Montevideo, 4th August 2022. Uruguay "has low maternal and neonatal mortality and a great access to sexual and reproductive health," said Suzanne Serruya, Director of the Latin American Centre for Perinatology (CLAP/WR) from the Pan American Health Organization (PAHO/WHO), who pointed out that it is "one of the countries with the best indicators in these three areas in the entire region of the Americas". For this reason, from Monday 25 to Wednesday 27 July 2022, a delegation of representatives from the Brazilian Ministry of Health (MS-Brazil) and PAHO headquarters in Brazil made a technical visit to Montevideo.
During the mission, members of the ministries of health of the two countries "exchanged experiences, good practices and knowledge on maternal, child and adolescent health," said Ariel Karolinski, Coordinator of PAHO's Family, Gender and Life Course Unit in Brazil. The meeting was facilitated by PAHO, which has among its tasks the strengthening of horizontal cooperation among the countries of the region. It included meetings with authorities from the Ministry of Public Health of Uruguay (MSP) and the visit to two health care centers of the main public provider in the country, the State Health Services Administration (ASSE): the Pereira Rossell Hospital Centre (CHPR), a third level maternity hospital and of national reference, and the Health Center of Ciudad de la Costa of the Metropolitan Primary Health Care Network, located in the department of Canelones.
Information, monitoring and planning
One of the main points of interest of the Brazilian delegation was to learn about the use of the Perinatal Information System (SIP). The SIP is an electronic clinical record for the care of women during pregnancy, childbirth, puerperium and of the newborn developed by CLAP/WR in 1983 which has been updated based on evidence and needs that have arisen over the years; The latest version of the SIP Plus was developed during the pandemic and includes a module for care for COVID-19 and other conditions that can cause severe illness in pregnant women; it also has the potential to network primary health care units with maternity wards, so that digital information on pregnant women and newborns is available in real time at all points in the health care network. Dr. Serruya said that "Uruguay has a tradition that few countries can offer having an information and monitoring system with public transparency" and that "the SIP has always been the tool used by the country, through legal mandates and technical notes from the MOH, incorporated into all services in every corner of Uruguay". The director pointed out that the visit was aimed at getting to know the information management in Uruguay and "the experience of a system that is available from the furthest point of the country in the basic health units, to the central control of the Ministry" and, at the same time, publishes the available data on its website, democratising the information. The SIP "transforms data into information and this information into evidence and planning as well as decision-making for national policies such as maternal care," said Dr. Serruya.
From a key management position, Dr. Miguel Asqueta, General Manager of Health at the MOH, explained that "the SIP is a basic, elementary and extremely important source of data, since without the data obtained from the Perinatal Informatics System it would be impossible to construct new policies". He also valued the fact that the data collected in the SIP allows for the revision and reformulation of the health objectives that have been set.
Dr. Victoria Lafluf, director of the CHPR, highlighted that the SIP is "fundamental for the permanent improvement of the quality of care because it allows us to permanently monitor the main care indicators that we define at both institutional and national levels". She said that SIP allows health teams to measure results on a six-monthly basis. "We are adjusting the course and correcting or strengthening those indicators that we believe need to be strengthened, which clearly results in improved care," she explained. She added that the process generates very important areas for discussion "that provide feedback on the technical performance of the teams in the different areas of obstetrics, neonatology, midwifery, obstetrics and nursing". In addition to being a healthcare center, the CHPR is a space for training human resources; in this sense, she pointed out that the SIP "involves and teaches those who are being trained in the specialties about the importance of generating quality information for decision making.
According to Federico Focco, Director of the Metropolitan Primary Care Network of ASSE, having the information available was a key aspect during the COVID-19 pandemic. He explained that the unit he leads has 16 centers, involving an average of 96 births per week (around 5,000 per year). "Our main objective is that the information becomes universal, to collect the highest percentage of data that can be used for the benefit of our users," he said. Among the issues to be solved, he mentioned the need for "the computer system in each consultation to be loaded by the technician; in this way we will obtain information in real time and suitable for use, that is to implement the SIP Plus that allows the information to be loaded at the same time as the consultation," he said.
Actions to be implemented
Raphael Câmara Medeiros, secretary of the Secretariat of Primary Health Care (SAPS) of the Ministry of Health, valued the visit as very important and highlighted the benefits of the SIP to detect possible epidemiological problems, as well as to identify policies that are working well.
At the end of the meeting, Dr. Antonio Braga Neto, director of the Department of Programmatic Actions and Strategies (DAPES) of the Secretariat of Primary Health Care (SAPS) of the MS-Brazil explained that during the visit they created "a bipartite work agenda involving PAHO and MS-Brazil that will structure actions to promote the programme 'zero maternal death from haemorrhage, zero maternal death from infection and zero maternal death from hypertension'". He added that the agenda also includes a pilot project to implement the SIP Plus in three Brazilian maternity wards "that will help managers and clinical directors to seek strategies in the service to reduce maternal mortality".
Dr. Lana de Lourdes Aguiar Lima, Director of the SAPS's Maternal and Child Health Department, explained that because of COVID-19, "in 2020-2021 we had the highest maternal mortality rate in recent times". Both she and Dr. Raphael Câmara Medeiros, Secretary of the SAPS, reported that in 2022 the MS-Brazil created a department to advance in maternal and child care and with this exchange they sought to learn about the good practices of a country like Uruguay, which has "a very low maternal and infant mortality", said Dr. Câmara.
According to Dr. Aguiar, Brazil has several information systems with many variables, but he stressed that "the great difference of the SIP" is "the opportunity to have the information quicker, especially for this moment, when we are updating the maternal and infant care network," he said. Dr. Aguiar emphasized the responsibility of getting to know different experiences and specified that "in theory it is one thing and in practice it is another", thus the importance of having direct contact and seeing "the system developing". In this sense, the mission in Uruguay had the opportunity to learn about the implementation of the SIP in the first level of care, such as the Ciudad de la Costa Health Center, and in a specialized center, such as the CHPR.
Regarding these two centres, Dr. Serruya remarked that at the CHPR they have seen "how, year after year and for 27 years, they have had all the important information on perinatal care" and stated that "it is an unique example in the region because from a historical point of view it allows us doctors, epidemiologists and obstetricians to know the evolution of perinatal indicators over time, also identifying some problems, such as the increase in caesarean sections".
Dr. Aguiar confirmed that the implementation of the SIP "seems to be feasible" and added that it will be offered "with great caution", so that it does not mean a burden for those who carry out the task of care. Dr. Braga was encouraged: "I return to Brazil enriched with stories and experiences, but also confident that this public policy instrument will be very important for coordinating management actions in the Ministry of Health, in order to reduce maternal mortality among Brazilian women," he said. In the work plan to be designed by the MS-Brazil and the PAHO Representation in that country, Dr. Karolinski said that "CLAP technicians will play a fundamental role in contributing to the reduction of severe morbidity, maternal mortality and neonatal mortality in Brazil".