---|---|---|---|---|---|---|---|
| Level 1: Kotelchuck Adapted to the PHPN | Level-2: Level-1 + Clinical-Obstetric Exams | Level 3: Level-1 + Laboratory Tests | Level 4: Level-1 + Obstetric + Laboratory Exams | |||||
| ORcrude (CI 95%) | ORadjusted (CI 95%) | ORcrude (CI 95%) | ORadjusted (CI 95%) | ORcrude (CI 95%) | ORadjusted (CI 95%) | ORcrude (CI 95%) | ORadjusted (CI 95%) | |
| Age (years) | ||||||||
| <20 | 2.50 (1.43–4.38) | 3.74 (1.90–7.35) | 1.22 (0.78–1.90) | 1.60 (1.00–2.58) | 3.31 (1.92–5.73) | 1.34 (0.80–2.25) | ||
| 20–34 | 1.52 (0.89–2.57) | 1.79 (1.01–3.18) | 1.12 (0.74–1.67) | 1.35 (0.89–2.05) | 1.99 (1.27–3.12) | 1.38 (0.87–2.20) | ||
| ≥ 35 | 1 | 1 | 1 | 1 | 1 | 1 | ||
| Ethnicity | ||||||||
| White | 1 | 1 | 1 | 1 | ||||
| Brown | 1.83 (1.08–3.10) | 0.90 (0.60–1.33) | 1.08 (0.70–1.66) | 0.65 (0.38–1.13) | ||||
| Other | 2.41 (1.18–4.95) | 1.09 (0.59–2.00) | 0.71 (0.38–1.34) | 0.29 (0.29–1.29) | ||||
| Schooling | ||||||||
| ≤Elementary school | 4.03 (2.55–6.37) | 2.53 (1.41–4.53) | 1.45 (1.01–2.07) | 1.34 (0.91–1.98) | 1.07 (0.69–1.68) | |||
| High school | 2.31 (1.50–3.56) | 1.60 (0.94–2.70) | 1.15 (0.84–1.57) | 0.97 (0.70–1.35) | 0.82 (0.56–1.20) | |||
| University education | 1 | 1 | 1 | 1 | 1 | |||
| Marital Situation | ||||||||
| Without partner | 2.02 (1.42–2.89) | 1.62 (1.07–2.46) | 1.43 (1.01–2.02) | 1.82 (1.27–2.61) | 1.62 (1.09–2.41) | 1.71 (1.12–2.59) | 2.10 (1.29–3.46) | 2.33 (1.30–4.17) |
| With partner | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| Family Income | ||||||||
| Up to 1 MW | 3.49 (2.17–5.61) | 1.35 (0.77–2.36) | 1.24 (0.81–1.90) | 1.53 (0.94–2.47) | 1.43 (0.80–2.53) | 2.05 (1.07–3.92) | ||
| 1 to 3 MW | 1.84 (1.25–2.72) | 0.98 (0.62–1.54) | 0.94 (0.70–1.23) | 0.85 (0.61–1.19) | 0.69 (0.47–1.01) | 0.89 (0.58–1.36) | ||
| >3 MW | 1 | 1 | 1 | 1 | 1 | 1 | ||
| ABEP class | ||||||||
| A and B | 1 | 1 | 1 | 1 | ||||
| C, D, and E | 1.95 (1.30–2.90) | 1.13 (0.83–1.53) | 1.07 (0.76–1.48) | 0.92 (0.63–1.35) | ||||
| Planned Pregnancy | ||||||||
| No | 2.12 (1.55–2.90) | 1.73 (1.22–2.47) | 1.16 (0.90–1.50) | 1.50 (1.14–1.96) | 1.45 (1.09–1.93) | 1.42 (1.04–1.92) | 1.41 (1.01–2.00) | |
| Yes | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |
| PN care | ||||||||
| Public | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |
| Private | 0.37 (0.22–0.63) | 1.46 (1.00–2.12) | 1.43 (0.98–2.09) | 2.03 (1.30–2.03) | 3.08 (1.91–4.97) | 4.28 (2.13–8.56) | 6.80 (2.84–16.28) | |
| Abortion | ||||||||
| No | 1.51 (1.03–2.21) | 1.10 (0.79–1.54) | 1.75 (1.22–2.50) | 1.69 (1.13–2.52) | ||||
| Yes | 1 | 1 | 1 | 1 | ||||
| Number of Births | ||||||||
| Primiparous | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| Multiparous | 1.81 (1.35–2.42) | 2.25 (1.50–3.35) | 1.37 (1.07–1.76) | 1.33 (1.03–1.71) | 1.61(1.23–2.10) | 2.17 (1.59–2.96) | 1.53 (1.14–2.07) | 1.49 (1.06–2.11) |
Table 4.
Quality of prenatal care classification and criteria according to the adapted Kotelchuck index combined with prenatal care content.
Table 4.
Quality of prenatal care classification and criteria according to the adapted Kotelchuck index combined with prenatal care content.
| Levels of PN Care Quality Assessment | |||
|---|---|---|---|
| Level | Criteria | Quality | Description of Each Category Content |
| 1 | # of visits Initial GA at the beginning of PN care | More than adequate | Beginning of PN care ≤ 4th month with ≥110.0% of expected visits |
| Adequate | Beginning of PN care ≤ 4th month and with 80.0 to 109.9% of the expected visits | ||
| Intermediate | Beginning of PN care ≤ 4th month and with 50.0 to 79.9% of the expected visits | ||
| Inadequate | Start of follow-up > 4th month and/<50.0% of the expected visits | ||
| 2 | Level-1+Obstetric Procedures | More than adequate | More than adequate Level-1; and ≥5 records of arterial pressure (AP), weight, GA, uterine height (UH), or number of records equivalent to 100% of the number of visits; and ≥4 recordsof cardiofetal heartbeats (CFH) and fetal movement (FM). |
| Adequate | More than adequate or Adequate Level-1; and ≥5 records of AP, weight, GA, UH, or number of records equivalent to 75.0% of the number of visits; and ≥4 records of CFH and MF. | ||
| Intermediate | More than adequate, Adequate, or Intermediate Level-1; and 3–4 records of AP, weight, GA, UH, or number of records ≥50.0% of the number of visits (including for CFH and MF) | ||
| Inadequate | More than adequate, Adequate, Intermediate, or Inadequate Level-1; and <2 records of UH, GA, AP, weight, CFH, and MF | ||
| 3 | Level-1 + Laboratory tests | More than adequate | More than adequate Level-1; and 1 record of ABO/RH test, Hb/Ht, VDRL, QUE, fasting blood glucose, anti-HIV, HbsAg, and Toxop. (1st trimester) |
| Adequate | Adequate Level-1; and 1 record of ABO/RH test, Hb/Ht, VDRL, QUE, fasting blood glucose, anti-HIV, HbsAg, and Toxop.(1st trimester) | ||
| Intermediate | More than adequate, Adequate, or Intermediate Level-1; and at least one record of one of the exams | ||
| Inadequate | More than adequate, Adequate, Intermediate; or Inadequate Level-1; and no record of exams | ||
| 4 | (Level-1 + Level-2 + Level-3) | More than adequate | More than adequate Level-1; and ≥5 records or number of records equivalent to 100% of the number of visits AP, weight, GA, UH; and ≥4 records of CFH and MF; and Exam registration: ABO/RH test, Hb/Ht, VDRL, QUE, fasting blood glucose, anti-HIV, and Toxop. (1st trimester) |
| Adequate | More than adequate or Adequate Level-1; and ≥5 records of AP, weight, GA, UH, or number of records equivalent to 75.0% of the number of visits; and ≥4 records of CFH and MF; and exam records of ABO/RH test, Hb/Ht, VDRL, QUE, fasting blood glucose, anti-HIV, and Toxop. (1st trimester) | ||
| Intermediate | More than adequate, Adequate, or Intermediate Level-1; and 3–4 records of AP, weight, GA, UH, or number of records ≥50% of the number of visits (including CFH and MF); and at least one record of one of the exams | ||
| Inadequate | More than adequate, Adequate, Intermediate, or Inadequate Level-1; and/or <2 records of UH, GA, AP, weight, CFH, and MF; and/or no exam records. | ||
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
MDPI and ACS Style
de Aguiar, D.M.; de Andrade, A.M.; Ramalho, A.A.; Martins, F.A.; Koifman, R.J.; Optiz, S.P.; da Silva, I.F. Assessing the Quality of Prenatal Care: Use of the Kotelchuck Index Combined with Prenatal Care Data. Women 2023, 3, 225-236. https://doi.org/10.3390/women3020018
AMA Style
de Aguiar DM, de Andrade AM, Ramalho AA, Martins FA, Koifman RJ, Optiz SP, da Silva IF. Assessing the Quality of Prenatal Care: Use of the Kotelchuck Index Combined with Prenatal Care Data. Women. 2023; 3(2):225-236. https://doi.org/10.3390/women3020018
Chicago/Turabian Stylede Aguiar, Débora Melo, Andréia Moreira de Andrade, Alanderson Alves Ramalho, Fernanda Andrade Martins, Rosalina Jorge Koifman, Simone Perufo Optiz, and Ilce Ferreira da Silva. 2023. "Assessing the Quality of Prenatal Care: Use of the Kotelchuck Index Combined with Prenatal Care Data" Women 3, no. 2: 225-236. https://doi.org/10.3390/women3020018
