Práticas de atenção hospitalar ao recém-nascido saudável no Brasil

[Factors associated with breastfeeding at birth in maternity hospitals linked to the Rede Cegonha, Brazil, 2016-2017]

Breastfeeding (BF) is a human right, and it must start from birth. The adequacy of Rede Cegonha (RC) strategies can contribute to the promotion of BF. The objective was to identify factors associated with BF in the first and 24 hours of live births at full-term maternity hospitals linked to CR. Cross-sectional study with data from the second evaluation cycle 2016-2017 of the RC that covered all of Brazil. Odds ratios were obtained through binary logistic regression according to a hierarchical model, with 95% confidence intervals and p-value < 0.01. The prevalence of BF in the first hour was 31% and in the 24 hours 96.6%. The chances of BF in the first hour increased: presence of a companion during hospitalization, skin-to-skin contact, vaginal delivery, delivery assistance by a nurse and accreditation of the unit in the Baby-Friendly Hospital Initiative. Similar results at 24 hours, and association with maternal age below 20 years. BF in the first hour was less satisfactory than in the 24 hours, probably due to the high prevalence of cesarean sections, a factor associated with a lower chance of early BF. Continuous training of professionals about BF and the presence of an obstetric nurse during childbirth are recommended to expand BF in the first hour.

Implementation of strategies and programs for breastfeeding, complementary feeding, and malnutrition of young children in Brazil: advances and challenges

Malnutrition in all its forms has risen on global agendas due to the recognition of its magnitude and consequences for a wide range of human, social, and economic outcomes. Implementing strategies and programs with the needed scale and quality is a major challenge. The Brazilian National Survey on Child Nutrition (ENANI-2019) pointed out several advances but numerous challenges. In this paper, we reflect on the implementation progress of breastfeeding, complementary feeding and young children malnutrition strategies and programs in Brazil and how existing challenges can be overcome through the lens of implementation science. First, we present a brief history of such programs. Second, we selected two breastfeeding initiatives to illustrate and reflect on common implementation challenges. In these case studies, we used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to analyze the implementation and scaling up barriers and facilitators. We found common barriers related to unclear goals about the reach of programs, challenges in assessing effectiveness and fidelity/quality during the real-world implementation, discontinuation or lack of funding, and lack of monitoring and evaluation impacting the sustainability of programs. We also discuss the use of implementation science to achieve adequate nutrition by 2030 and present critical elements for successful scale implementation of nutrition programs based on global evidence. Despite the investment to implement different actions aimed at facing infant feeding and malnutrition, high-quality implementation research must become a priority to catalyze progress in Brazil.

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.

Obstetric interventions in a maternity hospital with a collaborative model of care: a comparative observational study

Collaborative models (CM) focused on intrapartum care shared between both midwives and obstetricians have been proposed as a strategy to reduce these rates. Our aim was to compare use of evidence-based practices, obstetric interventions and c-section rates in two settings: a maternity hospital that applies a CM of care (MRJ) and data from a pool of maternity hospitals included in the Birth in Brazil Survey (NB) that do not adopt a CM. Data was abstracted from medical and administrative records in MRJ and from medical records and face-to-face interviews in NB. Differences were compared using chi-square test, with significance level set at p<0.05. MRJ showed a higher frequency of labour companionship, labour care provided by nurse midwives, non-pharmacological pain relief methods, food intake during labour, and less use of oxytocin, analgesia and amniotomy. More women also had second stage assisted by a nurse midwife and in a vertical position, as well as lower use of episiotomies and vacuum-extractor/forceps. The c-section rate was lower at MRJ. Shared care between midwives and obstetricians can be an effective strategy to improve quality of intrapartum care.

Avaliação da organização e práticas de assistência ao parto e nascimento em três hospitais de Santa Catarina, Brasil

O objetivo foi avaliar a assistência hospitalar ao parto e ao nascimento, analisando aspectos de gestão e assistência desde a admissão das mulheres para o parto até o pós-parto. Foi realizada uma pesquisa avaliativa dos aspectos de gestão e práticas de assistência ao parto e nascimento, desenvolvida no período de novembro de 2019 a fevereiro de 2020, em três hospitais de Santa Catarina, Brasil, com melhor desempenho em uma avaliação nacional de boas práticas de assistência ao parto e ao nascimento. A coleta de dados envolveu análise documental, observação e entrevistas com profissionais da gestão, assistência e puérperas. Foram analisados 30 indicadores, que compuseram uma matriz de análise e julgamento, agrupados nas dimensões Político-Organizacional e Tático-Operacional. O julgamento orientou-se pela comparação entre a pontuação observada e a pontuação máxima esperada em cada um dos componentes da matriz avaliativa. A assistência ao parto e ao nascimento foi parcialmente satisfatória nos hospitais 2 e 3 e insatisfatória no hospital 1. A dimensão Político-Organizacional foi classificada como insatisfatória e a Tático-Operacional parcialmente satisfatória nos três hospitais. Nenhum hospital obteve avaliação satisfatória em mais de 40% dos indicadores. Os hospitais analisados ainda não conseguiram consolidar as mudanças no modelo assistencial na perspectiva do cuidado humanizado, orientado por evidências científicas e direitos.

SKIN-TO-SKIN CONTACT AND BREASTFEEDING AT CHILDBIRTH: WOMEN'S DESIRES, EXPECTATIONS, AND EXPERIENCES

Objective:

To analyze women’s desires, expectations and experiences regarding skin-to-skin contact and breastfeeding in the first hour of life of their newborns.

Methods:

Qualitative research carried out in a teaching hospital in the Northeast Region of Brazil. The patients were followed longitudinally during prenatal care, at birth and during the puerperium. The participants were pregnant women during normal risk prenatal care, aged over 18 years old. Structured and semi-structured interviews were carried out in the prenatal period, participant observation at the time of delivery and new interviews in the puerperium. Content analysis was applied in the thematic modality.

Results:

18 women between 21 and 38 years old were enrolled in the research. Women expressed the desire for skin-to-skin contact and breastfeeding as immediate practices right after delivery and birth. However, many women did not believe it was possible, and the performance of routine procedures was considered the main obstacle. These expectations that skin-to-skin contact and early breastfeeding would not be carried out were confirmed in the experiences immediately after birth.

Conclusions:

The expectations and experiences brought by these women suggest a flaw that starts in prenatal care and implies difficulties in implementing the studied practices. Thus, the empowerment and participation of women can become an important tool in the humanization of birth.

Implementation of childhood obesity prevention and control policies in the United States and Latin America: Lessons for cross-border research and practice

Progress has been made in the development and widespread implementation of effective interventions to address childhood obesity, yet important challenges remain. To understand how the United States and Latin American countries achieved success in implementing obesity policies and programs (PAPs) and identify improvement opportunities using implementation science principles. We identified three comparative case studies: (1) front-of-food package labeling (Mexico and Chile); (2) Open Streets/play streets (Colombia and the United States); and (3) the Baby-Friendly Hospital Initiative (Brazil and the United States). Information from multiple sources (e.g., scientific and gray literature and key informant interviews) was synthesized to describe barriers, facilitators, and progress of PAPs across RE-AIM framework dimensions. Evidence-based advocacy along with political will and evidence of scalability and impact were key for successful launch and implementation of all PAPs. Diverse adaptations of PAP design and implementation had to be done across contexts. Stronger process and impact monitoring and evaluation systems that track equity indicators are needed to maximize the population benefits of these PAPs. Implementation science offers an important contribution toward addressing knowledge gaps, enhancing obesity policy dialogue, and producing transferable lessons across the Americas and, therefore, should be used for research and evaluation during PAP development and throughout the implementation and maintenance phases.

Randomized clinical trial of the effect of the onset time of skin-to-skin contact at birth, immediate compared to early, on the duration of breastfeeding in full term newborns

Background

Skin-to-skin contact (SSC) compared to separation at birth has a positive effect on breastfeeding. However, separation at birth is common with negative impact on breastfeeding. The aim was to determine the effect of immediate SSC compared to early SSC on the duration of exclusive breastfeeding.

Methods

A randomized multicentre parallel clinical trial was conducted in two hospitals in Cundinamarca (Colombia) between November 2018 and January 2020. Low-risk full term newborns at birth were included. Neonates were assigned to immediate (in the first minute after birth) or early onset (start exactly at 60 min of life) skin to skin contact. Monthly follow-up was performed until 6 months of age. The primary outcome was the percentage of exclusively breastfed infants at 6 months (time in months with human milk as the only source of food). Secondary outcomes were the percentage of infants with exclusive breastfeeding at 3 months, duration in months of exclusive breastfeeding, neonate’s breastfeeding ability, percentage of weight change between birth and the first week of life and hospitalization in the neonatal unit in the first week. A bivariate analysis was performed to determine the variables associated with exclusive breastfeeding at 6 months. A survival analysis was performed to evaluate the effect of the onset of SSC on exclusive breastfeeding duration.

Results

A total of 297 newborns were included: 49.8% (n = 148) in the immediate SSC group, and 50.2% (n = 149) in the early SSC group. The mean duration of exclusive breastfeeding in both groups was 5 months. There were no differences between the groups in the percentage of exclusive breastfeeding at 6 months (relative risk [RR] 1.06, 95% CI 0.72, 1.58) or in the duration of exclusive breastfeeding (hazard ratio [HR] 0.98, 95% CI 0.74, 1.28).

Conclusions

The percentage of infants and the duration of exclusive breastfeeding in the first 6 months of age were the same between the two groups of SSC interventions. Given the current barriers to its implementation, the results of this study could positively impact the use of SSC at birth and standardize the intervention and improve breastfeeding indicators.

Trial registration

ClinicalTrials.gov NCT02687685.

Fatores associados às práticas assistenciais ao recém-nascido na sala de parto

RESUMO Objetivo identificar os fatores associados às práticas assistenciais ao recém-nascido adotadas na sala de parto de uma maternidade na baixada litorânea do Rio de Janeiro. Método estudo transversal, realizado em instituição pública no estado Rio de Janeiro, mediante coleta de dados em prontuários de nascimentos entre 2015 e 2017. Na associação entre variáveis, adotou-se o Teste Qui-Quadrado e a regressão logística. Resultados entre 351 (100,0%) prontuários, constituíram-se como práticas realizadas na sala de parto: contato pele a pele e aleitamento materno precoce (28,0%); secagem (92,3%); aspiração oronasofaríngea (82,1%); aspiração gástrica (52,7%); aspiração traqueal (12,2%); oxigênio inalatório (7,7%); e encaminhamento ao Alojamento Conjunto (91,1%). O contato precoce com o seio materno esteve associado ao tipo de parto (p=0,043) e às alterações no exame físico (p=0,001). Possuir alterações no exame físico ao nascimento diminuiu significativamente as chances de o bebê ser colocado nessa posição ainda na sala de parto (p=0,001) assim como os recém-nascidos de parto cesáreo (p=0,045). Nascer de cesárea aumentou duas vezes as chances de o recém-nascido ser submetido à aspiração gástrica (p=0,002). Conclusão e implicações para a prática é premente organizar as rotinas dos serviços, de modo a evitar intervenções desnecessárias visando uma atenção obstétrica e neonatal humanizada e de qualidade.

The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study

BACKGROUND

Amid efforts to improve the quality of care for women and neonates during childbirth, there is growing interest in the experience of care, including respectful care practices. However, there is little research on the prevalence of practices that might constitute mistreatment of neonates. This study aims to describe the care received by neonates up to 2 h after birth in a sample of three countries in west Africa.

METHODS

Data from this multicountry, facility-based, observational study were collected on 15 neonatal care practices across nine facilities in Ghana, Guinea, and Nigeria, as part of WHO's wider multicountry study on how women are treated during childbirth. Women were eligible if they were admitted to the participating health facilities for childbirth, in early established labour or active labour, aged 15 years or older, and provided written informed consent on behalf of themselves and their neonate. All labour observations were continuous, one-to-one observations of women and neonates by independent data collectors. Descriptive statistics and multivariate logistic regressions were used to examine associations between these neonatal care practices, maternal and neonate characteristics, and maternal mistreatment. Early neonate deaths, stillbirths, and higher order multiple births were excluded from analysis.

FINDINGS

Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; and from July 1 to Oct 30, 2017, in Guinea. We included data for 362 women-neonate dyads (356 [98%] with available data for neonatal care practices) in Nigeria, 760 (749 [99%]) in Ghana, and 558 (522 [94%]) in Guinea. Delayed cord clamping was done for most neonates (1493 [91·8%] of 1627); other practices, such as skin-to-skin contact, were less commonly done (1048 [64·4%]). During the first 2 h after birth, separation of the mother and neonate occurred in 844 (51·9%) of 1627 cases; and was more common for mothers who were single (adjusted odds ratio [AOR; adjusting for country, maternal age, education, marital status, neonate weight at birth, and neonate sex] 1·8, 95% CI 1·3-2·6) than those who were married or cohabiting. Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices. Neonates with a low birthweight (<2·5 kg) were more likely (1·7, 1·1-2·8) to not begin breastfeeding on demand than full weight neonates. When women experienced physical abuse from providers within 1 h before childbirth, their neonates were more likely to be slapped (AOR 1·9, 1·1-3·9).

INTERPRETATION

A high proportion of neonates did not receive recommended care practices, and some received practices that might constitute mistreatment. Further research is needed on understanding and measuring mistreatment to improve care, including respectful care, for mothers and neonates.

FUNDING

US Agency for International Development, and the UNDP/UN Population Fund/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

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.

Care for healthy newborns in Brazil: are we making progress in achieving best practices?

This paper aims to compare best practices for healthy newborns in public and mixed hospitals affiliated with SUS, according to type of birth, between "Nascer no Brasil/2011" (NB - Birth in Brazil) and in the last assessment cycle of Rede Cegonha, here called "Avaliação da Rede Cegonha/2017" (ARC - Stork Network Assessment). NB included a sample with national representativeness of 266 hospitals, and ARC was conducted in 606 maternity hospitals included in the Rede Cegonha strategy, totaling 15,994 and 8,047 pairs of healthy mothers and newborns, respectively.Between the two studies, NB-2011 and ARC-2017, although the proportion of cesarean sections remained around 44%, the prevalence of skin-to-skin contact with newborns, breastfeeding in the delivery room and breastfeeding in the first 24h of life increased by 140%, 82% and 6%, respectively. The proportion of upper airway aspiration of newborns dropped 65%. The results indicate that the use of evidence-based guidelines for the care of healthy newborns has increased in clinical practice, considering the six-year period between the compared studies. Despite the progress, important challenges remain to ensure best practices for all women and newborns, especially in relation to cesarean births.

Factors associated with a positive childbirth experience in Brazilian women: A cross-sectional study

BACKGROUND

Having a positive childbirth experience is an increasingly valued outcome. Few studies evaluated the women's satisfaction with childbirth through face-to-face interviews out of the health service environment. The objective of this study was to identify factors associated with a higher level of satisfaction with the childbirth experience among Brazilian women.

METHODS

This cross-sectional study involved 287 women giving birth in two hospitals in southern Brazil. Women who gave birth to healthy newborns at term were randomly selected. Face-to-face interviews were conducted 31-37 days after delivery, at the mothers' homes, using a structured questionnaire. Satisfaction with the childbirth experience was measured using a Likert-type scale ranging from very satisfied to very dissatisfied. Prevalence ratios (PR) were estimated using Poisson regression with robust variance.

RESULTS

Following hierarchical multivariate analysis, the following factors remained associated with a higher level of satisfaction with the childbirth experience: being satisfied with antenatal care (PR=1.30; 95% confidence interval [95%CI]=1.06-1.59), understanding the information provided by health professionals during labor and delivery (PR=1.40; 95%CI=1.01-1.95), not having reported disrespect and abuse (PR=1.53; 95%CI=1.01-2.31), and having had the baby put to the breast within the first hour of life (PR=1.63; 95%CI=1.26-2.11). No association was observed with type of delivery or hospital status (public or private).

CONCLUSIONS

A higher level of satisfaction with the childbirth experience is related to satisfactory antenatal care, a non-abusive, respectful, and informative environment during childbirth, and to the opportunity to breastfeed the baby within the first hour of life. In clinical practice, greater attention to these basic principles of care during pregnancy and delivery could provide more positive experiences during birth.

Using the Maternity Safety Thermometer to estimate harm-free care in Southeast Brazil: A hospital-based cohort

BACKGROUND

High rates of unnecessary cesareans and interventions in vaginal births contribute to stagnant maternal and neonatal mortality rates in Brazil. We used the Maternity Safety Thermometer (MST) to assess the prevalence of harm during maternity care.

METHODS

This secondary analysis of the "Birth in Brazil" survey included a representative sample of 10 155 women who gave birth in public and private hospitals in southeastern Brazil. The main outcomes were perineal and abdominal trauma, maternal infection and hemorrhage, newborn vitality, and women's perception of safety. We calculated the odds ratios (OR) for the number of MST harms (dependent variable).

RESULTS

About 81.6% of the women with vaginal births had sutures for perineal trauma (87.7% of these due to episiotomies). Poor perception of safety was reported by 83.1% of women, and 69.5% of all infants not admitted to the NICU were separated from their mother after birth. The overall rate of cesarean birth was 52.6%, and 7.5% of term infants were admitted to the NICU. In public settings, having an intrapartum cesarean significantly increased the chances of one (OR 2.21; 95% CI 1.20-4.07), or two or more (4.08 [2.27-7.32]) harms. In private settings, cesarean deliveries without labor were also associated with higher chances of one (4.26 [2.65-6.85]), or two or more (4.60 [2.35-9.02]) harms. Only 2% of the women had harm-free care.

CONCLUSIONS

In southeastern Brazil, there is a high prevalence of preventable harm during maternity care.

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.

Impact of intention to become pregnant on breastfeeding in the first postpartum hour

This study aimed to analyze the impact of the intention to become pregnant on breastfeeding within the first hour after delivery. This is a cross-sectional study nested in the research "Birth in Brazil: national survey into labor and birth" carried out by the Oswaldo Cruz Foundation. Multiple logistic regression was used to analyze the data of 5,563 puerperae and their newborns who participated in the study. The following women evidenced a lower propensity to begin breastfeeding in the first hour of life: puerperae who did not wish to become pregnant (OR = 0.85; CI: 0.73-0.98) and who were dissatisfied upon learning that they had become pregnant (OR = 0.72; CI: 0.61-0.83). The intentionality of pregnancy affected maternal breastfeeding behavior so that women with unintended pregnancies were less likely to initiate breastfeeding in the first hour postpartum, thus evidencing that inadequate family planning may indirectly harm breastfeeding. Therefore, the quality of family planning services should be improved to reduce unintended pregnancies and prevent unfavorable outcomes for mother-and-child health, such as the late onset of breastfeeding.

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.

Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: A systematic review

BACKGROUND

Despite the World Health Organization's (WHO) recommendation for immediate skin-to-skin contact (SSC) after birth, separation of mothers and infants seems to be common practice in many hospitals. It is unknown how common the practice of SSC is worldwide. Therefore, we aimed to determine the reported prevalence of SSC for healthy mothers and infants immediately after normal birth.

METHODS

We systematically searched CINAHL, Medline, ProQuest Central, PubMed and the Cochrane Library for articles published between January 2007 and October 2017 using the keywords "kangaroo care" or "skin to skin contact" or "breastfeeding initiation" or "breast crawl" or "maternal infant contact" or "maternal newborn contact" or "baby friendly hospital initiative" or "ten steps for successful breastfeeding".

RESULTS

After an initial screening of 5266 records, 84 full text articles were assessed for eligibility, and 35 of these met the inclusion criteria. The studies were from 28 countries representing all six WHO world regions. There was a wide range in the practice of SSC for mother-infant dyads around the world: from 1% to 98%. Only 15 studies clearly defined SSC. Most of the studies were from high-income countries, and these reported higher rates of SSC than studies from low and middle-income countries.

CONCLUSION

There was a great heterogeneity in the definition of SSC as well as study designs, which makes cross-county comparison difficult. National studies reporting SSC rates are lacking. Future studies and guidelines to enhance SSC practice should include a standardised set of indicators and measurement tools that document SSC starting time and duration of SSC.

[Quality of care for labor and childbirth in a public hospital network in a Brazilian state capital: patient satisfaction]

The study assessed the quality of care for labor and childbirth in the public hospital system in the city of Recife, Pernambuco State, Brazil, according to the mothers' satisfaction, using a cross-sectional exploratory study in all the public hospitals in the network, grouped according to type of hospital management and interviews with 1,000 mothers. Quality of care was measured according to management strata and the following dimensions of quality: reception; respect for individual rights; prenatal and childbirth care; and ambience. The results' significance was analyzed with the Pearson and Friedman chi-square test. There was high prenatal coverage, not linked to childbirth care, and intense migration of deliveries. Waiting time for care by the healthcare team was long, the proportion of vaginal deliveries in the municipal maternity services was 80%, and only 16% of the deliveries included skin-to-skin contact with the newborn; breastfeeding occurred in the birthing room in 11% of the deliveries. Among the various management modalities, the charitable hospital rated highest. The target dimension showed significant differences, with higher satisfaction rates for the following: respect (88.2%), kindness (86.7%), physicians' work (85.2%), and trust in the healthcare staff (84.3%). The highest rates of dissatisfaction were for: temperature on the ward (62.2%), possibility of lodging complaints (48.1%), quantity and quality of hospital clothing and bedding (49.2%), and privacy (43%). Despite positive strides, the findings show the need for reorganization of obstetric care policy, with regionalization, regulation, consolidation of networks of care, and interventions in the healthcare setting, aimed at consolidating the humanization of care.

Factors related to health services determine breastfeeding within one hour of birth in the Federal District of Brazil, 2011

Objective:

To identify factors associated with breastfeeding in the first hour of life.

Methods:

A cross-sectional study conducted among mothers and children under one year of age, who attended the second stage of the polio vaccination campaign in the Federal District, Brazil, in 2011. The sample was composed of 1,027 pairs of mothers and children. Breastfeeding in the first hour of life was considered as the dependent variable; and the independent variables were: socio-demographic characteristics of the mother, prenatal, delivery and postpartum care, reference to physical or verbal violence/neglect during delivery, and children health. Unadjusted and adjusted prevalence ratios (PR) were used as measures of association, calculated by Poisson regression.

Results:

The prevalence of breastfeeding in the first hour of life was 77.3%. Inadequate prenatal care (PR = 0.72), cesarean section (PR = 0.88) and no access to rooming-in after birth (PR = 0.28) were factors that interfered negatively in breastfeeding in the first hour of life. No factor was associated with breastfeeding in the first hour of life for mother and children.

Conclusions:

Factors related to health services such as prenatal care, type of delivery and postpartum rooming-in interfered with breastfeeding in the first hour of life, indicating that health services, as well health professional practices were major determinants the breastfeeding in the first hour of life.

Relação mãe-filho e fatores associados: análise hierarquizada de base populacional em uma capital do Brasil-Estudo BRISA

Resumo Diversos fatores podem interferir na relação mãe-filho. Estudos sobre as diferentes características maternas e esta relação são escassos, avaliam principalmente mulheres com psicopatologias e utilizam modelos de regressão simultânea com ajuste para múltiplos confundidores. Este estudo objetivou avaliar fatores associados a prejuízos na relação mãe-filho por meio de uma coorte com 3.215 mães de crianças entre 15 e 36 meses de idade. Prejuízos na relação mãe-filho, avaliado pelo Postpartum Bonding Questionnaire, constituiu a variável desfecho e as variáveis explanatórias foram características demográficas, socioeconômicas, da saúde reprodutiva e da saúde mental das mães bem como das condições do nascimento das crianças. Foi utilizada análise de regressão multivariada com abordagem hierarquizada em que os blocos hierárquicos foram estruturados segundo influência na relação mãe-filho. A prevalência de prejuízos na relação mãe-filho foi elevada (12,6%) e associada com fatores de risco à menor escolaridade da mãe (RR = 1,64), não ter planejado a gravidez (RR = 1,42), consumo de bebida alcoólica durante a gravidez (RR = 1,42) e sintomas maternos de estresse (RR = 1,88) e depressão (RR = 2,00). Escolaridade e elementos relacionados à saúde mental materna constituíram risco para prejuízos na relação mãe-filho.

Amamentação na primeira hora de vida: conhecimento e prática da equipe multiprofissional

Objetivo: Evaluar el conocimiento y la práctica sobre la lactancia materna en la primera hora de vida entre los miembros del equipo multidisciplinario de un hospital en la ciudad de Maringá, Paraná.Metodología: Estudio descriptivo-exploratorio con enfoque cualitativo. Los datos fueron recolectados entre octubre y noviembre del 2013 mediante entrevistas grabadas con 11 participantes. Para el procesamiento de los datos, se utilizó la técnica de análisis de contenido.Resultados: Se encontró que los profesionales de la salud tienen deficiencias en el conocimiento acerca de la lactancia materna en la primera hora de vida; además, la práctica no suele realizarse en la institución, a partir de lo cual surgen desafíos y recomendaciones para establecer esta actividad.Conclusiones: Se sugiere incluir esta práctica en las políticas del hospital para la promoción y protección de la lactancia materna, que consoliden el equipo multidisciplinario y el trabajo colaborativo entre sus miembros.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

The baby-friendly hospital initiative and breastfeeding at birth in Brazil: a cross sectional study

BACKGROUND

Breastfeeding in the first hour after birth is important for the success of breastfeeding and in reducing neonatal mortality. Government policies are being developed in this direction, highlighting the accreditation of hospitals in the Baby-Friendly Hospital (BFH) initiative. The aim of this study was to analyze the association between delivery in a BFH (main exposure), compared to non BFH, and timely initiation of breastfeeding (outcome).

METHODS

Data came from the "Birth in Brazil" survey, a nationwide hospital-based study of postpartum women and their newborns, coordinated by the Oswaldo Cruz Foundation. A sample of 22,035 mothers/babies was analyzed through a hierarchical theoretical model on three levels, and all analyzes considered the complex sample design. Odds ratios were obtained by logistic regression, with a 99 % CI.

RESULTS

Among all births, 40 % occurred in hospitals accredited or in accreditation process for the BFHI and 52 % of women underwent caesarean section. In the final model, at the distal level, mothers less than 35 years old, and those who lived in the North Region, had a higher chance of timely initiation of breastfeeding. At the intermediate level, prenatal care in the public sector and advice on breastfeeding during pregnancy were directly associated with the outcome. At the proximal level, being born in a Baby-Friendly Hospital and vaginal delivery increased the chance of timely initiation of breastfeeding, while prematurity and low birth weight reduced the chance of the outcome.

CONCLUSIONS

The chance of being breastfed in the first hour after birth in Baby-Friendly hospitals was twice as high as at non-accredited hospitals, which shows the importance of this initiative for timely initiation of breastfeeding.

Factors associated with the use of supplemental oxygen or positive pressure ventilation in the delivery room, in infants born with a gestational age ≥ 34 weeks

Background

Approximately 5–10 % of newborns require some form of resuscitationupon delivery; several factors, such as maternal abnormal conditions, gestational age and type of delivery could be responsible for this trend. This study aimed to describe the factors associated with the need for positive pressure ventilation (PPV) via a mask or endotracheal tube and the use of supplemental O2 in newborns with a gestational age greater than 34 weeks in Brazil.

Methods

We performed a cross-sectional study and obtained data from the Birth in Brazil Survey. The inclusion criterion was a gestational age ≥34 weeks. Exclusion criteria were newborns with congenital malformations, and cases with undetermined gestational age or type of delivery (vaginal, pre labor cesarean section and cesarean section during labor). The primary outcomes were need of PPV via a mask or endotracheal tube and the use of supplemental oxygen without PPV. Confounding variables, including maternal age, source of birth payment, years of maternal schooling, previous birth, newborn presentation, multiple pregnancy, and maternal obstetric risk, were analyzed.

Results

We included 22,720 newborns. Of these, 2974 (13.1 %) required supplementary oxygen. PPV with a bag and mask was used for 727 (3.2 %) newborns and tracheal intubation for 192 (0.8 %) newborns. Chest compression was necessary for 136 (0.6 %) newborns and drugs administered in 114 (0.5 %). 51.3 % of newborns were delivered by cesarean section, with the majority of cesarean sections (88.7 %) being performed prior to labor. Gestational age (late preterm infants: (Relative Risk-(RR) 2.46; 95 % (Confidence interval-CI 1.79–3.39), maternal obstetric risk (RR 1.59; 95 % CI1.30–1.94), and maternal age of 12–19 years old (RR 1.36; 95 % CI1.06–1.74) contributed to rates of PPV in the logistic regression analysis. Newborns aged between 37–38 weeks of gestaional age weren´t less likely to require PPV compared with those aged 39–41 weeks of gestational age.

Conclusions

Late preterm infants, previous maternal obstetric risks and maternal age contributed to the higher needs of PPV and use of O2 in the delivery room. These variables need to be considered in planning care in the delivery room.

[The use of Bologna Score to assess normal labor care in maternities]

OBJECTIVE

To assess care during labor and delivery in habitual risk maternity units in a capital in southern Brazil.

METHOD

It is an evaluation research, retrospective, quantitative, developed in three hospitals. The variables relating to the Bologna Score (presence of a companion, use of partograph, absence of stimulation to labor, delivery in non-supine position; skin-to-skin mother with newborn) were collected in 406 records, tabulated in spreadsheets and submitted to simple frequency analysis. Collection lasted from June to September 2014.

RESULTS

The assigned scores range from 0 to 5, according to the performance or not of practical activities. The following scores were obtained: 0 (7%); 1 (44,1%); 2 (40,4%); 3 (12,1%), 4 (2,5%), e 5 (0,2%).

CONCLUSION

In the usual risk maternities evaluated, the labor and birth care provided do not match the standards recommended by the World Health Organisation.

Fatores associados ao contato pele a pele entre mãe/filho e amamentação na sala de parto

RESUMO Objetivo Investigar fatores associados ao contato pele a pele entre mãe e filho e à amamentação na sala de parto entre nutrizes atendidas em um banco de leite humano. Métodos Foram avaliadas 12.283 mães em estudo retrospectivo (2009-2012) com dados secundários obtidos de protocolo estruturado. Adotou-se modelo de Poisson com abordagem hierarquizada em níveis distal, intermediário e proximal para dados sociodemográficos maternos; pré-natais e gestacionais; do bebê; e atenção hospitalar. Resultados Estiveram associados, respectivamente, à maior prevalência do contato pele a pele e da amamentação na sala de parto: parto normal (RP=1,34; IC95% 1,27-1,41 e RP=1,63; IC95% 1,45-1,83) e sem complicação (RP=1,24; IC95% 1,12-1,38 e RP=1,27; IC95% 1,03-1,56), peso ao nascer adequado (RP=1,23; IC95% 1,11-1,36 e RP=1,92; IC95% 1,48-2,48) e a termo (RP=1,18; IC95% 1,10-1,28 e RP=1,40; IC95% 1,17-1,67). Conclusão A forte influência da atenção hospitalar e as condições ao nascer do recém-nascido explicaram os desfechos em estudo. Ressalta-se a necessidade da adoção de medidas que priorizem o contato pele a pele e a amamentação na sala de parto nos grandes hospitais da capital, como a redução ou adiamento de intervenções na assistência pós-parto. Estudos longitudinais poderão esclarecer outras questões sobre o tema.

Childbirth care in Brazil: a critical situation has not yet been overcome. 1999-2013

Abstract Objectives: to analyze the evolution of childbirth care in Brazil, between 1999-2013. Methods: a time-series ecological study, using data from Ministry of Health, Brazilian Institute of Geography and Statistics, and Interagency Network of Information for Health. 18 indicators were analyzed related to childbirth and mortality. Results: there was a reduction in rates of fertility, natality and the total number of births, with increased cesarean surgeries. Growth of prenatal consultation, intensive care beds and reduction of beds in obstetrics sector. The significant growth of caesarean deliveries, prenatal consultation coverage and concentration of births in hospitals occurred simultaneously with the growth: of preventable child deaths by adequate attention, management causes and appropriate delivery, prematurity; low weight; Down's syndrome; and the persistence of maternal deaths due to direct obstetric causes. Conclusions: persists hegemonic technocratic model of childbirth care without considering the observed changes in the profile of mothers and births, with slow reduction of perinatal and neonatal deaths and maintenance of high maternal mortality demonstrating that the critical situation of delivery care model in Brazil has not, yet, been overcome.

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.

Neonatal care in Brazil: hospital structure and adequacy according to newborn obstetric risk

BACKGROUND

In Brazil, hospital birth care is available to all, but there are important differences between hospitals in the public and private sectors, geographical regions and capitals/inland cities, resulting in inequalities of infant health.

AIMS

To assess the hospital structure for birth care in Brazil and analyze hospital adequacy to care for newborns according to levels of risk.

METHODS

Data were collected as part of a nationwide hospital-based cohort study, 'Birth in Brazil'. The hospitals were classified according to whether they had a neonatal intensive care unit and divided into two models of governance: public and private financing. Three structure domains were assessed: human resources, medications and equipment for post-natal women and newborn emergency care. Newborns were classified according to the obstetric risk.

RESULTS

There are more NICUs in private hospitals and they cater mostly for low obstetric risk newborns; the public sector serves 50% of at-risk patients in hospitals without an NICU. The differences between hospital service structures according to geographic region and capital/inland cities were evident. Hospitals in less developed regions and inland cities had poorer adequacy in the three domains.

CONCLUSION

The distribution of neonatal care to Brazilian infants varied between the public and private sectors. The public sector offered less complex services for newborns at risk, and infants without obstetric risk were born in facilities with an NICU, creating the possibility of unnecessary intervention, especially in the private sector.