Experiências assistenciais de mulheres vivendo em municípios rurais remotos do semiárido: atenção ao pré-natal, parto e puerpério e controle do câncer de colo do útero

Abstract

A Master’s Thesis examines the experiences and care trajectories of residents in Remote Rural Municipalities (RRMs) in the Brazilian Semi-Arid region, through two tracer events - prenatal care, parturition, postpartum care and Cervical Cancer Control. It is a case study overlaid levels of analysis, employing a qualitative approach, with data collected through semi-structured interviews conducted with women in four RRMs across three Brazilian states - Bahia, Minas Gerais, and Piauí. This Master’s Thesis utilizes part of the data from the national research on Primary Health Care (PHC) in Remote Rural Municipalities in Brazil coordinated by the Escola Nacional de Saúde Pública Sérgio Arouca (ENSP), of the Fundação Oswaldo Cruz (Fiocruz). The study participants were 27 women, aged ≥ 18 years, residing in urban and rural areas of RRMs, divided into two groups: group 1 - 14 PHC users who had pregnancy/parturition in the last 12 months; and group 2 - 13 PHC users who had an abnormal Pap smear test at least 12 months ago. The results are organized into two articles: 1) Experiences lived by residents of remote rural municipalities in the Brazilian semi-arid region regarding prenatal, childbirth, and postpartum care: access and care trajectories.; 2) Actions for screening and control of cervical cancer in residents of remote rural municipalities in the Brazilian semi-arid region. In both cases, the results show that inequalities in access to health services in the Brazilian semi-arid region are persistent and strongly affect women in more remote areas. Nonetheless, PHC has emerged as a fundamental organizational model for reducing inequities, as its reach allows for the daily care of residents in more isolated locations. PHC professionals, especially community health workers (CHWs), play an essential role in linkage women to health services, often serving as community spokespeople. However, barriers to access specialized care persist, leading to discontinuity and loss of timely care. In summary, in RRMs, users face difficulty in ensuring coordinated care across different care levels. In article 1, users expressed satisfaction with the quality of prenatal care consultations, which ensured strong adherence and attendance to PHC appointments. However, users commonly relied on other means to access laboratory and imaging tests for pregnancy monitoring, and frequently, public sanitary transport was not available during childbirth. In article 2, women who underwent Pap smear tests in PHC also experienced interrupted or delayed care pathways when they needed specialized consultations/tests, particularly in the case of precursor lesions of cervical cancer, due to difficulties in accessing specialized services located in other municipalities or due to delays in scheduling or regulating consultations. Thus, women needing access to a reference gynecologist, complementary tests, and even treatment for cervical cancer did not have regular assurance of satisfactory sanitary transport, and the logistics to fulfill care trajectories were fragmented and produced inequalities. Finally, the fragmentation in the care experiences for the two conditions studied calls into question one of the essential attributes of PHC, which is the continuity of care, making the most vulnerable populations, paradoxically, need to rely on a mix of public-private services to ensure their minimum health access conditions, usually through the use of financial own resources, further exacerbating social inequalities.