Daphne Rattner

Birth in Brazil: national survey into labour and birth

BackgroundCaesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction.MethodsNationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients’ medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson’s groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design.DiscussionThis study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it’s consequences on postnatal health.

Sobre a hipótese de estabilização das taxas de cesárea do Estado de São Paulo, Brasil

Sao relatados os dados sobre cesareas no Estado de Sao Paulo, entre 1987 e 1993, e verificadas as associacoes entre a pratica de cesareas e o desenvolvimento social e economico, adotando como unidades de analise os Escritorios Regionais de Saude (ERSAs) e os hospitais. Foi realizado estudo transversal, com base em dados secundarios, tendo sido estudadas as seguintes variaveis: taxas de cesareas em 1987, 1992 e 1993 de hospitais e regioes; tipo de prestador; vinculo com ensino medico; coeficiente de mortalidade infantil tardia; numero de bancos por habitantes (BANCOS); e potencial de consumo da cidade-sede da regiao por habitantes (POTCONS). As taxas de cesarea no periodo foram cerca de 48% no Estado de Sao Paulo; nos ERSAs, entre 21,3 (Capao Bonito) e 85,2% (Sao Jose do Rio Preto, 1987); as hospitalares variaram entre zero e 100%, sendo mais altas nos hospitais privados (56% em 1993). Os hospitais universitarios apresentaram taxas estaveis, cerca de 39%. Na regressao linear multipla, BANCOS e POTCONS explicaram 48% da variacao das taxas regionais. Questiona-se a estabilizacao da taxa estadual, pois os dados sugerem que esta havendo deslocamento da moda das taxas hospitalares para valores mais altos. E necessaria uma reorientacao da assistencia ao nascimento, uma vez que a cesarea, alem de seu carater de procedimento medico, adquiriu o de bem de consumo, um sintoma da perversa logica que vem se instalando no sistema de saude.Abstract Births in S. Paulo State (Brazil) between 1987 and 1993 were studied to testthe association between cesarean section rates and the social and economicdevelopment. The study used both Health Regions and hospitals as units ofanalysis. The cross-sectional study of secondary data adopted as variables:cesarean section rates in 1987, 1992 and 1993 by hospital and region; kind ofprovider; link of hospital with medical school; post-neonatal infant mortalityrate; number of banks per inhabitant; and consumption potential of the regionalcentral town per inhabitant. The C-section rates in the period studied were Sobre a hipotese de estabilizacao das taxas decesarea do Estado de Sao Paulo, Brasil* On the hypothesis of the cesarean birth rates stabilizationin south eastern, Brazil Daphne Rattner Nucleo de Investigacao sobre Saude da Mulher e da Crianca. Instituto da Saude. Sao Paulo, SP - Brasil Resumo Sao relatados os dados sobre cesareas no Estado de Sao Paulo, entre 1987 e1993, e verificadas as associacoes entre a pratica de cesareas e odesenvolvimento social e economico, adotando como unidades de analise osEscritorios Regionais de Saude (ERSAs) e os hospitais. Foi realizado estudotransversal, com base em dados secundarios, tendo sido estudadas as seguintesvariaveis: taxas de cesareas em 1987, 1992 e 1993 de hospitais e regioes; tipode prestador; vinculo com ensino medico; coeficiente de mortalidade infantiltardia; numero de bancos por habitantes (BANCOS); e potencial de consumoda cidade-sede da regiao por habitantes (POTCONS). As taxas de cesarea noperiodo foram cerca de 48% no Estado de Sao Paulo; nos ERSAs, entre 21,3(Capao Bonito) e 85,2% (Sao Jose do Rio Preto, 1987); as hospitalares variaramentre zero e 100%, sendo mais altas nos hospitais privados (56% em 1993).Os hospitais universitarios apresentaram taxas estaveis, cerca de 39%. Naregressao linear multipla, BANCOS e POTCONS explicaram 48% da variacaodas taxas regionais. Questiona-se a estabilizacao da taxa estadual, pois osdados sugerem que esta havendo deslocamento da moda das taxas hospitalarespara valores mais altos. E necessaria uma reorientacao da assistencia aonascimento, uma vez que a cesarea, alem de seu carater de procedimentomedico, adquiriu o de bem de consumo, um sintoma da perversa logica quevem se instalando no sistema de saude.

O parto como eu vejo... ou como eu o desejo? Expectativas de gestantes, usuárias do SUS, acerca do parto e da assistência obstétrica

Explanations for increased cesarean section rates in Brazil have focused on the organization of obstetric care, training of health professionals, and womens demand for surgical deliveries. This study aimed to identify pregnant womens expectations towards childbirth. Three focus groups were conducted in a public hospital in the city of São Paulo. Analytical categories were: vaginal birth, forceps, c-section, prenatal care, and obstetric care. The desire for c-sections was associated with a demand for tubal ligation, and although women feared labor pains, they were more afraid of how the obstetric team might react to their complaints. Lack of information on reproductive issues was associated with a demand for more information. There was a preference for vaginal births, since most women feared c-sections due to risks associated with this surgical intervention. The authors propose that the demand for cesareans among women should be reconsidered as one of the main factors in the rise in surgical deliveries in the Brazilian health care system.

A epidemiologia na avaliação da qualidade: uma proposta

This paper proposes a strategy for defining indicators to assess the quality of the process of health care, based on the identification of the objectives of the care being delivered and on the verification of whether the technical guidelines for the procedures are being enforced. The article goes on to apply the proposed methodology to the process of health care during childbirth, based on a perspective of comprehensive care and adopting both an individual and collective risk approach. It uses a data bank of 4,558 Simplified Perinatal Clinical Histories (CLAP/PAHO/WHO) from 12 hospitals.The indicators selected were: V.D.R.L., Rh blood typing, antitetanus vaccination, rate of cesarean sections, reception of the baby by a pediatrician at birth, Apgar score, evaluation of the gestational age by physical exam, rooming-in, exclusive breastfeeding upon discharge, and referral for a puerperal consultation. Methods for classification of hospitals were the sum of their scores for each indicator, gold standard, and ranking. This methodology warranted identification of one hospital with excellent quality of care, five with good care, two with fair care, and four whose performances were completely unsatisfactory. Finally, some remarks on the assessment of quality of health care are made and future developments are proposed.

Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar

The objective is to identify factors associated with womens satisfaction towards the care provided by the health professionals during hospital assisted delivery and identify how those factors influence their general levels of satisfaction. The cohort hospital based study was carried out in connection with the Birth in Brazil research. 15,688 women were included, interviewed at home, through the phone, from March 2011 to February 2012. All the variables that compose the professional/pregnant woman relationship (waiting time, respect, privacy, clarity of explanations, possibility of asking questions and participating in the decisions) and schooling remained independently associated with general satisfaction towards delivery care, in the adjusted model. The white women assisted in the southeastern and southern regions of the country, by the private sector and with a companion present gave a better evaluation of the care provided. Women value the way in which they are assisted by the health professionals, and there are inequalities in the way they are treated based on skin color, geographic region and financial situation.O objetivo foi identificar fatores associados a avaliacao das mulheres quanto a relacao profissionais de saude/parturiente e como esses fatores influenciam a satisfacao com o atendimento ao parto. Estudo de coorte de base hospitalar, realizado com base na pesquisa Nascer no Brasil. Foram incluidas 15.688 mulheres entrevistadas no pos-parto, por telefone, de marco de 2011 a fevereiro de 2013. Todas as variaveis componentes da relacao profissional/parturiente (tempo de espera, respeito, privacidade, clareza nas explicacoes, possibilidade de fazer perguntas e participacao nas decisoes) e escolaridade mantiveram-se associadas de forma independente a satisfacao geral com o atendimento ao parto, no modelo ajustado. As mulheres atendidas na Regiao Sudeste e na Sul, no setor privado e com acompanhante avaliaram melhor a relacao com os profissionais de saude, o oposto ocorreu com as pardas e que tiveram trabalho de parto. As mulheres valorizam a forma como sao atendidas pelos profissionais e existem desigualdades de cor, regiao geografica e fonte de pagamento do parto nessas relacoes.

Nascimentos no Brasil: associação do tipo de parto com variáveis temporais e sociodemográficas

Objectives: to identify caesarean and vaginal births and their association with temporal and socio-demographic variables. Methods: a mixed approach involving descriptive time series studies (2000, 2005, 2010) and one cross-sectional study (2011), using data from the Live Births Information System. The data were corrected for under-reporting; the type of birth was analyzed in terms of day of the week, time of the day, area of residence, race/color, level of education and marital status of mother. Raw and adjusted probability ratios for surgical births were calculated using Poisson regression. Results: the proportion of caesarean births in the country increased around 40% from 2000 to 2010. Vaginal births were distributed similarly over the days of the week (around 14% for each day) and according to time of day (around 25%), while caesareans were concentrated on week days and during the daytime. The proportion of caesareans was lower in the Northern region (42.8%), among the indigenous population (16.2%), among women with no schooling (25.2%) and among single mothers (42.0%), with a tendency to increase in proportion to age and level of schooling. After adjustment, the Center West region had the highest proportion of caesarean births with the same associated variables. Conclusions: the proportion of caesarean births in the country is over 50% and is associated primarily with age and level of education of the mother.

Structure in Brazilian maternity hospitals: key characteristics for quality of obstetric and neonatal care

This study aimed to evaluate key characteristics of structure in a sample of maternity hospitals in Brazil. Structure was evaluated according to Ministry of Health criteria and included: geographic location, obstetric volume, presence of ICU, teaching activities, staff qualifications, and availability of equipment and medicines. The results showed differences in staff qualifications and availability of equipment in obstetric and neonatal care according to type of financing, region of the country, and degree of complexity. The North/Northeast and Central-West regions presented the most serious problems with structure. The public and mixed hospitals were better structured in the South/Southeast, reaching satisfactory levels on various items, similar or superior to the private hospitals. The current study contributes to the debate on quality of structure in Brazils hospital services and emphasizes the need to develop analytical studies considering process and results of obstetric and neonatal care.This study aimed to evaluate key characteristics of structure in a sample of maternity hospitals in Brazil. Structure was evaluated according to Ministry of Health criteria and included: geographic location, obstetric volume, presence of ICU, teaching activities, staff qualifications, and availability of equipment and medicines. The results showed differences in staff qualifications and availability of equipment in obstetric and neonatal care according to type of financing, region of the country, and degree of complexity. The North/Northeast and Central-West regions presented the most serious problems with structure. The public and mixed hospitals were better structured in the South/Southeast, reaching satisfactory levels on various items, similar or superior to the private hospitals. The current study contributes to the debate on quality of structure in Brazil’s hospital services and emphasizes the need to develop analytical studies considering process and results of obstetric and neonatal care.

Social inequalities and women's satisfaction with childbirth care in Brazil: a national hospital-based survey

The objective is to identify factors associated with womens satisfaction towards the care provided by the health professionals during hospital assisted delivery and identify how those factors influence their general levels of satisfaction. The cohort hospital based study was carried out in connection with the Birth in Brazil research. 15,688 women were included, interviewed at home, through the phone, from March 2011 to February 2012. All the variables that compose the professional/pregnant woman relationship (waiting time, respect, privacy, clarity of explanations, possibility of asking questions and participating in the decisions) and schooling remained independently associated with general satisfaction towards delivery care, in the adjusted model. The white women assisted in the southeastern and southern regions of the country, by the private sector and with a companion present gave a better evaluation of the care provided. Women value the way in which they are assisted by the health professionals, and there are inequalities in the way they are treated based on skin color, geographic region and financial situation.O objetivo foi identificar fatores associados a avaliacao das mulheres quanto a relacao profissionais de saude/parturiente e como esses fatores influenciam a satisfacao com o atendimento ao parto. Estudo de coorte de base hospitalar, realizado com base na pesquisa Nascer no Brasil. Foram incluidas 15.688 mulheres entrevistadas no pos-parto, por telefone, de marco de 2011 a fevereiro de 2013. Todas as variaveis componentes da relacao profissional/parturiente (tempo de espera, respeito, privacidade, clareza nas explicacoes, possibilidade de fazer perguntas e participacao nas decisoes) e escolaridade mantiveram-se associadas de forma independente a satisfacao geral com o atendimento ao parto, no modelo ajustado. As mulheres atendidas na Regiao Sudeste e na Sul, no setor privado e com acompanhante avaliaram melhor a relacao com os profissionais de saude, o oposto ocorreu com as pardas e que tiveram trabalho de parto. As mulheres valorizam a forma como sao atendidas pelos profissionais e existem desigualdades de cor, regiao geografica e fonte de pagamento do parto nessas relacoes.

Estrutura das maternidades: aspectos relevantes para a qualidade da atenção ao parto e nascimento

This study aimed to evaluate key characteristics of structure in a sample of maternity hospitals in Brazil. Structure was evaluated according to Ministry of Health criteria and included: geographic location, obstetric volume, presence of ICU, teaching activities, staff qualifications, and availability of equipment and medicines. The results showed differences in staff qualifications and availability of equipment in obstetric and neonatal care according to type of financing, region of the country, and degree of complexity. The North/Northeast and Central-West regions presented the most serious problems with structure. The public and mixed hospitals were better structured in the South/Southeast, reaching satisfactory levels on various items, similar or superior to the private hospitals. The current study contributes to the debate on quality of structure in Brazils hospital services and emphasizes the need to develop analytical studies considering process and results of obstetric and neonatal care.This study aimed to evaluate key characteristics of structure in a sample of maternity hospitals in Brazil. Structure was evaluated according to Ministry of Health criteria and included: geographic location, obstetric volume, presence of ICU, teaching activities, staff qualifications, and availability of equipment and medicines. The results showed differences in staff qualifications and availability of equipment in obstetric and neonatal care according to type of financing, region of the country, and degree of complexity. The North/Northeast and Central-West regions presented the most serious problems with structure. The public and mixed hospitals were better structured in the South/Southeast, reaching satisfactory levels on various items, similar or superior to the private hospitals. The current study contributes to the debate on quality of structure in Brazil’s hospital services and emphasizes the need to develop analytical studies considering process and results of obstetric and neonatal care.

A Vigilância Sanitária no controle de riscos potenciais em serviços de hemoterapia no Brasil

The article describes the risks of hemotherapy services evaluated by the Health Surveillance in 2011 and 2012 through the Valuation Method of Potential Risks in Hemotherapy Services (MARPSH), classifying them into five categories: Low, Medium-Low, Medium, Medium-High and High. Of the 560 evaluated, there was an increase of 9% among the classified as low risk and a decrease of 6% among the high risk. The main problems were found in the Northern Region, in transfusion agencies (Hospital Blood Banks) and public services. Nonconformities were mostly related to quality management, of personnel and of equipment. Despite the observed improvements, there were services with critical aspects related to their commitment to the safety and effectiveness of products and services.