Rev Saúde Pública 2013;47(2)
2013047003789
Lygia Carmen de Moraes
VanderleiI
María Luisa Vázquez NavarreteII
I
Programa de Pós-Graduação em Avaliação
em Saúde. Instituto de Medicina Integral
Prof. Fernando Figueira. Recife, PE, Brasil
II
Servei d’Estudis i Prospectives en Polítiques
de Salut. Consorci de Salut i Social de
Catalunya. Barcelona, Cataluña, Espanha
Correspondence:
Lygia Carmen de Moraes Vanderlei
Instituto de Medicina Integral Prof. Fernando
Figueira (IMIP)
Diretoria de Ensino
Rua dos Coelhos, 300 Boa Vista
50070-550 Recife, PE, Brasil
E-mail: lygiacarmen@yahoo.com.br
Received: 9/30/2011
Approved: 10/7/2012
Article available from: www.scielo.br/rsp
Public Health Practice DOI: 10.1590/S0034-8910.
Original Articles
Preventable infant mortality and
barriers to access to primary care
in Recife, Northeastern Brazil
ABSTRACT
OBJECTIVE: Analyze the factors influencing avoidable infant mortality from
the perspective of the protagonists involved.
METHODS: Qualitative study with a critical-constructivist approach,
examining children’s access to health care and avoiding preventable infant
mortality through health care campaigns and services in Health District I of
Recife, Northeastern Brazil, between February 2007 and February 2008. The
theoretical sample was designed in two stages: I) institutions providing health
services to children; II) interviewees: managers (11); professionals [from the
Family Health Strategy and Programme of Community Health Workers (48);
and from outpatient clinics (12)]; mothers (20), with sample size defined
by “saturation of the speeches”. Data was collected using individual semi-
structured interviews and case studies of avoidable infant death. Thematic
content analysis was used, generating mixed categories (emerging and scripted).
RESULTS: There were perceived to be conflicting positions between different
stakeholder groups reflecting their role in the care network. All institutional
participants related infant deaths to the absence/poor dissemination of child
health policies and inter-sectoral actions; professionals and mothers highlighted
difficulties in accessing health care due to insufficient global resources,
especially the lack of doctorsinFamily Health Strategy, shifting health care
to nurses. Lack ofdoctors,acutediseases rejection, and dehumanized and/or
poortechnical quality carewere the mainfactors which the mothers relatedto
deaths. Family Health Strategy participants from the Programme of Community
Health Workers and mothers identified thecondition ofsocial exclusionand
maternal neglectwith deaths, but the case studyof deathrevealedthe association
withlowerquality of care offered.
CONCLUSIONS: Numerous barriers to access indicate insufficient Brazilian
Unified Health System implementation and lack of resolution of the main
access route, the Family Health Strategy. The results indicate the need for
improvement of structural and organizational factors of supply, with emphasis
on mechanisms to stimulate the recruitment of doctors for the Family Health
Strategy professional training of all staff consistent with the model of care to
comply with health care policies for children and avoiding preventable infant
mortality.
DESCRIPTORS: Infant Mortality. Health Services Accessibility.
Quality of Health Care. Family Health Program. Health Inequalities.
Qualitative Research.
2 Infant mortality and barriers to access Vanderlei LCM & Vázquez ML

INTRODUCTION

Over the last three decades, the Brazilian government The extensive literature which relates to infant deaths
has shown great interest in reducing infant mortality which could have been prevented through access to
through the introduction of programs, plans and health care services, makes use of epidemiological or
projects.25,a These activities, together with a signifi- evaluative methods as the principal investigative tool.
cant decrease in fecundity over the same period, have While these methods demonstrate the magnitude of the
contributed to a decline in figures for infant mortality. problem,9,12,13,23 they do not deepen the perspective of
However, the number of preventable infant deaths in the social protagonists (users, health care professionals)
the country remains considerable.9,12,13 or contextual factors (political and characteristics of
supply) which influence access.
There is a strong link between preventable infant death
and timely access to health care services, as preventable The majority of qualitative studies concentrate on
deaths, according to Rutstein et al19 (1976), are defined barriers relating to the performance of health care
as “deaths which could be partially or totally avoided professionals in welcoming and connecting,21,22 or on
by the presence of effective health care services”. the maternal perspective of infant death,10,15,20 and few
The emphasis is even greater when the scene of these analyze the influence of barriers to access on the ongoing
deaths is a regional hub city, constitutionally bound occurrence of avoidable deaths, or else do not include the
to provide universal access and comprehensive health points of view of all the participants involved.
care according to the precepts of the SUS (Brazilian
Unified Health System).25,a Access to health care refers to the possibility of
obtaining health care, conveniently and easily, when
Child health care policies, in accordance with these they need it.1 As access is something that can only
principles, aim to provide health care which is resolu- be observed when health care services are actually
tory, welcoming, humane and accountable, provided used by those who need them, Aday & Andersen’s2
by teams working together and with intersectoral (1974) theoretical model analyzes factors which
cooperation, preferably offered by the Family Health influence use of health care services, defining the
Strategy (ESF) and the Program of Community Health two most important dimensions of access: potential
Workers (PACS). The objective is to promote health and and realized. Potential access is concerned with the
reduce infant mortality.b It is the duty of the health care characteristics of supply (availability and organiza-
team to monitor the child throughout their first year, to tion of health care services) and of the users: predis-
identify at birth risk factors for illness and death (low
posing factors (sociodemographic characteristics,
birth weight, premature birth, hypoxia, teenage mothers
beliefs and attitudes, level of information); enabling
and mothers with low levels of schooling and family
factors (personal and community) and health care
history of death before age five) and decide upon the
needs. Realized access refers to actual use of health
appropriate medical care.c Also taken into consideration
care services.2
as risk factors are previous hospital admissions, delays
in vaccination, living in risk areas, having no income The aim of this study was to analyze factors which
and drug addiction. influence preventable infant mortality, from the pers-
pective of all participants involved in the phenomenon.
In line with the national pattern, the infant mortality
coefficient (IMC) for Recife, Northeastern Brazil,
show a progressive reduction (IMC = 13 deaths/1,000 METHODS
live births in 2007), similar to that seen in other, more
developed, Brazilian cities such as Rio de Janeiro, São This was a qualitative, descriptive-interpretive study
Paulo and Belo Horizonte, all located in Southeastern using a critical-constructivist approach,11,14 aiming to
Brazil. However, 86% of these deaths could have been uncover the relationship between children’s access
prevented by actions on the part of the health sector to health care and infant death which could be
or partner organizations in other social sectors. This prevented by actions and health care services,using
suggests the existence of barriers to access to health Aday & Andersen’s2 (1974) theoretical framework
care services and campaigns.d to analyze access. The field work, the largest part
a
Frias PG, Mullachery PH, Giugliani ERJ. Políticas de saúde direcionadas às crianças brasileiras: breve histórico com enfoque na oferta de
serviços de saúde. In: Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise de Situação em Saúde. Saúde Brasil
2008: 20 anos do Sistema Único de Saúde (SUS) no Brasil. Brasília (DF); 2009. p.85-110. (Série G. Estatística e Informação em Saúde).
b
Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Agenda de compromissos para a
saúde integral da criança e a redução da mortalidade infantil. Brasília (DF); 2005. (Série A. Normas e Manuais Técnicos).
c
Ministério da Saúde, Secretaria de Políticas de Saúde, Departamento de Atenção Básica. Saúde da Criança: acompanhamento do
crescimento e desenvolvimento infantil. Brasília (DF); 2002.
d
Secretaria Municipal de Saúde do Recife, Diretoria de Vigilância à Saúde, Gerência de Epidemiologia. Perfil epidemiológico da criança e do
adolescente. Recife; 2007.
Rev Saúde Pública 2013;47(2)
of the research,e took place between February 2007
and February 2008 in Health District 1 of Recife,
Northeastern Brazil, as it had the highest IMC figures
during the period.
A two-stage theoretical sample was designed.6 The
following institutions were selected: Health District
1 Administrative Headquarters; Primary Health Care
Services (nine ESF units and one Traditional Primary
Care Unit [UBT], which provide health care according
to the traditional model, with basic children’s health
care provided by pediatricians and without being
ascribed to areas); and services of medium complexity
(two outpatients clinics and an Allergology Service,
which offered primary health care within the traditional
model, as well as specialized health care). Ninety-one
interviewees were selected, aiming for the greatest
possible variety of discourse in order to guarantee
sample sufficiency and saturation.6,11,14
A two-part collection strategy was used to collect data:
a) individual, semi-structured interviews (scripted
according to the theoretical framework) with partici-
pants associated with the institutions and mother of
children aged between 28 and 365 days. Ninety-one
interviewees took part: 11 managers – nine district
managers (M) and two unit managers (Geradm); 48
health care professionals from PACS and ESF: ten
doctors (MED); 12 nurses (N); 26 Community Health
Workers (ACS), 20 from ESF (PSF) and six from
PACS; four outpatient clinic general managers (UB),
one UBT director and seven pediatricians from outpa-
tient clinics (PED); 20 mothers; b) a case study of a
preventable, post-natal infant death. The areas of Health
District 1 with the highest occurrence for post-natal
infant death classified as preventable were identified;
18 events which occurred during the period in question
were analyzed in order to select those which best exem-
plified problems with health care access culminating
in a death which could have been avoided. In order
to build the case, the following methods were used:
examining ante-natal care cards completed by doctors
and nurses in ESF units; examining medical records
for mother and child appointments in maternity and
pediatric hospitals; looking at notes from ACS home
visits to mother and child; examining child’s growth
and development and vaccination records; examining
records from child’s appointments and referrals by
the ESF; examining child’s death certificate from the
Institute of Legal Medicine; individual, semi-structured
interviews which health care professionals involved
in child’s care and the death (ACS, doctors and nurses
from ESF); and non-structured interviews with mother.
Two interviews were necessary in order to establish a
satisfactory relationship conducive to dialogue. The
interviews took into account the mother’s wishes as
e
Moraes Vanderlei LC. Mortalidad infantil evitable y acceso a la atención de la salud en Recife, Brasil en la perspectiva de los principales
actores sociales [tese de doutorado]. Bellaterra: Universidad Autónoma de Barcelona; 2010.
3
to the details revealed about the events leading to her
daughter’s death and took place at a time and place
convenient to her.
The interviews lasted between 30 and 60 minutes, and
were recorded and transcribed and accompanied by
the field diary.
Thematic content analysis was carried out, with a
topic deemed to be a unit of meaning, taken from the
text according to criteria from the theoretic-concep-
tual framework.4 Mixed categories were produced
(scripted and emerging). The quality of the data was
guaranteed by triangulation between groups of inter-
viewees, techniques and strategies of data collection
and an external analysis.6,11
The categories and sub-categories for analyzing access
where those which the social protagonists associated
with infant mortality: a) Factors related to SUS policies:
implementation; dissemination, infant health programs;
inter-sectoral actions; b) Factors concerned with the
structure of supply: availability of human and material
resources; c) Factors concerned with the organization
of supply and professional performance: preventive
and curative care (location; professional providing
care); aspects of care (welcoming/humane/technical
quality); d) Factors concerned with social context:
social conditions of the families and the environment;
social support networks.
The research was approved by the Instituto de Medicina
Integral Prof. Fernando Figueira (IMIP), Committee
of Ethical Research in Humans, process nº 892, 2006.
All of the participants signed consent forms.
RESULTS
The majority of the participants were women; of the
ten men interviewed, two were managers, three were
health care unit directors, three were ACS and two
were doctors. The interviewees from the institutions
had been carrying out their work for between five and
ten years, with the extremes represented by ACS from
PACS and health care professionals from the outpatient
clinics and the UBT (traditional model), who had been
working there for more than 15 years, and for a doctor
and ACS from ESF, where some members of the team
had been there for a year. The 21 mothers interviewed
were aged between 17 and 38; nine of them lived with
their child’s father; 13 had not completed primary
education, one had finished high school and two had
steady employment; nine were employed informally
and ten reported they were not working; monthly
household income was of one minimum wage, with
this being supplemented by benefits.
4 Infant mortality and barriers to access Vanderlei LCM & Vázquez ML

For the majority of the interviewees, clear barriers to
access emerged throughout the continuous care. The
basic level stands out, with important differences in
the level of intensity of the discourse, depending on
the group from which it came. Four groups of barriers
feedback into themselves, with repercussions on the
avoidance of preventable infant mortality.
Infant death and SUS policies
The majority of participants from institutions related
the persistence of deaths to barriers due to the SUS
care model, including policies dealing with children’s
health, not being properly established. However, there
was disagreement among the different groups. The
majority of participants from the traditional model
(professionals from the UBT and the outpatient clinics)
were unaware of policies aimed at infant health,
emphasizing the effective absence of children’s health
programs in the municipality; managers and profes-
sionals from the ESF/PACS highlighted the fragility
of inter-sectoral cooperation. The mothers perceived
the low problem solving capabilities of the ESF to be
contributing factors. However, there were narratives
about the decline in deaths being utilized by ESF/PACS,
especially between members of these teams (Table 1).
Infant deaths and structural and organizational
factors of supply
Almost all of the interviewees perceived the overall
scarcity of resources to be prejudicial to access to
preventive and curative health care. The groups had
different perspectives regarding the outcome of infant
death. For PACS/ESF health care professionals, infant
mortality was linked to the large number of families
the ESF teams were responsible for, meaning the
health care professionals were overstretched. This
would lead to programmed activities, such as those
aimed at child health, not being carried out. All of
the participants emphasized the lack of doctors in the
ESF, displacing curative care onto nurses, adversely

Table 1. Opportunities and barriers to access related to SUS policies. Recife, Northeastern Brazil, 2007.
Category/participant group Quotes
SUS policies incompletely established - [...] once there are guidelines for children, the program for at-risk
(participants from institutions) children, they must actually make it happen
[...] things are not happening as they were planned to, visits monitoring
this very child [...]. (M8).
- [...] this clinic (referring to the outpatient clinic) should be for support
[...] and here the demand has been more direct to the staff rather than
referred by the doctors (referring to ESF doctors) and ACS [...] there has to
be integration [...] I believe it would significantly cut down on child illness
and mortality. (PED4).
Lack of awareness of child health care policies - With regards to pediatrics, when there is not a specific program [...] I
on the part of health care professionals (health believe that this still needs to be improved [...] in order for there to be
care professionals in outpatient clinics/UBT) better health care, be more attentive in these cases of infant mortality [...]
or if this exists, I’m not aware of it, but this is not only my fault as I was
not informed [...]. (UB1).
Fragility of inter-sectoral activities (managers/ - [...] when discussing avoidable deaths, the first aspect to be considered
ESF/PACS health care professionals) is the lack of effective inter-sectoral work [...]. The health care sector
managed to establish partnerships with other sectors, guarantee
women’s education, housing, income, generate employment.All of this is
happening, but at a slow pace. (M1).
- [...] the responsibility for infant mortality does not lie so much with
health care [...] it is also a political question, of social exclusion [...] there
are other factors involved here, structural, socio-economic, political,
family, health care is limited to treating these problems. (N9).
Poor problem solving on the part of the ESF - I don’t know why they open at all! (referring to the USF) [...] when the
(mothers) boy gets sick I don’t even bother going there, they don’t resolve anything!
(Mother 15).
- I don’t like going to appointments at the USF very much, because the
doctor there often doesn’t know what’s wrong, and refers us to another
clinic (referring to outpatient clinics) [...] I prefer to go straight there.
(Mother 1).
Establishing ESF/PACS (ESF/PACS health care - [...] I don’t think we’re one hundred percent there yet, but we’re getting
professionals) there [...] infant mortality is falling [...] due to monitoring, the specific
treatment we provide these children with [...] in the case of vaccination,
diarrhea, these have been controlled. (PACS3).
SUS: Brazilian Unified Health System; ESF: Family Health Strategy; UBT: Traditional Primary Care Unit; PACS: Community Health
Worker Program; USF: Family Health Center; N: nurse; M: district managers; UB: general managers; PED: outpatient clinics
Rev Saúde Pública 2013;47(2) 5

Table 2. Barriers to access related to structural and organizational factors or supply. Recife, Northeastern Brazil, 2007.
Category/participant groups
Overall lack of resources (all
participants)
Shortage of doctors in the ESF (all
participants)
Lack of supervision for the ACSs (ESF/
PACS health care professionals)
Lack of medicines
(mothers)
Categories
Barriers to the treatment of acute
illness in the ESF (mothers)
Doctors and/or pediatricians
substituted by nurses in ESF health
care (mothers and doctors)
ESF: Family Health Strategy; UBT: Traditional Primary Care Unity; PACS: Community Health Worker Program; USF: Family
Health Center; ACS: Community Health Worker; PSF: Family Health Program; MED: doctor; PED: outpatient clinics; N: nurse
Structural factors
Quotes
- Maybe lack of conditions, lack of care [...] I think lack of everything, in terms of
the doctors, of medication [...]. Sometimes on the part of the mother [...] there is
nowhere else to turn, you’re unable to buy medicine [...] the child ends up dying.
(Mother 2).
- [...] there are no scales, none of the children are weighed [...] There is no
measuring tape, no charts of cephalic perimeter [...]... There’s absolutely nothing
(PED6).
- [...] Children are not the only group the PSF cares for [...] we try to give priority
to children, to women, to patients with high blood pressure and diabetes [...], the
bureaucracy, the work, the blame, staff shortages, it all ends up affecting care [...]
(N9).
- [...] We have to solve all the problems [...] sometimes just looking after children
who arrive here poorly, those who need advice and prevention to not fall ill
[...] it’s wishful thinking, because there’s no doctor; if there is a doctor, they are
overworked [...] (N9).
-In the center (USF) near home, you have to make an appointment (for a
consultation) you have to go there early in the morning [...] there are times I
don’t manage to get an appointment, sometimes there is a draw to see which day
you will get an appointment! (Mother 12).
- [...] I think nurses should accompany ACSs on home visits more often.
Sometimes the ACSs are left totally alone (ACS5).
- Just yesterday I bought this medicine here [...] sometimes I have to use grocery
money because [...] they give you medicines that are not available at the center,
then you have to buy it(Mother 11)
Organizational factors
Quotes
- If I have to get an appointment for my daughter to be seen, because she’s sick,
she should be seen then and there, without having to wait for an appointment,
without making an appointment, if it wasn’t serious I would make an
appointment for another day, not wait one or two months [...]. Everything goes
to the emergency room, when they could be seen at the center (referring to the
USF) which is much closer (Mother 8).
- [...] if it’s an illness that I know the center (USF) won’t deal with, if it’s going to
be a wasted journey, I’ll go to the emergency room (Mother 16).
- [...] at the center (USF) we have to wait for those who have an appointment to
be seen [...] to be squeezed in [...] then the boy will die, right? (Mother1).
- I don’t like the health care at the center (USF) where I live, because it’s not
a doctor who sees you, it’s a nurse, and she’s not really as capable as a doctor
is [...]. and there is only a general clinic there [...] there should be pediatrics.
(Mother 18).
- [...] this idea of children being treated at the clinic, I don’t think it works out [...]
and the mothers don’t seem to like it. [...] here (referring to the outpatient clinic)
it is always really busy because they (referring to the mothers) are not satisfied
with the care provided by the general practitioner at the PSF. (PED3).
- I can’t understand nurses providing pediatric care [...] a 10-month-old child
turns up with a heart murmur and I immediately refer them to cardiology [...]
nurses don’t have the training to diagnose heart murmurs [...] (MED5).

affecting the ability to solve problems. For health care
professionals from the PACS/ESF, the lack of doctors
interferes with supervision of the ACSs on their house
calls, fundamental to monitoring at risk children.
There was conflict between the mothers’ discourse,
which linked infant death to the constant lack of
medicines, and those of participants from institutions,
who viewed the availability of medication as one of
the positive points of the SUS and did not perceive
any connection with the deaths (Table 2).
The great intensity with which organizational barriers
emerged, and the refusal to treat serious illness in ESF
units, was unanimous among the mothers, who viewed
this as one of the causes of infant mortality, obliging them
to make use of emergency pediatric services (Table 2).
6 Infant mortality and barriers to access Vanderlei LCM & Vázquez ML

Table 3. Barriers to access related to factors of professional performance. Recife, Northeastern Brazil, 2007.
Categories/groups of participants
Poor technical- scientific quality (all
participants)
Lack of professional commitment in ESF
activities (participants from institutions)
Dehumanized unwelcoming health care
(mothers)
ESF: Family Health Strategy; USF: Family Health Center; PSF: Family Health Program; M: district managers; Geradm: unit
managers; N: nurse; MED: doctor; UB: general managers
Quotes
- [...] I think that these children who are still dying from diarrhea and
pneumonia it is because there is no guidance and advice are lacking,
there is no team (referring to the ESF) together [...] more health care.
(N7).
- Give more attention to children [...] because in the majority of centers
(USF) and emergency rooms we go to, they don’t even look at the child
[...] they give you any medicine and send you home [...] they should
examine the child, see what’s wrong [...] when the child ends up back in
the emergency room, they are admitted and may die [...] something that
could be avoided. (Mother 16).
- [...] they (referring to the ESF health care professionals) are simply
doing their job for the money [...] the municipality provides a lot, but
they don’t use that provision to guide families. (Geradm1).
- [...] I remember one child who presented with diarrhea and vomiting
[...] the child was looked over quickly in the outpatient clinic and sent
home [...] he arrived at another health center and died! What were our
failures that lead to this child dying that very day? (UB1).
- I suffer a lot [...] I don´t treat the children because the other categories
of the PSF keep me too busy and pediatrics ended up with no medical
care. (MED9).
- [...] I suffer over this because you can’t do what you would like to [...] I
already started a group (education and health) and I couldn’t go ahead
with it, we didn’t have the energy for it [...] due to being overworked
(N1).
- Our universities don’t train people to work from the perspective of
promoting, preventing, comprehensive treatment, clinical responsibility.
(M1).
- [...] in the university they teach you that bad doctors work at the PSF,
students who end up in the PSF are weak [...]because the good students
are going to be specialists. (M4).
- [...] being patient with the children, being conscientious and treating
people with courtesy because there are a lot who [...] have already
argued with the doctor here for being rude, if we ask what is wrong with
the child, if it’s something serious he answers “ Who is the doctor here:
me or you?”. But I’m the mother [...] they should explain properly so that
I know what’s happening (Mother 4).
- [...] there are doctors who are not caring, who don’t even touch the
child as if it made them nauseous! (Mother 5).

Barriers to curative health care in the form of the ESF
substituting pediatricians with general practitioners
and/or nurses were reported by mothers and doctors in
outpatient clinics and the ESF as contributing to deaths.
In the doctors’ opinions, nurses do not have the proper
professional training to provide curative health care,
suggesting conflicts within the heath care team (Table 2).
Infant mortality and factors of professional
performance
Almost all participants linked inadequate perfor-
mance by professionals with low technical quality to
preventable infant deaths. Among the interviewees
from institutions, this lack of professional commit-
ment was attributed to ESF health care teams being
overworked, to specialists being poorly trained and to
the perception of not being professionally valued. The
mothers attributed infant mortality not only to poor
technical quality but to de-humanized, unwelcoming
health care at all levels of care (Table 3).
Infant death and the social context
The main determinant of preventable infant morta-
lity was the families’ social exclusion, high levels of
poverty, unemployment, violence and drug use, accor-
ding to almost the participants. The mothers talked of
a lack of social support network. For the participants
from the ESF/PACS, in concordance with the mothers,
infant death was particularly associated with maternal
characteristics, blaming the mothers for negligence
towards their children (Table 4).
The case of preventable infant death
The case of preventable, post-natal infant death in an
area assigned to the ESF permitted a deeper analysis
Rev Saúde Pública 2013;47(2) 7

Table 4. Barriers to access related to factors of family context. Recife, Northeastern Brazil, 2007.
Categories/groups of participants
Poverty (all participants)
Blaming the mothers, poverty, violence and lack
of social support networks (mothers)
Blaming the mothers for negligence and drug use
(ESF/PACS health care professionals and mothers)
Blaming mothers for negligence and not realizing
the seriousness of the illness (mothers)
Blaming mothers for negligence and poor quality
care (mothers)
ESF: Family Health Strategy; PACS: Community Health Worker Program; UB: general managers; MED: doctor
Barriers
- [...] I think it’s down to people’s miserable living conditions, because
the majority of these deaths are from the poor social classes [...]
employment is more and more difficult, [...] there’s not enough food,
a decent living place, they live there in that swamp with all kinds of
illnesses. (UB2).
- Mothers who don’t take care [...] they make a career out of having
children [...] they have a five-year-old child looking after a one-
year-old one [...] and there they are, playing in the rubbish, pick up
bacteria, get sick and end up dying. (Mother 16).
- [...] where I live, it’s like that, the people are settled, they’re used
to the violence, children begging [...] if someone needs help, no one
wants to give it [...] and sometimes, when someone seeks health care,
there is not help [...]. Those are not the kind of people you can go
up to and ask “Can you lend me some money to take my child to
hospital?”. Nobody helps! (Mother 13).
- Unplanned pregnancies, alcoholism and drug abuse [...] they leave
the children at home alone and go to the bar [...] those children die
because of neglect. (MED5).
- Lack of health care is it? I don’t know [...] the mother, in my opinion,
if the child has a fever you go straight to hospital, because it’s ill
[...] me, when mine was ill, I go straight there, and there are lots of
mothers who keep the child at home “it’s a daft little fever” and when
they finally see that it’s something serious it’s too late and there is not
time for it to be treated and the child dies. (Mother 8).
- Poor treatment is it? It’s also an emergency case [...] if the mother
doesn’t also care for the child, doesn’t head straight to the doctor [...].
In an emergency like that, you still have to wait your turn [...] the child
had a high fever [...] and you have to wait, right? There are a lot of
tired children there [...] lots of hospitalized children [...] (Mother 10).
- When a mother delays taking the child to the doctor, trying to treat
the child at home, when they finally get to the hospital it’s too late
[...]. The health care provided in the hospital is often poor [...] I think
it’s because of this. (Mother 12).

of the actual obstacles to health care services and DISCUSSION

campaigns which had emerged from the interviews,
and showed links between the main barriers to access
to children’s health care throughout the course of their
day to day access (or lack of it) to health care. Situations
which emerged in the process of interaction between
the various participants involved with the child from
in-utero to its death were analyzed: a) barriers to access
such as the mother not having ante-natal checks, social
risk and ESF doctors and nurses not monitoring at
risk children. This suggests that SUS child health care
policies are not completely established and a lack of
professional commitment on the part of the ESF; b)
the sick child not receiving care the day before their
death, which demonstrates the barrier to treatment of
acute illness in USF; and c) the lack of references to
timely medical assistance when the USF refused treat-
ment. Poor technical and scientific quality and a lack of
professional commitment on the part of the ESF were
reported. The events contributed to preventable infant
death which could have been avoided by actions and
health care services (Table 5).
In spite of the Brazilian government’s directors’
commitment to comprehensive child health care and
a significant decline in infant mortality,25,a numerous
barriers to access indicate the fragility with which
the SUS has been established and of the main access
point: basic health care. Ultimately, this has repercus-
sions on the perpetuation of preventable infant deaths.
There were significant differences in the perception
and/or intensity of the statements, probably due to the
participant’s position with regards to the phenomenon.
Lack of awareness of policies aimed at children’s health
and of the health care model25,a on the part of health
care professionals, together with professionals from
both levels of health care’s views that care is supplied
better in the traditional model and the mothers’ percep-
tions of poor problems solving capabilities in the ESF,
are examples of the model’s poor consolidation. This
is worrying, especially in relation to the main point
of access, where the majority of activities to avoid
8 Infant mortality and barriers to access
Table 5. The course of preventable infant mortality: the diverse barriers to access. Recife, Northeastern Brazil, 2007.
Barriers in the ESF Primary Care
Ante natal
- Lack of home visits to at-risk pregnant women by the
whole ESF team to provide guidance
Post natal
- Lack of preventative actions
- RN not included in monitoring activities for at-risk
children according to social criteria: unemployed mother,
drug use, multiple partners, single mother, areas of social
risk.
- No home visit by nurse and/or doctor.
- Child only has USF appointments when ill; lack of
guidance on promoting health and avoiding infant death
No responsibility taken for the child throughout the course
of their health care
- Team does not continue to provide care after referral and
return to specialist services.
Failures in access to health care during illness which
contributed to the death
- Failure to comply with policies: at risk children not
receiving medical/nurse appointments for more than a
month before death.
- Refusal by the USF to treat a child with acute respiratory
disease the day before death occurred.
No guidance given as to other services where treatment
would be provided.
- Death due to aspirating milk triggered by respiratory
disease (and/or aggravated by smoke in the household /
compression by the body of another child).
- Blame placed on the mother and on overwork caused by
the death of the child. Intra-team conflicts.
ESF: Family Health Strategy; USF: Family Health Unit; ACS: Community Health Worker
preventable infant death through actions and health
care services take place. Infant death in areas assigned
to the ESF as a result of failures in the Government
Program to Reduce Infant Mortality f highlights
barriers to implementing child health care policies. The
conflicts between the current model and the traditional,
Vanderlei LCM & Vázquez ML
Example Quotes
-[...] she did not carry out the ante natal checks during
pregnancy, nor was the child’s well being monitored. She
only cam when the child was sick (Nurse).
-[...] she (ACS) came to the house on the day we went there
(the maternity hospital) [...] later I went to the center (USF)
and I told here (ACS) “the girl doesn’t have a crib and she’s
sleeping with me in the bed with me and the other four
children, five altogether counting her [...].” (Mother).
[...] I always turned up at the center without making an
appointment, I arrived at the last minute with the girl [...].
(Mother).
[...] so she (ACS) comes to the house to go through her
routine; and I said “the girl is distressed and vomiting” and
she said “take her to the center”. I took her to the center.
The doctor saw us and sent us to the hospital, gave me a
bus ticket. (Mother).
The doctor there (the children’s hospital) sent us home
again [...] he suspected she had a stomach infection, and
prescribed an antibiotic, but I didn’t want to give it to her
because it was very strong [...] she was very young [...] I
gave her saline, I asked for it at the center [...]. (Mother).
- [...] then I had a problem, phlebitis, and I was off for ten
days. (Doctor).
- [...] So I tried to get in touch with the ACS and they told me
“she’s not here, she’s out”, so I asked “where is the doctor?”
“The doctor has left”. I took her back home, gave her
Dipirona, the fever passed, I fed her, winded her, put her to
sleep, she was playing, she wasn’t poorly, she was alert, and
so we went to sleep. (Mother).
- [...] so I said: “hey! She’s asleep, I’m going to get her and
feed her, my breasts were really full” [...] I went up and lit
a cigarette. Smoked it and turned around and she was still
asleep [...] and I said to myself:” she’s sleeping a lot” [...]
and when I went to pick her up her clothes were all wet
with milk, her nose was blocked with catarrh and she was
purple [...] so I picked her up and went running into the
street (Mother).
- [...] as she (the mother) is a drug user, she fell asleep on
top of the child, suffocating her, or she did not pay attention
when she was feeding her, the child regurgitated the
milk and ended up aspirating it [...]. It was an unplanned
pregnancy [...] she didn’t use contraceptives, the doctor
didn’t give her a prescription, and I don’t give medicine if
the doctor hasn’t already prescribed it. (Nurse).
[...] I believe the following: that families who need more
health care should be monitored [...] more closely. [...] the
vehicle for the doctor, the nurse, are the ACSs, no? we say:
“look at him, or look at her, these people need to be looked
after” [...] but we are here with a lot of other people to look
after [...]. (Doctor).
well-structured network, in which primary health care
was provided by pediatricians, demonstrate the need
for fresh adjustments to enable the new model to be
understood and legitimized.5,22
The main criticisms of the new model which emerged
from the mothers’ statements were the lack of doctors
Rev Saúde Pública 2013;47(2)
in the ESF, limited curative health care, doctors being
substituted for nurses and the refusal to treat acute
illness. They made it difficult to monitor at-risk chil-
dren, the priority of the whole health care team.18,22,f The
lack of doctors interfered in work processes and in inter-
-personal relationships as nurses were overworked and
their roles in the ESF not clearly defined. This increased
conflicts in the teams’ work, permeating into values,
attitudes and historically determined conceptions.3,17,18,21
The infant death case study revealed the ESF’s failure
to monitor at risk children as one of the main deter-
minants of infant death as well as indicating the link
between other lapses in the health care provided, such
as difficulties in working in teams. The fact that respon-
sibility for the death was avoided and blame placed on
the mother reflects serious problems in communication
and professional conduct as well as probable corpo-
rate issues.3,6 On the one hand, there is resistance to
hierarchical change among medical professionals in
the former care model and, on the other, promotion
of nurses to a level equal to that of the doctors, which
generates intra-team conflicts.3,17
Barriers related to poor performance indicate the lack
of quality health care in the ESF and no responsibi-
lity being taken for the child throughout the course
of their health care. Failing to comply with govern-
ment child health care directives highlight failures
in the way comprehensive child health care policies
are established.f These were aspects present in the
statements of all participants and in the infant death
case study.
The mothers’ unanimous vision of the health care
process as dehumanized suggests that access to health
care through the means of welcoming, sympathetic
interpersonal relationships between patient and health
care provider8,15 is not common practice, making this
a SUS operational directive which has not become
incorporated in the minds of health care professionals
dealing with children’s health care.7,21
Blaming the child’s death on the mother’s negli-
gence was something which emerged mainly among
the mothers and female ESF/PACS health care
f
Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Agenda de compromissos para a
saúde integral da criança e a redução da mortalidade infantil. Brasília (DF); 2005. (Série A. Normas e Manuais Técnicos).
9
professionals. These health care professionals empha-
sized maternal factors, separating them from the context
of social misery and played down inadequate access
to health care. These statements implied prejudiced,
probably ideological attitudes. Among the mothers,
contradiction appeared in the statements, which had a
note of involuntary maternal involvement, intertwined
with conditions of extreme vulnerability. These data are
consistent with those from the Scheper-Hughes20 study,
developed in Northeastern Brazil, but not with those of
the study carried out by Nations,16 in the same area at
the same time, in which the mothers perceived failures
in health care as one of the determinants of death. The
results show an attitude more of resignation on the part
of the mothers, towards the miserable conditions of the
context which overcame the perception of obstacles to
health care access.9,12,13,20,22,24 They also reflect a position
of little solidarity, based on the impersonality of the
guiding question, which referred to the deaths of the
children of mothers they did not know, which contri-
buted to the development of blame in their statements.
To conclude, the existence of numerous barriers to
access to child health care reflects the way the SUS,
and its main access point, the ESF, have not been firmly
established. The participants fail to perceive the link
between poor quality health care services and the conti-
nuing occurrence of preventable infant mortality which
could be avoided by actions and health care services
through child health care policies.
The structural (lack of medicines in the ESF), organi-
zational (restrictions on care for acute illnesses/doctors
substituted for nurses) and professional performance
(poor technical quality, care that is not welcoming/
dehumanized and problems with team work) barriers
prove themselves to be the main obstacles to access to
primary care which takes responsibility for the child
throughout the whole course of their health care.
Despite the mothers’ conditions of social exclusion
being linked to infant mortality, these factors can
be minimized with efficient primary care, bearing in
mind the important role played by fairer and effective
social policies.
10
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The authors declare that there are no conflicts of interests.

HIGHLIGHTS

The article analyzes barriers to primary health care as one of the factors associated with preventable infant mortality
in Recife, PE.

The authors estimate that 86% of infant deaths could be avoided through timely, effective actions on the part of
the health care services.

Managers and directors of health care units and districts, health care professionals, community health workers
and mothers were interviewed. The authors selected 18 sentinel events for the study of health care access barriers

The barriers identified by the interviewees were: the health care model being inadequately established, the fragility
of inter-sectoral links, poor ability, on the part of the Family Health Service teams, to solve problems, scarcity of
material and human resources, lack of medication, pediatricians substituted by clinicians not trained to care for
children and inadequate professional performance.

The study showed concrete difficulties related to the implementation of the child health program, limitations of
the care model and scarce health resources.

Profa. Rita de Cássia Barradas Barata

Scientific Editor