Factors Associated with Preference for Vaginal Birth among Undergraduate Students from Southern Brazil.

BACKROUND: Cesarean rates in Brazil have reached over 50 percent of all births. Multiple factors have been studied aiming to explain these rates. Mode of delivery preferences among university students may provide insights into strategies to reduce those numbers. METHODS: A cross-sectional study was conducted enrolling students who attended Health Sciences and Human Sciences undergraduate programs in 2013. Participants answered a semi-structured questionnaire about which mode of delivery they considered the "best" (less risky and more beneficial) and the "preferred" mode (the one they would choose for themselves or their partners). Pearson chi-square was used to assess association among variables. Multiple regression analysis identified independent factors associated with the outcome measures. RESULTS: Among the 797 students who provided complete responses (76% response rate), the mean age was 22.6 years, 61.6 percent were female, 2.6 percent had previous pregnancies, and 56.7 percent were born by cesarean. Vaginal birth was chosen as the "best" mode of delivery by 91.2 percent, and the "preferred" mode by 75.5 percent of students. Being male, born vaginally, and a Health Sciences student was associated with a preference for vaginal birth. Being a Health Sciences student and born vaginally was associated with considering vaginal birth the "best" mode of delivery. CONCLUSIONS: Our findings indicate that the recognition of the benefits of vaginal birth do not always translate into a personal preference for vaginal birth. The student's own mode of birth was a strong predictor of their preferences for mode of delivery.

Maternal deaths among Brazilian indigenous women-Analysis from 2015 to 2021.

OBJECTIVE: This study examines maternal mortality among Brazilian indigenous women from 2015 to 2021, contrasting their causes of death with non-indigenous women. METHODS: An observational study utilizing Ministry of Health data analyzed maternal deaths' characteristics, comparing indigenous and non-indigenous groups based on death certificates and live-birth records. Variables included age, region, location, time, and cause of death. Maternal mortality ratios (MMR) were calculated with linear regression and outliers identified with Grubbs test. Prevalence ratios compared MMR and causes of death. RESULTS: Between 2015 to 2021, Brazil recorded 13 023 maternal deaths. Among these, with 205 among indigenous women (1.60% of total). Indigenous women had higher MMR (115.14/100 000), than non- indigenous women (66.92/100 000), consistently across years. Hemorrhagic causes notably contributed to the indigenous women's elevated MMR. CONCLUSION: Indigenous Brazilian women face elevated maternal mortality rates across all causes, primarily due to hemorrhage, contrasting wih national trends.

Medical students' personal choice for mode of delivery in Santa Catarina, Brazil: a cross-sectional, quantitative study.

BACKGROUND: The increase in overall rates of cesarean sections (CS) in Brazil causes concern and it appears that multiple factors are involved in this fact. In 2009, undergraduate students in the first and final years of medical school at the University of Santa Catarina answered questionnaires regarding their choice of mode of delivery. The aim of the study was to evaluate whether the education process affects decision-making regarding the way of childbirth preferred by medical students. METHODS: A cross-sectional, quantitative study was conducted based on data obtained from questionnaires applied to medical students. The questions addressed four different scenarios in childbirth, as follows: under an uneventful pregnancy; the mode of delivery for a pregnant woman under their care; the best choice as a healthcare manager and lastly, choosing the birth of their own child. For each circumstance, there was an open question to explain their choice. RESULTS: A total of 189 students answered the questionnaires. For any uneventful pregnancy and for a pregnant woman under their care, 8.46% of the students would opt for CS. As a healthcare manager, only 2.64% of the students would recommend CS. For these three scenarios, the answers of the students in the first year did not differ from those given by students in the sixth year. In the case of the student's own or a partner's pregnancy, 41.4% of those in the sixth year and 16.8% of those in the first year would choose a CS. A positive association was found between being a sixth year student and a personal preference for CS according to logistic regression (OR = 2.91; 95%CI: 1.03-8.30). Pain associated with vaginal delivery was usually the reason for choosing a CS. CONCLUSIONS: A higher number of sixth year students preferred a CS for their own pregnancy (or their partner's) compared to first year students. Pain associated with vaginal delivery was the most common reason given for haven chosen a CS. The students' preference for childbirth changed over time during their graduation in favor of cesarean sections. This finding deserves considerable attention when structuring medical education in Obstetrics.

Adequacy of Antenatal Care during the COVID-19 Pandemic: Observational Study with Postpartum Women.

OBJECTIVE: The present study aimed to evaluate the antenatal care adequacy for women who gave birth at the University Hospital of Santa Catarina in Florianopolis (Brazil) during the COVID-19 pandemic, and to evaluate the association of adequacy with sociodemographic, clinical, and access characteristics. METHODS: Data were collected between October and December 2020, including 254 patients who delivered in the University Hospital from Federal University of Santa Catarina and answered our questionnaires. Additional data were obtained from patients' antenatal booklets. Antenatal care was classified as adequate, intermediate, or inadequate according to the number of appointments, gestational age at the beginning of follow-up, and tests results. We carried out a descriptive statistical analysis and a bivariate/with odds ratio analysis on maternal sociodemographic, clinical and health access variables that were compared with antenatal adequacy. RESULTS: Antenatal care was considered adequate in 35.8% of cases, intermediate in 46.8%, and inadequate in 17.4%. The following maternal variables were associated with inadequate prenatal care (intermediate or inadequate prenatal care): having black or brown skin colour, having two or more children, being of foreign nationality, not being fluent in Portuguese, and using illicit drugs during pregnancy; the clinical variables were more than 6 weeks between appointments, and not attending high-risk antenatal care; as for access, the variables were difficulties in attending or scheduling appointments, and attending virtual appointments only. CONCLUSION: In a sample of pregnant women from a teaching hospital in Florianópolis during the COVID-19 pandemic, antenatal care was considered adequate in 35.8%, intermediate in 46.8%, and inadequate in 17.4% of cases.

OBJETIVO: O objetivo deste estudo foi avaliar a adequabilidade do pré-natal de puérperas atendidas no hospital universitário da Universidade Federal de Santa Catarina, em Florianópolis, durante a pandemia de COVID-19 e avaliar a associação de características sociodemográficas, clínicas e de acesso com essa adequabilidade. MéTODOS: Este estudo foi realizado de outubro a dezembro de 2020, com 254 puérperas que tiveram seus partos no hospital universitário. Os dados foram obtidos a partir de questionários respondidos pelas pacientes e dos seus cartões de pré-natal e prontuários para obter demais dados clínicos. O pré-natal foi classificado como adequado, intermediário ou inadequado segundo o número de consultas, idade gestacional ao início do pré-natal, e realização de exames. Inicialmente, se realizou uma análise estatística descritiva e, após, bivariada/com razão de chance quanto às variáveis maternas sociodemográficas, clínicas, e de acesso a saúde comparados com adequabilidade do pré-natal. RESULTADOS: O pré-natal foi considerado adequado em 35,8%, intermediário em 46,8% e inadequado em 17,4% dos casos. Estiveram associados a uma assistência pré-natal não-adequada (pré-natal intermediário ou inadequado) as seguintes variáveis maternas: cor de pele preta, parda, ou indígena, ter dois ou mais filhos, ser de nacionalidade estrangeira, não possuir fluência em português, uso de drogas ilícitas durante a gestação; as variáveis clinicas foram: lacuna de mais de 6 semanas entre consultas e não ser atendida em pré-natal de alto risco; quanto a acesso, as variáveis foram: dificuldade de ir e de agendar as consultas e ter tido consultas virtuais. CONCLUSãO: Em uma amostra de gestantes de um hospital universitário de Florianópolis durante a pandemia do Covid-19, a assistência pré-natal foi considerada adequada em 35,8%, intermediária em 46,8%, e inadequada em 17,4% dos casos.

Maternal mortality and COVID-19.

OBJECTIVE: The aim of this study was to collect and analyze data from different sources to have a general overview of COVID-19-related maternal deaths in Brazil, as well as to compare data with worldwide reports. STUDY DESIGN: We systematically searched data about COVID-19 maternal deaths from the Brazilian Ministry of Health surveillance system, State Departments of Health epidemiological reports, and media coverage. Data about timing of symptom onset and death (pregnancy or postpartum), gestational age, mode of birth, maternal age, comorbidities and/or risk factors, date of death, and place of death were retrieved when available. RESULTS: We identified 20 COVID-19-related maternal deaths, age range 20-43 years. Symptoms onset was reported as on pregnancy for 12 cases, postpartum for 3 cases, and during the cesarean section for 1 case (missing data for 4). In 16 cases, death occurred in the postpartum period. At least one comorbidity or risk factor was present in 11 cases (missing data for 4). Asthma was the most common risk factor (5/11). Ten cases occurred in the Northeast region, and nine cases occurred in the Southeast region (5 of them in São Paulo, the first epicenter of COVID-19 in the country). CONCLUSIONS: To the best of our knowledge, this is the largest available series of maternal deaths due to COVID-19. Barriers to access healthcare, differences in pandemic containment measures in the country and high prevalence of concomitant risk factors for COVID-19 severe disease may play a role in the observed disparity compared to worldwide reports on maternal outcomes.

[Prenatal care for normal-risk pregnant women by obstetric nurses and midwives: cost-effectiveness from the perspective of the Supplementary Health System in Brazil]. / Pré-natal de gestantes de risco habitual por enfermeira obstetra e obstetriz: custo-efetividade sob a perspectiva do Sistema de Saúde Suplementar.

In several countries, primary care for pregnant women is performed by obstetric nurses and/or midwives. In Brazil's Supplementary Health System (private health insurance and out-of-pocket care), coverage of prenatal care is mandatory and is performed by medical obstetricians. The objective of this study is to conduct a cost-effectiveness analysis, comparing clinical outcomes and costs associated with the incorporation of prenatal care by obstetric nurses and midwives in the Supplementary Health System, from the perspective of the operator of health plans as the payment source. A decision tree was built, based on data from a Cochrane Collaboration meta-analysis that showed a reduction in the risk of premature birth in the group of normal-risk pregnant women accompanied by obstetric nurses and midwives. The analysis only considered the direct medical costs covered by health plan operators for essential appointments and tests, according to the prevailing Ministry of Health protocol. The study assumed equal unit costs of consultations by medical professionals and applied an increase in the overall cost of prenatal tests associated with medical follow-up, based on data from the literature. Incremental cost-effective ratio was estimated at -BRL 10,038.43 (savings of BRL 10,038.43) per premature birth avoided. This result was consistent with the sensitivity analyses, with savings associated with the substitution ranging from -BRL 2,544.60 to -BRL 31,807.46 per premature death avoided. In conclusion, prenatal care provided by obstetric nurses and midwives was superior to that provided by medical obstetricians for the prevention of premature birth, besides resulting in cost savings.

Em diversos países, a atenção primária às gestantes é conduzida por enfermeiras obstetras e/ou obstetrizes. No Sistema Suplementar de Saúde no Brasil, a cobertura da assistência pré-natal é obrigatória e realizada por médicos obstetras. O objetivo deste estudo é conduzir análise de custo-efetividade, comparando desfechos clínicos e custos associados à incorporação do pré-natal por enfermeiras obstetras e obstetrizes no âmbito do Sistema de Saúde Suplementar, sob a perspectiva da operadora de planos de saúde como fonte pagadora. Foi construída uma árvore de decisão, baseada nos dados de metanálise da Colaboração Cochrane que mostrou redução do risco de parto prematuro no grupo de gestantes de risco habitual acompanhado por enfermeiras obstetras e obstetrizes. Foram considerados apenas os custos médicos diretos cobertos pelas operadoras de planos de saúde para a realização de consultas e exames essenciais, conforme protocolo do Ministério da Saúde vigente. Assumiu-se custo unitário de consulta com cada profissional como iguais e aplicou-se um aumento do custo global com exames pré-natais associado ao acompanhamento médico, conforme dado obtido na literatura. Estimou-se a razão de custo-efetividade incremental de -R$ 10.038,43 (economia de R$ 10.038,43) por parto prematuro evitado. Esse resultado mostrou-se consistente nas análises de sensibilidade, com economias associadas à substituição variando de -R$ 2.544,60 até -R$ 31.807,46 por parto prematuro evitado. Como conclusão, observou-se que o cuidado pré-natal por enfermeiras obstetras e obstetrizes é superior ao prestado por médicos obstetras para o desfecho prevenção de parto prematuro, resultando ainda em economia de recursos.

En diversos países, la atención primaria a las gestantes se realiza con enfermeras obstetras y/o parteras. En el Sistema Suplementario de Salud en Brasil, la cobertura de la asistencia prenatal es obligatoria y la realizan médicos obstetras. El objetivo de este estudio es realizar un análisis de costo-efectividad, comparando resultados clínicos y costes asociados a la incorporación en el período prenatal de enfermeras obstetras y parteras, en el ámbito del Sistema de Salud Suplementaria, desde la perspectiva de una operadora de planes de salud como fuente pagadora. Se construyó un árbol de decisión, basado en datos de metaanálisis de la Colaboración Cochrane, que mostró una reducción del riesgo de parto prematuro en el grupo de gestantes de riesgo habitual, con un seguimiento de enfermeras obstetras y parteras. Se consideraron solo los costes médicos directos, cubiertos por las operadoras de planes de salud para la realización de consultas y exámenes esenciales, conforme el protocolo vigente del Ministerio de Salud. Se asumió el coste unitario de consulta con cada profesional como iguales, y se aplicó un aumento del coste global con exámenes prenatales asociado al seguimiento médico, conforme los datos obtenidos en la literatura. Se estimó la razón de costo-efectividad incremental de -BRL 10.038,43 (economía de BRL 10.038,43) por parto prematuro evitado. Este resultado se mostró consistente en los análisis de sensibilidad, con ahorros asociados a la sustitución, variando de -BRL 2.544,60 hasta -BRL 31.807,46 por parto prematuro evitado. Como conclusión, se observó que el cuidado prenatal por parte de enfermeras obstetras y parteras es superior al prestado por médicos obstetras para el desenlace de prevención de parto prematuro, resultando incluso en un ahorro de recursos.

COVID-19-related deaths among women of reproductive age in Brazil: The burden of postpartum.

OBJECTIVE: To compare risk of death due to COVID-19 among pregnant, postpartum, and non-pregnant women of reproductive age in Brazil, using the severe acute respiratory syndrome surveillance system (SARS-SS). METHODS: A secondary analysis was performed of the Brazilian official SARS-SS, with data retrieved up to August 17, 2020. Cases were stratified by pregnancy status, risk factors or co-morbidities, and outcome (death or recovery). Multiple logistic regression was employed to examine associations between independent variables and risk of death. RESULTS: A total of 24 805 cases were included, with 3129 deaths (12.6%), including 271 maternal deaths. Postpartum was associated with increased risk of death, admission to the intensive care unit (ICU), and mechanical ventilation. Co-morbidities with higher impact on case fatality rate among non-obstetric cases were cancer and neurological and kidney diseases. Among pregnant women, cancer, diabetes mellitus, obesity, and rheumatology diseases were associated with risk of death. In the postpartum subgroup, age over 35 years and diabetes mellitus were independently associated with higher chance of death. CONCLUSION: Postpartum was associated with worse outcomes among the obstetric population, despite lower risk of dying without accessing ICU care. Non-pregnant women with cancer, neurological diseases, and kidney diseases have a higher risk of death due to COVID-19.

Planning, construction and use of handmade simulators to enhance the teaching and learning in Obstetrics.

METHOD: to describe the development process and present the results of a pilot study on the use of low-cost handmade simulators for teaching and learning Obstetrics.presentation of 3 low-cost simulators designing, based on educational needs identified in real-world training contexts. The developing process is presented in detail and each simulator was tested and re-tested, being submitted to improvements until their final version. The simulators presented are: delivery simulator shorts, Neoprene uterus for postpartum hemorrhage management, and perineal repair simulator. A pilot study was carried out to evaluate the perception of apprentices through a structured questionnaire, using the Kirkpatrick evaluation model. Data were descriptively analyzed. RESULTS: the respondents (31 apprentices) positively evaluated the simulators, perceiving significant gains in theoretical knowledge, ability to solve clinical problems and decreased anxiety to deal with situations similar to those simulated. CONCLUSION: low-cost, handmade simulators are feasible and effective, resulting in positive learner evaluations. Their availability as open technology allows the dissemination of their use.

Cesarean-section Rates in Brazil from 2014 to 2016: Cross-sectional Analysis Using the Robson Classification.

OBJECTIVE: To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. METHODS: A descriptive epidemiological study using data from secondary birth records from the Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. RESULTS: The overall rate of CS was of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. CONCLUSION: Over half of the births in Brazil were cesarean sections. The Midwest had the highest CS rates, while the North had the lowest. The largest obstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.

OBJETIVO: Identificar as taxas de cesárea de acordo com a Classificação de Robson nas cinco regiões do Brasil. MéTODOS: Estudo epidemiológico descritivo utilizando dados secundários obtidos do Departamento de Informática do Sistema Único de Saúde (Datasus) entre 1° de janeiro de 2014 e 31 de dezembro de 2016, incluindo todos os nascidos vivos no Brasil. RESULTADOS: Cesáreas representaram 56% de todos os nascimentos. A amostra foi dividida em 11 grupos, e partos vaginais foram mais frequentes nos grupos 1 (53,6%), 3 (80,0%) e 4 (55,1%). As maiores taxas de cesárea foram encontradas nos grupos 5 (85,7%), 6 (89,5%), 7 (85,2%) e 9 (97,0%). A taxa geral de cesárea variou de 46,2% no Norte a 62,1% no Centro-Oeste. O grupo 5 representou a maior população obstétrica no Sul, Sudeste e Centro-Oeste, e o grupo 3, no Norte e Nordeste. O grupo 5 contribuiu mais para a taxa geral de cesárea, totalizando 30,8%. CONCLUSãO: Mais da metade dos nascimentos no Brasil ocorreu por cesárea. O Centro-Oeste apresentou a maior taxa, e o Norte, a mais baixa. A maior população obstétrica no Norte e no Nordeste foi o grupo 3, enquanto no Sul, Sudeste e Centro-Oeste foi o grupo 5. Entre todas as regiões, a maior contribuição para a taxa geral de cesárea foi do grupo 5.

Risk factors for adverse outcomes among pregnant and postpartum women with acute respiratory distress syndrome due to COVID-19 in Brazil.

OBJECTIVE: To evaluate whether clinical and social risk factors are associated with negative outcomes for COVID-19 disease among Brazilian pregnant and postpartum women. METHODS: A secondary analysis was conducted of the official Acute Respiratory Syndrome Surveillance System database. Pregnant and postpartum women diagnosed with COVID-19 ARDS until July 14, 2020, were included. Adverse outcomes were a composite endpoint of either death, admission to the intensive care unit (ICU), or mechanical ventilation. Risk factors were examined by multiple logistic regression. RESULTS: There were 2475 cases of COVID-19 ARDS. Among them, 23.8% of women had the composite endpoint and 8.2% died. Of those who died, 5.9% were not hospitalized, 39.7% were not admitted to the ICU, 42.6% did not receive mechanical ventilation, and 25.5% did not have access to respiratory support. Multivariate analysis showed that postpartum period, age over 35 years, obesity, diabetes, black ethnicity, living in a peri-urban area, no access to Family Health Strategy, or living more than 100 km from the notification hospital were associated with an increased risk of adverse outcomes. CONCLUSION: Clinical and social risk factors and barriers to access health care are associated with adverse outcomes among maternal cases of COVID-19 ARDS in Brazil.

Assistência ao parto pélvico / Breech birth assistance

É imprescindível retomar o ensino da versão cefálica externa e das manobras tocúrgicas no parto pélvico vaginal, tanto em litotomia quanto na posição vertical. A adoção de protocolos rígidos para o parto pélvico vaginal planejado correlaciona-se com taxa de sucesso de aproximadamente 70% e taxas de resultados adversos inferiores a 7%. A morbimortalidade fetal e neonatal é semelhante à de cesárea planejada. Gestantes elegíveis para o parto pélvico vaginal devem concordar com a via de parto, possuir baixo risco de complicações e ser assistidas por profissionais com experiência em parto vaginal de apresentações anômalas e suas manobras obstétricas. Cesariana prévia e prematuridade entre 32 e 36 semanas não são contraindicações absolutas ao parto pélvico vaginal, devendo ser individualmente avaliadas na decisão da via de parto. Neonatologistas devem estar presentes no nascimento de fetos pélvicos, e um exame neonatal completo deve ser realizado. A rotação posterior do dorso fetal, o prolapso de cordão umbilical, a deflexão dos braços e/ou do polo cefálico e o encarceramento da cabeça derradeira são as principais distocias relacionadas à assistência ao parto pélvico por via vaginal. Todo profissional que assiste parto pélvico vaginal deve estar capacitado para a resolução adequada desses eventos. No parto pélvico vaginal em litotomia, as principais manobras para o auxílio ao desprendimento da pelve fetal são a tração inferior bidigital na prega inguinal e a manobra de Pinard; para o desprendimento do tronco fetal, as de Rojas, Deventer-Miler e Pajot; e para o desprendimento da cabeça derradeira, as de Mauriceau, Bracht, Champetier de Ribes e Praga e o parto vaginal operatório com o fórcipe de Piper. As posições não litotômicas no parto pélvico vaginal se associam à redução dos períodos de dilatação e expulsão, da taxa de cesariana, da necessidade de manobras para extração fetal e da taxa de lesões neonatais. No parto pélvico vaginal assistido na posição de quatro apoios, os aspectos a serem observados durante o desprendimento do corpo fetal incluem o tônus dos membros inferiores fetais, a rotação correta do tronco fetal (abdome fetal voltado para o dorso materno), o ingurgitamento vascular do cordão umbilical, a presença dos cotovelos e das pregas do tórax fetal e a dilatação anal materna. No parto pélvico vaginal assistido na posição de quatro apoios, mais da metade dos fetos se desprendem sem a necessidade de nenhuma manobra. Habitualmente, apenas duas manobras podem ser necessárias: uma para auxílio à saída dos ombros ("rotação 180°-90°") e outra para desprendimento da cabeça fetal ("Frank nudge").

[Obstetric care models in the Southern Region of Brazil and associated factors]. / Modelos de assistência obstétrica na Região Sul do Brasil e fatores associados.

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

Os objetivos do estudo foram identificar modelos de assistência obstétrica em gestantes de risco habitual na Região Sul do Brasil, estimar os fatores associados a esses modelos e os desfechos maternos e neonatais. Realizou-se estudo seccional a partir da pesquisa Nascer no Brasil, de base hospitalar, que envolveu puérperas e recém-nascidos. Foram identificadas 2.668 gestantes de risco habitual. Procedeu-se a uma análise exploratória, com a utilização da proporção de práticas por hospital, entre elas o desencadeamento do trabalho de parto, a presença de acompanhante, a cesárea e o contato pele a pele, para a obtenção de modelos de assistência obstétrica denominados Boas Práticas, Intervencionista I e Intervencionista II. Em seguida, realizou-se uma análise inferencial das características associadas. Os resultados mostraram que o acesso ao financiamento público ou privado, os fatores culturais e a atuação dos profissionais de saúde apresentaram associações com os modelos de assistência. A assistência pública apresentou diferentes contextos: um primeiro, alicerçado em políticas públicas e na prática baseada em evidência; um segundo, baseado na intencionalidade pelo parto vaginal, sem considerar os princípios de humanização. Já a assistência privada é padronizada e centrada no profissional médico, com maiores níveis de intervenção. Conclui-se que há predomínio dos modelos de assistência obstétrica intervencionistas na Região Sul do Brasil, uma assistência na contramão das melhores evidências, e que as mulheres assistidas em hospitais públicos possuem mais chance de serem beneficiadas com as boas práticas.

Los objetivos del estudio fueron identificar modelos de asistencia obstétrica en gestantes de riesgo habitual en la región sur de Brasil, estimar los factores asociados a estos modelos y los desenlaces maternos y neonatales. Es un estudio transversal, a partir de la pesquisa Nascer no Brasil, de base hospitalaria, compuesta por puérperas y recién nacidos. Se identificaron a 2.668 gestantes de riesgo habitual. Se procedió a un análisis exploratorio utilizando la proporción de prácticas por hospital, entre ellas el desencadenamiento de la labor de parto, presencia de acompañante, cesárea y contacto piel a piel, para la obtención de modelos de asistencia obstétrica, denominados Buenas Prácticas, Intervencionista I, e Intervencionista II; seguido de un análisis inferencial de las características asociadas. Los resultados mostraron que el acceso a la financiación pública o privada, factores culturales y la actuación de los profesionales de salud presentaron asociaciones con los modelos de asistencia. La asistencia pública presentó diferentes contextos, el primero basado en políticas públicas y en la práctica fundamentada en la evidencia; y un segundo, que sugiere la intencionalidad del parto vaginal sin considerar los principios de humanización; mientras que la asistencia privada está estandarizada y centrada en el profesional médico, con mayores niveles de intervención. Se concluye que existe un predominio de los modelos de asistencia obstétrica intervencionistas en la región sur de Brasil, una asistencia a contracorriente de las mejores evidencias, así como que las mujeres asistidas en hospitales públicos tienen una mayor oportunidad de beneficiarse de las buenas prácticas.

Prevalence of sexually transmitted infections and bacterial vaginosis among lesbian women: systematic review and recommendations to improve care.

Our aim was to systematically review data about the risk of sexually transmitted infections (STI) and bacterial vaginosis among lesbian women and to suggest strategies to improve prevention, diagnosis and treatment. A search strategy for lesbian, STI and bacterial vaginosis was applied to PubMed, LILACS and BDENF databases. Of 387 unique references retrieved, 22 fulfilled the inclusion criteria (cross-sectional studies reporting prevalence for 8 STIs/bacterial vaginosis and history of a STI). The most frequent infection reported was bacterial vaginosis, and none study reported data on hepatitis B. A wide range of prevalence was observed for most infections. In terms of risk factors, the number of sexual partners, the past or current smoking, a history of forced sex and sexual stigma seem to increase the risk of STI and bacterial vaginosis. The findings of this review are discussed considering guidelines directly addressing the LGBT community's health and relevant studies investigating both safe sexual practices and the intricate relationship between LGBT people and their care providers. A set of recommendations to improve preventive care for lesbian women is proposed. Affirming that little is known about the extent of STIs and bacterial vaginosis transmission in female-to-female sexual activities or about the risk factors for STI and bacterial vaginosis among lesbian women is reasonable. In fact, the overall quality of the studies was low or very low with significant uncertainty around their findings. However, we consider that the available knowledge indicates some paths to be followed by care providers and policy decision-makers to improve their actions towards better sexual health of lesbian women.

The pain reported by postpartum women in rooming-in according to the mode of delivery / Dor relatada por puérperas no alojamento conjunto segundo a via de nascimento

ABSTRACT BACKGROUND AND OBJECTIVES: Pain is the most frequently reported symptom in the immediate puerperium. The aim of this study was to quantify pain levels and sociodemographic, obstetric, and care characteristics associated with severe pain and inadequate analgesia according to the mode of delivery. METHODS: Observational, descriptive, cross-sectional study conducted between October and December 2020, with a sample of 229 postpartum women considered eligible (baby born alive, weighing > 500 g and/or gestational age > 22 weeks) to answer the study questionnaire. RESULTS: The mean reported pain was 5.34 by Visual Analogue Scale (VAS) and there was a difference (p<0.001) between modes of delivery. Cesarean section was associated with severe pain (p=0.006) and pain above eight on the VAS (p=0.02). Vaginal delivery was associated with the perception of inadequate analgesia (p=0.04). Severe pain reported was associated with the admission of the baby to the ICU (p=0.01) and cases of postpartum hemorrhage (p=0.002). Among women who gave birth vaginally, there was an association between severe pain and instrumental delivery (p=0.05). Reported severe pain was associated with difficulties in self-care (p<0.001) and care of the newborn (p= 0.02), sensation of weakness (p<0.001), and fainting (p=0.002). The perception of inadequate analgesia was associated with vaginal birth (p=0.04) end non-white skin color (p=0,03). CONCLUSION: The average reported pain was moderate. Intense pain and the perception of inadequate analgesia were associated with instrumental delivery, newborns being referred to the NICU, postpartum hemorrhage, and non-white skin color.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor é o sintoma mais frequentemente relatado no puerpério imediato. O objetivo deste estudo foi quantificar os níveis de dor e as características sociodemográficas, obstétricas e da assistência associadas à dor intensa e à percepção de analgesia inadequada segundo a via de nascimento. MÉTODOS: Estudo observacional, descritivo, transversal, conduzido entre outubro e dezembro de 2020, com uma amostra de 229 puérperas consideradas elegíveis (nativivos com peso > 500g e/ou idade gestacional > 22 semanas) para responder ao questionário do estudo. RESULTADOS: A média de dor relatada foi 5,3 pela Escala Analógica Visual (EAV) e houve diferença (p<0,001) entre as vias de nascimento. A cesariana apresentou associação com dor intensa referida (p=0,006) e dor acima de oito pela EAV (p=0,02). O parto vaginal obteve associação com percepção de analgesia inadequada (p=0,04). Entre as mulheres que referiram dor intensa, houve associação com recém-nascido encaminhado à unidade de terapia intensiva neonatal (UTIN) (p=0,01) e nos casos de hemorragia pós-parto (p=0,002). Entre as mulheres que tiveram parto vaginal, também houve associação entre dor intensa e o parto instrumental (p=0,05). Dor intensa referida teve associação com dificuldades para o autocuidado (p<0,001) e do recém-nascido (p=0,02), sensação de fraqueza (p<0,001) e de desmaio (p= 0,002). A percepção de analgesia inadequada esteve associada a parto vaginal (p=0,04) e cor da pele não branca (p=0,03). CONCLUSÃO: A média de dor relatada foi moderada. Dor intensa e percepção de analgesia inadequada estiveram associadas com parto instrumental, recém-nascido encaminhado à UTIN, hemorragia pós-parto e cor de pele não branca.

Support actions undertaken for the woman by companions in public maternity hospitals.

OBJECTIVE: to identify the support actions undertaken for the woman during labor, birth, cesarean section and the postpartum period. METHOD: a transversal study, undertaken in three public maternity hospitals, with a sample of 1,147 companions. The data were collected through interviews and were analyzed using descriptive statistics. The support actions were classified in four dimensions: emotional, physical, informational and relating to intermediation. RESULTS: the majority of interviewees were the partner/father of the baby (76.7%). In labor, birth and the postpartum period, the actions of emotional support - such as calming, encouraging and praising, were performed by more than 80.0% of the companions; informational support, by approximately 70.0%; and intermediation by fewer than 65.0% of them. In childbirth, the emphasis on physical support was observed in assisting with walking (84.4%), and in changing position (90.4%). CONCLUSION: the companions participate actively in the birth process, performing actions of support in the four dimensions. Emotional support is the most frequent, followed by physical and informational support, mainly during labor and birth. The results contribute to valuing the companion from the woman's social network in the birth scenario and to the recognition of his/her role as a provider of support.

A Simple, Reproducible and Low-cost Simulator for Teaching Surgical Techniques to Repair Obstetric Anal Sphincter Injuries.

OBJECTIVE: To describe and evaluate the use of a simple, low-cost, and reproducible simulator for teaching the repair of obstetric anal sphincter injuries (OASIS). METHODS: Twenty resident doctors in obstetrics and gynecology and four obstetricians participated in the simulation. A fourth-degree tear model was created using low-cost materials (condom simulating the rectal mucosa, cotton tissue simulating the internal anal sphincter, and bovine meat simulating the external anal sphincter). The simulator was initially assembled with the aid of anatomical photos to study the anatomy and meaning of each component of the model. The laceration was created and repaired, using end-to-end or overlapping application techniques. RESULTS: The model cost less than R$ 10.00 and was assembled without difficulty, which improved the knowledge of the participants of anatomy and physiology. The sutures of the layers (rectal mucosa, internal sphincter, and external sphincter) were performed in keeping with the surgical technique. All participants were satisfied with the simulation and felt it improved their knowledge and skills. Between 3 and 6 months after the training, 7 participants witnessed severe lacerations in their practice and reported that the simulation was useful for surgical correction. CONCLUSION: The use of a simulator for repair training in OASIS is affordable (low-cost and easy to perform). The simulation seems to improve the knowledge and surgical skills necessary to repair severe lacerations. Further systematized studies should be performed for evaluation.

OBJETIVO: Descrever e avaliar a utilização de um simulador simples, de baixo custo e reprodutível para o ensino de sutura de lacerações perineais de 4° grau. MéTODOS: Participaram da simulação 20 residentes de ginecologia e obstetrícia e quatro profissionais especialistas. Um modelo de laceração de 4° grau foi criado com materiais de baixo custo (preservativo simulando a mucosa retal, tecido de algodão simulando o esfíncter anal interno e carne bovina simulando o esfíncter anal externo). O simulador foi inicialmente montado com ajuda de fotos anatômicas, para estudar a anatomia e o significado de cada componente do modelo. A laceração foi criada e suturada, utilizando técnicas de borda a borda e de sobreposição do esfíncter anal. RESULTADOS: O modelo custou menos de R$ 10,00 e foi montado sem dificuldade, aprimorando os conhecimentos dos participantes sobre anatomia e fisiologia. As suturas das camadas (mucosa retal, esfíncter interno e esfíncter externo) foram realizadas seguindo a técnica cirúrgica. Todos os participantes ficaram satisfeitos com a simulação e consideraram que esta melhorou seus conhecimentos e habilidades. Entre 3 a 6 meses após o treinamento, 7 participantes presenciaram em sua prática lacerações graves e relataram que a simulação foi útil para a correção cirúrgica. CONCLUSãO: A utilização de um simulador para treinamento de sutura de lacerações obstétricas graves é acessível (baixo custo e fácil execução). A simulação parece aprimorar conhecimentos e habilidades cirúrgicas para sutura de lacerações graves. Mais estudos sistematizados devem ser realizados para avaliação.