| Managerial |
The analysis pointed to difficulties in referring preterm infants to specialized services and prolonged time to carry out exams, in addition to the inefficiency of referral and counter-referral, which indicate the need for improvements in written and verbal communication between professionals from different points of the care network. |
What makes it difficult is the lack of tools themselves. Vacancy for baby hearing test and tongue-tie assessment. This is more complicated, it takes too long, the heel prick test also takes too long (E2A).
Our hands are tied, because there are some referrals that take time to obtain. There are things you can’t solve. This is not part of primary care itself, it is a problem with the SUS (E2M).
What makes it difficult is the delay in getting places in referrals for certain specialties. Because I think there are very few neuropediatricians, for example, in Cuiabá (E4A).
You refer this child or mother to the reference service at the time of birth and, generally, the reference service -when they are teaching hospitals - tends to be a little better, everything is explained in details, while others are not so good. The existing communication is the written reference and counter-reference. I think it could still improve (E1M). |
Challenges in caring for preterm infants in the unit and referring them to specialized services |
| Managerial |
Professionals indicate difficulties regarding access and availability of inputs, equipment, and work instruments in their units. |
The difficulties are related to the network, I think the network is a little weakened as a whole, not only regarding premature babies and equipment management... unfortunately I have been asking for more than a year and I think the issue of the anthropometric tape used to take measurements is on a bidding process. We improvised a tape, because we don’t have any (E1E).
There is lack of material, there is no otoscope, so it is an amount that I cannot afford to leave in the unit. We have already placed an order, the health department takes forever to respond, so far, nothing (E2M).
A premature child in our area needed a gastrostomy. The procedure requires materials and costs a lot, but the bottles and equipment don’t come to primary care, so we depend on another level of care. We guide the mother to obtain the materials in other places (E1E). |
| Relational Management |
Data analysis showed difficulties or delays in referring preterm infants to specialties or other RAS services, in urgent situations. Situations were also identified in which scheduling is only made possible due to the informal contact that the FHS professional makes, to try to resolve the demand. |
Some referrals take us a while to book. Sometimes if we have someone we know in a hospital to try to speed things up, we try, but this is through the doctor, the nurse, if there is someone we know who can help, you know. But via SUS, the problem sometimes takes a long time (E2M).
This communication is established via SISREG (National Regulation System), but they try to achieve it in another way. A phone call to someone you know, something more informal (E3M).
If we need another service, in this case we understand that as the child is premature or even other types of special cases, for example “I need a pediatrician now”, I will not send this child to the Regulation Center and wait, you know - we don’t know how many days to get a consultation. So we call our colleagues “You see, I have a pediatrician at Health Center X”, so we call, book the consultation (E3E). |
Relational
Informational |
The content of the interviews made it clear that professionals from the FHS teams are not sufficiently clear about their role in monitoring children and that they may be unaware of the role of neonatology outpatient clinics/follow-up. |
This last child who has hydrocephalus came in November and I went to her house. Then in December the child was hospitalized and the health agent monitored her, admitted her again, and now she’s back from the hospital, I go to her house, but the mother is staying more there (at the Neonatology outpatient clinic) than here. It often happens that they spend more time at the clinic than here. The first year, I understand, but there are many mothers who come with a four-year-old child who was born pre-term and want to continue monitoring at the outpatient clinic. It’s something that is no longer needed (E2E).
They usually come with a letter to follow up. When this is not the case, they already make a referral there to enter their own premature clinic. And after they are discharged from the outpatient clinic, they come with a letter for us to follow up with childcare (E4M). |
Informational Fragilities in the preterm care network |
| Informational |
The lack of communication with the hospital where the preterm baby was admitted is a reality of the investigated scenario. Despite obtaining information about the birth and the postpartum woman’s health status, mother of the PTNB, the professionals claim that they do not receive enough information about the premature baby’s clinical condition. |
And another challenge, another experience with a preterm child, we don’t receive anything from the hospital, we receive the information that the mother brings and the papers that the mother brings from the hospital. If it is an organized family, who has everything from the hospital, then you know everything (E2E).
From the university hospital I receive the patient’s discharge, the mother, but I don’t receive anything from the preterm baby. I get what comes with the family, which actually belongs to the family (E2E). |
| Informational |
Despite recognizing that there are specificities for the different services that care for preterm infants, it was evident that some FHS professionals are not aware of the MS guidelines in relation to monitoring preterm infants after hospital discharge. |
I think this (FHS) is an assistance that complements the assistance provided by the neonatology outpatient clinic, you know, that generally these children who are premature, they are already guided and even scheduled for consultations in the neonatology outpatient clinics of the hospital where they were born. But it is a situation that we complement in the unit, we see this patient within the community (E1M). |
| Informational |
The COVID 19 pandemic hindered information management among professionals on the same team in the FHS due to the suspension of weekly multidisciplinary meetings. |
Now with the pandemic our routine has changed a little, but before we had frequent meetings to discuss cases of premature children and we looked for a solution as a team, but now it has been suspended because our focus is COVID-19 (E4E).
Generally, before the pandemic, on Friday we meet for a home visit, the health agent gives the information and then we discuss the case and make a referral, either to carry out the visit or book a consultation. (E2E). |
| Relational |
Difficulties in establishing a bond with the preterm baby’s family, among which the high turnover of team professionals stands out, which reflects the poor relationship between the ACS and the community. |
We usually find out whether it is preterm or not when the mother comes to the unit looking for the first vaccination. We do not yet have, in this unit, the connection with the ACS for him-her to pass this information on to us. So we already register the child, carry out home visits, and follow-up at the unit (E3E).
Sometimes it is difficult to maintain the entire schedule of women in prenatal care and also of those who are in the postpartum period, in addition to all the other situations that we also have to accommodate within the family health unit. We have difficulty maintaining a team to embrace the patient from the reception desk to the physician. We have high turnover in family health teams (E1M). |
Fragile interactions between the preterm baby’s family and professionals |
| Relational |
The large number of patients per area assigned to FHS care contributes to increased demand, weakening the bond between the community and the health unit. |
Due to the large number of patients, we are often unable to have this bond. As there are units that serve uncovered areas, the flow is very large in some units. It’s intense here too. There are premature children that I cannot give the necessary attention to, I take care of a lot of children and there has to be that bond (E3M). |
| Relational |
The active search carried out by the ACS for the family to have follow-up at the FHS is a reality identified in the research scenario. In the perception of professionals, the family may not recognize the importance of the follow-up carried out by the FHS. |
The right monitoring would have to be one hundred percent, but if it isn’t, we have to go for it and bring up the problem, it ends up being very difficult for the mother to come. As she already has greater support, which is the hospital, they think that the support from primary care is very little. (E4A). |
