Abstract

Puerperium is a period of significant morbimortality for women, and Primary Health Care (PHC) is important in developing actions to meet women’s health needs. This study aimed to systematize the knowledge produced on postpartum care programs actions within PHC at both national and international levels. This is an integrative review of the literature in databases LILACS (Latin American and Caribbean Health Sciences Literature), BDENF (Nursing Database), SciELO (Scientific Electronic Library Online) and PubMed (US National Library of Medicine). Search was performed in the period April-May 2017. Forty-three papers met the selection criteria. Results indicate that PHC has the physical structure to provide puerperae with care, but has a shortage of human and material resources; there is low postpartum consultation coverage and home visits; there is a good evaluation of the incentive for breastfeeding, but focused on the child; international screening of Postpartum Depression through the Edinburgh Postnatal Depression Scale and care shortage for this condition in Brazil. Postpartum care still focuses on care for the newborn and is mostly restricted to the immediate and late puerperium.

Key words
Primary health care; Postpartum; Women’s health

Introduction

Although life expectancy is higher for women than for men in most countries, a number of social and health factors combine to have a lower quality of life for women¹1 World Health Organization (WHO). Global Health Observatory (GHO) data. Women and health [Internet] 2017 [cited 2017 Jun 10]. Available from: http://www.who.int/gho/en/
http://www.who.int/gho/en/... . Gender inequality leads to many risks to women’s health, including physical and sexual violence, sexually transmitted infections, malaria, chronic obstructive pulmonary disease and maternal morbidity and mortality¹1 World Health Organization (WHO). Global Health Observatory (GHO) data. Women and health [Internet] 2017 [cited 2017 Jun 10]. Available from: http://www.who.int/gho/en/
http://www.who.int/gho/en/... .

Mortality rates during pregnancy and childbirth remain high in developing countries, despite their worldwide decline in recent decades, with 99% of maternal deaths occurring in these countries¹1 World Health Organization (WHO). Global Health Observatory (GHO) data. Women and health [Internet] 2017 [cited 2017 Jun 10]. Available from: http://www.who.int/gho/en/
http://www.who.int/gho/en/... . Avoidable deaths continue to occur in alarming proportions, mainly due to hypertensive diseases, hemorrhages, sepsis/infections and abortion-related complications¹1 World Health Organization (WHO). Global Health Observatory (GHO) data. Women and health [Internet] 2017 [cited 2017 Jun 10]. Available from: http://www.who.int/gho/en/
http://www.who.int/gho/en/... ^,22 Bhutta ZA, Cabral S, Chan C-w, Keenan WJ. Reducing maternal, newborn, and infant mortality globally: An integrated action agenda. Obstet Gynecol Int J 2012; 119(Supl. 1):13-17..

Maternal health is sensitive to Primary Health Care (PHC)²2 Bhutta ZA, Cabral S, Chan C-w, Keenan WJ. Reducing maternal, newborn, and infant mortality globally: An integrated action agenda. Obstet Gynecol Int J 2012; 119(Supl. 1):13-17.^,33 World Health Organization (WHO). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO Library Cataloguing-in-Publication Data; 2013.. Thus, increasing the quality of this point of care is key to reducing the mortality rates of this population. Deaths and morbidities during pregnancy, childbirth and puerperium are avoidable by implementing integrated and universal access actions through light technologies and primary care²2 Bhutta ZA, Cabral S, Chan C-w, Keenan WJ. Reducing maternal, newborn, and infant mortality globally: An integrated action agenda. Obstet Gynecol Int J 2012; 119(Supl. 1):13-17.^,33 World Health Organization (WHO). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO Library Cataloguing-in-Publication Data; 2013..

It should be noted that most maternal deaths are concentrated in the immediate puerperium (1-10 days postpartum), besides being a significant morbidity stage⁴4 Nabukera SK, Witte K, Muchunguzi C, Bajunirwe F, Batwala VK, Mulogo EM, Farr C, Barry S, Salihu HM. Use of postpartum health services in rural Uganda: knowledge, attitudes, and barriers. J Community Health 2006; 31(2):84-93.^,55 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9. that extends to late puerperium (from the 11^th to the 45^th day) and remote puerperium (after 45 days)⁶6 Brasil. Ministério da Saúde (MS), Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da Atenção Básica: Saúde das Mulheres. Brasília: MS; 2016., with studies that indicate persistent conditions for more than 4 years postpartum⁷7 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312.^,88 Gartland D, MacArthur C, Woolhouse H, McDonald E, Brown S. Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. Int J Obstet Gynecol 2016; 123(7):1203-1211.. PHC is primarily responsible for postpartum women care through integration of technical knowledge and an ability to receive, support and detect early physical and emotional changes, performing prevention, treatment and follow-up on women referring to others services when needed⁹9 National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2015.^,1010 Correa MS, Feliciano KV, Pedrosa EN, Souza AI. Women's perception concerning health care in the post-partum period: a meta-synthesis. Open J Obstet Gynecol 2014; 4:416-426..

Considering the significant morbimortality of women in the puerperal period, and the fact that PHC is the caregiver responsible for solving most health problems, it is important to develop efficient and effective actions to meet the needs of women’s health in the puerperium.

To that end, health policies at national and international levels work together and establish guidelines, actions and strategies for puerperal care, especially in primary care, understanding that adequate resources are essential requirements for comprehensive care¹1 World Health Organization (WHO). Global Health Observatory (GHO) data. Women and health [Internet] 2017 [cited 2017 Jun 10]. Available from: http://www.who.int/gho/en/
http://www.who.int/gho/en/... ^,66 Brasil. Ministério da Saúde (MS), Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da Atenção Básica: Saúde das Mulheres. Brasília: MS; 2016.. Despite these initiatives, there is evidence that postpartum care in PHC requires adjustments, with improvements in physical and material structure, management and care in health services, professional qualification, women-centered care, overcoming technicist care, thus contributing to improved women’s health⁷7 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312.^,1010 Correa MS, Feliciano KV, Pedrosa EN, Souza AI. Women's perception concerning health care in the post-partum period: a meta-synthesis. Open J Obstet Gynecol 2014; 4:416-426.

11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^-1212 Corrêa MSM, Feliciano KVO, Pedrosa EN. Souza AI. Acolhimento no cuidado à saúde da mulher no puerpério. Cad Saude Publica 2017; 33(3):1-12..

Knowing the activities developed and results achieved by puerperal care programs is important for the planning and improvement of PHC care for postpartum women’s health. Based on the above, we enquire as to the characteristics and results of the studies that address postpartum care in the context of PHC. Thus, this study aimed to systematize knowledge produced on postpartum care in PHC both at national and international levels.

Methods

This is an integrative review of the literature, which is characterized by a method that allows the search, critical evaluation and synthesis of available evidence about the subject investigated, whose final product consists of the current state of knowledge, implementation of interventions and identification of gaps that guide the development of other studies¹³13 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & contexto enferm 2008; 17(4):758-764..

The operational stages of the integrative review are identification of the theme and selection of the hypothesis or research question; establishment of inclusion/exclusion criteria of studies/sampling or search in literature; definition of the information to be extracted from the selected studies/categorization of studies; evaluation of studies included in the integrative review; interpretation of results; and presentation of knowledge review/synthesis¹³13 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & contexto enferm 2008; 17(4):758-764..

The following guiding question was formulated in the first step: What are the characteristics - type of study, criteria, parameters, indicators - and results of the studies that address postpartum care in PHC?

In the second step, we searched for references through the Virtual Health Library (BVS), with simultaneous search in the main national and international databases, and we selected LILACS (Latin American and Caribbean Health Sciences Literature) and BDENF (Nursing Database). We conducted advanced search in SciELO (Scientific Electronic Library Online) and PubMed (National Library of Medicine of the United States).

We established the following inclusion criteria for the selection of papers: original work, answering the guiding question; published in Portuguese, English or Spanish; published in a scientific journal with at least Qualis B2 for public health; and when Qualis evaluation was unavailable, we verified the Journals Impact Factors (JCR), including papers with a minimum rating of 1.0. Duplicated studies in one or more databases were excluded.

The search for references occurred between April and May 2017 using the following descriptors indexed in Health Sciences Descriptors (DeCS), all of which were grouped using Boolean expressions AND and OR: período pós-parto OR postpartum period OR período pós-parto OR saúde materna OR maternal health OR salud materna OR saúde da mulher OR women’s health OR salud de la mujer OR saúde materno-infantil OR maternal and child health OR salud materno infantil AND Atenção Primária à Saúde OR Primary Health Care OR Atención Primaria de Salud OR Saúde da Família OR Family Health OR Salud de la família. In PubMed, we used the following Mesh Terms: postpartum period OR maternal health OR women’s health AND primary health care OR family health.

The wide range of descriptors used is justified since the postpartum subject is handled in conjunction with others related to women’s health, and restriction to descriptor “postpartum period” would limit the possibility of finding studies that approach the subject. Given the relevance of some studies, we selected references that considered the inclusion criteria of the study cited by the selected articles.

In order to evaluate the methodological quality of studies found, we used specific tools for each type of study. Evaluative studies were analyzed through by adapting the meta-evaluation criteria established by Stufflebeam¹⁴14 Stufflebeam DL. Program Evaluation Models Metaevaluation Checklist (Based on The Program Evaluation Standards). Evaluation Checklists Project [Internet] 1999 [cited 2017 May 15]. Available from: http://dmeforpeace.org/learn/program-evaluations-models-metaevaluation-checklist
http://dmeforpeace.org/learn/program-eva... , excluding studies classified as “weak” and “reasonable”, that is, with more than 50% of the evaluation questions answered negatively. The other studies were evaluated using the Critical Appraisal Skills Program (CASP)¹⁵15 Critical Appraisal Skills Programme (Casp). Programme AS. Making sense of evidence. CASP Checklists [Internet] 2017 [ cited 2017 May 15]. Available from: http://www.casp-uk.net/casp-tools-checklists
http://www.casp-uk.net/casp-tools-checkl... , which consists of specific checklists for each type of study, and does not suggest a scoring system, so the authors chose to use the same classification of Stufflebeam¹⁴14 Stufflebeam DL. Program Evaluation Models Metaevaluation Checklist (Based on The Program Evaluation Standards). Evaluation Checklists Project [Internet] 1999 [cited 2017 May 15]. Available from: http://dmeforpeace.org/learn/program-evaluations-models-metaevaluation-checklist
http://dmeforpeace.org/learn/program-eva... , excluding reasonable and poor studies. These studies, except evaluative ones, were also classified according to their level of evidence, according to the criteria of Stetler et al.¹⁶16 Stetler CBMD, Rucki S, Broughton S, Corrigan B, Fitzgerald J, Giuliano K, Havener P, Sheridan A. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res 1998; 11(4):195-206..

For the accomplishment of the third stage (definition of the information to be extracted from the selected studies), the tool elaborated by Ursi¹⁷17 Ursi E. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2005. was used, which addresses, among other information, the study identification, methodological characteristics, evaluation of methodological rigor, interventions and results found.

The results of the selected studies were systematized according to similarities of data analyzed in each research. Data synthesis and interpretation were based on the results of the critical evaluation of selected studies. A comparison was made with theoretical knowledge, identification of conclusions and implications resulting from the integrative review.

In order to minimize bias, two reviewers performed the search, evaluation and selection of studies, and then a consensus discussion was held on papers to be included in the review.

Results

After completing cross-referencing between the DeCS / Mesh Terms, 1,974 references were found, and at the end of the material selection strategies, 43 papers were shortlisted for analysis and discussion, as shown in Figure 1.

Year of publication of papers ranged from 1995 to 2016, with 69.8% (30) in the last five years, with 20.9% (9) published in 2013. Regarding the study site, 60.5% (26) were performed in the American continent, mainly Brazil, with 51.2% (22). Other studies were held in Europe, 6 (14%), Oceania, 6 (13.9%), Asia, 2 (4.7%), Africa, 2 (4.7%) and one in three countries, Bangladesh and Nepal (Asia) and Malawi (Africa). The main three languages were English, 51.2% (22), followed by Portuguese, 44.2% (19), and 4.7% (2) Spanish.

Most studies were quantitative (76.7%) (33), and 37.2% (16) are evaluative, 20.9% (9) qualitative, 13.9% (6) cross-sectional, 11.6% (5) clinical trial, 7% (3) cohort and the same quantity of quasi-experimental, and one was descriptive. Regarding evaluation of methodological quality, 12.5% (2) of the 16 evaluative papers were rated excellent, 56.25% (9) very good and 31.25% (5) good, with two value judgments¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,1919 Rito RV, Oliveira MI, Brito Ados S. Degree of compliance with the ten steps of the Breastfeeding Friendly Primary Care Initiative and its association with the prevalence of exclusive breastfeeding. J Pediatr (Rio J) 2013; 89(5):477-484.. The others were classified by level of evidence, predominantly at level IV, 59.3% (16), followed by level III, 22.2% (6) and level II, 18.5% (5); and regarding CASP, most were classified as very good, 51.8% (14), 25.9% (7) as excellent and 22.2% (6) as good.

The main results of the analyzed papers are shown below, grouped by similarities for a better understanding:

Evaluation of the structure of puerperal care health facilities

Of the evaluative papers, three¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^,2020 Parada CMG. Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005. Rev. bras. saúde mater. infant 2008; 8(1):113-124.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123. addressed the evaluation of the structure for puerperal care, all performed in Brazil. Puerperal care is mainly provided by doctors and nurses¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^,2020 Parada CMG. Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005. Rev. bras. saúde mater. infant 2008; 8(1):113-124., with problems mainly in fixing and qualifying doctors in PHC¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.. In the Santos (SP) study, the introduction of nutritionists was evaluated; this initiative is insufficient, professionals are found in about 65% of facilities for one or two periods of the week²¹21 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123..

Regarding the evaluation of the physical and material structure, the studies found that most of the health establishments had a minimum infrastructure for puerperae care, such as single room and availability of materials, vaccines and medicines. However, one of the limitations of care is the availability and maintenance of the functionality of materials¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^,2020 Parada CMG. Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005. Rev. bras. saúde mater. infant 2008; 8(1):113-124.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123.. The studies also pointed out poor health education actions and inadequate or non-existent physical space for this purpose¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^,2020 Parada CMG. Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005. Rev. bras. saúde mater. infant 2008; 8(1):113-124.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123..

Postpartum consultation: demand/supply and reasons for non-adherence

Studies evaluating prenatal care, as recommended by the Pre-Natal and Birth Humanization Program (PHPN) in Brazil, have shown, since implementation to date, that the recommendation to have six or more prenatal consultations, all basic exams, HIV testing, the 2^nd dose, booster or immunizing tetanus vaccine and puerperium consultation is poorly complied with²⁰20 Parada CMG. Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005. Rev. bras. saúde mater. infant 2008; 8(1):113-124.^,2222 Serruya SJ, Lago T, Cecatti JG. Avaliação preliminar do programa de humanização no pré-natal e nascimento no Brasil. Rev bras ginecol obstet 2004; 26(7):517-525.^,2323 Corrêa MD, Tsunechiro MA, Lima MOP, Bonadio IC. Avaliação da assistência pré-natal em unidade com estratégia saúde da família. Rev Esc Enferm USP 2014; 48(n. esp.):23-31..

Regarding Brazilian studies that evaluated the indicator of puerperium consultation up to 42 days postpartum, a low achievement was observed, varying from 16.8% to 58%²⁴24 Santos SR, Cunha AJLA, Gamba CM, Machado FG, Leal Filho JMM, Moreira NLM. Avaliação da assistência à saúde da mulher e da criança em localidade urbana da região Sudeste do Brasil. Rev Saude Publica 2000; 34(3):266-271.

25 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319.^-2626 Hass CN, Teixeira LB, Beghetto MG. Adequabilidade da assistência pré-natal em uma estratégia de saúde da família de Porto Alegre-RS. Rev Gaucha Enferm 2013; 34(3):22-30.. A lack or little flexibility of prior scheduling of puerperal consultation¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^,1818 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8. and hosting the First Comprehensive Health Week¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123. were identified. Studies indicate that active search for defaulting women is performed in more than half of the studies, but it is not a systematic practice for all puerperae¹¹11 Oliveira DC, Teixeira RC, Tomiyoshi JT, Correa ACdP, Mandu ENT. Estrutura organizacional da atenção pós-parto na estratégia saúde da família. Esc Anna Nery Rev Enferm 2013; 17(3):446-554.^,2020 Parada CMG. Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005. Rev. bras. saúde mater. infant 2008; 8(1):113-124.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123.^,2525 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319..

A study carried out in nine poorer regions of Peru showed that 58% of women reported postpartum control within 42 days²⁷27 Velásquez Hurtado JE, Solís Alcedo L, Vigo Valdez WE, Rosas Aguirre AM, Giusti Hundskopf P, Alfaro Fernandez P, Cabrera Arredondo H. Evaluación de las prácticas de cuidado materno infantil en áreas con pobreza extrema del Perú, 2012. Rev Peru Med Exp Salud Publica 2014; 31(2):243-253.. A survey conducted in the UK in 1995 found that 91% of women attended the puerperal consultation six weeks into postpartum²⁸28 Bick DE, MacArthur C. Attendance, content and relevance of the six week postnatal examination. Midwifery 1995; 11(2):69-73..

International and national literature shows the reasons for not adhering to the puerperal consultation, and they are: professionals’ lack of information on postpartum actions⁴4 Nabukera SK, Witte K, Muchunguzi C, Bajunirwe F, Batwala VK, Mulogo EM, Farr C, Barry S, Salihu HM. Use of postpartum health services in rural Uganda: knowledge, attitudes, and barriers. J Community Health 2006; 31(2):84-93.^,55 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.; lack of medicines and equipment; lack of professional qualification; cultural barriers⁴4 Nabukera SK, Witte K, Muchunguzi C, Bajunirwe F, Batwala VK, Mulogo EM, Farr C, Barry S, Salihu HM. Use of postpartum health services in rural Uganda: knowledge, attitudes, and barriers. J Community Health 2006; 31(2):84-93.; and perception that postpartum care is intended for the child⁴4 Nabukera SK, Witte K, Muchunguzi C, Bajunirwe F, Batwala VK, Mulogo EM, Farr C, Barry S, Salihu HM. Use of postpartum health services in rural Uganda: knowledge, attitudes, and barriers. J Community Health 2006; 31(2):84-93.^,55 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.^,77 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312.. In addition, puerperae educational actions are still traditional, which also discourages their participation²⁹29 Guerreiro EM, Rodrigues DP, Queiroz ABA, Ferreira MA. Educação em saúde no ciclo gravídico-puerperal: sentidos atribuídos por puérperas. Rev Bras Enferm 2014; 67(1):13-21..

In Australia, it has been shown that problems related to the occurrence of postpartum care in an organized and higher quality way is due to the lack of consistent and cohesive guidelines for community care of new mothers and their babies⁵5 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.. Two Australian studies⁵5 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.^,77 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312. and one from the UK²⁸28 Bick DE, MacArthur C. Attendance, content and relevance of the six week postnatal examination. Midwifery 1995; 11(2):69-73. identified that puerperae value and are open to primary care⁵5 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.^,77 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312.^,2828 Bick DE, MacArthur C. Attendance, content and relevance of the six week postnatal examination. Midwifery 1995; 11(2):69-73., provided that consultation is a time of understanding, support and reassurance and are more likely to talk about their needs when asked about them⁵5 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.^,77 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312..

Addressing women in puerperal consultation

Regarding actions performed by professionals during puerperium consultation, a survey in the UK indicates that 93% of the women had abdominal examination and 70% vaginal examination. However, many women are submitted to exams with no obvious reason (such as unnecessary vaginal examination), while other tests that may be useful for some conditions (such as hemogram for fatigued women) are used infrequently²⁸28 Bick DE, MacArthur C. Attendance, content and relevance of the six week postnatal examination. Midwifery 1995; 11(2):69-73..

Brazilian studies indicate that the most common activities carried out in the puerperium by health professionals, besides encouraging breastfeeding, are guidelines on contraception methods¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2525 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319., food and nutrition¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123. and use of ferrous sulfate¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.. Less frequent actions are cytopathology of the uterine cervix²⁴24 Santos SR, Cunha AJLA, Gamba CM, Machado FG, Leal Filho JMM, Moreira NLM. Avaliação da assistência à saúde da mulher e da criança em localidade urbana da região Sudeste do Brasil. Rev Saude Publica 2000; 34(3):266-271., clinical breast examination¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2424 Santos SR, Cunha AJLA, Gamba CM, Machado FG, Leal Filho JMM, Moreira NLM. Avaliação da assistência à saúde da mulher e da criança em localidade urbana da região Sudeste do Brasil. Rev Saude Publica 2000; 34(3):266-271., investigation of women’s emotional state, orientation regarding return to sexual intercourse, evaluation of lochia and examination of the genital region¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.. A national study that evaluated puerperal care among adolescents classified it as adequate for 43.2% of the users, and the other ones received intermediate or inadequate care, considering in this evaluation the consultation of puerperal review, home visit in the first week after childbirth, clinical and gynecological evaluation, guidance on family planning, and guidance on breastfeeding²⁵25 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319.. In Peru, it was found that only 38.5% of the women used ferrous sulfate and 12.6% vitamin A 30 days after delivery, and 31% had chosen a contraceptive method²⁷27 Velásquez Hurtado JE, Solís Alcedo L, Vigo Valdez WE, Rosas Aguirre AM, Giusti Hundskopf P, Alfaro Fernandez P, Cabrera Arredondo H. Evaluación de las prácticas de cuidado materno infantil en áreas con pobreza extrema del Perú, 2012. Rev Peru Med Exp Salud Publica 2014; 31(2):243-253..

During the first 3 months postpartum, Australian studies indicated that 89% of women had sexual health problems, and although most women had contact with PHC professionals during that time, only 24% remembered being asked about the theme by general practitioners and 14% by nurses³⁰30 Woolhouse H, McDonald E, Brown SJ. Changes to sexual and intimate relationships in the postnatal period: women's experiences with health professionals. Aust J Prim Health 2014; 20(3):298-304.^,3131 McDonald E, Woolhouse H, Brown SJ. Consultation about sexual health issues in the year after childbirth: a cohort study. Birth 2015; 42(4):354-361.. Women expressed dissatisfaction with the quality of postnatal primary health care, reporting a strong shift from maternal health to baby health after birth³⁰30 Woolhouse H, McDonald E, Brown SJ. Changes to sexual and intimate relationships in the postnatal period: women's experiences with health professionals. Aust J Prim Health 2014; 20(3):298-304..

Home visit as a postpartum care tool

Of the 42 studies selected for the review, nine addressed the topic of home visits (HV) in the postpartum period, four of them national¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123.^,2525 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319.^,3232 Graça LCC, Figueiredo MCB, Conceição MTCC. Contributions of the nursing intervention in primary healthcare for the promotion of breastfeeding. Rev Lat Am Enfermagem 2011; 19(2):429-436. and five international³³33 Sitrin D, Guenther T, Murray J, Pilgrim N, Rubayet S, Ligowe R, Pun B, Malla H, Moran A. Reaching mothers and babies with early postnatal home visits: the implementation realities of achieving high coverage in large-scale programs. PLoS One 2013; 8(7):e68930.

34 Mejdoubi J, van den Heijkant SC, van Leerdam FJ, Crone M, Crijnen A, HiraSing RA. Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: a randomized controlled trial. Midwifery 2014; 30(6):688-695.

35 Bashour HN, Kharouf MH, AbdulSalam AA, El Asmar K, Tabbaa MA, Cheikha SA. Effect of postnatal home visits on maternal/infant outcomes in Syria: a randomized controlled trial. Public Health Nurs 2008; 25(2):115-125.

36 Robling M, Bekkers M-J, Bell K, Butler CC, Cannings-John R, Channon S, Martin BC, Gregory JW, Hood K, Kemp A, Kenkre J, Montgomery AA, Moody G, Owen-Jones E, Pickett K, Richardson G, Roberts ZE, Ronaldson S, Sanders J, Stamuli E, Torgerson D. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 2016; 387(10014):146-155.^-3737 Saïas T, Lerner E, Greacen T, Simon-Vernier E, Emer A, Pintaux E, Guédeney A, Dugravier R, Tereno S, Falissard B, Tubach F; CAPEDP Study Group, Revah-Levy A. Evaluating fidelity in home-visiting programs a qualitative analysis of 1058 home visit case notes from 105 families. PloS One 2012; 7(5):e36915.. Four studies indicate a low level of HV¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2121 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123.^,2525 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319.^,3333 Sitrin D, Guenther T, Murray J, Pilgrim N, Rubayet S, Ligowe R, Pun B, Malla H, Moran A. Reaching mothers and babies with early postnatal home visits: the implementation realities of achieving high coverage in large-scale programs. PLoS One 2013; 8(7):e68930., and the same occurs more frequently in Brazil when it comes to family health facilities, performed mainly by Community Health Workers¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,2525 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319.. HV are more likely when the team monitors women during the prenatal period¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8.^,3333 Sitrin D, Guenther T, Murray J, Pilgrim N, Rubayet S, Ligowe R, Pun B, Malla H, Moran A. Reaching mothers and babies with early postnatal home visits: the implementation realities of achieving high coverage in large-scale programs. PLoS One 2013; 8(7):e68930..

As to the positive impact of HV programs during the gestational-puerperal cycle, international studies have pointed to reduced tobacco use among puerperae³⁴34 Mejdoubi J, van den Heijkant SC, van Leerdam FJ, Crone M, Crijnen A, HiraSing RA. Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: a randomized controlled trial. Midwifery 2014; 30(6):688-695., improved care and development of the child³⁶36 Robling M, Bekkers M-J, Bell K, Butler CC, Cannings-John R, Channon S, Martin BC, Gregory JW, Hood K, Kemp A, Kenkre J, Montgomery AA, Moody G, Owen-Jones E, Pickett K, Richardson G, Roberts ZE, Ronaldson S, Sanders J, Stamuli E, Torgerson D. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 2016; 387(10014):146-155.^,3737 Saïas T, Lerner E, Greacen T, Simon-Vernier E, Emer A, Pintaux E, Guédeney A, Dugravier R, Tereno S, Falissard B, Tubach F; CAPEDP Study Group, Revah-Levy A. Evaluating fidelity in home-visiting programs a qualitative analysis of 1058 home visit case notes from 105 families. PloS One 2012; 7(5):e36915., greater social and psychological support to women and households³⁷37 Saïas T, Lerner E, Greacen T, Simon-Vernier E, Emer A, Pintaux E, Guédeney A, Dugravier R, Tereno S, Falissard B, Tubach F; CAPEDP Study Group, Revah-Levy A. Evaluating fidelity in home-visiting programs a qualitative analysis of 1058 home visit case notes from 105 families. PloS One 2012; 7(5):e36915., and three international³⁴34 Mejdoubi J, van den Heijkant SC, van Leerdam FJ, Crone M, Crijnen A, HiraSing RA. Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: a randomized controlled trial. Midwifery 2014; 30(6):688-695.

35 Bashour HN, Kharouf MH, AbdulSalam AA, El Asmar K, Tabbaa MA, Cheikha SA. Effect of postnatal home visits on maternal/infant outcomes in Syria: a randomized controlled trial. Public Health Nurs 2008; 25(2):115-125.^-3636 Robling M, Bekkers M-J, Bell K, Butler CC, Cannings-John R, Channon S, Martin BC, Gregory JW, Hood K, Kemp A, Kenkre J, Montgomery AA, Moody G, Owen-Jones E, Pickett K, Richardson G, Roberts ZE, Ronaldson S, Sanders J, Stamuli E, Torgerson D. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 2016; 387(10014):146-155. and two national²¹21 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123.

22 Serruya SJ, Lago T, Cecatti JG. Avaliação preliminar do programa de humanização no pré-natal e nascimento no Brasil. Rev bras ginecol obstet 2004; 26(7):517-525.

23 Corrêa MD, Tsunechiro MA, Lima MOP, Bonadio IC. Avaliação da assistência pré-natal em unidade com estratégia saúde da família. Rev Esc Enferm USP 2014; 48(n. esp.):23-31.

24 Santos SR, Cunha AJLA, Gamba CM, Machado FG, Leal Filho JMM, Moreira NLM. Avaliação da assistência à saúde da mulher e da criança em localidade urbana da região Sudeste do Brasil. Rev Saude Publica 2000; 34(3):266-271.

25 Vilarinho LM, Nogueira LT, Nagahama EEI. Avaliação da qualidade da atenção à saúde de adolescentes no pré-natal e puerpério. Esc Anna Nery Rev Enferm 2012; 16(2):312-319.

26 Hass CN, Teixeira LB, Beghetto MG. Adequabilidade da assistência pré-natal em uma estratégia de saúde da família de Porto Alegre-RS. Rev Gaucha Enferm 2013; 34(3):22-30.

27 Velásquez Hurtado JE, Solís Alcedo L, Vigo Valdez WE, Rosas Aguirre AM, Giusti Hundskopf P, Alfaro Fernandez P, Cabrera Arredondo H. Evaluación de las prácticas de cuidado materno infantil en áreas con pobreza extrema del Perú, 2012. Rev Peru Med Exp Salud Publica 2014; 31(2):243-253.

28 Bick DE, MacArthur C. Attendance, content and relevance of the six week postnatal examination. Midwifery 1995; 11(2):69-73.

29 Guerreiro EM, Rodrigues DP, Queiroz ABA, Ferreira MA. Educação em saúde no ciclo gravídico-puerperal: sentidos atribuídos por puérperas. Rev Bras Enferm 2014; 67(1):13-21.

30 Woolhouse H, McDonald E, Brown SJ. Changes to sexual and intimate relationships in the postnatal period: women's experiences with health professionals. Aust J Prim Health 2014; 20(3):298-304.

31 McDonald E, Woolhouse H, Brown SJ. Consultation about sexual health issues in the year after childbirth: a cohort study. Birth 2015; 42(4):354-361.^-3232 Graça LCC, Figueiredo MCB, Conceição MTCC. Contributions of the nursing intervention in primary healthcare for the promotion of breastfeeding. Rev Lat Am Enfermagem 2011; 19(2):429-436. studies reported increased exclusive breastfeeding was identified up to six months. A multiprofessional team is required to perform postpartum HV, which influences the improvement of the quality of care and nears ties between the team and women/households²¹21 Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev nutr 2016; 29(1):109-123.^,3737 Saïas T, Lerner E, Greacen T, Simon-Vernier E, Emer A, Pintaux E, Guédeney A, Dugravier R, Tereno S, Falissard B, Tubach F; CAPEDP Study Group, Revah-Levy A. Evaluating fidelity in home-visiting programs a qualitative analysis of 1058 home visit case notes from 105 families. PloS One 2012; 7(5):e36915.^,3838 Laporte-Pinfildi ASC, Medeiros MAT. Nutritional care during prenatal and postpartum periods: A report of experiences in a city on São Paulo's coast. Rev nutr 2016; 29(6):947-961..

Breastfeeding

From the reviewed studies, breastfeeding appeared as the main action addressed by professionals in Brazil, and is a subject poorly investigated internationally when addressing actions regarding puerperae in PHC. Seven Brazilian studies have evaluated the impact of its prevalence before and after breastfeeding promotion initiatives (such as “breastfeeding-friendly basic facility” or “Brazil breastfeeding network”), identifying that such actions contribute to an increased rate of breastfeeding, both exclusive up to six months and subsequent to this period¹⁹19 Rito RV, Oliveira MI, Brito Ados S. Degree of compliance with the ten steps of the Breastfeeding Friendly Primary Care Initiative and its association with the prevalence of exclusive breastfeeding. J Pediatr (Rio J) 2013; 89(5):477-484.^,3232 Graça LCC, Figueiredo MCB, Conceição MTCC. Contributions of the nursing intervention in primary healthcare for the promotion of breastfeeding. Rev Lat Am Enfermagem 2011; 19(2):429-436.^,3939 Cardoso LO, Vicente AS, Damião JJ, Rito RV. The impact of implementation of the Breastfeeding Friendly Primary Care Initiative on the prevalence rates of breastfeeding and causes of consultations at a basic healthcare center. J Pediatr 2008; 84(2):147-153.

40 Alves ALN, Oliveira MIC, Moraes JR. Iniciativa Unidade Básica Amiga da Amamentação e sua relação com o aleitamento materno exclusivo. Rev Saude Publica 2013; 47(6):1130-1140.^-4141 Passanha A, Benicio MHD, Venancio SI, Reis MCG. Implantação da Rede Amamenta Brasil e prevalência de aleitamento materno exclusivo. Rev Saude Publica 2013; 47(6):1141-1148.. Two studies did not find statistical significance in their results, although they also showed superiority in the percentage of breastfeeding after the implementation of the initiative⁴²42 Almeida CC, Scochi MJ, Souza RKT, Carvalho WO. Prevalência de aleitamento materno antes e após a implantação de um programa de redução de morbimortalidade infantil, no município de Campo Mourão (PR). Cien Saude Colet 2010; 15(2):575-583.^,4343 Brandao DS, Venâncio SI, Giugliani ER. Association between the Brazilian Breastfeeding Network implementation and breastfeeding indicators. J Pediatr 2015; 91(2):143-151..

A study carried out in Francisco Morato/SP, which evaluated the knowledge of health professionals about breastfeeding showed that they recognize the importance of breastfeeding for the mother-child binomial, but more easily mention the benefits to the child. In addition, although women receive guidance, they have limited knowledge on the subject⁴⁴44 Ciconi RCV, Venancio SI, Escuder MML. Avaliação dos conhecimentos de equipes do Programa de Saúde da Família sobre o manejo do aleitamento materno em um município da região metropolitana de São Paulo. Rev bras saúde mater infant 2004; 4(2):193-202..

Postpartum depression (PPD): non-specialized management in PHC

The international literature shows that PPD screening programs in PHC can improve women’s mental health outcomes in the postpartum period⁴⁵45 Leung SS, Leung C, Lam T, Hung S, Chan R, Yeung T, Miao M, Cheng S, Leung SH, Lau A, Lee DT. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health 2010; 33(2):292-301.

46 Milgrom J, Ericksen J, Negri L, Gemmill AW. Screening for postnatal depression in routine primary care: properties of the Edinburgh Postnatal Depression Scale in an Australian sample. Aust N Z J Psychiatry 2005; 39(9):833-839.

47 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M, Guajardo V, Lewis G, Peters TJ, Araya R. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007; 370(9599):1629-1637.

48 Glavin K, Smith L, Sørum R, Ellefsen B. Redesigned community postpartum care to prevent and treat postpartum depression in women-a one-year follow-up study. J Clin Nurs 2010; 19(21-22):3051-3062.^-4949 Segre LS, O'Hara MW, Brock RL, Taylor D. Depression screening of perinatal women by the Des Moines Healthy Start Project: program description and evaluation. Psychiatr Serv 2012; 63(3):250-255., even in low-income regions with low-cost technologies, as pointed out by Chilean⁴⁷47 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M, Guajardo V, Lewis G, Peters TJ, Araya R. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007; 370(9599):1629-1637. and Australian⁵⁰50 Reilly N, Harris S, Loxton D, Chojenta C, Forder P, Austin MP. The impact of routine assessment of past or current mental health on help-seeking in the perinatal period. Women Birth 2014; 27(4):e20-e7. studies. The Edinburgh Postnatal Depression Scale (EPDS) validated in several countries is recognized as the main PPD tracking tool by non-specialized professionals in PHC⁴⁵45 Leung SS, Leung C, Lam T, Hung S, Chan R, Yeung T, Miao M, Cheng S, Leung SH, Lau A, Lee DT. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health 2010; 33(2):292-301.

46 Milgrom J, Ericksen J, Negri L, Gemmill AW. Screening for postnatal depression in routine primary care: properties of the Edinburgh Postnatal Depression Scale in an Australian sample. Aust N Z J Psychiatry 2005; 39(9):833-839.

47 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M, Guajardo V, Lewis G, Peters TJ, Araya R. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007; 370(9599):1629-1637.

48 Glavin K, Smith L, Sørum R, Ellefsen B. Redesigned community postpartum care to prevent and treat postpartum depression in women-a one-year follow-up study. J Clin Nurs 2010; 19(21-22):3051-3062.^-4949 Segre LS, O'Hara MW, Brock RL, Taylor D. Depression screening of perinatal women by the Des Moines Healthy Start Project: program description and evaluation. Psychiatr Serv 2012; 63(3):250-255.^,5151 Abiodun O. Postnatal depression in primary care populations in Nigeria. Gen Hosp Psychiatry 2006; 28(2):133-136..

It is emphasized that public health nurses are well positioned to identify and treat depressed women and refer them when needed. A small investment in the training of nurses to identify and treat PPD may have a positive long-term effect⁴⁵45 Leung SS, Leung C, Lam T, Hung S, Chan R, Yeung T, Miao M, Cheng S, Leung SH, Lau A, Lee DT. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health 2010; 33(2):292-301.^,4848 Glavin K, Smith L, Sørum R, Ellefsen B. Redesigned community postpartum care to prevent and treat postpartum depression in women-a one-year follow-up study. J Clin Nurs 2010; 19(21-22):3051-3062..

According to an Australian study⁵⁰50 Reilly N, Harris S, Loxton D, Chojenta C, Forder P, Austin MP. The impact of routine assessment of past or current mental health on help-seeking in the perinatal period. Women Birth 2014; 27(4):e20-e7., a health professional’s investigation about the past or current mental health of women is associated with the search for help throughout the perinatal period. In Denmark, it was found that puerperae who developed a psychiatric episode had higher rates of consultation by health professionals before, during and after pregnancy⁵²52 Munk-Olsen T, Pedersen HS, Laursen TM, Fenger-Grøn M, Vedsted P, Vestergaard M. Use of primary health care prior to a postpartum psychiatric episode. Scand J Prim Health Care 2015; 33(2):127-133..

Barriers to treatment of PPD were evidenced by a study in Chile, such as lack of user knowledge about the disease, negative conceptualization and rejection of the available treatment options; poor network support and long waiting times and a lack of coordination between clinical and administrative decisions⁵³53 Rojas. Barreras de acceso a tratamiento de la depresión posparto en centros de atención primaria de la Región Metropolitana: un estudio cualitativo. Rev Med Chile 2015; 143(4):424-432..

Among studies that addressed PPD, three were national and identified insufficient knowledge by PHC professionals to prevent and treat PPD, lack of a systematic tool for PPD screening and that work focus during gestation and postpartum is still biological⁵⁴54 Meira B, Pereira P, Silveira M, Gualda D, Santos Jr H. Desafios para profissionais da atenção primária no cuidado à mulher com depressão pós-parto. Texto & Contexto Enferm 2015; 24(3):706-712.

55 Felix TA, Siqueira DA, Ximenes Neto FRG, Nascimento KV, Mira QLM. Actuación de enfermería frente a la depresión postparto en las consultas de puericultura. Enferm Glob 2013; 12(29):404-419.^-5656 Santos Junior HPO, Gualda DMS, Silveira MFA, Hall WA. Postpartum depression: the (in) experience of Brazilian primary healthcare professionals. J Adv Nurs 2013; 69(6):1248-1258..

Discussion

The bibliographic search in this study started with a large number of references (1,974), and 43 were selected for analysis according to inclusion and exclusion criteria. Most of the references that made up the initial sample of the search addressed child health or women’s health at other periods of life unrelated to puerperium.

We can affirm that literature that addresses women’s care in the puerperium in the context of PHC is scarce, since most studies selected did not provide a comprehensive approach to puerperal care, so evidence was limited to one-off issues of specific actions, and evaluative studies were restricted to process evaluations only. Of the studies that evaluated the puerperium process, only Silva et al.¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8. conducted a more extensive investigation of the actions carried out in puerperium, while others, mainly Brazilians, mostly limited themselves to investigating the number of postpartum consultations and impact of breastfeeding promotion programs.

An increased national and international scientific production was noted in the last 5 years, indicating a rising concern for women’s health in the puerperium, possibly by the promotion of strategies aimed at reducing maternal and child morbimortality, for example, proposed by the Sustainable Development Goals, and adopted by several countries. Despite worldwide decline, in the last decades, maternal and infant mortality remains a public health problem, especially in developing countries, and developed countries identified the need to qualify care for women in the postpartum period to reduce maternal morbidity, which may also have fueled increased studies in recent years.

According to the studies analyzed, puerperal care provided in PHC predominates in postpartum consultation and breastfeeding indicators, in national papers and home visits and PPD programs conducted mainly at the international level. Other aspects of care, such as assessment of physical structure and materials, health professionals and other activities performed in the puerperium (general guidelines, physical assessment and social vulnerability assessment) are poorly investigated.

In Brazil, investigations are restricted to the immediate and late puerperium, addressing remote puerperium only when it comes to breastfeeding, and the latter focusing on the child. International studies dealt with remote puerperium in a maximum of two and a half years postpartum³⁴34 Mejdoubi J, van den Heijkant SC, van Leerdam FJ, Crone M, Crijnen A, HiraSing RA. Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: a randomized controlled trial. Midwifery 2014; 30(6):688-695.^,3636 Robling M, Bekkers M-J, Bell K, Butler CC, Cannings-John R, Channon S, Martin BC, Gregory JW, Hood K, Kemp A, Kenkre J, Montgomery AA, Moody G, Owen-Jones E, Pickett K, Richardson G, Roberts ZE, Ronaldson S, Sanders J, Stamuli E, Torgerson D. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 2016; 387(10014):146-155., with a predominance of PDD investigation⁴⁶46 Milgrom J, Ericksen J, Negri L, Gemmill AW. Screening for postnatal depression in routine primary care: properties of the Edinburgh Postnatal Depression Scale in an Australian sample. Aust N Z J Psychiatry 2005; 39(9):833-839.

47 Rojas G, Fritsch R, Solis J, Jadresic E, Castillo C, González M, Guajardo V, Lewis G, Peters TJ, Araya R. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet 2007; 370(9599):1629-1637.^-4848 Glavin K, Smith L, Sørum R, Ellefsen B. Redesigned community postpartum care to prevent and treat postpartum depression in women-a one-year follow-up study. J Clin Nurs 2010; 19(21-22):3051-3062.^,5050 Reilly N, Harris S, Loxton D, Chojenta C, Forder P, Austin MP. The impact of routine assessment of past or current mental health on help-seeking in the perinatal period. Women Birth 2014; 27(4):e20-e7.

51 Abiodun O. Postnatal depression in primary care populations in Nigeria. Gen Hosp Psychiatry 2006; 28(2):133-136.^-5252 Munk-Olsen T, Pedersen HS, Laursen TM, Fenger-Grøn M, Vedsted P, Vestergaard M. Use of primary health care prior to a postpartum psychiatric episode. Scand J Prim Health Care 2015; 33(2):127-133.. While many women traverse puerperium without intercurrences, others experience significant issues that may persist for weeks, months or even more than 4 years after giving birth⁷7 Hartley S, Sutherland G, Brown S, Yelland J. 'You're more likely to tell the GP if you're asked': women's views of care from general practitioners in the first postpartum year. Aust J Prim Health 2012; 18(4):308-312.^,88 Gartland D, MacArthur C, Woolhouse H, McDonald E, Brown S. Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. Int J Obstet Gynecol 2016; 123(7):1203-1211., indicating these women’s need for care over time.

Considering that maternal health is PHC-sensitive²2 Bhutta ZA, Cabral S, Chan C-w, Keenan WJ. Reducing maternal, newborn, and infant mortality globally: An integrated action agenda. Obstet Gynecol Int J 2012; 119(Supl. 1):13-17.^,33 World Health Organization (WHO). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO Library Cataloguing-in-Publication Data; 2013. and that this point of care should provide care for women longitudinally, there is a need to qualify such actions in order to follow-up on women in all stages of puerperium, including the remote stage, neglected not only by public policies and clinical guidelines³3 World Health Organization (WHO). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO Library Cataloguing-in-Publication Data; 2013.^,66 Brasil. Ministério da Saúde (MS), Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da Atenção Básica: Saúde das Mulheres. Brasília: MS; 2016.^,5757 National Institute for Health and Care Excellence (Nice). Postnatal care up to 8 weeks after birth [Internet] 2015 [cited 2017 Out 27]. Available from: nice.org.uk/guidance/cg37
nice.org.uk/guidance/cg37... , but also in scientific studies. It is noteworthy that most of PHC care is low cost and has significant results in reducing maternal morbimortality with integrated and universal access actions²2 Bhutta ZA, Cabral S, Chan C-w, Keenan WJ. Reducing maternal, newborn, and infant mortality globally: An integrated action agenda. Obstet Gynecol Int J 2012; 119(Supl. 1):13-17.^,33 World Health Organization (WHO). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO Library Cataloguing-in-Publication Data; 2013..

Results showed that, in developing countries (Brazil and Peru), the puerperal consultation still does not occur with a satisfactory frequency, and maternal mortality rates remain high in such countries. There is a need for change in PHC access policies for women, their partners and/or family members during this period, which could affect the improvement of maternal and child morbimortality rates. Most studies approach the topic of puerperal consultation only as to its frequency rather than investigating their quality.

The highest risk of mortality is during the immediate and late postpartum period, with a higher morbimortality rate in the first postpartum week, which makes it a critical time for women and their child. Postpartum consultation is a primary intervention to reduce maternal morbimortality through prevention, early detection and treatment of complications, and advice on contraception⁴4 Nabukera SK, Witte K, Muchunguzi C, Bajunirwe F, Batwala VK, Mulogo EM, Farr C, Barry S, Salihu HM. Use of postpartum health services in rural Uganda: knowledge, attitudes, and barriers. J Community Health 2006; 31(2):84-93.^,55 Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013; 14(1):1-9.. However, this action does not seem to provide an opportunity for women to have their health needs met, either because of poor quality of care²⁸28 Bick DE, MacArthur C. Attendance, content and relevance of the six week postnatal examination. Midwifery 1995; 11(2):69-73. or because of the low frequency of these consultations²³23 Corrêa MD, Tsunechiro MA, Lima MOP, Bonadio IC. Avaliação da assistência pré-natal em unidade com estratégia saúde da família. Rev Esc Enferm USP 2014; 48(n. esp.):23-31..

In addition to the low frequency of puerperal consultation, results of the studies on the topic “women approach in puerperium consultation” indicate the incipient and poor care provided in PHC, with fragmented, biologicist care, childcare priority, focus on the “mother” role and not in women and their needs, in both national and international studies.

International clinical guidelines³3 World Health Organization (WHO). WHO recommendations on Postnatal care of the mother and newborn. Geneva: WHO Library Cataloguing-in-Publication Data; 2013.^,99 National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2015.^,5757 National Institute for Health and Care Excellence (Nice). Postnatal care up to 8 weeks after birth [Internet] 2015 [cited 2017 Out 27]. Available from: nice.org.uk/guidance/cg37
nice.org.uk/guidance/cg37... ^,5858 Austin MP, Highet, Guidelines Expert Advisory Committee. Clinical practice guidelines for depression and related disorders: anxiety, bipolar disorder and puerperal psychosis, in the perinatal period. A guideline for primary care health professionals. Melbourne: Beyondblue; 2011. guide the delivery of care to women in the puerperium, primarily by PHC professionals, through comprehensive and coordinated care, valuing women’s health needs, stimulating autonomy, self-care and care for their child. These guidelines are based on a high degree of scientific evidence and stand out for the quality of care delivery, which must be better investigated in the studies that address puerperal consultation and better implemented in the practice of providing care to women in the puerperium within PHC in different Brazilian and international settings.

HV is an important moment for the PHC team to detect early physical and emotional changes⁹9 National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2015., develop educational actions, identify household risks and vulnerabilities, establish a professional-user bond and improve the protection of women and children health in the postpartum period¹⁸18 Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral". Rev Gaucha Enferm 2016; 37(3):1-8..

Regarding the mentioned health care strategy, international studies have analyzed HV programs and their impacts, showing their importance for puerperal care. Brazilian studies are limited to investigating the frequency of visits and, incipiently, actions performed in HV, especially during the first week postpartum, and the main professional to perform this function is the community health worker, who also focuses on child and biologicist care.

With respect to breastfeeding, although it is an indicator of women’s health in the postpartum period, studies still address the issue with greater emphasis on the child. This topic and the indicator number of postpartum consultations were the ones with most emphasis in Brazilian studies, with predominantly quantitative analysis, indicating a gap in investigations of the quality of care provided in PHC.

Breastfeeding benefits to women’s health are countless¹⁹19 Rito RV, Oliveira MI, Brito Ados S. Degree of compliance with the ten steps of the Breastfeeding Friendly Primary Care Initiative and its association with the prevalence of exclusive breastfeeding. J Pediatr (Rio J) 2013; 89(5):477-484. and the main difficulties in its maintenance occur in the first months postpartum, and PHC is an incentive environment for this practice⁴¹41 Passanha A, Benicio MHD, Venancio SI, Reis MCG. Implantação da Rede Amamenta Brasil e prevalência de aleitamento materno exclusivo. Rev Saude Publica 2013; 47(6):1141-1148., considering its proximity to women and their priority role in the provision of puerperal care⁹9 National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2015..

PPD care identified in the papers analyzed was extensively investigated, especially in international studies. EPDS has emerged as an important tool for PPD screening by PHC professionals in developing countries to ensure early detection and appropriate therapeutic intervention in cases of PPD. National studies point to “empirical” PPD care, with professionals unprepared for screening, prevention and treatment of this condition⁵⁴54 Meira B, Pereira P, Silveira M, Gualda D, Santos Jr H. Desafios para profissionais da atenção primária no cuidado à mulher com depressão pós-parto. Texto & Contexto Enferm 2015; 24(3):706-712.

55 Felix TA, Siqueira DA, Ximenes Neto FRG, Nascimento KV, Mira QLM. Actuación de enfermería frente a la depresión postparto en las consultas de puericultura. Enferm Glob 2013; 12(29):404-419.^-5656 Santos Junior HPO, Gualda DMS, Silveira MFA, Hall WA. Postpartum depression: the (in) experience of Brazilian primary healthcare professionals. J Adv Nurs 2013; 69(6):1248-1258..

PPD is an international phenomenon and the most common complication in the postpartum period. Viewed as a public health problem whose prevalence ranges from 10% to 15% in developed countries, reaching up to 40% in developing countries⁴⁵45 Leung SS, Leung C, Lam T, Hung S, Chan R, Yeung T, Miao M, Cheng S, Leung SH, Lau A, Lee DT. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health 2010; 33(2):292-301.^,5353 Rojas. Barreras de acceso a tratamiento de la depresión posparto en centros de atención primaria de la Región Metropolitana: un estudio cualitativo. Rev Med Chile 2015; 143(4):424-432.^,5656 Santos Junior HPO, Gualda DMS, Silveira MFA, Hall WA. Postpartum depression: the (in) experience of Brazilian primary healthcare professionals. J Adv Nurs 2013; 69(6):1248-1258., this condition affects women’s quality of life and link with the newborn and its development⁵³53 Rojas. Barreras de acceso a tratamiento de la depresión posparto en centros de atención primaria de la Región Metropolitana: un estudio cualitativo. Rev Med Chile 2015; 143(4):424-432.^,5454 Meira B, Pereira P, Silveira M, Gualda D, Santos Jr H. Desafios para profissionais da atenção primária no cuidado à mulher com depressão pós-parto. Texto & Contexto Enferm 2015; 24(3):706-712.^,5656 Santos Junior HPO, Gualda DMS, Silveira MFA, Hall WA. Postpartum depression: the (in) experience of Brazilian primary healthcare professionals. J Adv Nurs 2013; 69(6):1248-1258..

PHC health professionals are well positioned to provide psychosocial support to all women in the perinatal period and to perform preventive approaches among women who may be more likely to develop PPD or related disorders, particularly in the immediate postpartum period⁹9 National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2015.^,5858 Austin MP, Highet, Guidelines Expert Advisory Committee. Clinical practice guidelines for depression and related disorders: anxiety, bipolar disorder and puerperal psychosis, in the perinatal period. A guideline for primary care health professionals. Melbourne: Beyondblue; 2011.. These professionals should play an active role in screening and selecting PPD treatment, considering contextual factors, such as culture, socioeconomic condition, among others⁹9 National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2015.^,5858 Austin MP, Highet, Guidelines Expert Advisory Committee. Clinical practice guidelines for depression and related disorders: anxiety, bipolar disorder and puerperal psychosis, in the perinatal period. A guideline for primary care health professionals. Melbourne: Beyondblue; 2011..

The limitations found for the accomplishment of this review referred to the wide range of descriptors used, resulting in a large number of papers to perform the reading of titles and abstracts. However, this strategy was necessary, due to the scarcity of studies that use the postpartum period as a descriptor. This limitation was overcome by a thorough reading of titles and abstracts, ensuring selection of the studies that addressed the guiding question. Furthermore, a variety of research methods used to address the actions of puerperal programs was observed, which prevents a more accurate comparative analysis of the results achieved. As any type of study, this integrative review has advantages and limitations of the method itself, and care should be taken with regard to conclusions related to the findings. However, authors highlight the potential of the method used, since it has validity among experts in the review area.

Final considerations

Results indicate that there is a range of actions to be performed by PHC to assist women in the puerperium, which can be carried out using light and low-cost technologies, and that this point of care is paramount in helping to reduce of maternal morbimortality through counseling and support for recovery from pregnancy and birth, early identification and appropriate management of physical and emotional health needs.

Despite the recognized importance of puerperal care, Brazilian studies are mostly confined to investigating the number of postpartum visits, the number of home visits and the effect of breastfeeding programs, neglecting the comprehensive nature of postpartum care to women in PHC.

National and international studies indicate that postpartum care still focuses on newborn care and are mostly restricted to the immediate and late puerperium, and there is a need to improve the implementation of primary health care for women, especially in relation to the coordination and longitudinality of care, which evidences the need for better quality of care for puerperae in PHC.

It is noteworthy that PPD has been the target of countless studies in the international literature, given its high prevalence and public health issue, and evidenced the high potential of PHC professionals to act in the prevention, screening and treatment of said disease. In Brazil, this is a poorly studied topic worthy of attention of postpartum public policies, with results that point to the lack of qualification of PHC professionals for PPD care.

This review evidenced knowledge gaps regarding the subject matter, with the need for more robust studies that address comprehensive women care, as well as aspects of the quality of care provided in PHC. In addition, there is a need for evaluative research with a qualitative and quantitative approach in order to understand the implementation of puerperal care in PHC and the relationship of results found with the puerperal care program.

It is important to emphasize that the puerperium investigation can identify a range of activities to be developed and considered in PHC, both physical, material and human structure, as well as professional qualification, program planning and management, besides external factors cultural aspects of the woman receiving care. Thus, this study serves as a subsidy both to guide the elaboration and improvement of actions to the benefit of women in the puerperium in PHC by professionals and managers and to direct the elaboration of empirical studies that can investigate the integrality of puerperal care.

References

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