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

The effects of a quality improvement project to reduce caesarean sections in selected private hospitals in Brazil

BACKGROUND

Brazil is one of the countries with the highest rates of caesarean sections (CS), reaching almost 90% of births in the private sector. A quality improvement project called "Adequate Childbirth Project (PPA)" was conceived to reduce CS in the private sector. This project consisted of four primary components: "Governance", "Participation of Women", "Reorganization of Care" and "Monitoring". This paper aims to evaluate: (1) which specific activities of the PPA had the largest effect on the probability of a woman having a vaginal delivery; (2) which primary component of the PPA had the largest effect on the probability of vaginal delivery and (3) which scenarios combining the implementation of different activities planned in the PPA had a higher effect on the probability of vaginal delivery.

METHODS

A sample of 12 private hospitals participating in the PPA was evaluated. We used a Bayesian Network (BN) to capture both non-linearities and complex cause-effect relations. The BN integrated knowledge from experts and data from women to estimate 26 model parameters. The PPA was evaluated in 2473 women belonging to groups 1-4 of the Robson classification, who were divided into two groups: those participating or not participating in the PPA.

RESULTS

The probability of a woman having a vaginal delivery was 37.7% higher in women participating in the PPA. The most important component of the project that led to an increase in the probability of vaginal delivery was "Reorganization of Care", leading to a 73% probability of vaginal delivery among women in labor. The activity that had the greatest effect on the type of delivery was access to best practices during labor, with a 72% probability of vaginal delivery. Considering the 12 scenarios combining the different activities of the PPA, the best scenarios included: a non-scheduled delivery, access to information about best practices, access to at least 4 best practices during labor and respect of the birth plan, with an 80% probability of vaginal delivery in the best combinations.

CONCLUSION

PPA has been shown to be an effective quality improvement program, increasing the likelihood of vaginal delivery in private Brazilian hospitals.

An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals

BACKGROUND

Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil.

METHOD

Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model".

RESULTS

PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA.

CONCLUSION

The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.

Women's preference for a vaginal birth in Brazilian private hospitals: effects of a quality improvement project

BACKGROUND

In 2015, a quality improvement project called "Adequate Childbirth Project" (PPA) was implemented in Brazilian private hospitals in order to reduce cesarean sections without clinical indication. The PPA is structured in four components, one of which is directed at women and families. The objective of this study is to evaluate the effects of PPA on women's preference for vaginal birth (VB) at the end of pregnancy.

METHODS

Evaluative research conducted in 12 private hospitals participating in the PPA. Interviews were carried out in the immediate postpartum period and medical record data were collected at hospital discharge. The implementation of PPA activities and women's preference for type of birth at the beginning and end of pregnancy were compared in women assisted in the PPA model of care and in the standard of care model, using a chi-square statistical test. To estimate the effect of PPA on women's preference for VB at the end of pregnancy, multiple logistic regression was performed with selection of variables using a causal diagram.

RESULTS

Four thousand seven hundred ninety-eight women were interviewed. The implementation of the planned activities of PPA was less than 50%, but were significantly more frequent among women assisted in the PPA model of care. Women in this group also showed a greater preference for VB at the beginning and end of pregnancy. The PPA showed an association with greater preference for VB at the end of pregnancy in primiparous (OR 2.54 95% CI 1.99-3.24) and multiparous women (OR 1.44 95% CI 0.97-2.12), although in multiparous this association was not significant. The main factor associated with the preference for VB at the end of pregnancy was the preference for this type of birth at the beginning of pregnancy, both in primiparous (OR 18.67 95% CI 14.22-24.50) and in multiparous women (OR 53.11 95% CI 37.31-75.60).

CONCLUSIONS

The PPA had a positive effect on women's preference for VB at the end of pregnancy. It is plausible that more intense effects are observed with the expansion of the implementation of the planned activities. Special attention should be given to information on the benefits of VB in early pregnancy.

Achievement of appropriate cesarean rates using Robson's 10-Group classification system in Brazilian private practice

BACKGROUND

Increasing cesarean section (CS) rates are a global concern because they are related to higher maternal and neonatal complication rates and do not provide positive childbirth experiences. In 2019, Brazil ranked second globally, given its overall CS rate of 57%. According to the World Health Organization (WHO), populational CS rates of 10-15% are associated with decreased maternal, neonatal, and infant mortality rates. This study aimed to investigate whether multidisciplinary care following evidence-based protocols associated with a high motivation of both women and professionals for a vaginal birth leads to less overuse of CS in a Brazilian private practice (PP).

METHODS

This cross-sectional study evaluated CS rates by Robson group for women who sought vaginal birth in a private practice in Brazil comparing with Swedish data. Collaborative care of midwives and obstetricians who adopted evidence-based guidelines was offered. CS rates, overall and by Robson group, contribution of each Robson group to the overall CS rate, clinical and nonclinical interventions, vaginal birth, pre-labor CS, and intrapartum CS proportions were estimated. The expected CS rate was calculated using the World Health Organization C-model tool. The analysis used Microsoft Excel and R Studio (version 1.2.1335. 2009-2019).

RESULTS

The PP overall CS rate was 15.1% (95%CI, 13.4-17.1%) versus the 19.8% (95%CI, 14.8-24.7%) rate expected by the WHO C-model tool. The population included 43.7% women in Robson Group 1 (nulliparous, single, cephalic, at term, spontaneous labor), 11.4% in Group 2 (nulliparous, single, cephalic, at term, induced labor or CS before labor), and 14.9% in Group 5 (multiparous women with previous CS), the greatest contributors to higher CS rates (75.4% of them). The Swedish overall CS rate was 17.9% (95%CI, 17.6-18.1%) in a population of 27% women in Robson Group 1, 10.7% in Group 2, and 9.2% in Group 5.

CONCLUSIONS

Multidisciplinary care following evidence-based protocols, associated with high motivation of both women and professionals for vaginal birth, may lead to a significant and safe reduction of CS rates even in contexts such as Brazil, with high medicalization of obstetric care and excess CS.

Evaluation of labor and childbirth care by nurse-midwives in Brazilian private hospitals: results of a quality improvement project

BACKGROUND

In 2015, a quality improvement project-the "Adequate Childbirth Project" (Projeto Parto Adequado, or PPA)-was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals.

METHODS

Cross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test.

RESULTS

4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including "oral fluid and food", "maternal mobility and position", "monitoring of labor", "use of non-pharmacological methods for pain relief" and "epidural analgesia for pain relief" in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors.

CONCLUSIONS

There was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges.

Breastfeeding in the first hour of life in Brazilian private hospitals participating in a quality-of-care improvement project

BACKGROUND

The Baby-Friendly Hospital Initiative's Step 4 recommends: "support mothers to start breastfeeding as soon as possible after birth", thus contributing to the reduction of neonatal mortality. The objective of this study is to estimate the prevalence of breastfeeding in the first hour of life in private maternity hospitals participating in the "Adequate Childbirth Project", a quality-of-care improvement project, and to analyze determinants of this outcome.

METHODS

Secondary analysis of data collected by the cross-sectional evaluative "Healthy Birth Study", conducted in 2017 in 12 maternity hospitals participating in the Adequate Childbirth Project, where 4800 mothers were interviewed, and hospital records were observed. Conditions that prevented breastfeeding at birth, such as maternal HIV-infection and newborns' severe malformations, were excluded. Multiple logistic regression was performed according to a hierarchical theoretical model.

RESULTS

The prevalence of breastfeeding in the first hour of life was 58% (CI 95% 56.6-59.5%). Lower maternal education (aOR 0.643; CI 95% 0.528-0.782), lower economic status (aOR 0.687; CI 95% 0.504-0.935), cesarean section delivery (ORa 0.649; CI 95% 0.529-0.797), preterm birth (aOR 0.660; CI 95% 0.460-0.948) and non-rooming-in at birth (aOR 0.669; CI 95% 0.559-0.800) were negatively associated with the outcome. Receiving information during prenatal care about the importance of breastfeeding at birth (aOR 2.585; CI 95% 2.102-3.179), being target of the quality-of-care improvement project (aOR 1.273; CI 95% 1.065-1.522), skin-to-skin contact at birth (aOR 2.127; CI 95% 1.791-2.525) and female newborn (aOR 1.194; CI 95% 1.008-1.415) were factors positively associated with the outcome.

CONCLUSIONS

The private maternities participating in the Healthy Birth Study showed a good prevalence of breastfeeding in the first hour of life, according to WHO parameters. Prenatal guidance on breastfeeding at birth, being target of the quality-of-care improvement project and skin-to-skin contact at birth contributed to breastfeeding in the first hour of life.

Cesarean sections and social inequalities in 305 cities of Latin America

Background

Cesarean section (CS) is a surgical procedure that, when medically justified, can help reduce maternal and infant morbidity and mortality. Worldwide CS rates (CSR) have been increasing; Latin America has rates that are among the highest in the world.

Aim

Describe the variability of CSR across cities in Brazil, Colombia, Guatemala, Mexico, and Peru and examine the relationship of individual-level, sub-city, and city-level socioeconomic status (SES) with CSR.

Methods

We used individual level data from vital statistics over the period 2014-2016 (delivery method, mother's age and education), census data to characterize sub-city SES and city GDP per capita from other sources compiled by the SALURBAL project. We fitted multilevel negative binomial regression models to estimate associations of SES with CSR.

Results

11,549,028 live births from 1,101 sub-city units in 305 cities of five countries were included. Overall, the CSR was 52%, with a wide range across sub-cities (13-91%). Of the total variability in sub-city CSRs, 67% was within countries. In fully adjusted model higher CSR was associated with higher maternal education [(PRR (CI95%) 0.81 (0.80-0.82) for lower educational level, 1.32 (1.31-1.33) for higher level (ref. medium category)], with higher maternal age [PRR (CI95%) 1.23 (1.22-1.24) for ages 20-34 years, and 1.48 (1.47-1.49) for ages ≥ 35 years (ref. ≤19 years], higher sub-city SES [(PRR (CI95%) 1.02 (1.01-1.03) per 1SD)], and higher city GDP per capita [(PRR (CI95%): 1.03 (1.00-1.07) for GDP between 10,500-18,000, and 1.09 (1.06-1.13) for GDP 18,000 or more (ref. <10,500)].

Conclusion

We found large variability in CSR across cities highlighting the potential role of local policies on CSR levels. Variability was associated in part with maternal and area education and GDP. Further research is needed to understand the reasons for this pattern and any policy implications it may have.

Indicações de cesárea nas gestantes classificadas como Robson 1

Objetivos: os objetivos foram identificar as indicações mais prevalentes de cesárea em parturientes Robson 1, comparando variáveis maternas, antecedentes obstétricos e resultados perinatais.Métodos: estudo analítico observacional transversal, onde avaliou-se o Livro de Partos e prontuários eletrônicos das gestantes em trabalho de parto, classificadas como Robson 1. As variáveis quantitativas foram comparadas utilizando-se Teste T de Student ou Mann Whitney, às qualitativas foi empregado teste Qui-quadrado ou Exato de Fisher.Resultados: elegíveis 2267 gestantes, sendo 570 (25,1%) cesáreas. As indicações mais prevalentes de cesariana foram: sofrimento fetal, em 213 (37,4%) dos casos, e desproporção cefalopélvica, em 212 (37,2%). As variáveis relevantes para o desfecho do parto foram: idade materna (razão de chance 1,0), idade gestacional (1,4), índice de massa corpórea pré-gestacional (1,6 em sobrepeso e 1,8 em obesidade) e presença de síndrome hipertensiva (aumentou 3,6).Conclusão: conclui-se que algumas características maternas e obstétricas afetam diretamente a indicação de cesariana.

Strategies to reduce the caesarean section rate in a private hospital and their impact

There is a concern around the world of an increasing caesarean section rate. It was estimated that between 2010 and 2015, caesarean section rates increased by almost 50%. There are several implications for this, considering that caesarean sections are associated with higher costs and worse clinical outcomes. In this context, several interventions have been considered to increase vaginal delivery rates, including the Adequate Childbirth Project (PPA) in Brazil. This study aimed to verify the impact of the strategies adopted internally in the Hospital Israelita Albert Einstein (HIAE) located in São Paulo, Brazil, regarding the reduction of caesarean sections and their perinatal results. Actions to support our study were implemented in two phases based on the PPA schedule. These actions involved three axes: a multidisciplinary team, pregnant women and facility improvements. All pregnant women admitted for childbirth at the HIAE between 2014 and 2019 were included in this study. The overall rate of vaginal delivery in this study population and among primiparous women and the percentage of admissions to the neonatal intensive care unit (NICU) were analysed in three periods: before the implementation of PPA actions (period A), after the first phase of the project (period B) and after its second phase (period C). The results showed an increase in the average vaginal delivery rate from 23.57% in period A to 27.88% in period B, and to 30.06% in period C (AxB, p<0.001; BxC, p=0.004). There was a decrease in the average of NICU admissions over the periods (period A 19.22%, period B 18.71% and period C 13.22%); a significant reduction was observed when periods B and C (p<0.001) were compared.

Repeated cesarean section and vaginal delivery after cesarean section in São Paulo State in 2012

Abstract Objectives: describe mothers, pregnancies and newborns’ characteristics according to the type of childbirth history and to analyze repeated cesarean section (RCS) and vaginal delivery after cesarean section (VBACS), in São Paulo State in 2012. Methods: data are from the Sistema de Informações sobre Nascidos Vivos (Live Birth Information Systems). To find the RCS’s group, the current type of childbirth equal to cesarean section was selected and from these all the previous cesareans. To identify the VBACS’s group all live birth with current vaginal delivery were selected and from these all previous cesareans. Mothers with a history of RCS and VBACS were analyzed according to the characteristics of the pregnancy, newborn and the childbirth hospital. Results: 273,329 mothers of live birth with at least one previous child were studied. 43% of these were born of RCS and 7.4% of VBACS. Mothers who underwent RCS are older and higher educated and their newborns presented a lower incidence of low birth weight. Early term was the most frequent rating for gestational age born of RCS. Live births were of VBACS and had greater proportions of late term. The RCS was more common in hospitals not affiliated with the Sistema Único de Saúde (SUS) (Public Health System) (44.1%). Conclusion: the high RCS’s rates, especially in the private sector, highlight the necessity of improvements in childbirth care model in São Paulo.

Cost-effectiveness analysis of a quality improvement program to reduce caesarean sections in Brazilian private hospitals: a case study

Background

In 2015, a quality improvement project of childbirth care called Adequate Childbirth Project (“Projeto Parto Adequado”- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce caesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital—the model following the recommendations of the PPA and the standard of care model—in reducing the proportion of caesarean sections.

Methods

We conducted a cost-effectiveness analysis using data from one of the private hospitals included in the PPA project. The main outcome was the proportion of caesarean section. We used total cost of hospitalization for women and newborns, from the health care sector perspective, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of caesarean section and of maternal and neonatal complications.

Results

238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the caesarean section probability (88.6% vs 31.7%, p < 0.001) with an incremental cost-effectiveness ratio of US$1,237.40 per avoided caesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal near miss. The cost of uncomplicated vaginal births and caesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care.

Conclusion

The PPA model of care was cost-effective in reducing caesarean sections in women assisted in a Brazilian private hospital. Moreover, it reduced the frequency of early term births and did not increase the occurrence of severe negative maternal and neonatal outcomes.

Caesarean section is a safe intervention to save the lives of women and newborns. However, it is associated with negative health consequences for women and children in the short, medium and long term. Therefore, its harmful effects can outweigh its benefits when used excessively. Caesarean rates are increasing globally. In Brazil, caesarean section is the most frequent type of birth since 2009.

In 2015, a quality improvement project, called “Adequate Childbirth Project” (PPA), was implemented in Brazilian public and private hospitals with the aim of improving the quality of childbirth care and reducing caesarean sections without clinical indications.

In this study, we compared the caesarean rate and the hospitalization costs of women assisted in this new model of care and in the standard of care model. The women attended in the PPA model of care had a lower rate of caesarean section (31.7% vs 88.6% in the standard of care model), with no differences in severe negative maternal and neonatal outcomes. Women in the PPA model of care also had a higher frequency of spontaneous or induced labor and a lower frequency of early term births, that is, less than 39 weeks of gestation. The PPA model of care was considered cost-effective, that is, it produced good results for the amount of money spent. This is a promising result for services that face the problem of increasing numbers of caesarean sections and are looking for strategies to improve the quality of childbirth care.

Effects of elective cesarean sections on perinatal outcomes and care practices

Abstract Objectives: to verify the effects of elective cesarean sections on perinatal outcomes and care practices, as compared to vaginal deliveries. Methods: cohort study with 591 mothers and their babies, developed in a medium-sized city in the state of São Paulo, Brazil. Data were collected from hospital records and by interviews at the neonatal screening unit in the city from July 2015 to February 2016. Data regarding childbirth, newborns, sociodemography, and current gestational history were obtained from each mother. The associations of interest were evaluated with Cox regression analyses adjusted for the covariates identified through the results of bivariate analyses presenting a statistical significance level ofp<0.20. In adjusted analyzes, relationships were considered significant ifp<0.05, with relative risk being considered as the measure of effect. Results: if compared to women who had vaginal deliveries, those who were submitted to elective cesarean sections were at a higher risk of not having skin-to-skin contact with their babies in the delivery room, of not breastfeeding in the first hour of life, and of having their babies hospitalized in a neonatal unit. Conclusions: reducing the number of elective cesarean sections is essential to foster good neonatal care practices and reduce negative neonatal outcomes.

Reducing caesarean rates in a public maternity hospital by implementing a plan of action: a quality improvement report

BACKGROUND

Caesarean rates increased in different parts of the world, rising from 20% to 33% in the USA and from 40% to 55% in Brazil between 1996 and 2011; however, there was no reduction in morbimortality rates. Several factors have been suggested as responsible for this increase, such as health judicialisation, fear of the painful process on the patients' part and reduction of medical training in vaginal delivery and labour complications. It is urgent to reverse this process and, therefore, a model of actions was created with the intention of engaging the team in order to reduce caesarean rates in a Brazilian hospital.

METHODOLOGY

The model was based on the following actions: encouragement of labour analgesia; execution of written reports of any cardiotocographic examination; plan-do-study-act cycles for nursing orientations about the positions that favour pregnant women during labour; creation of a birth induction form; monthly feedback with physicians and nurses on caesarean rates achieved; verification of the caesarean rate by medical staff with individual feedback; daily round of medical coordination for case discussions; disclosure of caesarean rates on hospital posters; and constant dissemination of literature with strategies to reduce caesarean delivery. This plan of action started in January 2016. The mean caesarean section rate in the 31 months preceding the interventions (period A) was then compared with the 31 subsequent months (period B).

RESULTS

Both periods presented caesarean rates with normal distribution. The mean caesarean rate was 29.24% (range: 38.69%-23.89%, SD 3.24%) vs 25.84% (range: 17.96%-34.97%, SD 3.92%, p<0.05), respectively, for periods A and B.

CONCLUSION

After the implementation of the plan of action, there was a reduction in caesarean rates in this hospital.

Atuação dos hospitais de pequeno porte de pequenos municípios nas redes de atenção à saúde

Resumo O objetivo deste artigo é compreender os valores sociais e a atuação e inserção dos hospitais de pequeno porte em municípios pequenos nas redes de atenção à saúde. Realizou-se estudo de natureza qualitativa, entrevistando os secretários de saúde e diretores dos hospitais de pequeno porte localizados em 14 municípios de até 20 mil habitantes do estado do Paraná, tendo como referencial teórico conceitos bourdieusianos de capital simbólico, habitus e campo. Verificou-se que há o discurso pela manutenção destes hospitais, ainda que não respondam de forma resolutiva às demandas da população, pois o seu fechamento causaria um impacto negativo para a legitimação do gestor em exercício. Os hospitais de pequeno porte participam da rede de urgência, mesmo que não resolvam muitos dos problemas demandados. Entretanto, ao fazer parte do complexo regulador, seus usuários podem ser encaminhados para hospitais de maior porte. Quanto à Rede Mãe Paranaense, a maioria dos hospitais de pequeno porte atuam como encaminhadores de gestantes para hospitais/maternidades de referência, embora o desejo da população local seja que a atenção às parturientes ocorra nos municípios de residência. Conclui-se que a organização destes hospitais e sua inserção nas redes de atenção ainda é incipiente.

[Obstetric care models in the Southern Region of Brazil and associated factors]

The study sought to identify obstetric care models for low-risk pregnancies in the Southern Region of Brazil and to estimate factors associated with these models and maternal and neonatal outcomes. This is a cross-sectional, hospital-based study using data from the Birth in Brazil survey regarding puerperae and newborns. We identified 2,668 low-risk pregnant women. We carried out an exploratory analysis using the proportion of practices per hospital, among them inducing labor, presence of a companion, cesarean section and skin-to-skin contact, in order to obtain the care models we called Best Practice, Interventionist I and Interventionist II. We then carried out an inferential analysis of the associated characteristics. Results show that access to public or private funding, cultural factors and actions taken by health professional are associated with the care models. Public care had different contexts, one based on public policies and evidence-based practices; and another, that suggests the intentionality of vaginal delivery without considering humanization principles. Private care, on the other hand, is standardized and centered on the medical professional, with higher intervention levels. We conclude there is a predominance of interventionist obstetric care models in the Southern Region of Brazil, a type of care that goes against the best evidence, and that women who receive care in public hospitals have greater chances of benefiting from good practices.

Performance of resident nurses in obstetrics on childbirth care

Abstract Objectives: to describe good practices on childbirth care and obstetric interventions performed by resident nurses in obstetrics during the obstetric childbirth risk at a public maternity hospital in Salvador. Methods: a descriptive cross-sectional study with a quantitative approach, based on the of 102 parturients, between February and April 2016. The data collection was performed through the collection of information on clinical files for analysis by using descriptive statistics with absolute and relative frequencies for the evaluated categorical variables. Results: it was observed that 100.0% of the women used some kind of non-pharmacological method for pain relief, although the method of choice was to take a hot bath; 99.0% of the women drank liquids; 94.0% had the presence of a companion of free choice; 99.0% walked during labor; 100.0% had the freedom to choose a position during childbirth. It is noteworthy that no woman in this study was submitted to episiotomy, and more than 70.0% were not submitted to any obstetric intervention. Conclusions: the Programa de Residência em Enfermagem (Residency Nursing Program) an important point in the childbirth humanization process is directly associated to the increase in the normal childbirth rates, the highest use on good practices in childbirth care, and the reduction on obstetric interventions.

Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos

Resumo: Este artigo tem como objetivo descrever os primeiros resultados de dois estudos avaliativos, um sobre a Rede Cegonha e outro sobre o projeto Parto Adequado, denominados, respectivamente, de avaliação da Rede Cegonha e Nascer Saudável, e identificar possíveis melhorias em comparação ao estudo Nascer no Brasil. Ambos os estudos têm desenho seccional, realizados em 2017. O estudo avaliação da Rede Cegonha incluiu todas as 606 maternidades públicas e mistas envolvidas na Rede Cegonha e um total de 10.675 puérperas. O estudo Nascer Saudável incluiu uma amostra de conveniência de 12 hospitais da rede privada e um total de 4.798 mulheres. Os indicadores de atenção ao parto e nascimento avaliados foram: presença de acompanhante, atendimento por enfermeira obstétrica, preenchimento de partograma, uso de métodos não farmacológicos, deambulação, alimentação, uso de cateter venoso periférico, analgesia, posição da mulher para o parto, episiotomia e manobra de Kristeler. Esses indicadores foram comparados aos encontrados no Nascer no Brasil, estudo de base nacional realizado em 2011-2012, antes do início dos dois programas de intervenção. Para as comparações utilizamos o teste do qui-quadrado para amostras independentes e nível de 95% de confiança. Houve um aumento significativo do número de mulheres com acesso à tecnologia apropriada ao parto entre os anos de 2011 e 2017 e redução de práticas consideradas prejudiciais. No setor privado, observou-se também redução nas taxas de cesariana e aumento da idade gestacional ao nascer. Os resultados deste estudo mostram que políticas públicas bem conduzidas podem mudar o cenário da atenção ao parto e nascimento, promovendo a redução de desfechos maternos e neonatais negativos.

Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol

Background

In Brazilian private hospitals, caesarean section (CS) is almost universal (88%) and is integrated into the model of birth care. A quality improvement intervention, “Adequate Birth” (PPA), based on four driving components (governance, participation of women and families, reorganisation of care, and monitoring), has been implemented to help 23 hospitals reduce their CS rate. This is a protocol designed to evaluate the implementation of PPA and its effectiveness at reducing CS as a primary outcome of birth care.

Methods

Case study of PPA intervention conducted in 2017/2018. We integrated quantitative and qualitative methods into data collection and analysis. For the quantitative stage, we selected a convenient sample of twelve hospitals. In each of these hospitals, we included 400 women. This resulted in a total sample of 4800 women. We used this sample to detect a 2.5% reduction in CS rate. We interviewed managers and puerperal women, and extracted data from hospital records. In the qualitative stage, we evaluated a subsample of eight hospitals by means of systematic observation and semi-structured interviews with managers, health professionals and women. We used specific forms for each of the four PPA driving components. Forms for managers and professionals addressed the decision-making process, implemented strategies, participatory process in strategy design, and healthcare practice. Forms for women and neonatal care addressed socio-economic, demographic and health condition; prenatal and birth care; tour of the hospital before delivery; labour expectation vs. real experience; and satisfaction with care received. We will estimate the degree of implementation of PPA strategies related to two of the four driving components: “participation of women and families” and “reorganisation of care”. We will then assess its effect on CS rate and secondary outcomes for each of the twelve selected hospitals, and for the total sample. To allow for clinical, socio-demographic and obstetric characteristics in women, we will conduct multivariate analysis. Additionally, we will evaluate the influence of internal context variables (the PPA driving components “governance” and “monitoring”) on the degree of implementation of the components “participation of women and families” and “reorganisation of care”, by means of thematic content analysis. This analysis will include both quantitative and qualitative data.

Discussion

The effectiveness of quality improvement interventions that reduce CS rates requires examination. This study will identify strategies that could promote healthier births.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0636-y) contains supplementary material, which is available to authorized users.

Fatores de Risco e Proteção Associados à Depressão Pós-Parto no Pré-Natal Psicológico

Resumo: Esta investigação teve por objetivos gerais: a) identificar fatores de risco e de proteção associados à Depressão Pós-Parto (DPP); e b) avaliar a contribuição do Pré-Natal Psicológico (PNP) como programa de prevenção em Saúde da Mulher. Para tanto, empreendeu-se uma pesquisa-ação organizada em três fases, reunindo um total de 198 gestantes. Na última fase, as participantes foram distribuídas em Grupo Intervenção – GI (n = 47) e Grupo Controle – GC (n = 29). Para coleta de dados, utilizaram-se: Questionário Gestacional, BAI, BDI-II e EPDS. Os dados foram submetidos a análises estatísticas descritivas e comparativas. Não foi possível relacionar variáveis socioeconômicas, participação no PNP e desejo de gravidez com maior risco de DPP. Em contrapartida, verificou-se tal associação quanto a gravidez não planejada e a falta de apoio do pai do bebê. Contrariamente ao GC, não se constatou associação entre ansiedade e depressão gestacionais com a DPP no GI. Nesse grupo, 10,64% das puérperas revelaram tendência para DPP, ao passo que, em GC, 44,83% mostraram tal propensão. Em suma, considera-se que o PNP, somado a fatores de proteção, constitui ação preventiva a ser desenvolvida pelo profissional de Psicologia no contexto do acompanhamento pré e pós-natal.

[The impact of the type of hospital and delivery on the gestational age in São Paulo city, 2013-2014]

Introduction:

There was a left-shift on the distribution curve of gestational age (GA) and a reduction of the proportion of live births of 40 weeks, when compared to the expected standard in many countries.

Objective:

To study the distribution of gestational age births in São Paulo city (SP) and its relationship with the type of hospital and delivery.

Methods:

Data were extracted from Live Birth Information System (SINASC) linked to the National Database of Health Establishments (CNES) in 2013 and 2014. Data are presented according to birth in public (SUS) and private (non SUS) hospitals, type of delivery and gestational age, standardized according to the mother's age.

Results:

There was a left-shift in GA curve for total births which was more pronounced among cesarean births and private hospitals. The median GA of public hospitals was 39 weeks, while in the private hospitals, 38 weeks. The proportion of preterm births (9,5%) was similar in public and private hospitals, but among public hospital there was a higher proportion of very preterm births (<32 weeks), while (34-36) in private hospitals late preterm and early term were more frequent.

Conclusions:

The change in the distribution of gestational age in SP is related to the type of hospital and the proportion of cesarean sections in private hospitals.

Association between institutional factors, birth care profile, and cesarean section rates in Santa Catarina

Objectives:

To investigate how institutional factors, represented by the social profile of childbirth care, can relate to cesarean section rates.

Methods:

A cross-sectional study based on data from Sistema de Informações sobre Nascidos Vivos (SINASC) for the state of Santa Catarina collected information for each of the six municipalities with the largest number of births from the six macroregional areas. For those municipalities, all of the establishments that had obstetric facilities were considered. A total of 61.278 births took place over 61 selected maternity services. Cesarean prevalence ratios (PR), both crude and adjusted for confounders, were estimated for each one of the individual variables using robust Cox regression.

Results:

Cesarean births were almost as twice as high in private maternity facilities (89%) when compared to the public ones (45.1%). Giving birth in private hospitals increased by at least 50% the prevalence of caesarean section among primiparae (PR = 1.64), Caucasian (PR = 1.57), women with greater attendance to prenatal care (PR = 1.54), and women having daylight birth (PR = 1.5), when compared with those delivering inside the public sector.

Conclusion:

Differences in cesarean rates in favor of the private system, among women with better social conditions, amongst which it would be expected a lower obstetric risk, have pointed toward differences in obstetric/medical culture permeability and flexibility on medical judgment concerning clinical criteria for cesarean sections.

[Late maternal mortality: comparison of maternal mortality committees in Brazil]

This population-based study included all the late maternal deaths from the case series of the Maternal Mortality Committees in the city of São Paulo and the state of Paraná, Brazil. The study compared 134 deaths identified by the São Paulo committee and 124 from the Paraná committee in 2004-2013, aimed at demonstrating the magnitude and causes of late maternal mortality. Late maternal deaths accounted for 13.4% of all maternal deaths in the case series of the São Paulo committee and 12.1% in the cases series of the Paraná committee. Direct obstetric causes accounted for 32.1% of the late maternal deaths in São Paulo and 42.1% in Paraná, with postpartum cardiomyopathy as the principal cause in both case series. Death occurred between 43 and 69 days postpartum in 44% of the cases in São Paulo and 39.5% in Paraná. The correction factor for late maternal death was 3.3 in São Paulo and 4.3 in Paraná. Late maternal death had a relevant impact on overall maternal mortality, and postpartum cardiomyopathy was the principal cause of late direct obstetric death.

Determinants and materno-fetal outcomes related to cesarean section delivery in private and public hospitals in low- and middle-income countries: a systematic review and meta-analysis protocol

BACKGROUND

Despite the well-established morbidity, mortality, long-term effects, and unnecessary extra-cost burden associated with cesarean section delivery (CSD) worldwide, its rate has grown exponentially. This has become a great topical challenge for the international healthcare community and individual countries. Estimated at three times the acceptable rate as defined by the World Health Organization in 1985, the continued upward trend has been fuelled by higher income countries. Some low- and middle-income countries (LMICs) have now taken the lead, and the factors contributing to this situation are poorly understood. The expansion of the private healthcare sector may be playing a significant role. Distinguishing between the public and private hospitals' role is critical in this investigation as it has not yet been approached. This review aims to systematically synthesize knowledge on the determinants of the CSD rate rise in private and public hospitals in LMICs and to investigate materno-fetal and materno-infant outcomes of CSD in perinatal period, between private and public hospitals.

METHODS/DESIGN

We will include studies published in English, French, Spanish, and Portuguese since 2000, using any experimental design, including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, and interrupted time series. Outcomes of interest are the determinants of CSD and materno-fetal and materno-infant outcomes. We will only include studies carried out in private and public hospitals in LMICs. The literature searches will be conducted in the following databases: MEDLINE, Embase, CINAHL, Cochrane database, LILACS, and HINARI. We will also include unpublished studies in the gray literature (theses and technical reports). Using the two-person approach, two independent review authors will screen eligible articles, extract data, and assess risk of bias. Disagreements will be resolved through discussion with a third author. Results will be presented as structured summaries of the included studies. If possible, a meta-analysis will be conducted and, subsequently, an analysis for heterogeneity will be implemented.

DISCUSSION

The proposed systematic review of the CSD rate rise will provide up-to-date evidence in regard to differences in proportions, determinants, and materno-fetal and materno-infant outcomes in perinatal period, between private and public hospitals in LMICs. We believe that this knowledge synthesis will help to shed light on the evidence and support evidence-informed decision-making with a view to addressing the issue in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016036871.

Born in Brazil: shining a light for change

The Birth in Brazil study is the largest national hospital-based survey in Brazil regarding birth practices. Conducted in 2011–2012, it collected information from 266 public and private healthcare facilities and interviewed nearly 24,000 postpartum women. It is also the latest effort to map out how labor and delivery are managed in this county in the 21st century. The journal Reproductive Health has published a supplement including 10 articles presenting the results of a series of analyses using this valuable resource.

These articles describe a range of practices, determinants and risk factors that affect women and their babies in Brazil, a country of paradoxes. In the era of overmedicalization and high-tech medicine – arguably –, these articles highlight the unprecedented rates of cesarean sections in Brazil and differences between the public and the private sectors. It provides evidence for the need for adequate human resources, medications and emergency care equipment in many settings; and explains the use of non-evidence based interventions during labor and delivery. On the other hand, these studies also point to promising interventions that could be used to change this situation not only in Brazil but also in other countries facing similar challenges.

Labor and birth care by nurse with midwifery skills in Brazil

BACKGROUND

The participation of nurses and midwives in vaginal birth care is limited in Brazil, and there are no national data regarding their involvement. The goal was to describe the participation of nurses and nurse-midwives in childbirth care in Brazil in the years 2011 and 2012, and to analyze the association between hospitals with nurses and nurse-midwives in labor and birth care and the use of good practices, and their influence in the reduction of unnecessary interventions, including cesarean sections.

METHODS

Birth in Brazil is a national, population-based study consisting of 23,894 postpartum women, carried out in the period between February 2011 and October 2012, in 266 healthcare settings. The study included all vaginal births involving physicians or nurses/nurse-midwives. A logistic regression model was used to examine the association between the implementation of good practices and suitable interventions during labor and birth, and whether care was a physician or a nurse/nurse-midwife led care. We developed another model to assess the association between the use of obstetric interventions during labor and birth to the personnel responsible for the care of the patient, comparing hospitals with decisions revolving exclusively around a physician to those that also included nurses/nurse-midwives as responsible for vaginal births.

RESULTS

16.2 % of vaginal births were assisted by a nurse/nurse-midwife. Good practices were significantly more frequent in those births assisted by nurses/nurse-midwives (ad lib. diet, mobility during labor, non-pharmacological means of pain relief, and use of a partograph), while some interventions were less frequently used (anesthesia, lithotomy position, uterine fundal pressure and episiotomy). In maternity wards that included a nurse/nurse-midwife in labour and birth care, the incidence of cesarean section was lower.

CONCLUSIONS

The results of this study illustrate the potential benefit of collaborative work between physicians and nurses/nurse-midwives in labor and birth care. The adoption of good practices in managing labor and birth could be the first step toward more effective obstetric and midwifery care in Brazil. It may be easier to introduce new approaches rather than to eliminate old ones, which may explain why the reduction of unnecessary interventions during labor and birth was less pronounced than the adoption of new practices.

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.

Temporal evolution of the risk factors associated with low birth weight rates in Brazilian capitals (1996-2011)

Objective

To analyze the trend of low birth weight (LBW) and its determinants in Brazilian state capitals between 1996 and 2011. We intended to determine which variables are associated with LBW during the period studied.

Methods

This is a cross-sectional study that used data from the National Information System of Live Births from 26 state capitals and Brasilia (the federal capital), divided into five geographical regions. The Average Annual Percentage of Change (AAPC) was used to assess the possible time trend in the low birth weight rates for considering all regions together and each region separately, according to each variable, and the Poisson regression was calculated in order to demonstrate time trends in low birth weight and the impact of variables (age and educational maternal level, antenatal visits, type of delivery, and gestational age) during the period. All variables were analyzed together using the Poisson regression as well.

Results

From the total of 11,200,255 live births used in this study, there was a significant reduction in the number of live births, especially in the more developed regions. The low birth weight rate was 8 %, and it was stable during the period. Considering regional trends, the rate was higher in the Southeast and South regions, and significantly higher in the North, Northeast, and Central West regions. Improvements in maternal education and antenatal care coverage reduced the risk for low birth weight in all regions. Also, there was an increase in caesarean sections in all regions, with a small impact on low birth weight rates.

Conclusions

Improvements in education and health care reduced the risk for low birth weight in all Brazilian regions during the period of study. Trends in low birth weight rates and the associated factors differ from region to region, showing different stages of demographic, epidemiological and developmental transition in Brazil. The present study was approved by the Research Ethics Committee at the Hospital de Clínicas de Porto Alegre (Protocol 120323).