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.

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.

The association between mistreatment of women during childbirth and postnatal maternal and child health care: Findings from "Birth in Brazil".

BACKGROUND: The mistreatment of women during pregnancy, childbirth, and the puerperium is a global public health problem besides being a violation of human rights. However, research exploring the consequences of mistreatment of women and newborns is scarce. QUESTION: To shed light on this issue, we investigated the association between the mistreatment of women during childbirth and the subsequent use of postnatal health services by women and their newborns. METHODS: We used data from the study "Birth in Brazil", a national hospital-based survey of puerperal women and their newborns, carried out in 2011/2012. This analysis involved 19,644 women. Mistreatment was a latent variable composed of seven indicators. We assessed the attendance of women and newborns to a review consultation following birth, and the timing of this appointment. We applied multigroup structural equation modeling (based on childbirth payment source) and considered separate analysis for women (vaginal births and0 caesarean-sections) and newborns. FINDINGS: We found a causal association between mistreatment during childbirth and decreased and/or delayed use of postnatal health services, for both women and their newborns. These results also revealed that women who use the public sector are affected more than those who pay for private healthcare. CONCLUSION: Mistreatment during childbirth has broader implications than "maternal mental health", and it would be useful to understand that experience of care has vast implications for families. In Brazil, the mistreatment must be mitigated via the implementation of public policy. This is part of the path to dignified and respectful childbirth care for all women.

Different methods for assessing gestational weight gain and its association with birth weight. / Diferentes métodos para avaliação do ganho de peso gestacional e sua associação com o peso ao nascer.

OBJECTIVE: To analyze association of different methods of gestational weight gain assessment with live births small for gestational age (SGA) and large for gestational age (LGA). METHODS: This was a cross-sectional study with adult women, normal prepregnancy BMI, single pregnancy and gestational age at delivery ≥28 weeks, from the "Birth in Brazil" study, between 2011 and 2012. RESULTS: Among the 11,000 women participating in the study, prevalence of excessive weight gain was 33.1% according to the Brandão et al. and Institute of Medicine (IOM) methods, and 37.9% according to the Intergrowth method. The chance of being born SGA in the case of insufficient weight gain was OR=1.52 (95%CI 1.06;2.19), OR=1.52 (95%CI 1.05;2.20) and OR=1.56 (95%CI 1.06;2.30) for the Brandão et al., IOM and Intergrowth methods, respectively. Likelihood of excessive weight gain using the same methods was OR=1.53 (95%CI 1.28;1.82), OR=1.57 (95%CI 1.31;1.87) and OR=1.65 (95%CI 1.40;1.96), for LGA respectively. CONCLUSION: Compared to the IOM recommendations, the Intergrowth and Brandão et al. methods show themselves to be alternatives for identifying SGA and LGA.

Diferentes métodos para avaliação do ganho de peso gestacional e sua associação com o peso ao nascer / Diferentes métodos para evaluar el aumento de peso gestacional y su asociación con el peso al nacer / Different methods for assessing gestational weight gain and its association with birth weight

Objetivo: Analisar a associação de diferentes métodos para avaliação do ganho de peso gestacional com nascidos vivos pequenos para idade gestacional (PIG) ou grandes para idade gestacional (GIG). Métodos: Estudo transversal, com mulheres adultas, IMC pré-gestacional de eutrofia, gestação única e idade gestacional no parto ≥28 semanas, da pesquisa 'Nascer no Brasil', em 2011-2012. Resultados: Participaram do estudo 11 mil mulheres; a prevalência de ganho excessivo foi de 33,1% segundo os métodos Brandão et al., e IOM, e 37,9% segundo Intergrowth. A chance de nascer PIG para ganho de peso insuficiente foi de OR=1,52 (IC95% 1,06;2,19), OR=1,52 (IC95% 1,05;2,20) e OR=1,56 (IC95% 1,06;2,30) para Brandão et al., IOM e Intergrowth, respectivamente, enquanto o ganho de peso excessivo apresentou OR=1,53 (IC95% 1,28;1,82), OR=1,57 (IC95% 1,31;1,87) e OR=1,65 (IC95% 1,40;1,96), para GIG, respectivamente. Conclusão: Comparados às recomendações do IOM, Intergrowth e Brandão et al. apresentam-se como alternativas para identificar PIG e GIG.

Objetivo: Analizar diferentes métodos de evaluación del aumento de peso gestacional (APG) con nacidos vivos pequeños para la edad gestacional (PEG) y grandes para la edad gestacional (GEG). Métodos: Estudio transversal, con mujeres adultas, IMC pregestacional eutrófico, un solo embarazo y edad gestacional al nacer ≥28 semanas, del estudio `Nacer en Brasil´, entre 2011 y 2012. Resultados: En las 11.000 mujeres del estudio, la prevalencia de ganancia excesiva fue del 33,1% según los métodos de Brandão et.al. y el IOM y 37,9% para Intergrowth. La probabilidad de nacer PEG por una ganancia de peso insuficiente fue OR=1,52 (IC95% 1,06; 2.19), OR=1,52 (IC95% 1,05; 2.20) y OR=1,56 (IC95% 1,06; 2.30) para Brandão et.al, IOM e Intergrowth. La ganancia de peso excesiva, en los mismos métodos presentó OR=1,53 (IC95% 1,28;1,82), OR=1,57 (IC95% 1,31;1.87) y OR=1,65 (IC95% 1,40;1,96) para GEG. Conclusión: En comparación con las recomendaciones del IOM, Intergrowth y Brandão et.al. se presentan como alternativas en la identificación de PEG y GEG.

Objective: To analyze association of different methods of gestational weight gain assessment with live births small for gestational age (SGA) and large for gestational age (LGA). Methods: This was a cross-sectional study with adult women, normal prepregnancy BMI, single pregnancy and gestational age at delivery ≥28 weeks, from the "Birth in Brazil" study, between 2011 and 2012. Results: Among the 11,000 women participating in the study, prevalence of excessive weight gain was 33.1% according to the Brandão et al. and Institute of Medicine (IOM) methods, and 37.9% according to the Intergrowth method. The chance of being born SGA in the case of insufficient weight gain was OR=1.52 (95%CI 1.06;2.19), OR=1.52 (95%CI 1.05;2.20) and OR=1.56 (95%CI 1.06;2.30) for the Brandão et al., IOM and Intergrowth methods, respectively. Likelihood of excessive weight gain using the same methods was OR=1.53 (95%CI 1.28;1.82), OR=1.57 (95%CI 1.31;1.87) and OR=1.65 (95%CI 1.40;1.96), for LGA respectively. Conclusion: Compared to the IOM recommendations, the Intergrowth and Brandão et al. methods show themselves to be alternatives for identifying SGA and LGA.

Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study.

BACKGROUND: Many women are victims of disrespect and abuse during childbirth period. In Brazil, the prevalence of these acts has varied between 11.3% and 18.3%. Despite the high prevalence and grave consequences of mistreatment of women during birth care, women's mental health during this period, and its determining factors, are still poorly understood. The main objective is to investigate the association between mistreatment of women during childbirth and postpartum depression. METHODS: national survey in childbirth care carried out between 2011 and 2012. The sample was composed of 23,378 puerperal women. Disrespect and abuse was composed by seven indicator.We assessed postpartum depression using Edinburgh Postnatal Depression Scale screening questions. We applied multigroup structural equation modelling (childbirth payment source), considering different theoretical models for vaginal births and C-sections. RESULTS: Disrespect and abuse towards women during childbirth were associated with postpartum depression both in the public and private sectors, for both vaginal births and C-sections. In the public healthcare sector, disrespect and abuse were associated with maternal hospitalization. Presence of fundal pressure manoeuvre, not be white, and not receiving the desired mode of birth (only for C-sections). In the private sector, for both vaginal births and C-sections, not having the desired mode of birth was the only characteristic associated with disrespect and abuse. CONCLUSION: Disrespect and abuse towards women during childbirth may contribute to the development of postpartum depression. Identifying its causes may help prevent the problem and strengthen public policies that favor the good quality of childbirth care.

Prevalence of syphilis and HIV infection during pregnancy in incarcerated women and the incidence of congenital syphilis in births in prison in Brazil.

This study aimed to estimate the prevalence of syphilis and HIV infection during pregnancy, the mother to child transmission of syphilis and the incidence of congenital syphilis in incarcerated women in Brazil; to compare these rates to those observed in pregnant women outside of jail; and to verify the maternal factors associated with syphilis infection during pregnancy in free and incarcerated women. We used data from two nationwide studies conducted during the period 2011-2014. The Birth in Brazil study included 23,894 free women cared for in 266 hospitals. The Maternal and Infant Health in Prisons study included 495 incarcerated pregnant women or mothers living with their children, according to a census conducted in 33 female prisons. The same case definitions and data collection methods were used in both studies. The chi-square test was used to compare the characteristics of incarcerated and free women with a significance of 0.05. For incarcerated women, the estimated prevalence of syphilis during pregnancy was 8.7% (95%CI: 5.7-13.1) and for HIV infection 3.3% (95%CI: 1.7-6.6); the estimated mother to child transmission of syphilis was 66.7% (95%CI: 44.7-83.2) and the incidence of congenital syphilis was 58.1 per 1,000 living newborns (95%CI: 40.4-82.8). Incarcerated women had a greater prevalence of syphilis and HIV infection during pregnancy, lower quality of antenatal care and higher levels of social vulnerability. Syphilis infection showed to be an indicator of social vulnerability in free women, but not in incarcerated women. Health initiatives in prison are necessary to reduce healthcare inequalities and should include adequate antenatal and birth care.

Prevalence of syphilis and HIV infection during pregnancy in incarcerated women and the incidence of congenital syphilis in births in prison in Brazil / Prevalência de sífilis e HIV em gestantes encarceradas e incidência de sífilis congênita em crianças nascidas em prisões brasileiras / Prevalencia de sífilis y VIH en gestantes encarceladas e incidencia de sífilis congénita en niños nacidos en prisiones brasileñas

Abstract: This study aimed to estimate the prevalence of syphilis and HIV infection during pregnancy, the mother to child transmission of syphilis and the incidence of congenital syphilis in incarcerated women in Brazil; to compare these rates to those observed in pregnant women outside of jail; and to verify the maternal factors associated with syphilis infection during pregnancy in free and incarcerated women. We used data from two nationwide studies conducted during the period 2011-2014. The Birth in Brazil study included 23,894 free women cared for in 266 hospitals. The Maternal and Infant Health in Prisons study included 495 incarcerated pregnant women or mothers living with their children, according to a census conducted in 33 female prisons. The same case definitions and data collection methods were used in both studies. The chi-square test was used to compare the characteristics of incarcerated and free women with a significance of 0.05. For incarcerated women, the estimated prevalence of syphilis during pregnancy was 8.7% (95%CI: 5.7-13.1) and for HIV infection 3.3% (95%CI: 1.7-6.6); the estimated mother to child transmission of syphilis was 66.7% (95%CI: 44.7-83.2) and the incidence of congenital syphilis was 58.1 per 1,000 living newborns (95%CI: 40.4-82.8). Incarcerated women had a greater prevalence of syphilis and HIV infection during pregnancy, lower quality of antenatal care and higher levels of social vulnerability. Syphilis infection showed to be an indicator of social vulnerability in free women, but not in incarcerated women. Health initiatives in prison are necessary to reduce healthcare inequalities and should include adequate antenatal and birth care.

Resumo: O estudo teve como objetivos estimar a prevalência de infecção de sífilis e HIV na gravidez, transmissão vertical de sífilis e incidência de sífilis congênita em filhos de mulheres encarceradas no Brasil, comparar as taxas com aquelas observadas em gestantes não encarceradas e verificar os fatores maternos associados à sífilis gestacional em mulheres encarceradas e não encarceradas. Usamos os dados de dois inquéritos nacionais realizados entre 2011 e 2014. O estudo Nascer no Brasil incluiu 23.894 mulheres não encarceradas atendidas em 266 hospitais. O estudo sobre Saúde Materno-Infantil nas Prisões do Brasil incluiu 495 mulheres encarceradas, entre gestantes e mães vivendo com seus filhos, de acordo com um censo realizado em 33 presídios femininos. Os dois estudos usaram a mesma definição de casos e os mesmos métodos de coleta de dados. O teste do qui-quadrado foi utilizado para comparar as características das mães encarceradas e não encarceradas, com significância definida em p < 0,05. Nas mulheres encarceradas, a prevalência estimada de sífilis gestacional era 8,7% (IC95%: 5,7-13,1) e para infecção pelo HIV era 3,3% (IC95%: 1,7-6,6); a taxa de transmissão vertical da sífilis foi 66,7% (IC95%: 44,7-83,2) e a incidência de sífilis congênita foi 58,1 por 1.000 nascidos vivos (IC95%: 40,4-82,8). As mulheres encarceradas mostraram uma prevalência mais alta de sífilis e de infecção pelo HIV durante a gravidez, pior qualidade de atendimento pré-natal e níveis mais elevados de vulnerabilidade social, quando comparadas às mulheres não encarceradas. A sífilis mostrou ser indicador de vulnerabilidade social em mulheres não encarceradas, mas não em mulheres encarceradas. Os achados destacam a importância de iniciativas nas prisões para reduzir as desigualdades na assistência à saúde e de cuidados adequados durante o período pré-natal e parto.

Resumen: Los objetivos del estudio fueron estimar la prevalencia de infección de sífilis y VIH en el embarazo, la transmisión vertical de sífilis y la incidencia de sífilis congénita en hijos de mujeres encarceladas en Brasil, además de comparar las tasas con las observadas en gestantes no encarceladas y verificar los factores maternos asociados a la sífilis gestacional en mujeres encarceladas y no encarceladas. Usamos los datos de dos encuestas nacionales, realizadas entre 2011 y 2014. El estudio Nacer en Brasil incluyó a 23.894 mujeres no encarceladas, atendidas en 266 hospitales. El estudio sobre Salud Materno-Infantil en las Prisiones de Brasil incluyó a 495 mujeres encarceladas, entre gestantes y madres, viviendo con sus hijos, de acuerdo con un censo realizado en 33 presidios femeninos. Los dos estudios usaron la misma definición de casos y los mismos métodos de recogida de datos. El test del chi-quadrado se utilizó para comparar las características de las madres encarceladas y no encarceladas, con significancia definida en p < 0,05. En las mujeres encarceladas, la prevalencia estimada de sífilis gestacional era 8,7% (IC95%: 5,7-13,1) y para infección por VIH era 3,3% (IC95%: 1,7-6,6); la tasa de transmisión vertical de la sífilis fue 66,7% (IC95%: 44,7-83,2) y la incidencia de sífilis congénita fue 58,1 por 1.000 nacidos vivos (IC95%: 40,4-82,8). Las mujeres encarceladas mostraron una prevalencia más alta de sífilis y de infección por VIH durante el embarazo, peor calidad de atención prenatal y niveles más elevados de vulnerabilidad social, cuando se comparan con las mujeres no encarceladas. La sífilis mostró ser un indicador de vulnerabilidad social en mujeres no encarceladas, pero no en no mujeres encarceladas. Los hallazgos destacan la importancia de iniciativas en las prisiones para reducir las desigualdades en la asistencia a la salud y de cuidados adecuados durante el período prenatal y parto.

The color of pain: racial iniquities in prenatal care and childbirth in Brazil. / A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil.

Few studies on the influence of race/color on pregnancy and birthcare experiences have been carried out in Brazil. Additionally, none of the existing studies are of national scope. This study sought to evaluate inequities in prenatal and childbirth care according to race/color using propensity score matching. The data comes from the study Birth in Brazil: National Survey into Labor and Birth, a national population study comprised of interviews and revisions of medical records that included 23,894 women in 2011/2012. We used logistic regressions to estimate odds ratios (OR) and respective 95% confidence intervals (95%CI) of race/color associated with the outcomes were analyzed. When compared with white-skinned women, black-skinned women were more likely to have inadequate prenatal care (OR = 1.6; 95%CI: 1.4-1.9), to not be linked to a maternity hospital for childbirth (OR = 1.2 95%CI: 1.1-1.4), to be without a companion (OR = 1.7; 95%CI: 1.4-2.0), to seek more than one hospital for childbirth (OR =1.3; 95%CI: 1.2-1.5), and less likely to receive local anesthesia for an episiotomy (OR = 1.5; 95%CI: 1.1-2.1). Brown-skinned women were also more likely to have inadequate prenatal care (OR = 1.2; 95%CI: 1.1-1.4) and to lack a companion (OR = 1.4; 95%CI: 1.3-1.6) when compared with white-skinned women. We identified racial disparities in care during pregnancy and childbirth, which displayed a gradient going from worst to best care provided to black, brown and white-skinned women.

A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil / El color del dolor: inequidades raciales en la atención pre-natal y partos en Brasil / The color of pain: racial iniquities in prenatal care and childbirth in Brazil

Poucas pesquisas com foco nas influências da raça/cor no tocante à experiência de gestação e parto foram conduzidas no Brasil, sendo inédita a análise de abrangência nacional. Este estudo teve como objetivo avaliar as iniquidades na atenção pré-natal e parto de acordo com a raça/cor utilizando o método de pareamento baseado nos escores de propensão. Os dados são oriundos da pesquisa Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento, um estudo de base populacional de abrangência nacional com entrevista e avaliação de prontuários de 23.894 mulheres em 2011/2012. Regressões logísticas simples foram utilizadas para estimar as razões de chance (OR) e respectivos intervalos de 95% de confiança (IC95%) da raça/cor associada aos desfechos analisados. Em comparação às brancas, puérperas de cor preta possuíram maior risco de terem um pré-natal inadequado (OR = 1,6; IC95%: 1,4-1,9), falta de vinculação à maternidade (OR = 1,2; IC95%: 1,1-1,4), ausência de acompanhante (OR = 1,7; IC95%: 1,4-2,0), peregrinação para o parto (OR = 1,3; IC95%: 1,2-1,5) e menos anestesia local para episiotomia (OR = 1,5 (IC95%: 1,1-2,1). Puérperas de cor parda também tiveram maior risco de terem um pré-natal inadequado (OR = 1,2; IC95%: 1,1-1,4) e ausência de acompanhante (OR = 1,4; IC95%: 1,3-1,6) quando comparadas às brancas. Foram identificadas disparidades raciais no processo de atenção à gestação e ao parto evidenciando um gradiente de pior para melhor cuidado entre mulheres pretas, pardas e brancas.

Existen pocas investigaciones realizadas en Brasil centradas en las influencias de la raza/color, en lo que se refiere a la experiencia de la gestación y parto, siendo inédito un análisis de alcance nacional. Este estudio tuvo como objetivo evaluar las inequidades en la atención pre-natal y parto, de acuerdo a la raza/color, utilizando el método de apareamiento, basado en los marcadores de propensión. Los datos provienen de la investigación Nacer en Brasil: Investigación Nacional sobre Parto y Nacimiento, un estudio de base poblacional de alcance nacional con entrevista y evaluación de historiales médicos de 23.894 mujeres en 2011/2012. Se utilizaron regresiones logísticas simples para estimar las razones de oportunidad (OR) y sus respectivos intervalos de un 95% de confianza (IC95%) de la raza/color asociados a los desenlaces analizados. En comparación a las blancas, las puérperas de color negro tuvieron un mayor riesgo de tener un período pre-natal inadecuado (OR = 1,6; IC95%: 1,4-1,9), falta de vinculación a la maternidad (OR = 1,2; IC95%: 1,1-1,4), ausencia de acompañante (OR = 1,7; IC95%: 1,4-2,0), grandes desplazamientos para el parto (OR = 1,3; IC95%: 1,2-1,5) y menos anestesia local para episiotomía (OR = 1,5; IC95%: 1,1-2,1). Las puérperas mulatas también tuvieron un mayor riesgo de tener un período pre-natal inadecuado (OR = 1,2; IC95%: 1,1-1,4) y ausencia de acompañante (OR = 1,4; IC95%: 1,3-1,6), cuando se comparan con las blancas. Fueron identificadas disparidades raciales en el proceso de atención a la gestación y al parto, evidenciando un gradiente de peor para mejor cuidado entre mujeres negras, mulatas y blancas.

Few studies on the influence of race/color on pregnancy and birthcare experiences have been carried out in Brazil. Additionally, none of the existing studies are of national scope. This study sought to evaluate inequities in prenatal and childbirth care according to race/color using propensity score matching. The data comes from the study Birth in Brazil: National Survey into Labor and Birth, a national population study comprised of interviews and revisions of medical records that included 23,894 women in 2011/2012. We used logistic regressions to estimate odds ratios (OR) and respective 95% confidence intervals (95%CI) of race/color associated with the outcomes were analyzed. When compared with white-skinned women, black-skinned women were more likely to have inadequate prenatal care (OR = 1.6; 95%CI: 1.4-1.9), to not be linked to a maternity hospital for childbirth (OR = 1.2 95%CI: 1.1-1.4), to be without a companion (OR = 1.7; 95%CI: 1.4-2.0), to seek more than one hospital for childbirth (OR =1.3; 95%CI: 1.2-1.5), and less likely to receive local anesthesia for an episiotomy (OR = 1.5; 95%CI: 1.1-2.1). Brown-skinned women were also more likely to have inadequate prenatal care (OR = 1.2; 95%CI: 1.1-1.4) and to lack a companion (OR = 1.4; 95%CI: 1.3-1.6) when compared with white-skinned women. We identified racial disparities in care during pregnancy and childbirth, which displayed a gradient going from worst to best care provided to black, brown and white-skinned women.

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.

Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth.

The purpose of this article is to describe the factors cited for the preference for type of birth in early pregnancy and reconstruct the decision process by type of birth in Brazil. Data from a national hospital-based cohort with 23,940 postpartum women, held in 2011-2012, were analyzed according to source of funding for birth and parity, using the χ2 test. The initial preference for cesarean delivery was 27.6%, ranging from 15.4% (primiparous public sector) to 73.2% (multiparous women with previous cesarean private sector). The main reason for the choice of vaginal delivery was the best recovery of this type of birth (68.5%) and for the choice of cesarean, the fear of pain (46.6%). Positive experience with vaginal delivery (28.7%), cesarean delivery (24.5%) and perform female sterilization (32.3%) were cited by multiparous. Women from private sector presented 87.5% caesarean, with increased decision for cesarean birth in end of gestation, independent of diagnosis of complications. In both sectors, the proportion of caesarean section was much higher than desired by women.

Clinical practices in the hospital care of healthy newborn infant in Brazil.

The aim of this study was to evaluate the care of healthy full-term newborns and to identify variations in childbirth care and practices in the first hour of life. We used data from the Birth in Brazil survey. Unadjusted and adjusted odds ratio (OR) of hospital-delivered care for the mother and during childbirth were estimated for the following outcomes: upper airways and gastric aspiration, use of inhaled oxygen, use of incubator, skin-to-skin contact after birth, rooming-in and breastfeeding in the delivery room and within the first hour of life. We observed wide variations in the care of healthy full-term newborn in the delivery room. Practices considered inadequate, such as use of inhaled oxygen, (9.5%) aspiration of airways (71.1%) and gastric suctioning (39.7%), and the use of incubator (8.8%) were excessively used. Breastfeeding in the delivery room was low (16%), even when the Baby-Friendly Hospital Initiative had been implemented (24%). The results suggest poor knowledge and compliance by health practitioners to good clinical practice. Such noncompliance was probably not due to the differences in resources, since most births take place in hospitals where the necessary resources are available.

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

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.

Sampling design for the Birth in Brazil: National Survey into Labor and Birth.

This paper describes the sample design for the National Survey into Labor and Birth in Brazil. The hospitals with 500 or more live births in 2007 were stratified into: the five Brazilian regions; state capital or not; and type of governance. They were then selected with probability proportional to the number of live births in 2007. An inverse sampling method was used to select as many days (minimum of 7) as necessary to reach 90 interviews in the hospital. Postnatal women were sampled with equal probability from the set of eligible women, who had entered the hospital in the sampled days. Initial sample weights were computed as the reciprocals of the sample inclusion probabilities and were calibrated to ensure that total estimates of the number of live births from the survey matched the known figures obtained from the Brazilian System of Information on Live Births. For the two telephone follow-up waves (6 and 12 months later), the postnatal woman's response probability was modelled using baseline covariate information in order to adjust the sample weights for nonresponse in each follow-up wave.

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

This study aimed at assessing the validity of different measures for estimating gestational age and to propose the creation of an algorithm for gestational age at birth estimates for the Birth in Brazil survey--a study conducted in 2011-2012 with 23,940 postpartum women. We used early ultrasound imaging, performed between 7-20 weeks of gestation, as the reference method. All analyses were performed stratifying by payment of maternity care (public or private). When compared to early ultrasound imaging, we found a substantial intraclass correlation coefficient of ultrasound-based gestational age at admission measure (0.95 and 0.94) and of gestational age reported by postpartum women at interview measure (0.90 and 0.88) for the public and private payment of maternity care, respectively. Last menstrual period-based measures had lower intraclass correlation coefficients than the first two measures evaluated. This study suggests caution when using the last menstrual period as the first measure for estimating gestational age in Brazil, strengthening the use of information obtained from early ultrasound imaging results.

Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento / Diseño de la muestra Nacer en Brasil: Encuesta Nacional sobre Partos y Nascimientos en Brasil / Sampling design for the Birth in Brazil: National Survey into Labor and Birth

Este artigo descreve a amostra da Pesquisa Nacional sobre Parto e Nascimento no Brasil. Os hospitais com 500 ou mais nascidos vivos em 2007 foram estratificados por macrorregião, capital de estado ou não, e tipo, e selecionados com probabilidade proporcional ao número de nascidos-vivos em 2007. Amostragem inversa foi usada para selecionar tantos dias de pesquisa (mínimo de 7) quantos fossem necessários para alcançar 90 entrevistas realizadas com puérperas no hospital. As puérperas foram amostradas com igual probabilidade entre as elegíveis que entraram no hospital no dia. Os pesos amostrais básicos são o inverso do produto das probabilidades de inclusão em cada estágio e foram calibrados para assegurar que estimativas dos totais de nascidos vivos dos estratos correspondessem aos totais de nascidos vivos obtidos no SINASC. Para os dois seguimentos telefônicos (6 e 12 meses depois), a probabilidade de resposta das puérperas foi modelada pelas variáveis disponíveis na pesquisa de base, a fim de corrigir, para a não resposta, os pesos amostrais em cada onda de seguimento.

Este artículo describe la muestra de la Encuesta Nacional sobre Partos y Nacimientos en Brasil. Los hospitales con 500 o más nacimientos en 2007 fueron estratificados por región, capital del estado o no, y tipo, y se seleccionan con probabilidad proporcional al número de nacidos vivos en 2007. Se utilizó un muestreo inverso para seleccionar los días de encuesta (mínimo 7), con el fin de lograr 90 entrevistas en el hospital. Se realizó el muestreo de las mujeres posparto, con igual probabilidad entre las mujeres elegibles que entraron en el hospital cada día. Los pesos iniciales son el inverso del producto de las probabilidades de inclusión en cada etapa y se calibraron para asegurar que las estimaciones del total de nacidos vivos correspondieran al total de nacidos vivos, obtenidos a partir de SINASC. Para los dos seguimientos telefónicos (6 y 12 meses después), la probabilidad de respuesta de las mujeres posparto fue modelada a partir de variables disponibles en la investigación básica, a fin de corregir, debido a la no-respuesta, los pesos de la muestra de cada ola de seguimiento.

This paper describes the sample design for the National Survey into Labor and Birth in Brazil. The hospitals with 500 or more live births in 2007 were stratified into: the five Brazilian regions; state capital or not; and type of governance. They were then selected with probability proportional to the number of live births in 2007. An inverse sampling method was used to select as many days (minimum of 7) as necessary to reach 90 interviews in the hospital. Postnatal women were sampled with equal probability from the set of eligible women, who had entered the hospital in the sampled days. Initial sample weights were computed as the reciprocals of the sample inclusion probabilities and were calibrated to ensure that total estimates of the number of live births from the survey matched the known figures obtained from the Brazilian System of Information on Live Births. For the two telephone follow-up waves (6 and 12 months later), the postnatal woman’s response probability was modelled using baseline covariate information in order to adjust the sample weights for nonresponse in each follow-up wave.

Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual / Intervenciones obstétricas durante el trabajo de parto y parto en mujeres brasileñas de bajo riesgo / Obstetric interventions during labor and childbirth in Brazilian low-risk women Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz

Este artigo avaliou o uso das boas práticas (alimentação, deambulação, uso de métodos não farmacológicos para alívio da dor e de partograma) e de intervenções obstétricas na assistência ao trabalho de parto e parto de mulheres de risco obstétrico habitual. Foram utilizados dados da pesquisa Nascer no Brasil, estudo de base hospitalar realizada em 2011/2012, com entrevistas de 23.894 mulheres. As boas práticas durante o trabalho de parto ocorreram em menos de 50% das mulheres, sendo menos frequentes nas regiões Norte, Nordeste e Centro-oeste. O uso de ocitocina e amniotomia foi de 40%, sendo maior no setor público e nas mulheres com menor escolaridade. A manobra de Kristeller, episiotomia e litotomia foram utilizada, em 37%, 56% e 92% das mulheres, respectivamente. A cesariana foi menos frequente nas usuárias do setor público, não brancas, com menor escolaridade e multíparas. Para melhorar a saúde de mães e crianças e promover a qualidade de vida, o Sistema Único de Saúde (SUS) e, sobretudo o setor privado, necessitam mudar o modelo de atenção obstétrica promovendo um cuidado baseado em evidências científicas.

Se evaluó el uso de buenas prácticas (alimentación, métodos no farmacológicos para el alivio del dolor, caminar y el uso del partograma), además de las intervenciones obstétricas durante el parto, en mujeres con un riesgo obstétrico habitual. Los datos provienen del estudio Nacer en Brasil, una cohorte de base hospitalaria realizada en 2011-2012, con entrevistas a 23.894 mujeres. Las buenas prácticas durante el parto se produjeron en menos de un 50% y fueron menos frecuentes en el Norte, Nordeste y Centro-oeste. El uso de oxitocina y amniotomía fue del 40%, principalmente, en el sector público y en las mujeres de menor nivel educativo. La presión fúndica uterina, episiotomía y litotomía fueron utilizados en: un 37%, 56% y 92% respectivamente. La cesárea fue menos frecuente en mujeres que son usuarias del sector público, no blancas, con menor nivel educativo y multíparas. Para mejorar la salud de las madres y los niños, y con el fin de promover la calidad de vida, el Sistema Único de Salud (SUS), y sobre todo el sector privado, necesitará cambiar el modelo de atención obstétrica mediante la adopción de evidencias científicas.

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.