Marcos Augusto Bastos Dias

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.

The projected effect of scaling up midwifery

We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classified into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being prevented, meaning that midwifery care has the greatest effect when provided within a functional health system with effective referral and transfer mechanisms to specialist care.

Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil

A persistencia de desfechos perinatais negativos no Municipio do Rio de Janeiro, Brasil, sugere problemas na qualidade da assistencia pre-natal. A ultima investigacao realizada nessa cidade mostrou adequacao de apenas 38% dessa assistencia. O objetivo deste estudo e avaliar a adequacao da assistencia pre-natal na rede do SUS do Municipio do Rio de Janeiro. Foi realizado um estudo transversal, em 2007-2008, por meio de entrevistas com 2.422 gestantes em atendimento nos servicos de pre-natal de baixo risco. Para avaliacao da adequacao da assistencia, foi utilizado o indice PHPN, com as recomendacoes do Programa de Humanizacao do Pre-natal e Nascimento, do Ministerio da Saude, e um indice PHPN ampliado, em que foram acrescentados procedimentos clinico-obstetricos, prescricao de sulfato ferroso suplementar e acoes educativas. Foi encontrada adequacao de 38,5% para o PHPN e 33,3% para o PHPN ampliado. Estrategias de ampliacao da captacao precoce das gestantes e melhor utilizacao dos contatos com os servicos para a realizacao de acoes de atencao a saude sao prioritarias para a reversao desse quadro.The persistence of negative perinatal outcomes in Rio de Janeiro suggests problems in the quality of prenatal care. The most recent study in the city showed that only 38% of prenatal care was adequate. This study aimed to evaluate the adequacy of prenatal care under the Brazilian Unified National Health System in the city of Rio de Janeiro. A cross-sectional study in 2007-2008 interviewed 2,422 women receiving prenatal care for low-risk pregnancy. Evaluation of care used the PHPN index, based on guidelines from the Program for Humanization of Prenatal Care and Childbirth (Brazilian Ministry of Health) and an expanded PHPN index, which included clinical-obstetric procedures, prescription of supplementary ferrous sulfate, and educational activities. According to the PHPN index, 38.5% of prenatal care was adequate, as compared to 33.3% based on the expanded PHPN index. Strategies to expand early entry of pregnant women into prenatal care and better use of their contact with the health services in order to promote healthcare measures are essential to correct this situation.

Trajetória das mulheres na definição pelo parto cesáreo: estudo de caso em duas unidades do sistema de saúde suplementar do estado do Rio de Janeiro

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70% of the women had no initial preference for cesarean section, 90% of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.

Desafios na implantação de uma política de humanização da assistência hospitalar ao parto

Os objetivos deste ensaio sao discutir as dificuldades de implantacao de um novo modelo de assistencia ao parto de baixo risco na estrutura hospitalar e na sistematizacao de um campo de trabalho da enfermeira obstetra. Sob uma nova perspectiva do cuidado da parturiente, os autores fazem uma reflexao sobre o modelo de atuacao dessa categoria profissional, dos possiveis resultados positivos decorrentes dessa nova assistencia e do conflito gerado pela divisao de um espaco ate entao de dominio exclusivo da categoria medica e do consequente choque de modelos de cuidados.

Obstetric interventions during labor and childbirth in Brazilian low-risk women

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.Este artigo avaliou o uso das boas praticas (alimentacao, deambulacao, uso de metodos nao farmacologicos para alivio da dor e de partograma) e de intervencoes obstetricas na assistencia ao trabalho de parto e parto de mulheres de risco obstetrico habitual. Foram utilizados dados da pesquisa Nascer no Brasil, estudo de base hospitalar realizada em 2011/2012, com entrevistas de 23.894 mulheres. As boas praticas durante o trabalho de parto ocorreram em menos de 50% das mulheres, sendo menos frequentes nas regioes Norte, Nordeste e Centro-oeste. O uso de ocitocina e amniotomia foi de 40%, sendo maior no setor publico e nas mulheres com menor escolaridade. A manobra de Kristeller, episiotomia e litotomia foram utilizada, em 37%, 56% e 92% das mulheres, respectivamente. A cesariana foi menos frequente nas usuarias do setor publico, nao brancas, com menor escolaridade e multiparas. Para melhorar a saude de maes e criancas e promover a qualidade de vida, o Sistema Unico de Saude (SUS) e, sobretudo o setor privado, necessitam mudar o modelo de atencao obstetrica promovendo um cuidado baseado em evidencias cientificas.

Assistência pré-natal no Brasil

O estudo tem por objetivo analisar a assistencia pre-natal oferecida as gestantes usuarias de servicos de saude publicos e/ou privados utilizando dados da pesquisa Nascer no Brasil, realizada em 2011 e 2012. As informacoes foram obtidas por meio de entrevista com a puerpera durante a internacao hospitalar e dados do cartao de pre- natal. Os resultados mostram cobertura elevada da assistencia pre-natal (98,7%) tendo 75,8% das mulheres iniciado o pre-natal antes da 16a semana gestacional e 73,1% compareceram a seis ou mais consultas. O pre-natal foi realizado, sobretudo, em unidades basicas (89,6%), publicas (74,6%), pelo mesmo profissional (88,4%), em sua maioria medicos (75,6%), e 96% receberam o cartao de pre-natal. Um quarto das gestantes foi considerado de risco. Do total das entrevistadas, apenas 58,7% foram orientadas sobre a maternidade de referencia, e 16,2% procuraram mais de um servico para a admissao para o parto. Desafios persistem para a melhoria da qualidade dessa assistencia, com a realizacao de procedimentos efetivos para a reducao de desfechos desfavoraveis.

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.

Determining gestational age for public health care users in Brazil: comparison of methods and algorithm creation.

BackgroundA valid, accurate method for determining gestational age (GA) is crucial in classifying early and late prematurity, and it is a relevant issue in perinatology. This study aimed at assessing the validity of different measures for approximating GA, and it provides an insight into the development of algorithms that can be adopted in places with similar characteristics to Brazil. A follow-up study was carried out in two cities in southeast Brazil. Participants were interviewed in the first trimester of pregnancy and in the postpartum period, with a final sample of 1483 participants after exclusions. The distribution of GA estimates at birth using ultrasound (US) at 21–28 weeks, US at 29+ weeks, last menstrual period (LMP), and the Capurro method were compared with GA estimates at birth using the reference US (at 7–20 weeks of gestation). Kappa, sensitivity, and specificity tests were calculated for preterm (<37 weeks of gestation) and post-term (>=42 weeks) birth rates. The difference in days in the GA estimates between the reference US and the LMP and between the reference US and the Capurro method were evaluated in terms of maternal and infant characteristics, respectively.ResultsFor prematurity, US at 21–28 weeks had the highest sensitivity (0.84) and the Capurro method the highest specificity (0.97). For postmaturity, US at 21–28 weeks and the Capurro method had a very high sensitivity (0.98). All methods of GA estimation had a very low specificity (≤0.50) for postmaturity. GA estimates at birth with the algorithm and the reference US produced very similar results, with a preterm birth rate of 12.5%.ConclusionsIn countries such as Brazil, where there is less accurate information about the LMP and lower coverage of early obstetric US examinations, we recommend the development of algorithms that enable the use of available information using methodological strategies to reduce the chance of errors with GA. Thus, this study calls into attention the care needed when comparing preterm birth rates of different localities if they are calculated using different methods.

Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.Este artigo avaliou o uso das boas praticas (alimentacao, deambulacao, uso de metodos nao farmacologicos para alivio da dor e de partograma) e de intervencoes obstetricas na assistencia ao trabalho de parto e parto de mulheres de risco obstetrico habitual. Foram utilizados dados da pesquisa Nascer no Brasil, estudo de base hospitalar realizada em 2011/2012, com entrevistas de 23.894 mulheres. As boas praticas durante o trabalho de parto ocorreram em menos de 50% das mulheres, sendo menos frequentes nas regioes Norte, Nordeste e Centro-oeste. O uso de ocitocina e amniotomia foi de 40%, sendo maior no setor publico e nas mulheres com menor escolaridade. A manobra de Kristeller, episiotomia e litotomia foram utilizada, em 37%, 56% e 92% das mulheres, respectivamente. A cesariana foi menos frequente nas usuarias do setor publico, nao brancas, com menor escolaridade e multiparas. Para melhorar a saude de maes e criancas e promover a qualidade de vida, o Sistema Unico de Saude (SUS) e, sobretudo o setor privado, necessitam mudar o modelo de atencao obstetrica promovendo um cuidado baseado em evidencias cientificas.