Maria Helena Bastos

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of womens views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen womens capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

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.

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.

Prenatal care in Brazil.

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.

Determinação da idade gestacional com base em informações do estudo Nascer no Brasil

O objetivo deste estudo foi verificar a validade de diferentes metodos de estimacao da idade gestacional e propor a criacao de um algoritmo para calculo da mesma para a pesquisa Nascer no Brasil – estudo realizado em 2011-2012, com 23.940 puerperas. Utilizou-se a ultrassonografia precoce, realizada entre 7-20 semanas de gestacao, como metodo de referencia. Todas as analises foram estratificadas segundo tipo de pagamento do parto (publico ou privado). Quando comparado a ultrassonografia precoce, foram encontrados coeficientes de correlacao intraclasse substanciais tanto para o metodo idade gestacional na admissao baseado em ultrassonografia (0,95 and 0,94) quanto para o metodo idade gestacional relatada pela puerpera na entrevista (0,90 and 0,88), para o pagamento do parto publico e privado, respectivamente. Medidas baseadas na data da ultima menstruacao apresentaram coeficientes de correlacao intraclasse menores. Este estudo sugere cautela ao se utilizar a data da ultima menstruacao como primeiro metodo de estimacao da idade gestacional no Brasil, fortalecendo o uso de informacoes oriundas de ultrassonografia precoce.This study aimed at assessing the validity of different measures for estimating gestational age and to propose the creation of an algorithm for gestational age at birth estimates for the Birth in Brazil survey--a study conducted in 2011-2012 with 23,940 postpartum women. We used early ultrasound imaging, performed between 7-20 weeks of gestation, as the reference method. All analyses were performed stratifying by payment of maternity care (public or private). When compared to early ultrasound imaging, we found a substantial intraclass correlation coefficient of ultrasound-based gestational age at admission measure (0.95 and 0.94) and of gestational age reported by postpartum women at interview measure (0.90 and 0.88) for the public and private payment of maternity care, respectively. Last menstrual period-based measures had lower intraclass correlation coefficients than the first two measures evaluated. This study suggests caution when using the last menstrual period as the first measure for estimating gestational age in Brazil, strengthening the use of information obtained from early ultrasound imaging results.

Empowering women in Brazil

Brazil is a middle-income country with a fertility rate of 2.1 children per woman and a health-care system that guarantees universal free access-the Sistema Unico de Saude (SUS). It has vibrant social organisations in which activists from the feminist movement have influenced the development and implementation of progressive national womens health policies. Hospital births account for 96% of all births (and more than 99% in urban areas). Despite increases in investment in health-care provision maternal mortality rates have remained high for more than a decade although capture of accurate mortality data remains a problem. According to the Brazilian Ministry of Health the maternal mortality ratio in 2002 was 75.3 per 100 000 livebirths which is considered by WHO to be in the high mortality band. The World Health statistics (2000) estimated a much higher ratio: 260 maternal deaths per 100 000 livebirths although this figure is contested in Brazil. Three-quarters of all deaths happened in thepostpartum period. If we consider ethnic differences data from 2002 showed that whereas the average maternal mortality ratio in Brazil was 49.3 per 100 000 for white women it was 240.4 for black women. The risk of dying from hypertensive disease in pregnancy was 8.2 times higher for black than for white women. Because the data did not include late maternal deaths (between 43 days and 1 year after childbirth) maternal mortality is likely to be greater. (excerpt)

Determining gestational age based on information from the Birth in Brazil study

O objetivo deste estudo foi verificar a validade de diferentes metodos de estimacao da idade gestacional e propor a criacao de um algoritmo para calculo da mesma para a pesquisa Nascer no Brasil – estudo realizado em 2011-2012, com 23.940 puerperas. Utilizou-se a ultrassonografia precoce, realizada entre 7-20 semanas de gestacao, como metodo de referencia. Todas as analises foram estratificadas segundo tipo de pagamento do parto (publico ou privado). Quando comparado a ultrassonografia precoce, foram encontrados coeficientes de correlacao intraclasse substanciais tanto para o metodo idade gestacional na admissao baseado em ultrassonografia (0,95 and 0,94) quanto para o metodo idade gestacional relatada pela puerpera na entrevista (0,90 and 0,88), para o pagamento do parto publico e privado, respectivamente. Medidas baseadas na data da ultima menstruacao apresentaram coeficientes de correlacao intraclasse menores. Este estudo sugere cautela ao se utilizar a data da ultima menstruacao como primeiro metodo de estimacao da idade gestacional no Brasil, fortalecendo o uso de informacoes oriundas de ultrassonografia precoce.This study aimed at assessing the validity of different measures for estimating gestational age and to propose the creation of an algorithm for gestational age at birth estimates for the Birth in Brazil survey--a study conducted in 2011-2012 with 23,940 postpartum women. We used early ultrasound imaging, performed between 7-20 weeks of gestation, as the reference method. All analyses were performed stratifying by payment of maternity care (public or private). When compared to early ultrasound imaging, we found a substantial intraclass correlation coefficient of ultrasound-based gestational age at admission measure (0.95 and 0.94) and of gestational age reported by postpartum women at interview measure (0.90 and 0.88) for the public and private payment of maternity care, respectively. Last menstrual period-based measures had lower intraclass correlation coefficients than the first two measures evaluated. This study suggests caution when using the last menstrual period as the first measure for estimating gestational age in Brazil, strengthening the use of information obtained from early ultrasound imaging results.

Unlocking the potential of effective care for life-long maternal and infant health: the need to adress the 'invisible' service after birth

1 Professor of Evidence Based Midwifery Practice, Florence Nightingale School of Nursing and Midwifery, Waterloo Bridge Wing, King’s College London. debra.bick@tvu.ac.uk 2 MD, MSc, Research Obstetrician, Division of Health and Social Care Research, King’s College, London. maria.bastos@kcl.ac.uk 3 Assistante Professor, Maternal and Child Health Department, School of Public Health, University of São Paulo, SP, Brazil. sidiniz@usp.br There is increasing recognition among women, academics, policy makers, service providers and clinicians of the need to increase the normal birth rate. The reasons include enhanced maternal and neonatal health outcomes and more cost effective use of finite health care resources. The drive to increase normal birth is to be applauded, although ironically, in many countries, including the UK and Latin America, the normal birth rate continues to decline. Clearly, there is a long way to go before normal birth (defined in the UK as birth with no intervention at all becomes a reality for many women. However the focus on normal birth may inadvertently detract key maternity service stakeholders from promoting what should be an effective continuum of care through pregnancy, birth and the postnatal period, with each phase of a womans pregnancy and birth journey not managed or resourced as a separate entity, and no phase of the journey taking precedence over another.

Intervenciones obstétricas durante el trabajo de parto y parto en mujeres brasileñas de bajo riesgo

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.