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Publicação
Avaliação de desempenho de maternidades de primeira referência na prestação de cuidados obstétricos e perinatais de emergência, antes e depois da política de melhoria da qualidade de maternidades em Moçambique, 2013-2018
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Orientador(es)
Resumo(s)
Introdução
Melhorar a saúde materno-neonatal continua uma prioridade de saúde pública. África Subsaariana e Moçambique mantém altos níveis de resultados adversos no periparto. Os hospitais rurais-distritais provêem cuidados obstétricos-neonatais abrangentes. Analisar o desempenho de serviços de saúde perinatais é essencial para estratégias de sobrevivência de mães e recém-nascidos.
Objectivos
i) rever os factores de partos institucionais em países de baixa renda; ii) determinar níveis e os factores da utilização de serviços materno-neonatais (SMN) em Moçambique; iii) estimar os efeitos de intervenções - maternidade modelo (IMM) e pagamento por desempenho (P4P) - nos indicadores de SMN; iv) caracterizar a prontidão de SMN de hospitais distritais-rurais.
Métodos
1) revisão de literatura sobre partos institucionais; 2) análise de regressão identifica factores associados à subutilização de SMN; 3) análise de dados populacionais, por regressão e diferença-na-diferença, estima efeitos de P4P sobre provisão de SMN; 4) análise de base hospitalar, antes-depois e diferença-na-diferença, dos efeitos de P4P e IMM sobre: a) completude de partograma; b) determinantes de cesariana e complicações materno-fetais; c) tempo até o parto e alta; d) desempenho de SMN; e 5) inquérito à prontidão das maternidades dos hospitais rurais-distritais.
Resultados
Nos países de baixa renda, ainda predomina a baixa cobertura de partos institucionais, embora heterogénea (13-98%). Factores da subutilização de maternidades incluem longas distâncias até as unidades de saúde, má qualidade dos serviços providos, a demografia, socio-economia e fraco empoderamento das mulheres.Em Moçambique, a subutilização de SMN é prevalente: 13% de gestantes não realiza qualquer consulta pré-natal (CPN), e até 75% são perdidas na cascata de SMN. Os factores associados são a baixa escolaridade das mulheres, residência rural, pobreza, distância até unidades de saúde e situação de HIV desconhecida. As gestantes atendidas nos serviços de maternidade são jovens (idade média de 25 anos, DP = 7), multíparas (64%), com alto risco obstétrico (25%), e beneficiam de limitado monitoramento intraparto (40-50%).
A P4P incrementou testagem de HIV (incremento médio: 19,9%-24,6% pontos), sem efeito sobre cobertura de CPN, partos institucionais e conhecimento das mulheres acerca da transmissão do HIV. A IMM reduziu tempo para início de cesariana. A idade (-2 a -4% por incremento de 1 ano na idade), ser transferida (OR = 1,9-3,4) e apresentar pré-eclâmpsia (OR = 2,0 -2,2) são associados à complicação materno-fetal periparto.
A pontuação percentual de prontidão de CPN, de atendimento à parto normal e complicado foi de 56%, 81% e 67% respectivamente. A prontidão de SMN não está associada à prontidão de programas verticais, embora estes operem incorporados nos serviços de maternidade.
Conclusões
É reportado, em Moçambique, o incremento de acesso à SMN nas últimas 3 décadas, mas a proporção de gestantes retidas na cascata de cuidados perinatais ainda está aquém do almejado, sendo determinados por factores socioeconómicos. As intervenções sobre o desempenho de SMN não melhoraram a prontidão nem o monitoramento intraparto. O P4P não teve efeitos nos indicadores de SMN, tendo contribuído para incremento de indicadores de serviços-HIV. É importante promover a integração operacional dos programas de saúde e fortalecer os efeitos positivos das intervenções sobre desempenho de SMN.
Introduction Maternal-neonatal health (MNH) remains a major global and local public health priority. Sub-Saharan Africa, including Mozambique, burdens highest adverse peripartum events. Rural and district hospitals perform comprehensive obstetric-neonatal health care, and lessons learned from performance interventions targeting MNH are key for strategies on maternal-neonatal survival. Objectives The objectives were: i) to review levels and factors of institutional deliveries in low-income countries; ii) to determine levels and factors of MNH care non-utilization in Mozambique; iii) to estimate the effects of model maternity (MMI) and pay-for-performance (P4P) on MNH indicators; iv) to characterize rural-district hospitals readiness for peripartum health care. Methods Studies include: 1) literature review about institutional deliveries; 2) regression analysis identify factors associated with MNH cascade utilization; 3) a population based before-after, difference-in-difference, regression analysis estimate P4P effects on MNH indicators; 4) a hospital registry before-after, difference-in-difference, regression analysis of P4P and MMI effects on: a) partograph completeness; b) correlates of: first-caesarean, maternal and foetal complications; c) correlates of inpatient timespan until delivery, and until discharge; d) effects on maternity health care performance indicators; and 5) a survey on district-rural hospitals maternities readiness. Results In low-income countries, institutional deliveries uptake remains low although heterogeneous (13-98%). Factors associated with underutilization includes long distances to health facility, poor health care quality, women’s socio economics, demographics, and disempowerment.In Mozambique, MNH care cascade underutilization is prevalent: 13% of women miss any antenatal consultation (ANC), up to 75% of women drop-off the ante-natal to post-natal heath care cascade. Factors associated includes women’s low education, rural residency, low wealth, distance to health facilities and unknown HIV status. Women utilizing maternity services are characteristically young (mean age 25 years, SD=7), multiparous (64%), having obstetric-risk (25%), receive limited intrapartum monitoring (40-50%). The P4P intervention positively affected HIV testing by average between 19.9% and 24.6% points, but had no effects on ANC uptake, institutional deliveries, and women’s knowledge about HIV transmission. First-caesarean and maternal-foetal peripartum complication correlates were age (average decrease -2 to -4% per 1-year age increment), being referred-in (OR= 1.9-3.4), and presenting pre-eclampsia (OR=2.0-2.2). The ANC, normal delivery and advance delivery service readiness score were respectively 56%-points, 81%-points, 67%-points. Overall MNH service readiness was not associated with readiness of vertically run programs, although these operates embedded in maternity services. Conclusions While access to MNH care has improved in Mozambique over the past 3 decades, the proportion of women utilizing the entire MNH cascade is still suboptimal, being disadvantageous socio-economics key determinant. Performance improvement interventions on MNH services did not improve services readiness nor intrapartum monitoring. P4P had no effects on key maternal and neonatal coverage indicators but had positive effects primarily on HIV indicators. Policies need to address more aggressively programs integration and strengthen holistically quality improvement interventions impacts.
Introduction Maternal-neonatal health (MNH) remains a major global and local public health priority. Sub-Saharan Africa, including Mozambique, burdens highest adverse peripartum events. Rural and district hospitals perform comprehensive obstetric-neonatal health care, and lessons learned from performance interventions targeting MNH are key for strategies on maternal-neonatal survival. Objectives The objectives were: i) to review levels and factors of institutional deliveries in low-income countries; ii) to determine levels and factors of MNH care non-utilization in Mozambique; iii) to estimate the effects of model maternity (MMI) and pay-for-performance (P4P) on MNH indicators; iv) to characterize rural-district hospitals readiness for peripartum health care. Methods Studies include: 1) literature review about institutional deliveries; 2) regression analysis identify factors associated with MNH cascade utilization; 3) a population based before-after, difference-in-difference, regression analysis estimate P4P effects on MNH indicators; 4) a hospital registry before-after, difference-in-difference, regression analysis of P4P and MMI effects on: a) partograph completeness; b) correlates of: first-caesarean, maternal and foetal complications; c) correlates of inpatient timespan until delivery, and until discharge; d) effects on maternity health care performance indicators; and 5) a survey on district-rural hospitals maternities readiness. Results In low-income countries, institutional deliveries uptake remains low although heterogeneous (13-98%). Factors associated with underutilization includes long distances to health facility, poor health care quality, women’s socio economics, demographics, and disempowerment.In Mozambique, MNH care cascade underutilization is prevalent: 13% of women miss any antenatal consultation (ANC), up to 75% of women drop-off the ante-natal to post-natal heath care cascade. Factors associated includes women’s low education, rural residency, low wealth, distance to health facilities and unknown HIV status. Women utilizing maternity services are characteristically young (mean age 25 years, SD=7), multiparous (64%), having obstetric-risk (25%), receive limited intrapartum monitoring (40-50%). The P4P intervention positively affected HIV testing by average between 19.9% and 24.6% points, but had no effects on ANC uptake, institutional deliveries, and women’s knowledge about HIV transmission. First-caesarean and maternal-foetal peripartum complication correlates were age (average decrease -2 to -4% per 1-year age increment), being referred-in (OR= 1.9-3.4), and presenting pre-eclampsia (OR=2.0-2.2). The ANC, normal delivery and advance delivery service readiness score were respectively 56%-points, 81%-points, 67%-points. Overall MNH service readiness was not associated with readiness of vertically run programs, although these operates embedded in maternity services. Conclusions While access to MNH care has improved in Mozambique over the past 3 decades, the proportion of women utilizing the entire MNH cascade is still suboptimal, being disadvantageous socio-economics key determinant. Performance improvement interventions on MNH services did not improve services readiness nor intrapartum monitoring. P4P had no effects on key maternal and neonatal coverage indicators but had positive effects primarily on HIV indicators. Policies need to address more aggressively programs integration and strengthen holistically quality improvement interventions impacts.
Descrição
Palavras-chave
Saúde pública Maternidade Obstétricia Avaliação do desempenho de maternidades Melhoria da qualidade Moçambique