Precariousness of the obstetric network overloads Christmas maternity hospitals

Kayllani Lima Silva
news reporter

In the obstetric care network in Rio Grande do Norte, a situation repeats itself: the pilgrimage of women from the interior of the State in search of care in Natal. The scenario, according to experts interviewed by the TRIBUNA DO NORTE report, is due to a combination of factors that include the lack of qualification of teams in the municipalities, failures in the obstetric regulation center and the structuring of local basic networks. The result of this is the concentration of care and overload in maternity hospitals in Natal. In five years, Natal recorded 89,231 live births. The number is higher than that recorded in cities in the metropolitan region such as Macaíba (7,452), Parnamirim (11,733) and São José de Mipibu (16,439).

In the comparison with João Câmara, births in the capital exceeded the 234 births registered in the municipality by more than 300 times and by around 58 times that of Açu (1,528), both cities with reference units. There are also small municipalities such as Arês and Alto do Rodrigues with less than 10 registered births. For the president of the Gynecology and Obstetrics Association of Rio Grande do Norte (Sogorn), Robinson Dias de Medeiros, the data reflects a precariousness in the State’s obstetric network.

“Although Natal and the metropolitan region have the highest population density in the State, the data obtained from the number of live births in the capital goes beyond that. It’s not just because of this, but because it reflects the precariousness of assistance in other municipalities”, he points out. In addition to this, care for pregnant and postpartum women is permeated by failures in the Obstetric Regulation Center, which hinder communication between systems of lesser and greater complexity for the appropriate referral of patients.

Integrated into this structure, only two maternity hospitals and one hospital are a reference for high-risk births in the network linked to the State Health Department (Sesap/RN). Added to this, in ten years, the capital of Rio Grande do Norte had the highest number of Hospital Admission Authorizations (AIH) for normal and high-risk births, with 62,347 procedures. In the opposite direction, Portalegre, Poço Branco and Itaú appear with only one AIH.

The data are from Datasus, based on the Live Birth Information System (SINASC) and the SUS Hospital Information System. While the number of births corresponds to the period from 2018 to 2022 (limit year of the historical series), by Hospital and other health establishments, the information on AIH covers the period from January 2014 to January 2024.

In the absence of qualified services in some cities, says Robinson Dias de Medeiros, there is a ‘convergence of populations’ in the capital, leading to increased demand and overload in some units, such as the Januário Cicco Maternity School (Mejc/UFRN). The panorama, as described by the specialist in obstetrics and gynecology, is a set of chairs and stretchers occupying the corridors with postpartum women who need local care.

The gynecologist at Mejc, Maria da Guia de Medeiros Garcia, states that the centralization of demand happens mainly in cases of high-risk management, since there are only four units dedicated to these cases in the State. As for high-risk pregnancies, even though other cities have smaller maternity hospitals, they do not always have complete teams that allow patients to remain in their home cities.

“So, we see this data [de nascidos vivos do Datasus] with concern, [sobretudo] bringing it together with the reasons for maternal mortality in Rio Grande do Norte, which is very high”, highlights the president of Sogorn. Maternal death, he continues, consists of preventable death in more than 99% of cases during pregnancy, childbirth and the postpartum period.

Mortality
As data from Datasus shows, in the period from 2018 to 2022, Rio Grande do Norte recorded 182 cases of maternal deaths. In Natal alone, there were 39 cases, the highest recorded among cities. Next, Mossoró (16) and Parnamirim (9) appear. From Brazil to Rio Grande do Norte, the president of Sogorn states that the levels of this occurrence are assessed as high by the World Health Organization, being compared with rates in underdeveloped countries on the African continent.

Whether in the capitals, or in the interior of the State, the expert also warns that this is a data permeated by underreporting. Among the main factors that lead women to die during pregnancy, childbirth or the postpartum period are the lack of qualifications of municipal health teams to provide quality prenatal care. Robinson Dias de Medeiros argues that, apart from this support, professionals need to be qualified to be able to track the gestational risk and refer it appropriately to the necessary institution.

In his opinion, although some cities do not require a high-risk pregnancy service, they need to have a team of professionals to identify these cases. Once these conditions are not ensured, women go on a ‘pilgrimage’ to maternity wards and obstetric services due to a lack of guidance and assertive referrals.

According to Francisco Canindé dos Santos, president of the State Health Council (CES/RN), childbirth is a task that is the responsibility of primary care. Only in cases where patients need specialized attention, as happens at Mejc and Hospital Santa Catarina, should they leave their cities.

“In relation to this high number [de nascidos vivos] in the capital to the detriment of the interior of the State, I draw attention to the issue of ambulance therapy. In most municipalities, any situation that goes beyond the basics is sent to Natal, or taken to a larger municipality. As a result, a situation like this ends up happening”, emphasizes the president of CES/RN.

The set of challenges that permeate the obstetric network in Rio Grande do Norte, observes the president of Sogorn, sheds light on the duties that need to be fulfilled with a focus on better structuring care for the obstetric network in the health regions. He recalls that, according to WHO guidelines, women have the right to receive assistance close to where they live. “It’s not fair for a woman to wander from Canguaretama to Natal, [por exemplo]due to the lack of qualified staff in the municipality”, he criticizes.

The state has 16 service units

In total, Rio Grande do Norte has eight health regions (RS): 1st Region – São José de Mipibu; 2nd Region – Mossoró; 3rd Region – João Câmara; 4th Region – Caicó; 5th Region – Santa Cruz; 6th region – Pau dos Ferros; 7th region – Metropolitan and 8th region – Açu. According to Sesap, assistance for high-risk births takes place in all regions, where each has at least one reference service.

Care for high-risk gestational births, in turn, is present in two health macro-regions: the Extended West, in which the Almeida Castro Maternity Hospital is a reference; and Metropolitana Ampliada, which has Hospital Dr. José Pedro Bezerra and Mejc for service. Throughout the State network, 16 Units operate in the obstetric field. Of them, five are state managed, while the others are divided into municipal, federal and philanthropic management.

The State Government reported that those under its management properly meet demand, within the estimated capacity. At Mejc, in turn, the reality verified by Robinson Dias de Medeiros is reiterated. This is because, according to the Institution, in some periods the capacity for inpatient care is exceeded, reaching an occupancy rate equivalent to 130%. Furthermore, in just one day, approximately 360 patients circulate in the unit, including pregnant women, postpartum women and newborns, distributed in a structure that has 139 beds and 40 rooms/offices. As it is a listed building, there is no possibility of renovations or expansion of its physical structure.

The Ana Bezerra University Hospital (HUAB-UFRN), also under federal management, is able to meet the demand. In the capital of Rio Grande do Norte, in addition to Mejc, two other maternity hospitals managed by Natal City Hall are part of the structure: the Dr. Araken Irerê Pinto Maternity and the Leide de Morais Maternity. Unlike Januário Cicco, the units appear to meet the demand for regular risk. According to SMS, despite not having limitations in infrastructure, it is necessary to expand the structure in care for the mother-baby binomial.

The report contacted Parnamirim City Hall to find out what the Divino Amor Maternity Hospital is in, but received no response.

Pac Saúde plans new maternity hospital in Natal

While the State’s obstetric network shows weaknesses in the assistance offered to mothers, the New Pac Health brings new promises for maternal and child health. Launched by the Federal Government, the program foresees investments in ten areas, including the construction of new maternity hospitals and Normal Birth Centers (CPNs). For Rio Grande do Norte, resources were secured for the construction of a maternity hospital and 63 CPNs distributed across municipalities.

The project for the new maternity hospital was presented by Sesap/RN. According to the ministry, the Unit will be built in Natal, in addition to a CPN, in order to meet high-risk demand. Currently, the works are in the architectural and executive design phase and preparation of documentation for the construction of the building. The choice of the capital as the headquarters of the service took into account the existing structure and the need to expand assistance as it is a hub municipality in the macro-region.

According to the Ministry of Health, R$153 million is planned for the construction of the maternity ward. The criteria used by the ministry in choosing projects include rates of maternal mortality, socioeconomic vulnerability and black, brown and indigenous live births in the Health Macroregion; apart from regional proportionality and cities with inhabitants or more than 4500 live births in 2022.

In Sogorn’s assessment, the MS parameters were coherent as they were related to maternal and child health indicators, in addition to the high maternal mortality ratio in the chosen regions. “I believe that the choice of Natal to host the new maternity ward was the right one, given the greater problems inherent to the greater population density in the metropolitan region of the capital”, reinforces Robinson Dias de Medeiros.

Francisco Canindé dos Santos, in turn, evaluates the program with considerations. Although the set of planned works is quantitatively positive, he argues, it is necessary to think about structuring multi-professional teams in these spaces. “There is no point in building a health unit if, along with the physical construction, you do not provide the conditions that make it prosper and guarantee the assistance that the population needs”, he emphasizes.

Maria da Guia de Medeiros Garcia reiterates the importance of structuring teams, in addition to maintaining the quality of obstetric network services, and suggests the dissemination of consortium systems as a possible way to improve maternal and child care in small cities. In other words, promote partnerships between cities located in the same region to improve services.

Regarding the forecast for a new maternity hospital in Natal, although it recognizes the criteria considered by the Ministry of Health, it states that another more viable path would be to transform the maternity hospital in São José de Mipibu into a unit to care for high-risk cases. According to data from Mejc, provided to the TRIBUNA DO NORTE report, in addition to Natal, the municipality is one of those that most demand obstetrics care in the Maternity, alongside Canguaretama and Nísia Floresta.

According to the Ministry of Health, cities and states with works included in the PAC have until May 10th to complete formalization proposals. Afterwards, the technical analysis period will begin, which should be completed in approximately 20 days. From this, it will be possible to sign the terms of commitment and transfers from the National Health Fund to state and municipal health funds. The ministry’s expectation is that the commitment of resources for all equipment in the country will be ready by June 30th and that the first transfers will be made this year.