Positive impact
In the majority of the interviews held at stage 1 (6 months), the professionals understood that implementation of the network had produced positive effects and this was confirmed at 12 months, as shown in Table
2. The categories that were only identified in the interviews held in stage 2 (12 months) were the need to improve prenatal care and the importance of the findings at a scientific level.
Table 2
Why interviewees believe that the surveillance project on severe maternal morbidity had a positive feedback
Change in how cases are identified | × | × |
Better organization in the center/routine/standardization of staff activities | × | × |
Dissemination of knowledge at local/regional level/changes in health policies | × | × |
Proposed changes in routines/protocols | × | × |
Review of severe cases | × | × |
Reduction in maternal morbidity and mortality | × | × |
Local and/or national diagnosis of maternal morbidity | × | - |
Improvements required in prenatal care | - | × |
Importance at scientific level | - | × |
In the evaluation of the majority of the participants, the network project contributed towards introducing changes to improve the service. According to the interviewees, there was an improvement in the knowledge of the health professionals in relation to severe maternal morbidity. It was mentioned that participating in this project helped clarify the criteria established by the WHO, resulting in a better understanding by the participants.
I believe that this work helped … with the concepts, the concepts became clearer, I was able to fix the concepts of the criteria of severe maternal morbidity better in my mind and exactly because I was more aware of these concepts, these criteria, it is easier for me to identify these cases today, but it was because of this, basically because of this”. (Case 34A, coordinator).
Thirty-three of the subjects stated that improvements occurred in the organization of the center and in its routine, with the team activities being standardized. Several individuals at different moments mentioned that a standardization in attitudes enabled cases to be identified more easily. In particular, this achievement was a consequence of the standardization of the team’s clinical activities, including those of duty staff, and of defining data that should be mandatorily collected, but that had previously received little attention.
In addition, this standardization contributed towards changes in protocols. Seven of the interviewees stated that the network encouraged a review to be made of severe cases as a means of identifying where and how problems occurred. Individuals stated that reviewing cases allowed feedback to be given to colleagues with respect to care that was possibly inadequate or delays that may have occurred in any action.
“I believe it was worthwhile, because, as I said, it is about reevaluating each case, right, discussing it with the chief and finding out why some cases, despite having the criteria established for severe maternal morbidity, are not followed-up as they should be…so then we reevaluate them. (Case 43A, coordinator).
In both stages of the project, some of the interviewees mentioned that the main impact of the project was in disseminating knowledge, not only within their own center but also in other spheres (at local and regional level).
“Yes, because from the time it was implemented…all this training, particularly the…of the head of the ICU, right? Dr. X, we also began to…disseminate this knowledge within our own institute and at regional events”. (Case 62A, manager).
At 12 months, the most obvious improvements in the center, such as ensuring compliance with protocols, was evident even to physicians who had not been present during the implementation phase of the Brazilian Network for the Surveillance of Severe Maternal Morbidity. Some stated that strict compliance with protocols leads to excellent long-term results. Others mentioned that the greatest contribution to the health of these pregnant women was the reduction in the rates of maternal mortality and morbidity. In one interview, an individual stated that there had been a reduction in the mortality rate at the center.
“Definitely. After the network was implemented, we had no more maternal deaths. In 2009, at the beginning, before the network, we had four”. (Case 23A, investigator).
It was only in the interviews held at stage 2 that the importance of the study in “scientific” terms was mentioned, i.e. the results of implementing the network were published in journal articles that ratified the importance of the network itself.
Again I would say yes…nevertheless, I believe that it adds to current scientific knowledge on the subject; conduct is now professional. [So it would be scientific conduct. What do you mean by scientific conduct?] The analyses are now complete, a short time ago Dr. Y sent us two very interesting papers to analyze…with very interesting statistical and epidemiological methodology that confirmed what we already knew in the clinic, but showing the results scientifically, confirming the importance of the criteria”. (Case 49B, investigator).
There were reports in the interviews of proposed changes in the center after the network was implemented, with the objective of solving problems based on identified shortcomings. There was also mention of proposals to improve the center either by constructing an ICU or other facilities that would allow them to provide better care.
“I believe that (by talking about?) the subject, ensuring that…perhaps by making the center recognize its failings, seeing what is wrong within the center and also what is wrong with the center within the health system and where these problems are, trying to solve some of these problems, from the simplest to the most complex, so I think this experience should be expanded to all maternity hospitals, managing the problems to ensure that they are really prevented (in terms of severe conditions?) and solving these problems”. (Case 20B, coordinator).
The interviewees mentioned the importance of the project and the need to create health policies based on the results found.
“It’s like I already said. I think that if the results are shown to the managers, the health secretary or the managers of the unit itself, this is going to result in changes in behavior, in routines, protocols will be implemented”. (Case 40B, investigator).
Some interviewees pointed out a need to improve prenatal care and spoke of its importance in improving the health of the pregnant woman.
“In the sense of alerting doctors and the population itself to the importance of prenatal care. Its importance in preventing these diseases, alerting the government to invest more in hiring more doctors, invest more in basic healthcare, in the primary healthcare network to promote prevention and ensure that quality prenatal care is provided”. (Case 2B, manager).