Maria Célia de Carvalho Formiga

Unwanted caesarean sections among public and private patients in Brazil: prospective study

Abstract Objective: To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. Design: Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. Setting: Four cities in Brazil. Participants: 1612 pregnant women: 1093 public patients and 519 private patients. Main outcome measures: Rates of delivery by caesarean section in public and private institutions; womens preferences for delivery; timing of decision to perform caesarean section. Results: 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. Conclusions: The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery. What is already known on this topic In Brazil, one quarter of all women deliver in the private sector The rate of caesarean deliveries in the private sector is extremely high (70%) and more than twice that in the public sector, where rates have recently fallen due to a new policy Previous studies in which women were interviewed after birth showed that a substantial proportion of private patients who have caesarean sections would have preferred normal delivery What this study adds In two antenatal interviews, preferences regarding type of delivery were nearly identical among public and private patients and strongly favoured vaginal births Contrary to popular belief, middle and upper class women in Brazil do not want to deliver by caesarean section

Frustrated demand for postpartum female sterilization in Brazil

During the last three decades, Brazilians have relied almost exclusively on two contraceptive methods, the pill and female sterilization, with sterilization use increasing over time. Until a new law was passed in 1997, sterilization was virtually illegal and not covered by either public or private health insurance. It was, however, frequently provided in public and private hospitals in conjunction with a cesarean section. The new law regulating sterilization provided for reimbursement for interval sterilizations by public health insurance, but placed restrictions on availability intended to reduce the use of cesareans. These restrictions included the prohibition of postpartum sterilizations. This paper focuses on womens sterilization intentions during pregnancy and their experiences postpartum. In a prospective study of 1612 pregnant women carried out in four Brazilian cities, there was substantial demand for postpartum sterilization in both the private and public sectors among women who wanted no more children. However, public patients were much less likely to be sterilized than private patients. Thus, the new law may not have reduced inequities in access or, paradoxically, the incentive for unnecessary cesarean sections.

Desejo, intenção e comportamento na saúde reprodutiva: a prática da cesárea em cidade do Nordeste do Brasil

OBJETIVO: investigar os fatores determinantes da alta incidencia do parto cesareo e a sua inter-relacao com a esterilizacao. METODOS: a pesquisa e parte de estudo multicentrico sobre saude reprodutiva no Brasil, realizado de 1998 a 2000, que incluiu os estados do Rio Grande do Norte, Minas Gerais, Sao Paulo e Rio Grande do Sul. Caracterizou-se como longitudinal prospectivo, no qual foram entrevistadas mulheres, provenientes do servico publico e do privado, em tres momentos: no inicio da gravidez (ate a 22a. semana de gestacao), no final (entre 30 e 40 dias antes da data provavel do parto) e apos o nascimento do bebe (entre 15 e 45 dias pos-parto). As entrevistadas deveriam satisfazer aos criterios de elegibilidade: ter entre 18 e 40 anos e residir e ter o filho no municipio de Natal. Foram realizadas 433 entrevistas no primeiro momento, 380 no segundo e 269 no terceiro. Os dados foram submetidos ao teste x2 a uma significância de a=5%, para comprovacao da associacao entre as variaveis anos de estudo (de 0 a 8 e 9 ou +) e as variaveis representativas da saude reprodutiva. RESULTADOS: das entrevistadas que tiveram seguimento (269), 119 tiveram parto por cesarea (55% do setor privado), sendo 45% previamente marcadas e 60% delas dias antes do parto. Os resultados revelaram relacao estatisticamente significante (p<0,05) entre a escolaridade e as variaveis paridade, servico procurado, classe social, estarem trabalhando e consultas de pre-natal. Assim, ficou demonstrado que a maior escolaridade predomina entre aquelas mulheres provenientes do servico privado, de classe social mais elevada e com maior numero de consultas de pre-natal. Embora sem significância estatistica, observou-se para as mulheres desse servico uma maior realizacao do parto cesareo, provavelmente pela facilidade da interacao entre o medico e a paciente, quando o desejo pela cesarea e frustrado para 43% daquelas provenientes do servico publico, bem como o desejo para fazer uma ligadura de trompas na hora do parto (57%). CONCLUSOES: esses resultados mostraram os grandes diferenciais existentes entre as categorias publico e privado, demonstrando um claro favorecimento do setor privado, e que a pratica obstetrica no Brasil, precisa mudar e melhorar, tanto entre aquelas mulheres com acesso ao servico privado, que conseguem a realizacao da cesarea sem consistentes indicacoes medicas, quanto entre as mulheres com acesso ao servico publico, que enfrentam dificuldades para realizacao desse procedimento, mesmo com procedentes indicacoes medicas, de modo a proporcionar igualdade no direito reprodutivo dessas mulheres.

Comparison of prophylactic and therapeutic use of short-chain fatty acid enemas in diversion colitis: a study in Wistar rats

OBJECTIVES: To study the effect of short‐chain fatty‐acids on atrophy and inflammation of excluded colonic segments before and after the development of diversion colitis. INTRODUCTION: Diversion colitis is a chronic inflammatory process affecting the dysfunctional colon, possibly evolving with mucous and blood discharge. The most favored hypotheses to explain its development is short‐chain fatty‐acid deficiency in the colon lumen. METHODS: Wistar rats were submitted to colostomy with distal colon exclusion. Two control groups (A1 and B1) received rectally administered physiological saline, whereas two experimental groups (A2 and B2) received rectally administered short‐chain fatty‐acids. The A groups were prophylactically treated (5th to 40th days postoperatively), whereas the B groups were therapeutically treated (after post‐operative day 40). The mucosal thickness of the excluded colon was measured histologically. The inflammatory reaction of the mucosal lamina propria and the lymphoid tissue response were quantified through established scores. RESULTS: There was a significant thickness recovery of the colonic mucosa in group B2 animals (p  =  0.0001), which also exhibited a significant reduction in the number of eosinophilic polymorphonuclear cells in the lamina propria (p  =  0.0126) and in the intestinal lumen (p  =  0.0256). Group A2 showed no mucosal thickness recovery and significant increases in the numbers of lymphocytes (p  =  0.0006) and eosinophilic polymorphonuclear cells in the lamina propria of the mucosa (p  =  0.0022). CONCLUSION: Therapeutic use of short‐chain fatty‐acids significantly reduced eosinophilic polymorphonuclear cell numbers in the intestinal wall and in the colonic lumen; it also reversed the atrophy of the colonic mucosa. Prophylactic use did not impede the development of mucosal atrophy.

Absence of peritumoral fibrosis or inflammatory infiltrate may be related to clinical progression of papillary thyroid microcarcinoma.

Rio Grande do Norte (RN) shows the highest relative incidence of papillary carcinomas in Brazil. To analyze histological features that might be associated with this incidence, the authors compared thyroid glands from 463 autopsies performed in RN with 427 surgical and autopsy glands previously studied in Sao Paulo (SP). The authors found 41 papillary thyroid microcarcinomas (PTMs) in 35 glands (8.1%), an incidence similar to the one reported in SP (7.8%). However, PTMs were predominantly nonencapsulated nonsclerosing at microscopy (44.0%), in contrast with SP where these types of lesion represented only 4 out of 32 PTMs (12.5%; P = .0046). The authors suggest that these nonencapsulated lesions with no sign of inflammation may represent an early stage that may evolve to clinical cancers, contributing to the high incidence of clinically differentiated thyroid carcinomas observed in RN.

Liver iron overload induced by tamoxifen in diabetic and non-diabetic female Wistar rats

Tamoxifen (TX), a drug used in the treatment of breast cancer, may cause hepatic changes in some patients. The consequences of its use on the liver tissues of rats with or without diabetes mellitus (DM) have not been fully explored. The purpose of this study was to evaluate the correlation between plasma hepatic enzyme levels and the presence of iron overload in the hepatic tissue of female Wistar rats with or without streptozotocin-induced DM and using TX. Female rats were studied in control groups: C-0 (non-drug users), C-V (sorbitol vehicle only) and C-TX (using TX). DM (diabetic non-drug users) and DM-TX (diabetics using TX) were the test groups. Sixty days after induced DM, blood samples were collected for glucose, alanine aminotransferase (ALT), aspartate aminotransferase (AST) alkaline phosphatase (ALP) and bilirubin measures. Hepatic fragments were processed and stained with hematoxylin and eosin, Masson’s trichrome, Perls. The hepatic iron content was quantified by atomic absorption spectrometry. AST, ALT and ALP levels were significantly elevated in the DM and DM-TX groups, with unchanged bilirubin levels. Liver iron overload using Perls stain and atomic absorption spectrometry were observed exclusively in groups C-TX and DM-TX. There was positive correlation between AST, ALT and ALP levels and microscopic hepatic siderosis intensity in group DM-TX. In conclusion, TX administration is associated with liver siderosis in diabetic and non-diabetic rats. In addition, TX induced liver iron overload with unaltered hepatic function in non-diabetic rats and may be a useful tool for investigating the biological control of iron metabolism.