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Conteúdo (article):

CONCORDÂNCIA ENTRE INFORMAÇÕES REGISTRADAS NO CARTÃO PRÉ-NATAL E NO ESTUDO MINA-BRASIL
AGREEMENT BETWEEN INFORMATION RECORDED DURING ANTENATAL CARE AND IN THE MINA-BRAZIL STUDY
Título resumido: Concordância entre medidas de pré-natal
Short title: Agreement between antenatal care measurements

Ana Alice de Araújo Damasceno
Instituição: Universidade Federal do Acre- Campus Floresta
E-mail: anaalice_czs@hotmail.com
ORCID: 0000-0001-7975-7791

Paola Soledad Mosquera
Instituição: Faculdade de Saúde Pública- Universidade de São Paulo
E-mail: paolamosquera@usp.br
ORCID: 0000-0001-8423-7344

Maíra Barreto Malta
Instituição: Faculdade de Saúde Pública- Universidade de São Paulo
E-mail: mairamaltanutri@gmail.com
ORCID: 0000-0003-4993-1589

Alicia Matijasevich
Instituição: Faculdade de Medicina –Universidade de São Paulo
E-mail: alicia.matijasevich@usp.br
ORCID: 0000-0003-0060-1589

Marly Augusto Cardoso
Instituição: Faculdade de Saúde Pública- Universidade de São Paulo
E-mail: marlyac@usp.br.
ORCID: 0000-0003-0973-3908

Correspondência:
Marly Augusto Cardoso
Departamento de Nutrição, Faculdade de Saúde Pública. Universidade de São Paulo
Av. Dr. Arnaldo 715. CEP: 01246-904 São Paulo (SP), Brasil.
E-mail: marlyac@usp.br.

RESUMO
Objetivo: Analisar a concordância entre dados de peso pré-gestacional, peso na gravidez, altura e pressão arterial sistólica (PAS) e diastólica (PAD) registradas na caderneta da gestante e as mesmas informações obtidas no estudo longitudinal MINA-Brasil. Métodos: Foram selecionadas as gestantes participantes do estudo MINA-Brasil que apresentavam cartão do pré-natal no momento do parto. A análise de concordância dos dados utilizou o coeficiente de correlação de concordância de Lin e análise de Bland-Altman. Resultados: Foram incluídas 428 gestantes. Houve concordância moderada entre as informações para o peso pré-gestacional autorreferido (0,935) e altura (0,913), e concordância substancial para o peso da gestante no segundo (0,993) e terceiro (0,988) trimestres de gestação. Verificou-se baixa concordância da PAS e PAD no segundo (PAS=0,447; PAD=0,409) e terceiro (PAS=0,436; PAD=0,332) trimestres gestacionais. Conclusão: As medidas antropométricas apresentaram boa concordância. Houve baixa concordância entre as medidas de pressão arterial, que podem estar relacionadas tanto à variabilidade como também à padronização dessas medidas, sugerindo-se necessidade de capacitação e treinamento contínuo das equipes de pré-natal na atenção primária à saúde.
Descritores: Antropometria. Cuidado pré-natal. Gravidez. Saúde Materna.

ABSTRACT
Objective: to examine agreement of pre-pregnancy weight, pregnancy weight, height and systolic (SBP) and diastolic (DBP) blood pressure measurements recorded on antenatal record cards with the same information obtained in the MINA-Brazil longitudinal study. Methods: 428 pregnant women who participated in the MINA-Brazil study and had an antenatal card at time of childbirth were selected. Concordance analysis of the data used Lin’s correlation coefficient and Bland-Altman analysis. Results: there was moderate agreement on self-reported pre-pregnancy weight (0.935) and height (0.913) information, and substantial agreement on the pregnant women’s weight in the second (0.993) and third (0.988) trimesters of pregnancy. Little agreement was found on SBP and DBP measured in the second (SBP = 0.447; DBP = 0.409) and third (SBP = 0.436; DBP = 0.332) trimesters of pregnancy. Conclusion: anthropometric measurements showed strong agreement. There was weak agreement between blood pressure measurements, which may relate both to the variability and the standardisation of these measurements, suggesting the need for continued training of antenatal teams in primary health care.
Descriptors: Anthropometry. Antenatal care. Pregnancy. Maternal Health.

INTRODUCTION
With proper antenatal care, it is possible to prevent, diagnose and treat disorders of pregnancy, childbirth and puerperium. Studies using information on care during pregnancy have been essential to guiding the actions of health services1, 2.
In Brazil, the expectant mother’s antenatal booklet is a record of care that should contain information on all management and procedures performed during pregnancy monitoring. The Ministry of Health recommends the booklet be filled in by the expectant mother as of the first antenatal appointment. The information should include data on pre-pregnancy weight and height, as well as pregnancy monitoring information from all antenatal appointments, such as the pregnant woman’s weight and blood pressure, and other information necessary to prevent and treat unfavourable pregnancy outcomes, so that the baby can be born healthy and with no adverse effects on the mother’s health3.
Proper records of comprehensive antenatal care offer a good indicators of the quality of care. Accordingly, research to investigate agreement between data entered in expectant mothers’ antenatal care booklets and from other information sources is fundamental to assessing pregnancy monitoring services and their concepts, given that the lack or inappropriate provision of antenatal care has been associated with higher rates of maternal and neonatal morbi-mortality4,5. Also, as the data entered by the various health services in expectant mothers’ antenatal care records are easy to access, they have been used for conducting epidemiological studies.
Some Brazilian studies have found good agreement between anthropometric measurements recorded in expectant mothers’ antenatal care records and the values obtained in surveys6 or information reported by pregnant women7. It is important to ascertain whether there are differences between the data recorded on antenatal record cards and data obtained by other methods, so as to identify variations in the methods. The literature search found no studies to date evaluating to what extent anthropometric and blood pressure measurements taken during antenatal monitoring agree with measurements obtained in longitudinal studies.
Information from antenatal monitoring can differ depending on the method, standardisation and instruments used and it is important to know the magnitude of error involved in measuring such information. Accordingly, this study examined to what extent data on pre-pregnancy weight, and gestational weight, height and systolic (SBP) and diastolic (DBP) blood pressure entered on antenatal record cards during routine antenatal appointments agreed with the same information obtained by researchers in the MINA-Brazil longitudinal study of maternal and child health in Cruzeiro do Sul, Acre, Brazil.

METHODS
STUDY DESIGN AND POPULATION
The MINA-Brazil study: Maternal and Child Health in Cruzeiro do Sul, Acre, is a prospective cohort designed mainly to investigate factors associated with the health and nutrition of mothers and their babies through pregnancy up to two years of age. For the study reported here, a subsample of participants was selected in order to assess agreement between the data obtained by the MINA-Brazil study team and the same data entered on antenatal record cards during routine antenatal monitoring.
The pregnant women who participated in the MINA-Brazil study were identified by their having enrolled in the antenatal programme at primary health care facilities in the urban zone of the Cruzeiro do Sul municipality in the period between February 2015 and February 2016, as described in a previous publication8, and whose antenatal record cards had entries from at least one antenatal appointment.
Pregnant women with fewer than 20 weeks gestational age, as based on the date of their last menstruation, were contacted by telephone by the research team to invite them to take part in the study. On accepting, home visits were scheduled to interview them on sociodemographic and health history information. Two clinical assessments were then scheduled in order to monitor the study participants: the first, during the second trimester of pregnancy and the second in the third trimester, using the best estimate of gestational age (date of the last menstruation or ultrasound performed at the first evaluation).
All the pregnant women monitored by the MINA-Brazil study at any of the assessments conducted during the period of pregnancy were selected, providing their antenatal record card, at the moment of childbirth, recorded at least one antenatal appointment. The antenatal cards were previously digitised and the data were double-entered by the research team.
The agreement analysis in this study first identified the self-reported pre-pregnancy weight and height measurements recorded in the antenatal record card and in the MINA-Brazil study. Agreement was then evaluated between the records of self-reported pre-pregnancy weight in the MINA-Brazil study and the pregnant women’s weight measured at 13 weeks of pregnancy as recorded in the antenatal card, with a view to observing differences possibly related to memory bias. Agreement for weight during pregnancy and for SBP and DBP was examined at two points, in the second and third trimesters of pregnancy, allowing a maximum tolerance period of seven days earlier or later between the measurements taken by health personnel and recorded in the antenatal record card and those in the MINA-Brazil study evaluations (Figure 1).
The study used the MINA-Brazil research protocol submitted to and approved by the research ethics committee of the Public Health Faculty of the Universidade de São Paulo (Projeto MINA approval protocol No. 872.613, of 13 November 2014).

DATA COLLECTION
Information on the pregnant women’s demographic and socioeconomic characteristics was obtained by interview, as follows: age (< 19, 19 to < 35 and ≥ 35 years), schooling (≤ 9, 10 to 12 and >12 years), self-reported skin colour (white, non-white), is head of family (Yes, No), has paid occupation (Yes, No), receives Bolsa Família conditional cash transfer programme benefit (Yes, No), marital status (lives with partner, does not live with partner) and first pregnancy (Yes, No).
The measurements used in the MINA-Brazil study as regards the variables of interest to the agreement analysis in this study (weight prior to and during pregnancy, height and blood pressure) were standardised and taken by a trained research team. The pregnant women’s bodyweight was measured using a Tanita Corporation® (Tokyo, Japan), portable scales model UM061, with 150 kg capacity and 0.1 kg graduation, which was regularly calibrated by the team. Weight was measured with the participant barefoot and in light clothing, standing upright, arms at her side and feet together; that position was held while the measurement was read and recorded. Height was measured using a portable Alturaexata® stadiometer (Belo Horizonte, Brazil) precise to 0.1 cm and with capacity of 213 cm. Height was measured with the participant barefoot and bareheaded, with no ornaments (hair clips, hair stick and so on) or hairstyles (ponytail, plaits and so on), positioned at the centre of the equipment, upright, arms at her sides, head upright, looking at a fixed point at eye level, and that position was held while the measurement was read and recorded. All measurements were taken twice, following the recommendations of the World Health Organisation (WHO)9 The mean of the measurements was then calculated and the exact value of the mean was used for analysis. Blood pressure was measured using an OMRON HEM-705CPINT digital apparatus. Measurement was standardised for all the pregnant women who participated in the study, following the recommendations of the Ministry of Health low-risk antenatal care manual3. Blood pressure measurements were taken on the right arm using a cuff of appropriate size, with the participant seated, her feet on the floor and arm at heart level, after resting for at least five minutes. Three measurements were taken, at one-minute intervals, and the mean was calculated for SBP and DBP. High blood pressure in pregnancy was defined by identifying absolute values of SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg10.

STATISTICAL ANALYSIS
Means and their respective 95% confidence intervals (95% CI) were calculated for the continuous variables. The categorical variables were described by absolute and relative frequencies.
Bland-Altman analysis11, 12 was performed to identify the Limits of Agreement (LoA) intervals with 95% confidence, making it possible to analyse the overall distribution of agreement values by dimension of the measurements in question. The Bland-Altman technique produces a graph displaying bias (how far the differences are from zero, i.e., the mean difference), error (the dispersion of difference points around the mean) and outliers.
Lin’s Concordance Correlation Coefficient (CCC)13 was used to complement the analysis of agreement by ascertaining the magnitude of deviation from the line of perfect agreement. In order to assess the degree of agreement by CCC, the following classification was used: near perfect (> 0.99), substantial (0.95 to 0.99), moderate (0.90 to 0.95) and low (< 0.90)14.
A 5% level of significance was used. Data were processed with the aid of the Stata statistical package, version 12.0 (Stata Corp, College Station, TX, USA).

RESULTS
A total of 428 pregnant women for whom information was available on their antenatal record cards and in the MINA-Brazil study were included in this study. From these, pairs of measurements were obtained, as follows: 363 for self-reported pre-pregnancy weight, 260 for pre-pregnancy weight entered on the antenatal record card up to the 13th week of pregnancy, 106 for height, 178 for second-trimester gestational weight and 185 for third-trimester gestational weight, 180 for second-trimester SBP and DBP and 185 for third-trimester SBP and DBP.
From data on the antenatal record cards, the prevalence of systemic arterial hypertension was 2.2% in the second trimester of pregnancy and 1.6% in the third trimester. From the MINA-Brazil study data, there were no cases of arterial hypertension in the second trimester and prevalence in the third trimester was 0.5%.
The pregnant women who participated in the study were, on average, between 19 and 34 years old (71%), 85% considered themselves non-white, 58% had completed from 10 to 12 years’ schooling and 79% reported living with a partner. Most participants did not have a paid occupation (64%) and were not heads of household (85%), 38% received benefits from the Bolsa Família conditional cash transfer programme, 11% belonged to the first household wealth quintile and 44% were in their first pregnancy (Table 1).
Table 2 shows mean values and 95% CIs for the measurements taken in the MINA-Brazil study and from the antenatal record cards, with a sample total for each variable and CCC values and mean differences with their respective Bland-Altman limits of agreement.
The Bland-Altman analysis showed that the expectant mothers’ second- and third-trimester weights measured and recorded in the antenatal record card were, on average, very close to those in the MINA-Brazil study (mean differences of -0.278 and -0.186, respectively). The SBP measurements taken at antenatal appointments and entered on the antenatal record card in the second and third trimesters of pregnancy were underestimated in comparison with those of the MINA-Brazil study (-5.443 and -4.638, respectively). The measurements of self-reported pre-pregnancy weight and height in the antenatal record cards were, on average, greater than those in the MINA-Brazil study (0.809 and 0.223, respectively). The mean difference was greater (0.960) when considering pre-pregnancy weight measured at up to the 13th week of pregnancy and entered on the antenatal record card (Table 2).
In limit of agreement assessment, smaller variations were observed in pre-pregnancy weight (LoA = -6.689; 8.306) (Figure 2A), height (-5.148; 5.595) (Figure 2B) and weight assessed in the two trimesters: (-2.660; 2.104 at the second trimester and 3.192; 2.821 in the third trimester) (Figure 2C and 2D). Greater variation in limits of agreement were observed in all blood pressure measurements: second-trimester SBP returned LoA = -26.185; 15.299 and third-trimester SBP returned LoA= -24.798; 15.522 (Figure 2E and 2F), while LoA for second-trimester DBP was -18.624; 18.994 and, for third-trimester DBP, -17.368; 20.665 (Figure 2G and 2H). Limits of agreement values are shown in Table 2.
CCC returned moderate agreement between the information on the antenatal cards and those recorded by the MINA-Brazil study for pre-pregnancy weight (0.935), pre-pregnancy weight measured at up to the 13th week of pregnancy (0.920) and height (0.913). Agreement for weight in the second and third trimesters of pregnancy was substantial, at 0.993 and 0.988, respectively. Blood pressure measured in the second and third trimesters of pregnancy returned low agreement: respectively, SBP = 0.447; DBP = 0.409 and SBP = 0.436; DBP = 0.332 (Table 2).

DISCUSSION
In this study, the data for pre-pregnancy weight, height and weight during pregnancy entered on antenatal record cards returned good agreement with the measurements taken by the MINA-Brazil study. However, the systolic and diastolic arterial pressure data obtained in routine antenatal care showed greater error than the corresponding information obtained by the MINA-Brazil research team.
The Ministry of Health stresses that taking these measurements is indispensable to proper physical examination of pregnant women and, given their importance, they should be assessed starting at the first antenatal appointment. It also standardises the procedures for taking all these measurements, so as to ensure better healthy service quality3,10.
Pre-pregnancy nutrition assessment is of prime importance to monitoring weight gain during pregnancy and indispensable to identifying women at nutritional risk15. The pre-pregnancy weight entered on antenatal record cards may be self-reported or measured up to the 13th complete week of pregnancy16. Self-reported measurements have been used for pre-pregnancy nutritional monitoring, mainly because they are difficult to take before pregnancy. In this study, there was moderate agreement between self-reported pre-pregnancy weights. The mean difference increased in the pregnant women’s weight measured at up to the 13th week of pregnancy as entered on the antenatal record card.
Shin et al.17, in a study in the United States which assessed agreement between self-reported weight and weight measured in the first trimester, found a mean difference of 2.3 kg. The difference found in a study by Natamba et al.18 in Lima, Peru, was greater (0.27 kg). Both studies concluded that there was good agreement between the measurements and that self-reported pre-pregnancy weights are generally valid and reliable for proper evaluation of, and guidance on, gestational weight gain and also for purposes of research and population-based surveillance17,18. In the study reported here, the mean difference observed in self-reported pre-pregnancy weight was 0.81 kg.
Proper evaluation of nutritional status during pregnancy and related practical interventions have positive impact during pregnancy and after childbirth. In addition to preventing adverse health outcomes for the conceptus, appropriate nutritional status in pregnancy contributes to a favourable prognosis for the child’s health status in the early years of life9,15,19. In this study, there was good intrapair agreement in height measurements, as indicated by the CCCs and narrow LoAs. Some Brazilian studies that have evaluated agreement between self-reported height and the values entered on antenatal record cards have found that height was overestimated6,7. Another study that examined the reliability of using self-reported values for pregnant women observed that women pregnant for the first time tended to underestimate their height and weight, which affected calculations of BMI20. The findings of those studies underline the importance of measuring the height of pregnant women and of that procedure’s being performed appropriately.
In this study, the information that returned best agreement between the variables investigated was gestational weight in the second and third trimesters of pregnancy. That high degree of agreement may be related to the use of suitable digital scales in antenatal care services, and to health personnel’s following procedures appropriately. On the other hand, Niquini et al.7 found that, despite strong agreement between data, certain criteria were not properly met when pregnant women were weighed in antenatal appointments at Rio de Janeiro’s municipal primary care facilities and hospitals. This undermined the validity of those measurements and pointed to a need to train health personnel in taking weight measurements.
It is of paramount importance to measure pregnant women’s blood pressure during antenatal appointments in order to identify hypertensive disorders early21. In this study, the measurements of systolic and diastolic arterial pressure in the second and third trimesters were highly discrepant in all the analyses of agreement. Silva et al.22 reported similar findings in the general population, where values measured by what they considered to be the “gold standard” were discrepant from those measured in a public emergency facility in São Paulo. In another study of antenatal care at primary care facilities in Campinas23, considerable variations were found in arterial pressure measured by sphygmomanometer (an aneroid apparatus more used in Brazil) and by oscillometer (an electronic apparatus). The oscillometer returned systolic arterial pressure values similar to those of the cuff method, but underestimated diastolic arterial pressure. In both methods, using the standard width cuff, rather than the correct wide cuff, resulted in underestimation of blood pressure.
Note that this is the first study in Brazil’s North region to examine agreement between data recorded on antenatal record cards and the standardised measurements of a longitudinal study. However, certain limitations should be noted. The findings as regards arterial pressure measurements should be treated with caution, because the values may vary, even over small time intervals. The measurements in this study were taken over periods ranging from zero to seven days, rather than in quick succession, which may preclude any more substantial analysis of the agreement estimates. Some studies corroborate this, pointing out that even at normal levels, arterial pressure can show a pattern of variation over the course of pregnancy24,25,26.
The findings warrant the conclusion that there was good agreement between the anthropometric measurements as entered on antenatal record cards in routine antenatal care and the measurements obtained by a research team. Note also that weak agreement between blood pressure measurements may be related to the intra-individual variability of such measurements and to the use of different equipment and unsuitable cuffs. Nonetheless, even though there may be such variation, our findings suggest a need to use appropriate, duly calibrated equipment and for continued capacity-building and training for antenatal teams in primary health care.

cOLLABORATIONS

AAAD: collection, analysis and interpretation of data, writing and revision of the manuscript. PSM: data processing and analysis, manuscript review. MBM: supervision of data collection, processing and analysis and manuscript review. AM: conception, data interpretation and critical manuscript review. MAC: design, analysis and interpretation of data, manuscript review, approval of the final version, public responsibility for the content of the article.

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