Jacqueline Alves Torres

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.

Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final

El proposito de este articulo es describir los factores de preferencia en el tipo de parto durante el embarazo temprano, y estudiar el proceso de decision en la opcion de parto en Brasil. Los datos de una cohorte de base hospitalaria nacional, con 23.894 mujeres, durante el periodo 2011-2012, se analizaron de acuerdo a la fuente de los fondos para el parto y la paridad, mediante la prueba de χ2. La preferencia inicial por cesarea fue de un 27,6%, desde el 15,4% (sector publico primiparas) al 73,2% (sector privado multiparas con cesarea). La principal razon para la eleccion de parto vaginal era la mejor recuperacion de este tipo de parto (68,5%), y para la cesarea, el temor al dolor durante el parto (46,6%). La experiencia positiva con el parto vaginal (28,7%); parto por cesarea (24,5%) y la esterilizacion femenina (32.3%) fueron citados por multiparas. Las mujeres en el sector privado tuvieron un 87,5% de cesarea con una mayor decision hacia este tipo de parto a finales del embarazo, independientemente del diagnostico de las complicaciones. En ambos sectores, la proporcion de la cesarea fue mucho mayor de lo deseado.The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.O objetivo deste artigo e descrever os fatores referidos para a preferencia pelo tipo de parto no inicio da gestacao e reconstruir o processo de decisao pelo tipo de parto no Brasil. Dados de uma coorte de base hospitalar nacional com 23.940 puerperas, realizada em 2011-2012, foram analisados, segundo fonte de pagamento do parto e paridade, com utilizacao do teste χ2. A preferencia inicial pela cesariana foi de 27,6%, variando de 15,4% (primiparas no setor publico) a 73,2% (multiparas com cesariana anterior no setor privado). O principal motivo para a escolha do parto vaginal foi a melhor recuperacao desse tipo de parto (68,5%) e para a cesariana o medo da dor do parto (46,6%). Experiencia positiva com parto vaginal (28,7%), parto cesareo (24,5%) e realizacao de laqueadura tubaria (32,3%) foram citadas por multiparas. Mulheres do setor privado apresentaram 87,5% de cesariana, com aumento da decisao pelo parto cesareo no final da gestacao, independentemente do diagnostico de complicacoes. Em ambos os setores, a proporcao de cesariana foi muito superior ao desejado pelas mulheres.

Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth

El proposito de este articulo es describir los factores de preferencia en el tipo de parto durante el embarazo temprano, y estudiar el proceso de decision en la opcion de parto en Brasil. Los datos de una cohorte de base hospitalaria nacional, con 23.894 mujeres, durante el periodo 2011-2012, se analizaron de acuerdo a la fuente de los fondos para el parto y la paridad, mediante la prueba de χ2. La preferencia inicial por cesarea fue de un 27,6%, desde el 15,4% (sector publico primiparas) al 73,2% (sector privado multiparas con cesarea). La principal razon para la eleccion de parto vaginal era la mejor recuperacion de este tipo de parto (68,5%), y para la cesarea, el temor al dolor durante el parto (46,6%). La experiencia positiva con el parto vaginal (28,7%); parto por cesarea (24,5%) y la esterilizacion femenina (32.3%) fueron citados por multiparas. Las mujeres en el sector privado tuvieron un 87,5% de cesarea con una mayor decision hacia este tipo de parto a finales del embarazo, independientemente del diagnostico de las complicaciones. En ambos sectores, la proporcion de la cesarea fue mucho mayor de lo deseado.The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.O objetivo deste artigo e descrever os fatores referidos para a preferencia pelo tipo de parto no inicio da gestacao e reconstruir o processo de decisao pelo tipo de parto no Brasil. Dados de uma coorte de base hospitalar nacional com 23.940 puerperas, realizada em 2011-2012, foram analisados, segundo fonte de pagamento do parto e paridade, com utilizacao do teste χ2. A preferencia inicial pela cesariana foi de 27,6%, variando de 15,4% (primiparas no setor publico) a 73,2% (multiparas com cesariana anterior no setor privado). O principal motivo para a escolha do parto vaginal foi a melhor recuperacao desse tipo de parto (68,5%) e para a cesariana o medo da dor do parto (46,6%). Experiencia positiva com parto vaginal (28,7%), parto cesareo (24,5%) e realizacao de laqueadura tubaria (32,3%) foram citadas por multiparas. Mulheres do setor privado apresentaram 87,5% de cesariana, com aumento da decisao pelo parto cesareo no final da gestacao, independentemente do diagnostico de complicacoes. Em ambos os setores, a proporcao de cesariana foi muito superior ao desejado pelas mulheres.

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.

Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa nacional nascer no Brasil

Robust evidence of the benefits of continuous support during childbirth led to the recommendation that it should be offered for all women. In Brazil, it has been guaranteed by law since 2005, but scarce data on implementation is available. We aimed to estimate the frequency and associated socio-demographic, obstetric and institutional predictors of women having companionship during childbirth in the Birth in Brazil survey. Descriptive statistical analysis was done for the characterization of companions (at different moments of hospital stay), maternal and institutional factors; associations were investigated in bivariate and multivariate models. We found that 24.5% of women had no companion at all, 18.8% had continuous companionship and 56.7% had partial companionship. Independent predictors of having no or partial companionship at birth were: lower income and education, brown color of skin, using the public sector, multiparity, and vaginal delivery. Implementation of companionship was associated with having an appropriate environment, and clear institution al rules about womens rights to companionship.As evidencias sobre os beneficios do apoio continuo durante o parto levou a recomendacao de que este apoio deve ser oferecido a todas as mulheres. No Brasil, ele e garantido por lei desde 2005, mas os dados sobre a sua implementacao sao escassos. Nosso objetivo foi estimar a frequencia e fatores sociodemograficos, obstetricos e institucionais associados a presenca de acompanhantes durante o parto na pesquisa Nascer no Brasil. Foi feita analise estatistica descritiva para a caracterizacao dos acompanhantes (em diferentes momentos do tempo da internacao), fatores maternos e institucionais; as associacoes foram investigadas em modelos bi e multivariada. Vimos que 24,5% das mulheres nao tiveram acompanhante algum, 18,8% tinham companhia continua, 56,7% tiveram acompanhamento parcial. Preditores independentes de nao ter algum, ou parcial, foram: menor renda e escolaridade, cor parda da pele, usar o setor publico, multiparidade e parto vaginal. A implementacao do acompanhante foi associada com ambiencia adequada e regras institucionais claras sobre os direitos das mulheres ao acompanhante.

Provider-Initiated Late Preterm Births in Brazil: Differences between Public and Private Health Services.

Background A large proportion of the rise in prematurity worldwide is owing to late preterm births, which may be due to the expansion of obstetric interventions, especially pre-labour caesarean section. Late preterm births pose similar risks to overall prematurity, making this trend a concern. In this study, we describe factors associated with provider-initiated late preterm birth and verify differences in provider-initiated late preterm birth rates between public and private health services according to obstetric risk. Methods This is a sub-analysis of a national population-based survey of postpartum women entitled “Birth in Brazil”, performed between 2011 and 2012. We included 23,472 singleton live births. We performed non-conditional multiple logistic regressions assessing associated factors and analysing differences between public and private health services. Results Provider-initiated births accounted for 38% of late preterm births; 32% in public health services and 61% in private health services. They were associated with previous preterm birth(s) and maternal pathologies for women receiving both public and private services and with maternal age ≥35 years for women receiving public services. Women receiving private health services had higher rates of provider-initiated late preterm birth (rate of 4.8%) when compared to the ones receiving public services (rate of 2.4%), regardless of obstetric risk–adjusted OR of 2.3 (CI 1.5–3.6) for women of low obstetric risk and adjusted OR of 1.6 (CI 1.1–2.3) for women of high obstetric risk. Conclusion The high rates of provider-initiated late preterm birth suggests a considerable potential for reduction, as such prematurity can be avoided, especially in women of low obstetric risk. To promote healthy births, we advise introducing policies with incentives for the adoption of new models of birth 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.

Cesariana e resultados neonatais em hospitais privados no Brasil: estudo comparativo de dois diferentes modelos de atenção perinatal

Objetiva-se comparar a prevalencia de cesariana e desfechos neonatais de dois modelos de atencao ao parto em hospitais privados brasileiros, utilizando-se dados do estudo Nascer no Brasil, coorte de base hospitalar realizada nos anos 2011/2012. Foram analisadas 1.664 puerperas e seus conceptos, atendidos em 13 hospitais localizados na Regiao Sudeste, divididos em “tipico” – modelo de atencao padrao, e “atipico” – Hospital Amigo da Crianca com equipes de plantao e trabalho colaborativo entre enfermeiras obstetricas e medicos na atencao ao parto. A classificacao de Robson foi adotada para a comparacao das prevalencias de cesariana, que foram menores no hospital atipico (47,8% vs. 90,8%, p < 0,001). Desfechos positivos relativos ao aleitamento materno foram mais frequentes no hospital atipico. Eventos neonatais adversos nao apresentaram diferenca significativa entre os hospitais. A intervencao adotada no hospital atipico deve ser avaliada em profundidade, uma vez que parece ter reduzido a prevalencia de cesariana e aumentado as boas praticas de cuidado neonatal.

Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey

Robust evidence of the benefits of continuous support during childbirth led to the recommendation that it should be offered for all women. In Brazil, it has been guaranteed by law since 2005, but scarce data on implementation is available. We aimed to estimate the frequency and associated socio-demographic, obstetric and institutional predictors of women having companionship during childbirth in the Birth in Brazil survey. Descriptive statistical analysis was done for the characterization of companions (at different moments of hospital stay), maternal and institutional factors; associations were investigated in bivariate and multivariate models. We found that 24.5% of women had no companion at all, 18.8% had continuous companionship and 56.7% had partial companionship. Independent predictors of having no or partial companionship at birth were: lower income and education, brown color of skin, using the public sector, multiparity, and vaginal delivery. Implementation of companionship was associated with having an appropriate environment, and clear institution al rules about womens rights to companionship.As evidencias sobre os beneficios do apoio continuo durante o parto levou a recomendacao de que este apoio deve ser oferecido a todas as mulheres. No Brasil, ele e garantido por lei desde 2005, mas os dados sobre a sua implementacao sao escassos. Nosso objetivo foi estimar a frequencia e fatores sociodemograficos, obstetricos e institucionais associados a presenca de acompanhantes durante o parto na pesquisa Nascer no Brasil. Foi feita analise estatistica descritiva para a caracterizacao dos acompanhantes (em diferentes momentos do tempo da internacao), fatores maternos e institucionais; as associacoes foram investigadas em modelos bi e multivariada. Vimos que 24,5% das mulheres nao tiveram acompanhante algum, 18,8% tinham companhia continua, 56,7% tiveram acompanhamento parcial. Preditores independentes de nao ter algum, ou parcial, foram: menor renda e escolaridade, cor parda da pele, usar o setor publico, multiparidade e parto vaginal. A implementacao do acompanhante foi associada com ambiencia adequada e regras institucionais claras sobre os direitos das mulheres ao acompanhante.

Caesarean section and neonatal outcomes in private hospitals in Brazil: comparative study of two different perinatal models of care.

Objetiva-se comparar a prevalencia de cesariana e desfechos neonatais de dois modelos de atencao ao parto em hospitais privados brasileiros, utilizando-se dados do estudo Nascer no Brasil, coorte de base hospitalar realizada nos anos 2011/2012. Foram analisadas 1.664 puerperas e seus conceptos, atendidos em 13 hospitais localizados na Regiao Sudeste, divididos em “tipico” – modelo de atencao padrao, e “atipico” – Hospital Amigo da Crianca com equipes de plantao e trabalho colaborativo entre enfermeiras obstetricas e medicos na atencao ao parto. A classificacao de Robson foi adotada para a comparacao das prevalencias de cesariana, que foram menores no hospital atipico (47,8% vs. 90,8%, p < 0,001). Desfechos positivos relativos ao aleitamento materno foram mais frequentes no hospital atipico. Eventos neonatais adversos nao apresentaram diferenca significativa entre os hospitais. A intervencao adotada no hospital atipico deve ser avaliada em profundidade, uma vez que parece ter reduzido a prevalencia de cesariana e aumentado as boas praticas de cuidado neonatal.