Karla Simônia de Pádua

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America

BACKGROUND Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

The opinion of Brazilian women regarding vaginal labor and cesarean section

Objectives: The opinions of Brazilian women regarding vaginal delivery and cesarean sections was studied. Methods: Six hundred and fifty‐six women who had given birth in seven hospitals in São Paulo and Pernambuco, using the Public Health Service, were interviewed. The opinions of women who had delivered only by cesarean section was compared with those of women who had had at least one vaginal delivery. Results: Significantly more women who had experienced at least one vaginal delivery considered this to be the best way of giving birth (90.4% vs. 75.9% among C‐section‐only women). Similar proportions in both groups (45.5% and 42.8%) stated that vaginal labor is better because it causes less pain and suffering for the woman. Significantly more women who had experienced a vaginal labor (47.1% vs. 30.3%) reported that it had no disadvantage. More women who had only had cesarean sections referred not having contractions/pain as an advantage of this method (56.7% vs. 41.7%). Conclusions: Apparently, pain and womens perception of pain were the characteristics which differentiated women with history of vaginal delivery from those with cesarean sections in the sample studied. However, the opinion that vaginal delivery is better than cesarean section was expressed independently of the recognition that pain could be its main disadvantage.OBJECTIVES The opinions of Brazilian women regarding vaginal delivery and cesarean sections was studied. METHODS Six hundred and fifty-six women who had given birth in seven hospitals in São Paulo and Pernambuco, using the Public Health Service, were interviewed. The opinions of women who had delivered only by cesarean section was compared with those of women who had had at least one vaginal delivery. RESULTS Significantly more women who had experienced at least one vaginal delivery considered this to be the best way of giving birth (90.4% vs. 75.9% among C-section-only women). Similar proportions in both groups (45.5% and 42.8%) stated that vaginal labor is better because it causes less pain and suffering for the woman. Significantly more women who had experienced a vaginal labor (47.1% vs. 30.3%) reported that it had no disadvantage. More women who had only had cesarean sections referred not having contractions/pain as an advantage of this method (56.7% vs. 41.7%). CONCLUSIONS Apparently, pain and womens perception of pain were the characteristics which differentiated women with history of vaginal delivery from those with cesarean sections in the sample studied. However, the opinion that vaginal delivery is better than cesarean section was expressed independently of the recognition that pain could be its main disadvantage.

Fatores associados à realização de cesariana em hospitais brasileiros

OBJETIVO: Avaliar a prevalencia de cesariana em hospitais brasileiros. METODOS: Estudo transversal com dados do Sistema Global de Dados para a Saude Materna e Perinatal, da Organizacao Mundial da Saude, para os estados de Sao Paulo, Pernambuco e Distrito Federal. Analisaram-se dados de 15.354 mulheres que tiveram parto entre setembro/2004 e marco/2005, segundo caracteristicas sociodemograficas e reprodutivas e do hospital. Foram realizadas analises bivariada - com calculos de razoes de prevalencia e respectivos intervalos de confianca- e multivariada por regressao de Poisson. RESULTADOS: A razao de prevalencia de cesarianas foi significativamente maior entre mulheres com maior idade, entre as casadas/unidas, e com maior indice de massa corporal. As condicoes apresentadas durante a gravidez ou parto, como diagnostico de HIV da parturiente, maior peso e perimetro cefalico do recem-nascido, e maior numero de consultas de pre-natal, se associaram a maior razao de prevalencia de cesariana. Na analise de regressao mostraram associacao direta com o desfecho: maior idade e escolaridade da parturiente; presenca de hipertensao/eclâmpsia, doencas cronicas e de outras condicoes medicas; maior perimetro cefalico do recem-nascido, ser primipara, ter tido cesariana na ultima gravidez, e ter recebido analgesia peridural ou raquidiana durante o trabalho de parto. Embora a proporcao de cesarianas tenha sido maior nos hospitais com indice de complexidade alto, a diferenca nao foi estatisticamente significante, assim como para as demais caracteristicas dos hospitais. CONCLUSOES: As condicoes da gravidez, do recem-nascido e as caracteristicas sociodemograficas e reprodutivas da parturiente associaram-se independentemente a realizacao de cesariana. O indice de complexidade hospitalar nao esteve associado, provavelmente pela homogeneidade da amostra de hospitais.OBJECTIVE To assess the prevalence of cesarean sections in Brazilian hospitals. METHODS A cross-sectional study was carried out with data from the World Health Organizations Global Data System for Maternal and Perinatal Health, for the Brazilian states of São Paulo, Pernambuco and the Federal District. Data relating to 15,354 women who gave birth between September/2004 and March/2005 were analyzed, according to sociodemographic, reproductive, and hospital-related characteristics. Bivariate analyses - with calculations of the prevalence ratios and respective confidence intervals - and multivariate Poisson regression analyses were performed. RESULTS The prevalence ratio of cesarean sections was significantly higher among older women, who were married/living with a partner and with higher body mass index. The following conditions during pregnancy or birth were associated with higher cesarean section prevalence ratio: parturient being diagnosed as HIV-positive, heavier weight and greater head circumference of the newborn, and more prenatal consultations. In regression analysis, the following variables showed direct association with the outcome: parturient being older and with higher schooling level, presence of hypertension/eclampsia, chronic condition or some other medical condition, newborns greater head circumference, being primiparous, having had a cesarean in the last pregnancy and having received an epidural block or rachidian analgesic during labor. Although the proportion of cesareans was higher in hospitals with a high complexity index, the difference was not statistically significant, as well as for other characteristics of hospitals. CONCLUSIONS The conditions of the pregnancy, newborn and the sociodemographic and reproductive characteristics of the parturient were independently associated with cesarean delivery. The hospital complexity index was not associated with cesarean delivery, probably due to the homogeneity of the hospital sample.

Exclusive breastfeeding among working women with free daycare available at workplace

OBJETIVO: Investigar os fatores relacionados a decisao das mulheres em amamentar e a duracao planejada e, de fato observada, do aleitamento exclusivo entre trabalhadoras que dispoem de creche na empresa. METODOS: Estudo qualitativo no qual se comparou um grupo de 15 trabalhadoras cujos bebes estavam sendo alimentados apenas com leite materno quando comecaram a frequentar a creche da empresa com outro similar que incluia mulheres cujos bebes que, ao ingressar, ja estavam recebendo, alem do leite materno, outros alimentos. Foram realizadas entrevistas semi-estruturadas e grupos focais. RESULTADOS: Evidenciaram-se como fatores relacionados a decisao de iniciar a amamentacao e mante-la ao retornar ao trabalho: o desejo de amamentar, embasado no valor que as mulheres dos dois grupos atribuiam ao aleitamento materno, bem como seus maridos e outras pessoas significativas (por exemplo: mae, irma, amigas). A duracao do aleitamento exclusivo relacionou-se principalmente a orientacao do pediatra que cuidava do bebe, que foi distinta em cada um dos grupos estudados. CONCLUSAO: A existencia da creche no local de trabalho aparece como elemento relevante para a manutencao do aleitamento apos a licenca de maternidade, especialmente o materno exclusivo. A decisao sobre quanto tempo amamentar de forma exclusiva esteve relacionada as informacoes recebidas acerca do assunto antes e durante a gestacao, e no pos-parto. A diferenca entre os dois grupos estudados foi que as mulheres que mantiveram o aleitamento exclusivo por quase seis meses acreditavam que quanto mais tempo dessem somente o leite materno, mais beneficios o bebe teria, enquanto as mulheres do outro grupo acreditavam que tres meses de aleitamento exclusivo eram suficientes.

Choice of contraceptive methods by women attending a public health clinic

This paper presents the perceptions of 250 women who requested contraceptive methods (CM) at a public health clinic in relation to their freedom of choice and the role of an educational activity and consultation in this degree of freedom. Satisfaction with the chosen method and continuation after 6 months were also studied. Nearly all the women (99.6%) had already chosen a CM when they came to the clinic, and 90.0% left the clinic with the method; 81.9% reported that they felt very free to choose the method, and 60.0% felt that the educational activity and consultation had improved their degree of freedom. Six months later, 87.3% were using the same CM they had chosen. The proportion of women who changed the method and the proportion of those who felt they had not received sufficient information about the CM when they initiated use were significantly higher among women who reported any dissatisfaction with that method. The educational activity and consultation legitimated the womens choices (which they had already made before attending the health clinic) on the basis of such supplementary sources of information. This fact appears to have contributed to the womens feeling that they had sufficient freedom of choice.

Women's preferences for vaginal antimicrobial contraceptives. V: Attitudes of Brazilian women to the insertion of vaginal products

The rapid spread of HIV/AIDS in the female population increases the urgency of developing new formulations that offer protection from this disease as well as other sexually transmitted infections. In many cultures, women do not readily accept touching their genitals or inserting products into their vaginas. Information on this subject was collected during a study involving 635 women in Brazil to determine the preferred attributes of vaginal products. Seventy-six percent would use an idealized contraceptive method that offered dual protection even though it could only be inserted with a finger and 96% would use this method if it could only be placed with an applicator. Qualitative analyses of responses to open questions suggest that the majority of Brazilian women studied did not like to touch their vagina with their finger or to insert devices. Although the introduction of safe and effective vaginal microbicides into many cultural settings can be successful, it should be accompanied by significant efforts to educate women about their bodies.

Premenstrual syndrome as reported by Brazilian women

To describe the perspectives and attitudes of Brazilian women toward premenstrual syndrome (PMS).

Menstrual bleeding: perspective of Brazilian women.

BACKGROUND Menstrual patterns, induced amenorrhea and the use of some contraceptive methods which induce non-bleeding are issues under debate among health professionals and women. The objective of the study was to describe perspectives and attitudes of Brazilian women regarding menstruation and its interference in daily activities. STUDY DESIGN A semistructured questionnaire was applied to nonpregnant, nonlactating women between 18 and 45 years old, who were menstruating, consulting at public health services for other complaints than gynecological or reproductive health care, and staff members and teachers of public universities in one city of each geographic region of Brazil and the Federal District. RESULTS Of the 885 women interviewed, 51.5% were aged 20-29 years, almost 60% reported normal frequency of bleeding, 22% and 43% reported interference of menstruation in their school activities and in the relationship with their partner, respectively. The value attributed to each interference (<5; ≥ 5; in a scale up to 10) was >5 for more than 60% of the women in all evaluated domains. The most common reason for disliking menstruation was inconvenient and/or discomfort, and for liking menstruation were feeling healthy and confirmation of not being pregnant. The variables associated to liking menstruation were attending <8 years of school and low economic class, having more than one child and no history of premenstrual tension. CONCLUSION A great proportion of the interviewed women disliked having menstruation even when they did not present menstrual-related problems. However, some women still preferred monthly menstruation because they felt healthy and it was a free pregnancy test.

Inequitable access to assisted reproductive technology for the low-income Brazilian population: a qualitative study

BACKGROUND In Brazil, access to infertility care, including assisted reproductive technology (ART) is restricted. This is a second report of a study which evaluated the availability and access of low-income couples to ART services. The objective was to assess the perspective of health professionals and patients with respect to access to ART procedures within the public health network METHODS Qualitative case studies were conducted in five centres offering ART in the public sector. Semi-structured interviews were conducted with 19 health professionals based at these centres and 48 patients (men and women). Data were analysed using thematic content analysis. RESULTS All services implemented ART procedures using resources already available. In all except one centre, patients had to pay for the drugs used for the procedures and, in some cases, a fee to cover operative costs and supplies. These charges were incompatible with the financial possibilities of the majority of the low-income Brazilian population. The waiting time for access to ART varied between 3 months and 6 years. In the perspective of both patients and health professionals, the government should help centres to offer ART procedures at no cost to low-income populations. CONCLUSIONS The low-income Brazilian population has limited access to ART procedures at the public services. The implementation of ART services cannot be based only on initiatives of the professionals involved but must be part of public health policies. One possible solution is to provide ART at lower cost, making it accessible for a large part of the population.

Associação entre prevalência de laqueadura tubária e características sócio-demográficas de mulheres e seus companheiros no Estado de São Paulo, Brasil

Brazil has a high prevalence of tubal ligation. The hypothesis that it indicates undercover birth control efforts specifically addressed to the poorest sector of Brazilian society has been raised. The purpose of this paper is to evaluate whether there are differences in rates of tubal ligation depending on socioeconomic status. Data were gathered from interviews with 1335 women 15-49 years of age, of low or lower-middle socioeconomic status, carried out in 1991 in two regions of the State of Sao Paulo. The results showed an apparently higher prevalence of tubal ligation among women with less schooling,, but also among those living in better housing. However, after controlling for womens age, these associations disappeared, suggesting that they were explained by lower educational levels and greater economic resources of women of older age, where the latter factor is more heavily associated with a higher prevalence of tubal ligation. The complexity of the associations between socioeconomic status and tubal ligation are discussed, including the correlations between socioeconomic status and C-sections, which are in turn closely related to tubal ligation.