With a view to improving maternal health, the United Nations (UN), in 2015, launches a global agenda that brings together goals for sustainable development to be achieved by the year 2030. The perspective is that, based on integrated actions that address the promotion of health and well-being, the maternal health rate will be reduced to less than 70 deaths for every 100,000 live births worldwide.⁵

In the search to achieve the objectives agreed worldwide, as well as to guarantee health to women during the pregnancy-puerperal period, in Brazil prenatal care is a right recommended by the Unified Health System (UHS) and has primary health care (PHC), preferably covered by the Family Health Strategy (FHS), a gateway to longitudinal care for low-risk pregnant women, with monthly consultations up to the 28th week, biweekly between 28th and 36th weeks and weekly from the 36th until delivery.

In addition, during the prenatal period, the partner's right to be cared for through consultations, laboratory tests and access to health education practices is guaranteed. This attention to women contributes to the favorable perinatal and maternal outcome, due to the identification of risk factors that can cause complications to pregnancy, in addition to allowing the detection and timely treatment of complications.^6-7

In order to promote maternal health, it is necessary to comply with the recommended number of prenatal consultations, to ensure the prevention, diagnosis and treatment of intercurrent diseases of pregnancy and the establishment of a maternal immunization program. Adequate prenatal care is given by incorporating welcoming conducts and building spaces for groups of pregnant women, to share experiences, feelings, fears, expectations and doubts, in order to meet the main complaints and demands to promote a care plan individual and group support.^6,8-9

In view of the need to face problems related to assistance during pregnancy, the Humanization Program for Prenatal care and Birth (HPPB) was implemented in Brazil. This program aims to ensure the improvement of access, coverage and quality of monitoring, in addition to the provision of assistance during childbirth and the puerperium (to pregnant women and the newborn), to achieve an integrated, qualified and humanized obstetric care.¹⁰

As a complement to PHPN, the federal government has been implementing the Stork Network Program since 2011, which aims to foster the implementation of a new model of health care for women and children, from childbirth to 24 months of age. The aim is to organize the Maternal and Child Health Care Network to guarantee access, reception, resolution and reduce maternal and child mortality, with emphasis on the neonatal component.¹⁰

In this program, the nurse is highlighted in terms of low-risk prenatal care, since it serves the majority of pregnant women in the FHS. Therefore, this study was the basis for low-risk prenatal care according to what is recommended by the Primary Care Notebook (PCN) of the Ministry of Health (MH), in order to evaluate the attributes that impact the reduction of unfavorable obstetric results. The quality of care for pregnant women is closely related to the health levels of mothers and babies, and its investigation is a powerful guiding tool for managers and health professionals.⁶

Despite wide coverage, prenatal care in Brazil still presents a context of inequities and a low supply of adequate care, especially among black women living in the poorest regions of the country.³Given the above, it is necessary to evaluate the execution of care and actions that aim at comprehensive care in an equitable way within the UHS and in the context of the Northeast region of the country. Thus, it presents itself as a research question: how prenatal care is offered from the perspective of nurses within the scope of the FHS? This study aimed to: evaluate prenatal care from the perspective of nurses within the scope of the FHS.

Method

This is a descriptive, exploratory study with a quantitative approach, carried out in the Sanitary District II (SD II) of the city of Recife, Pernambuco (PE), Brazil. The population consisted of 42 nurses assigned to the 20 FHS and the sample consisted of 29 participants (seven professionals refused to participate in the research; four were on sick leave and two were on vacation). Those who met the following inclusion criteria were invited to participate in the research: exercise their activities in the FHSs belonging to the SDII. Those on vacation and those on sick leave during the research period were excluded.

For collection of primary data, a questionnaire prepared by the researchers with open and closed questions was used, with a total of 58 questions, elaborated from the PCN: attention to low-risk prenatal care, edited by the MH,⁶ focusing on the attributions of the nursing professional in the care of pregnant women.

The questionnaire was organized considering the following variables: Profile of nurses (age, sex, training institution, postgraduate courses and length of experience in PHC); Organization of services, planning and programming (physical structure of the units, human resources, equipment and materials available at the FHS, the planning and programming of activities); Reception (form of reception of the pregnant woman and her companion); Prenatal care (pregnancy diagnosis, classification of gestational risk, first and subsequent consultations, assessment of nutritional status, gynecological examination and collection of materials for oncotic colpocytology, clinical breast examination) and Educational actions (topics covered and the way these activities are developed).

The research data collection was carried out from October to November 2016. The collection time was extended to 60 days, because some FHS had to be visited more than twice, due to the difficulty in locating the nursing professional, who was on home visits or in other activities.

Data analysis was performed by building a database in the Statistical Package for Social Sciences for Personal Computer (SPSS-PC),¹¹ version 22. The purpose of using this program was to obtain agility in the interpretation and analysis of the information collected. After coding, data was analyzed statistically from which its relative and absolute frequencies were obtained. The tables were presented using the Excel 2010 program.

The research was guided by ethical aspects and legal implications according to the National Health Council of nº. 466, of December 12, 2012 which approves the guidelines and standards for research involving human beings and approved by the Ethics Committee of the Oswaldo Cruz University Complex Hospital, Cardiology Emergency Room of Pernambuco, on 08/09/2016 with Opinion nº 1,716,887.

Results

The participants in the present study were aged between 26 and 65 years, with the majority belonging to the age group of 26 to 45 years (51.7%). There was a predominance of female nurses (96.6%), graduated from a public university (62.1%), with title of specialists / residents (93.1%).

Table 1 shows that 75.9% of respondents were dissatisfied with the FHS physical area. When consulted about human resources, more than half (55.2%) answered that they are not sufficient for adequate care. As for material resources, 69.0% have material for gynecological examination. Regarding the efficiency of the referral and counter-referral system, 20.7% of nurses considered the system to be efficient. During prenatal consultations, 100.0% of the participants answered that they perform a risk classification. When asked if they frequently consulted the Low Risk Prenatal PCN, 34.5% answered that they did not.

Table 1 - Distribution of the frequency of aspects related to the adequacy of the organization of services, planning and programming of prenatal activities. Sanitary District II, Recife, Brazil, 2016.

Variables	n	%
Adequacy of the physical area
Yes	7	24.1
No	22	75.9
Human Resources
Yes	13	44.8
No	16	55.2
Material resources
Gynecological Table	29	100.0
Spotlight	28	96.6
Sphygmomanometer	28	96.6
Adult scale	27	93.1
Flexible and inelastic measuring tape	22	75.9
Sonar Doppler	22	75.9
Gestogram or Obstetric Disc	22	75.9
Material for gynecological examination	20	69.0
Efficiency of the Reference and Counter-reference system
Yes	6	20.7
No	23	79.3
Gestational Risk Classification
Yes	29	100.0
Use of the Primary Care Notebook
Yes	18	62.1
No	10	34.5
Did not answer	1	3.4
Source: Primary data

Regarding the immediate reception of pregnant women, it was observed that 7.0% of the participants answered that they do not. Regarding the reception of the woman's companion for participation in prenatal care, 96.6% of the professionals answered that they do so.

Graph 1 shows the distribution of items related to prenatal care in relation to early uptake and the diagnosis of pregnancy by offering a rapid pregnancy test and requesting the Beta Human Chorionic Gonadrotopin (BHCG). It was observed that 82.2% of pregnant women were caught early by the professionals and that in more than 80.0% of these women were asked to prove pregnancy tests.

Graph 1 - Distribution of the characteristics of prenatal care, in relation to early uptake, and pregnancy diagnosis in the FHS of the DSII, Recife, 2016.

Source: primary data

Table 2 shows the results related to filling out the prenatal clinical form, registering the reference maternity on the pregnant woman's card, prenatal consultations and performing preventive exams. It is observed that the majority of nurses reported completing the prenatal clinical form, requesting complementary exams and registering the reference maternity (93.1%, 93.1% and 79.3%, respectively).

Table 2 - Distribution of characteristics of prenatal care provided by nurses in the FHS of the SDII, Recife, 2016.

	n (Yes)	% (Yes)
Completion of the PN Clinical record	27	93.1
Request for Complementary Exams	27	93.1
Reference maternity registry	23	79.3
First consultation
Anamnesis	28	96.6
Vitamin supplementation	29	100.0
Interwoven consultations with the Doctor	25	86.2
Offer fast testing for syphilis / HIV*	12	41.4
Subsequent consultations
Targeted Physical Exam	29	100.0
Control of vaccination schedule	29	100.0
Evaluation of laboratory tests and others	29	100.0
Assessment of emotional state	29	100.0
Active search	28	96.6
Assessment of nutritional status	25	86.2
Preventive tests
Oncotic cytology	16	55.2
Clinical breast examination	28	96.6
HIV: Human Immunodeficiency Virus* Source: Primary data

Regarding the complementary tests requested in the first consultation, as recommended by the Low Risk Prenatal CAB, the most cited regarding the request were: blood count (86.2%), blood typing and Rh factor (86.2%), fasting blood glucose (86.2%), serologies that include screening for syphilis and or Venereal Disease Research Laboratory (VDRL) (89.7% ), anti-HIV (Human Immunodeficiency Virus) (89.7%), toxoplasmosis (86.2%), serology for hepatitis B (HbsAg) (82.8%) and urine summary (82.8%). Those cited less frequently were: urine culture (75.9%), hemoglobin electrophoresis (58.6%), obstetric ultrasound (51.7%) and parasitological stool examination (27.6%). The question about the complementary exams was not answered by 10.3% of the participants.

Regarding the targeted and specific physical examination, clinical and obstetric, it was found that 100% of nurses refer to their performance. Among the most frequently performed procedures are the control of blood pressure, obstetric palpation and measurement of uterine height, auscultation of heartbeat and verification of edema. When asked about what educational activities, 89.7% of nurses reported that they perform individual activities and 13.8% of respondents did not answer about activities in groups and waiting room as described in Table 3.

Table 3 – Distribution of educational activities and topics addressed in groups in Family Health Units in the Sanitary District II, Recife-PE, Brazil 2016.

Variable	n	%
Educational activities
Individual
Yes	26	89.7
No	3	10.3
In group and waiting room
Yes	15	51.7
No	10	34.5
Did not answer	4	13.8
Theme of educational activities
Breastfeeding	29	100.0
Healthy Habits	28	96.6
Family Planning	27	93.1
Newborn care	27	93.1
Importance of Prenatal care	26	89.7
Signs of Labor	26	89.7
Risks associated with pregnancy and childbirth	25	86.2
Self-medication risks	25	86.2
Risks of alcohol and drugs	25	86.2
Sexual activity and STI / AIDS prevention*	24	82.8
Rights of the pregnant woman and the father	22	75.9
Domestic and sexual violence	16	55.2

* STI: Sexually Transmitted Infections / AIDS: Acquired Immunodeficiency Syndrome

Source: primary data

Among the various educational themes that should be addressed in prenatal care, the following stand out: guidelines on breastfeeding (100%), followed by guidelines on healthy habits, family planning, newborn care, prenatal importance, among others. The themes such as the rights of the pregnant woman and the father and domestic and sexual violence were the least addressed (Table 3).

Discussion

In the present study, it was possible to analyze the quality of the prenatal care process in the city of Recife from the perspective of FHS nurses located in the SDII. To this end, the recommendations in the Low Risk Prenatal PCN were used as a reference, which deals with the organization of the work process, the health service and planning aspects, established by the MH to monitor pregnant women with low gestational risk and possible complications. In addition, aspects related to health promotion, special pregnancies and legal aspects related to pregnancy, childbirth / birth and the puerperium were evaluated.¹⁰

In this research most of the participants were female. It is evident the female predominance in nursing and the context of women's participation in health care activities. This aspect may be related to its insertion in the labor market and the possibilities of activities outside the domestic scope, given the assistance nature and role of caregiver historically assigned by society.¹²

In the studied scenario, low adherence to the National Program for Improvement of Access and Quality of Primary Care (PIQC) was identified. The small adherence to the strategic focuses of prenatal care, to the strategic initiatives and programs of the MH, such as Stork Network and Pact for Life, can contribute to risks of morbidity and mortality and adverse maternal and child outcomes that could be avoided.¹³

Regarding the organization of services, planning and programming, the lack of adequate infrastructure and insufficient human resources was highlighted. These difficulties alluded to by these nurses may reduce the quality of care provided to the population, as they hinder care, comprehensive monitoring and problem solving.In addition, the inadequacy of some physical spaces, their unavailability, due to the low number of rooms for service and limited spaces for group activities, are factors that hinder the quality of care.¹⁴

A study carried out at the national level showed inadequacy of the infrastructure of the primary care network that offers prenatal care in all geopolitical regions of Brazil. In addition, he mentioned the precariousness of the adequacy of clinical actions for the quality of care and insufficient management capacity of the teams to guarantee access. There was also a direct relationship between adequacy of infrastructure and social contexts with higher Municipal Human Development Index and income.¹⁵The monitoring of the pregnant woman and the mother / child binomial occurs in a longitudinal way, and the environment is suitable for carrying out the detailed physical examination, during the nurse's consultations, a fundamental strategy to reduce maternal and neonatal morbidity and mortality.⁸

With regard to equipment and materials, health units must have at least: table and chairs for consultations; gynecological table; two-step ladder; light focus; anthropometric scale for adults; sphygmomanometer; clinical stethoscope; Pinard's stethoscope; measuring tape; specula; Cheron forceps; instruments for collecting material for Pap smear; gestogram or obstetric disc; and Doppler sonar (if possible).⁶

Data referring to material equipment showed that most FHS have the materials as recommended by the MH, and in 24.7% there was an absence of Doppler sonar, Pinard's stethoscope (37.9%) and collection materials for oncotic colpocytology (COC)(31%). Corroborating with a study from Ceará, in which the conceptions of pregnant women and nurses about prenatal care in PHC were evaluated, there was a lack of materials in the FHS, to check fetal heartbeat.⁷ Most FHS have two teams and prenatal care is scheduled, due to the unavailability of the device for each team, the teams have to share, the professional has to leave the room and get the sonar with the other professional who is also in attendance.

Considering the issues related to the classification of gestational risk, management can be considered high, since all professionals performed it, corroborating with the literature.¹⁵ The MH advises that the classification of gestational risk should be carried out in the first and subsequent consultations, in addition to ensuring access to the reference service for pregnant women classified as at risk.¹⁰

Regarding the mechanism for coordinating care in the referral and counter-referral system, it is worth mentioning the low efficiency reported by nurses, in relation to the care for pregnant women. The results found corroborate with other studies.^15-16 The low efficiency of the referral and counter-referral process is indicative of failures in the dynamics of referrals and the return of information by specialists who participate in the service network, thus, improvements in the management of this process are necessary in order to ensure the effectiveness of longitudinal monitoring of pregnant women during prenatal care.¹⁷

The implantation of the electronic medical record can make prenatal care viable, especially for the referral and counter-referral system, as it allows the flow of information between the health services of the different levels of care.¹⁶In this sense, the link between the FHS and the other health reference centers must be guaranteed for comprehensive care for pregnant women during prenatal care, childbirth and the puerperium, within the scope of primary care and in maternity hospitals, as defined by the local manager.

In addition, it is essential that all pregnant women are oriented / referred to specialized care when they have clinical / obstetric complications or when in labor. These health care centers must provide a counter-reference to the unit of origin for continuity of care, in a comprehensive and longitudinal manner by the FHS of their territory.

About regular use during PCN consultations Attention to Low Risk Prenatal Care, it was observed that for most nurses this document is an important tool for conducting care. It is noteworthy that most professionals had specialization in the field of public health and have worked for more than 11 years in the FHS. Theoretical-practical basis based on standardized assistance, with consultation to the PCN, are fundamental for comprehensive assistance.¹⁰

The MH recognizes the organizational structure as a fundamental point to ensure a safe practice during prenatal care. In this perspective, a facilitating environment for integrated health actions that consider aspects related to physical plant, human and material resources, laboratory support, and access to medication, registration instruments and the reference and counter-reference system is recommended.¹⁵

The ambience in health refers to the treatment given to the physical space, understood as a social, professional and interpersonal relations space that should provide welcoming, resolute and humane care. The quick reception is a guarantee of care for all newborns and all pregnant women and puerperal women who seek the FHS, recommended for effective prenatal care.

In the results, it was observed that 93.1% of the professionals immediately welcomed all pregnant women and women who had recently given birth. The quick reception is a guarantee of care for all newborns and all pregnant women and puerperal women who seek the FHS, recommended for effective prenatal care.⁶

Reception, as recommended in the humanization policy, implies the reception of women, since their arrival at the FHS.¹⁶ Thus, the construction of the bond is important for a satisfactory prenatal care. Welcoming is, first of all, an ethical action to be performed by all members of the multi-professional team for qualified listening, in order to meet the needs of the pregnant woman. This action also implies the flow of work processes, teams, services and networks, aimed at the conception of the expanded clinic.

Considering early uptake, the diagnosis of pregnancy through the offer of rapid testing and BHCG request obtained satisfactory results in relation to the adequacy of prenatal care. This assistance includes the diagnosis of pregnancy, either by offering a quick test, or by requesting the BHCG in the face of signs of presumption and probability presented by the patient, these tests were implemented by the MH, through the stork network, to increase the early capture of pregnant women, as it speeds up the process necessary for the confirmation of pregnancy and the beginning of prenatal care.⁶

In this research, the frequency of reference maternity records mentioned on the pregnant women card was higher than 79%. In another study, similar records were found, 87.3% of the mothers reported having received information about the reference maternity. Failure to do so may lead pregnant women to travel to health facilities at delivery or in case of emergencies.¹⁵

Prenatal screening for Sexually Transmitted Infections (STIs) is highly relevant. Detection of HIV and syphilis during prenatal care is essential to control vertical transmission.¹⁵

It is recommended that low-risk prenatal consultations be interspersed between the doctor and the nurse.³ The results showed that 13.8% of professionals reported that there were no appointments interspersed with a doctor, however, teamwork in prenatal care in primary care contributes to the sharing of knowledge and comprehensive care. Thus, interspersed consultations could favor decision-making for better targeting of consultations, request for additional tests, case discussion, in addition to educational actions with themes aimed at reducing maternal and child morbidity and mortality.

With regard to the Pap smear exam, the results found showed that 44.8% of professionals do not perform it during pregnancy. According to the MH, this examination should preferably be carried out on the 7th month of gestation according to the individualized indication.⁶

The prevention or diagnosis of cervical cancer during pregnancy is recommended by the MH, especially for women with delayed preventive follow-up. However, many women still do not undergo the examination during pregnancy, out of shame or fear, embarrassment, difficulty in communication, discomfort among other factors and therefore, they may miss the opportunity for prevention.⁶

Performing the breast exam is important during pregnancy, as it allows the observation of changes and transformations during the pregnancy period. Modifications such as increased pigmentation of the areola and nipple, presence of visible superficial veins, presence of sebaceous glands in the areola, colostrum and anomalies that may hinder lactation, among others, and should therefore be practiced from the first consultation.⁶Another study carried out in the Northeast region found that 50% of nurses performed the breast exam of pregnant women.⁸

It was evidenced that 90% of the pregnant women were satisfied with the nurse's care. However, it is essential to carry out other research that considers an empirical analysis about the performance of prenatal care, through permanent education with a view to qualifying care through action-reflection-action of their practices.¹⁸

Nurses must also be able to carry out home visits aimed at expanding assistance to the PN, when necessary, to avoid possible complications.In order to improve the quality of prenatal care, it is important to offer continuing education for managers, with an emphasis on the essential skills of prenatal care.^15-17 The implementation of permanent health education strategies must prioritize the critical-reflexive nature of the assistance anchored to the PHC precepts, agreed with the Stork Network and the knowledge and practices of the multidisciplinary team with a view to the quality of comprehensive care during prenatal care.¹⁹

Conclusion

The evaluation of prenatal care, from the perspective of nurses in the FHS scope, presented contributions to the recognition of the limits and possibilities for adherence to prenatal care. This adherence, as recommended by the MH, aims to reduce risks to maternal and fetal health, considering the context of social vulnerability of a health district in the northeast of Brazil.

The unsatisfactory quality of prenatal care was evidenced, due to inadequate infrastructure, insufficient human and material resources, ineffective referral and counter-referral systems, in addition to the delay and failure to perform the recommended exams. Such findings refer to the social determination of the health-disease process and the need to share responsibility with the State, health professionals and health users in facing maternal and perinatal morbidity and mortality.

The permanent qualification of nurses for prenatal care must enable a satisfactory and humanized experience, which considers the meanings of motherhood and provides opportunities for health promotion and prevention of diseases and injuries.

A possible limitation was the performance of data collection in only one SD, with an emphasis on nurses and aspects related to prenatal care in this area. On the other hand, the results made it possible to evaluate the quality of the participants' assistance, which enabled comparisons with other studies. Further research is recommended related to the importance of permanent education practices for nurses for qualified prenatal care.

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Corresponding Author

Paula Daniella de Abreu

Email: pauladdabreu@gmail.com

Address: Av. Prof. Moraes Rego, 1235 - Cidade Universitária, Recife – PE

CEP: 50670-901

Authorship contributions

1 – Luana Carla dos Santos Nascimento

Construction of the project, conducting data collection and analysis, as well as critical review of the final version of the research report.

2 – Maria Rejane Ferreira da Silva

Support and guidance in the construction of the project, conducting data collection and analysis, as well as critical review of the final version of the research report.

3 – Paula Daniella de Abreu

Support and guidance in the construction of the project, conducting data collection and analysis, as well as critical review of the final version of the research report.

4 – Ednaldo Cavalcante de Araújo

Support and guidance in the construction of the project, conducting data collection and analysis, as well as critical review of the final version of the research report.

5 – Maria Lúcia Neto de Menezes

Construction of the project, conducting data collection and analysis, as well as critical review of the final version of the research report.

6 – Elaine Cristina Tôrres Oliveira

Construction of the project, conducting data collection and analysis, as well as critical review of the final version of the research report.

How to cite this article

Nascimento LCS, Silva MRF, Abreu PD, Araújo EC, Menezes MLN, Oliveira ECT. Nurses' perspective on prenatal care under the Family Health Strategy. J Nurs. UFSM. 2020 [Acess IN: Year Month Day]; vol.10 e44: 1-20. DOI: https://doi.org/10.5902/2179769238444