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Rede Cegonha em Pernambuco: um olhar da auditoria do SUS na avaliação da atenção ao pré-natal
The Stork Network in Pernambuco: an overview of SUS auditing in the evaluation of prenatal care

Vania Nazaré da Costa Silva
Ministério da Saúde/PE, cedida à Secretaria de Saúde de Olinda-PE
vania.costa66@outlook.com
https://orcid.org/0000-0002-4701-2493
Daphne Rattner
Departamento de Saúde Coletiva da Faculdade de Ciências da Saúde/Universidade de Brasília
daphne.rattner@gmail.com
https://orcid.org/0000-0003-1354-9521
Rosamaria Giatti Carneiro
Departamento de Saúde Coletiva da Faculdade de Ciências da Saúde/Universidade de Brasília
rosacarneiro@unb.br
https://orcid.org/0000-0002-1271-7645
Antonio Flaudiano Bem Leite
Secretaria de Saúde e Bem-Estar da Vitória de Santo Antão-PE
afbemleite@gmail.com
https://orcid.org/0000-0002-8719-5562

Resumo
A estratégia Rede Cegonha (RC) foi criada para garantir a completude da linha de cuidado e intervir nas altas taxas de mortalidade materna e infantil. O estudo objetiva mensurar ações desenvolvidas pela RC nos municípios de Pernambuco e sua associação aos indicadores c de qualidade da atenção pré-natal (PN). Realizou-se estudo ecológico de múltiplos grupos e corte transversal de 2017 a 2020, referente ao Componente I da RC de Pernambuco, a partir dos relatórios de auditorias do Componente Estadual Auditoria. Dez ações foram relacionadas aos indicadores de qualificação da atenção PN. Os indicadores mais bem-avaliados foram “Garantia de ampliação do acesso ao PN de alto risco”, “Testagem rápida de sífilis/HIV” e “Exames laboratoriais de risco habitual e alto risco”. O indicador mais associado à taxa média de sífilis congênita foi o teste rápido para sífilis/HIV. Dois indicadores apresentaram significância estatística na associação com o coeficiente de mortalidade perinatal: “Garantia de ampliação do acesso ao pré-natal de alto risco” e “Apoio ao deslocamento”. Conclui-se que a gestão organizacional da política estudada e a prestação de serviços no componente I, em Pernambuco, não atenderam aos objetivos da Rede Cegonha. O estudo mostra o potencial da auditoria no apoio às políticas.
Palavras-chave: Rede Cegonha; Auditoria em Saúde; Cuidado Pré-Natal; Estudos Ecológicos.
Abstract
The Stork Network (SN) strategy was created to guarantee comprehensive care and address high maternal and infant mortality rates. The aim of this study was to assess the actions developed by the SN across municipalities in the state Pernambuco and the association between these actions and prenatal care quality indicators. We conducted a multi-group ecological study of Component I of the SN in Pernambuco using data from audits conducted under the state component of the National Audit System for the period 2017 to 2020. We explored the association between ten actions and the prenatal care quality indicators. The indicators with the highest ratings were "Improved access to high-risk prenatal care", "Rapid syphilis/HIV testing" and "Laboratory testing for low and high risk pregnant women". The indicator with the strongest association to mean congenital syphilis rate was rapid testing for syphilis/HIV. Two indicators showed a statistically significant association with mean perinatal mortality rate: "Improved access to high-risk prenatal care" and "Support for travel". We conclude that the organizational management of the SN in Pernambuco and provision of services under component I did not meet the objectives of strategy. Our findings demonstrate the potential of auditing for supporting policy implementation.
Keywords: Maternal-Child Health Services; Health Administration; Prenatal Care; Ecological Studies.
INTRODUCTION
Maternal and infant mortality have been analyzed throughout history and this has motivated the Ministry of Health to draw up and implement strategies to tackle this problem. With the support of management committees and feminist and socially oriented non-governmental organizations, health actions directed towards women and children underpinned by the principles of comprehensiveness have been expanded, strengthening the network-based model of care and guaranteeing affiliation.1 The infant mortality rate in Brazil dropped from 69.1 deaths/1,000 live births in 1980 to 16.1 deaths/1,000 live births in 2011, the year in which the Stork Network (SN) was launched. Among the components of infant mortality, post-neonatal mortality showed a greater reduction than neonatal mortality. While this represents a significant drop, rates remain higher than in developed countries. These figures have prompted reflection on the quality of prenatal and childbirth care and the management of newborns up to the 27th day of life.2
DEMITO, et al, (2017) reported a neonatal mortality rate of 17.7/1,000 live births in Maringá, in the state of Paraná, between September 2012 and 2013, with a higher proportion of deaths in the early neonatal phase. The causes of these deaths included preterm labor, very low birth weight (Apgar score of less than 7), which are factors for high risk of death. They concluded that the identification of risk factors and appropriate interventions during prenatal care and in perinatal services are measures that should be implemented and monitored to improve perinatal outcomes, including the reduction of neonatal mortality.
PACAGNELLA et al (2018) highlight that maternal mortality is multifactorial and systemic and systematic actions are needed to reduce these rates. Quality of health care, from preconception through postpartum care, is critical to reducing these rates. The authors emphasize that gaps in Brazil’s maternity care network may be responsible for delays in the delivery of adequate care, given that only 15% of public maternity facilities had an ICU, recommending that referral facilities should be no more than 20km away from hospitals that provide care for low-risk cases.4
HOWELL (2018) argues that quality of health care, from preconception through postpartum care, may be a critical lever for improving morbidity and mortality rates among racial and ethnic minority women. The author highlights that a promising model for reducing mortality, especially among these minorities, is enhanced prenatal care, adopting a multidisciplinary approach during antenatal and delivery care, especially for the management of high-risk pregnant women with preexisting conditions. This approach contributed to a decline in black maternal mortality rates in North Carolina. He goes on to say that this model could become a benchmark for prenatal care in various locations around the world.5
Brazil’s Northeast and North regions still have the country’s highest infant mortality rates. Despite a recent increase in investment in these models and the incorporation of new technologies, tackling this problem is a challenge due to the multifactorial nature of infant and maternal mortality.6
In the state of Pernambuco, prenatal and postpartum care is a major challenge, especially when it comes to guaranteeing examinations, timely treatment and affiliation to the maternity facility at delivery.4 One of the obstacles to providing quality hospital care for low-risk births is the difficulty municipal health authorities encounter in guaranteeing a complete obstetric team in local maternity facilities, leading to a large flow of pregnant women to state high-complexity maternity facilities in distant urban centers. This leads to the overburdening of these facilities and means that low-risk pregnancies can often develop into high-risk deliveries.6
Created by Ministerial Order 1459 (24 June 2011), the SN is the infant and maternal component of the country’s women\'s and children\'s health policies. The "SN Strategy"3 brings together a series of actions set out in previous women\'s health policies, establishing a network-based care model aimed at guaranteeing women\'s right to reproductive life planning and humanized care during pregnancy, childbirth and the postpartum period and affiliation to a hospital for childbirth care and newborn follow-up up to 2 years of age.7,8
Medical auditing contributes to the consolidation of the country\'s public health system, the Sistema Único de Saúde (SUS) or Unified Health System. Underpinned by the principles of public administration, audits assess policy implementation, identify irregularities and facilitate public participation, transparency and public access to health system information.7 The auditing process focuses on the quality of the outcomes of service provision and aims to bring actions into line with current standards. Operational auditing focuses on control and work processes, while analytical auditing evaluates specific aspects of care.7;9
Auditing is a management and governance tool for the normative evaluation of health actions, meaning that it can be used to determine the adequacy of health care actions. Studies adopting SUS auditing to support quality improvement were not found in the literature. Using data from the SUS audit system, the aim of this study was to measure the results of audits of the actions developed under Component I of the Stork Network in municipalities in the state of Pernambuco and the potential association between these actions and two prenatal care quality indicators: the congenital syphilis detection rate and perinatal mortality rate8,9.
METHODOLOGY
We conducted a multiple-group ecological study10. The ecological units were 184 of the 185 municipalities in the state of Pernambuco (the island of Fernando de Noronha was not audited). The municipalities were aggregated into macro health regions and categorized according to size as follows: small - up to 50,000 inhabitants; medium - between 50,001 and 100,001 inhabitants; and large - more than 100,001 inhabitants.
The study period was 2017 to 2020, based on the date of completion of audit processes for the state component of the National Audit System.
The data source was the SUS Audit System (SISAUD/SUS)11, consisting of anonymized secondary data from Component I of the SN audit reports, which use 20 variables. We used data from the first block of 10 variables directly related to actions and services provided under Component I of the SN (prenatal care), as set out in Consolidation Order 3/201711: (1) six prenatal visits (minimum), consisting of three alternate visits with nurses and three with doctors; (2) 12-week scan; (3) risk assessment and classification; (4) Improved access to high-risk prenatal care; (5) laboratory tests; (6) rapid syphilis/HIV testing; (7) medication provision; and (8) vaccination. Two other variables associated with affiliation were also included: (9) guarantee of affiliation to place of delivery; and (10) support for travel12. These indicators were applied to a sample of medical records in each municipality. The size of each sample was calculated based on the number of live births in the municipality in the previous year. An overall score was calculated based on the sum of the compliance rate for each of the ten indicators.
The audit reports (AR) were based on the results of specific on-site questionnaires completed by managers and workers in the following areas: primary care coordination, pharmaceutical services and primary care teams. Medical records were also simultaneously checked and analyzed, totaling 13,507 records for the 184 municipalities. A standardized list was used to determine compliance ("yes") and non-compliance ("no"). The compliance rate ranged from 0% to 100% for each of the ten indicators, resulting in a potential overall score of between 0 and 1,000. The second block of variables included two prenatal care quality indicators for the years 2017 to 2019: (1) mean congenital syphilis incidence rate (per 1,000 live births); and (2) mean perinatal mortality rate (per 1,000 births). To avoid measurement bias and standardize data collection, the data collection instruments were applied by a team of previously trained auditors.
Descriptive statistics
Arithmetic means and standard deviations were used as measures of central tendency and data dispersion, respectively. For these calculations, only the number of observations (N) with valid values was considered, excluding losses (no information, not evaluated and blank cells). The Kruskal-Wallis test, a non-parametric test, was used to assess the statistical significance of associations with macro-region and municipality size, as all the evaluative audit indicators from Component I – Low-risk prenatal obtained ρ-values of <0.05 after performing Lilliefors test (variation of the Kolmogorov-Smirnov test). The descriptive statistical analysis was performed using Epi Info version 7.2.4.0.13.
Analytical statistics
For the analytical stage, we used generalized linear models (GLMs), which extend linear regression. The dependent or response variables were the indicators in the second block, while the independent or explanatory variables were the indicators in the first block, macro health region and municipality size.
In this stage data from 89 of the 184 municipalities were used. The municipality inclusion criterion were all municipalities with less than three indicator fields with missing information.
Two GLMs were run, beginning with all the independent variables: one including the average syphilis incidence rate as the dependent variable (Model 1) and the other including the average perinatal mortality rate (Model 2). Stepwise (backward/forward) regression was used adopting a t-test ρ-value of < 0.20 as the initial cut-off point for including variables in the initial model and the lowest Akaike information criterion (AIC) assigned to the models, compared to those previously assessed.
The final two models were adjusted based on the following criteria: all independent variables with ρ-value <0.05; plot of the residuals showing normal distribution; and the Bonferroni test for non-studentized residuals with ρ-value <0.05.
The analyses in this stage were performed using R version 4.2.2 and Rcmdr version 2.8-0.14
ETHICAL CONSIDERATIONS
The study was conducted in accordance with the ethical norms and standards set out in National Health Council Resolution 510/2016 and National Health Council Resolution 466/2012, which governs research involving human subjects. The subjects were not identified, thus ensuring their anonymity. The study was approved by the University of Brasília’s Faculty of Health Sciences’ research ethics committee (CEP/FS/UnB) (reference code No. 54930321.8.0000.0030 and report No. 5.306.534, 23 March 2022). The search of the state component of the National Audit System was authorized by the Pernambuco State Health Department.
RESULTS
Tables 1a and 1b show that there was considerable variation in the number of observations for each indicator, revealing that information that was not available in many municipalities. The indicator with the lowest number of observations was "Support for travel" (85 municipalities), followed by "Improved access to high-risk prenatal care" (89 municipalities). The indicator with the highest number of observations was "Vaccination" (157 municipalities), followed by “12-week scan" (156 municipalities). None of the indicators had complete information for all municipalities.
The indicators with the lowest rating (less than 50% compliance) were "Low-risk prenatal visits" (27.9% compliance), which showed a statistically significant differences across health regions and municipality sizes, and "Affiliation to place of delivery" (37.3% compliance), which showed statistically significant differences across health regions. The indicators with the highest rating were "Improved access to high-risk prenatal care", "Rapid syphilis/HIV testing" and "Laboratory testing for low and high risk pregnant women" (86.0%, 83.2% and 82.8% compliance, respectively) (Tables 1a and 1b). No statistically significant differences were found across health regions or municipality sizes. The highest overall scores were found in health regions I (482.0) and II (486.1), and the lowest score was found in health region IV (287.1). The indicator "Low-risk prenatal visits" showed statistically significant lower scores in health regions II and IV, while "Affiliation to place of delivery" and "Support for travel" showed statistically significant lower scores in health regions III and IV (Tables 1a and 1b). In health region IV, the compliance rate for "Affiliation to place of delivery" was less than 10%, reflecting possible network organization difficulties this region.
Overall scores in large municipalities were 1.4 times higher than in small and medium cities. This difference was statistically significant. The only indicator that showed a statistically significant difference was "Low risk prenatal visits", with scores being three times higher in large municipalities (Tables 1a and 1b), suggesting greater availability of doctors in these municipalities.
Table 1a: Audit indicators from Component I - Low Risk Prenatal Care in the Stork Network by macro health region and municipality size. Pernambuco, 2017-2020
Table 1b. Audit indicators from Component I - Low Risk Prenatal Care in the Stork Network by macro health region and municipality size. Pernambuco, 2017-2020

Table 2 shows results of the first model, which adopted health region I as the reference. The most sensitive indicator was “Rapid syphilis/HIV testing”, which showed a negative association with mean congenital syphilis rate (MCSR), showing that a one per cent unit increase in compliance rate reduced the rate by 0.004/1,000 LB).
The model also shows that the MCSR in medium and small municipalities is 0.618/1,000 LB lower than in large municipalities, meaning that as the rapid syphilis/HIV testing compliance rate increases the MCSR decreases. This association is slightly more pronounced in smaller municipalities. Furthermore, the further away municipalities are from health region I (the reference region) the lower the MCSR (Table 2).
Table 2. Final generalized linear model estimating the impact of the audit indicators for Component I of the Stork Network on mean congenital syphilis rate (MCSR/1,000 LB). Pernambuco, 2017-2020

Table 3 shows the results of the final model including mean perinatal mortality rate (MPMR). Two of the ten indicators were associated with this outcome, one of which was “Improved access to high-risk prenatal care”, which showed a statistically significant positive association with increased MPMR.
The second indicator that warrants highlighting because it was retained in the final model (with a significance of less than 0.20 and greater than 0.05) was "Support for travel", showing that a one per cent unit increase in compliance rate was associated with a 0.029/1,000 TB reduction in MPMR (Table 3).
Table 3 also shows that no statistically significant differences were found across municipality sizes. However, the further away health regions were from health region I, the higher the MPMR, with a significant difference of 8.4/1,000 TB being found in health region IV (Table 3).
Table 3 - Final generalized linear model estimating the impact of the audit indicators for Component I of the Stork Network on mean perinatal mortality rate (MPMR/1,000 TB). Pernambuco, 2007-2020
DISCUSSION
This study showed that prenatal care in municipalities in the state of Pernambuco is precarious even after the implementation of the SN some years ago. The average overall score was 445.5, from a maximum 1,000, revealing that around only 45% of the medical records (from a total of 1,380) met the recommendations of Ministerial Order GM/MS 1459/2011 for prenatal care for low risk pregnant women15, 16, 17.
An important finding was the association between increased rapid syphilis/HIV testing compliance rates and reduced congenital syphilis rates, demonstrating the effectiveness of seeking diagnosis during prenatal care. A study in Brazil with more than 20 million children born over a seven-year period (2011 to 2017) and followed up for five years found 93,525 cases of congenital syphilis, most of which were avoidable and 2,476 of which were fatal, resulting in an all-cause mortality rate of 7.84/1000 person-years. The deaths associated with congenital syphilis extended beyond the first year of life18.
Mean indicator compliance rates ranged from 27.9% ("Visits to the doctor and nurse") to 86.0% ("Improved access to high-risk prenatal care"). The compliance rate was less than 50% per cent in two of the ten indicators and the mean compliance rate for "Risk assessment and classification" was 53.6%. Only three indicators had rates of more than 80 per cent: "Laboratory testing for low and high risk pregnant women", "Rapid syphilis/HIV testing " and "Improved access to high-risk prenatal care".
It is worth highlighting that Component I of the Stork Network (Low Risk Prenatal Care) is developed essentially in primary care services. National Family Health Strategy (FHS) coverage was 63.63% (e-Gestor) between 2017 and 2020. In addition, municipal governments in Brazil are responsible for providing 100% of primary care services, in accordance with the provisions of the Health Pact. In Pernambuco, FHS coverage is 76.4%.
The indicator "Improved access to high-risk prenatal care" showed a positive association with MPMR, which prompts reflection on the quality of prenatal care, more specifically in relation to the management of pregnant women in specialist referral facilities, the application of high-risk prenatal care protocols, access to care, the seriousness of referred cases, care quality, and access to testing and timely and appropriate treatment. Howell (2018)5 suggests that a promising model for reducing maternal mortality is enhanced prenatal and delivery care for high-risk pregnant women in specialist facilities, adopting a multidisciplinary approach to managing risk level.
Another indicator associated with the MPMR is "Support for travel", with higher compliance rates being related to lower MPMR. In general, the quality of prenatal care in Pernambuco’s macro health regions, when measured in terms of compliance with the actions set out in the ministerial order, was inadequate. These results serve as a warning: prenatal care quality indicators influence perinatal mortality as a portion of the mortality rate derives from causes that can be avoided with adequate prenatal care.3
Pacagnella et al. (2018)4 highlight that the increase in transfers of pregnant women to referral facilities that are farther than 20km in Brazil constitutes a gap in access to maternal care services and may be associated with an increase in maternal mortality. Providing travel support and creating a well-structured care network therefore helps to reduce maternal mortality rates.
Lansky et al.19 point out that inadequate prenatal and delivery care are indicators of poor care quality, with consequences for very low birth weight infants, especially when pregnant women need to be transferred for delivery to hospitals without a neonatal ICU. This demonstrates gaps in the organization of the health network. Low compliance for these indicators therefore constitutes a gap in organization of access to the health care network.
Veiga20 suggests that although progress has been made in prenatal care in primary care services, lack of qualified professionals and poor organization of access, care coverage and prenatal care management are some of the challenges for policy implementation3. The authors found that educational interventions to improve the quality of prenatal care in PHC – including the institutionalization of protocols and flowcharts, combined with improved communication, an interprofessional approach, active participation in decision-making, the promotion of comprehensive care from prenatal through postpartum care, and tailoring care to specific local characteristics and needs - proved to be relevant and broadened perceptions of theory, re-signifying work processes at the various points of the health network.
Individual and group initiatives in primary care services, such as home visits, health education, groupwork, contact tracing, prenatal visits, referrals to specialized multidisciplinary care services, as well as guaranteeing care in the care network, reduce maternal and infant mortality. Challenges in preventing maternal mortality include precarious care and ineffective public policies, together with a lack of management support4,15,21.
Hoque, Hoque and Kader22 conducted an audit to evaluate the quality of antenatal care and service, targeting pregnant women attending public health institutions in South Africa. The findings showed that the standard of antenatal care fell short of the required level and that lack of proper care represented missed opportunities to impact optimally on maternal and perinatal health outcomes16.
The current study innovates by measuring the functioning of Component I of the Stork Network in Pernambuco based on audit reports. Our findings can help strengthen SUS auditing as a tool for the management and evaluation of public policies, helping to consolidate this practice as a cultural process of internal control of public health institutions, underpinned by ethics, transparency, accountability and public participation. Through this process, the government can control, evaluate and propose new regulations15.
Evaluation research aims to produce knowledge that is recognized by the scientific community and linked to an area of knowledge, serving to guide management decision-making. From a management perspective, the current valuation provides information that can contribute to improving the Stork Network12, 16.
Approximately 50% of the audit reports had missing quantitative data and at least three indicators had no information. Almost half of the information on compliance in the medical records analyzed by the present study was not recorded, with the records stating either "not quantitatively analyzable" or "information not available".
This finding highlights the importance of standardizing records and enhancing collection instruments or information systems aimed at the systemization of both qualitative and, no less important, quantitative data, to improve the precision and effectiveness of interventions.
The findings of this study therefore serve as a wake-up call on the approach to the local management and governance of Component I of the Stork Network in Pernambuco. This approach involves: reproductive life planning; 12-week scanning; prenatal care delivered by qualified multi-professional team; risk assessment at each antenatal visit; availability of tests for diagnosis and timely treatment, including sexual partners; immunization; improving access to high-risk prenatal care; affiliation of pregnant women to place of delivery; and support for travel. These actions should be monitored with the involvement of local and state steering groups.
Study strengths and weaknesses
One of the limitations of this study is the fact that SUS internal audits use standardized binary outcomes ("compliance" and "non-compliance"), meaning that it is not possible to carry out quantitative studies using SISAUD/SUS audit reports as a research source. This limitation can be minimized when reports contain quantitative data on the indicators being audited, which was the case in this study. However, depending on the approach of each auditor, this cannot be guaranteed throughout the entire sample, which can compromise the adequate sample size (n) and, consequently, study viability.
Another limitation is the incompleteness of the information contained in the audit reports, reducing the number of municipalities included in the statistical analyses to 89, indicating the need to improve the audit process.
CONCLUSIONS
This is a first-of-its-kind study because it evaluates a public health policy using SUS internal audit reports. The "compliance" and "non-compliance" findings were transformed into audit indicators and analyzed together with recognized prenatal care quality indicators to provide inputs to inform management decision-making.
These indicators enable managers to review processes, develop effective actions and revise or update standards with the aim of improving the quality of health service provision to the target population of the policy under evaluation, positively impacting the lives and health of this often vulnerable population.
Our findings show that it is essential to investigate referrals of complex cases (high-risk prenatal care) and Component II of the Stork Network, which involves pre-delivery, delivery and postpartum care and monitoring of child development from birth to age 2, including the reorganization of the state obstetric network.
The analysis of compliance using audit data transformed into compliance rates represents yet another possibility for evaluating public policies. The findings of this study indicate that SUS auditing is a management tool that is capable of effectively highlighting strengths and weaknesses in the implementation of Component I of the Stork Network at municipal level in the state of Pernambuco.
REFERENCES
1 Fernandes RZS, Vilela MFG. Estratégias de integração das práticas assistenciais de saúde e de vigilância sanitária no contexto de implementação da Rede Cegonha. Cienc Saude Coletiva [Internet].2014 [acessado 2023 Jun 4];19(11):4457-66. Disponível em: https://www.scielo.br/j/csc/a/3tdBDFr4VTZSXq8Drcnb6hL/abstract/?lang=pt#
2 Santos ECC, Pereira MA (in memoriam). Rede Cegonha: avanços e desafios para gestão em saúde no Brasil. Braz J Health Rev [Internet].2021 [acessado 2023 Jun 4];4(5):18639-54p. Disponível em:  https://ojs.brazilianjournals.com.br/ojs/index.php/BJHR/article/view/35413
3 Demitto MO, Gravena AA, Dell\'Agnolo CM, Antunes MB, Pelloso SM. Gestação de alto risco e fatores associados ao óbito neonatal. Rev Esc Enferm USP [Internet]. 2017 [acessado 2023 Jun 4];51:e03208p. Disponível em: https://doi.org/10.1590/S1980-220X2016127103208
4 Pacagnella RC, Nakamura-Pereira M, Gomes-Sponholz F, Aguiar RALP, Guerra GVQL, Diniz CSG, Campos BBNS, et al. Maternal Mortality in Brazil: Proposals and Strategies for its Reduction. Rev Bras Ginecol Obstet [Internet]. 2018Sep [acessado 2023 Jun 4];40(9):501–6p. Disponível em: https://doi.org/10.1055/s-0038-1672181
5 Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol [Internet]. 2018 [acessado 2023 Jun 4];61(2):387-399p. Disponível em: https://journals.lww.com/clinicalobgyn/abstract/2018/06000/reducing_disparities_in_severe_maternal_morbidity.22.aspx
6. Pernambuco. Secretaria Estadual de Saúde. Plano Estadual de Saúde: 2016-2019. Recife: Secretaria Estadual de Saúde de Pernambuco; 2016.
7. Brasil. Ministério da Saúde. Portaria nº 1.459, de 24 de junho de 2011. Institui no âmbito do Sistema Único de Saúde – SUS – a Rede Cegonha. Brasília: Diário Oficial da União 2011; 27 jun.
8. Cavalcanti PCS, Gurgel Junior GD, Vasconcelos ALR, Guerrero AVP. Um modelo lógico da Rede Cegonha. Physis [Internet]. 2013 [acessado 2023 Jun 4];23(4):1297-316p. Disponível em: https://www.scielo.br/j/physis/a/cmcY4csz9hjDC48scBWCsVL/abstract/?lang=pt#
9. Santos ERR, Silva VNC. Guia prático do auditor: para o componente municipal de saúde. Recife: Advances in Science; 2021.
10. Brasil. Ministério da Saúde. Auditoria do SUS no contexto do SNA: qualificação do relatório de auditoria. Brasília: Ministério da Saúde; 2017.
11. Brasil. Sistema de Auditoria do SUS – SISAUD/SUS [Internet]. Brasília: Ministério da Saúde; [2022] [acessado 2022 Jun]. Disponível em: https://snaautentica.saude.gov.br/login
12. Brasil. Ministério da Saúde. Portaria de Consolidação nº 3 de 28 de setembro de 2017. Consolidação das normas sobre as redes do Sistema Único de Saúde. Brasília: Diário Oficial da União 2017; 28 set.
13. Centers for Disease Control and Prevention. Division of Health Informatics & Surveillance (DHIS). Center for Surveillance, Epidemiology & Laboratory Services (CSELS). Epi Info 7 - User Guide. 2015rev [acessado 2022 Jun]. Disponível em: http://www.cdc.gov/epiinfo/user-guide/index.htm
14. Fox J. The R Commander: A Basic-Statistics Graphical User Interface to R. J Stat Softw [2005] [acessado 2022 out 28];14(9),1–42p. Disponível em: https://doi.org/10.18637/jss.v014.i09
15. Peron P. Auditoria e pacto de gestão: perspectivas e desafios. Rev Rede Cuid Saude [Internet]. 2009 [acessado 2023 Jun 04];3(3):1-16p. Disponível em: http://publicacoes.unigranrio.edu.br/index.php/rcs/article/view/606
16. Novaes HMD. Avaliação de programas, serviços e tecnologias em saúde. Rev Saude Publica [Internet]. 2000 [acessado 2023 Jun 4];34(5):547-9p. Disponível em: https://www.scielo.br/j/rsp/a/6bwNKdzy7QdbsFxVnmyz93y/abstract/?lang=pt
17. Setz VG, D\'INNOCENZO M. Avaliação da qualidade dos registros de enfermagem no prontuário por meio da auditoria. Acta Paulista De Enfermagem [Internet]. 2009 [acessado 2023 Jun 4];22(3), 313–317p. https://doi.org/10.1590/S0103-21002009000300012
18. Paixão ES, Ferreira AJ, dos Santos IO, Rodrigues LC, Fiaccone R, et al. Mortality in children under 5 years of age with congenital syphilis in Brazil: A nationwide cohort study Mortality in children under 5 years of age with congenital syphilis in Brazil: A nationwide cohort study. PLOS Medicine [Internet]. 2023 [acessado 2023 Jun 04];20(4): e1004209p. Disponível em: https://doi.org/10.1371/journal.pmed.1004209
19. Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML et al. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saúde Pública [Internet]. 2014 [acessado 2023 Jun 4];30:S192-207p. Disponível em: https://www.scielo.br/j/csp/a/Ss5zQXrmrGrGJvcVMKmJdqR/#
20. Veiga AC, Medeiros LS, Backes DS, Sousa FGM, Hämel K, Kruel CS et al. Qualificação interprofissional da atenção pré-natal no contexto da Atenção Primária à Saúde. Cien Saude Colet [Internet]. 2023 [acessado 2024 Mar 6];28:993-1002p. Disponível em: https://www.scielo.br/j/csc/a/gbmfpnwBNVQfp9FRqmBfg8P/#
21. Figueiredo KMS, Gonçalves GAA, Batista HMT, Akerman M, Pinheiro WR, Nascimento VB. Actions of Primary Health Care professionals to reduce maternal mortality in the Brazilian Northeast. Int J Equity Health [Internet]. 2018 [acessado 2023 Jun 4];17(104). Disponível em: https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-018-0817-x#citeas
22. Hoque M, Hoque E, Kader SB. Audit of antenatal care in a rural district of KZN, South Africa. S Afr Fam Pract [Internet]. 2008 [acessado 2023 Jun 4];50(3):66-66p. Disponível em: https://www.tandfonline.com/doi/abs/10.1080/20786204.2008.10873721