Health facility structure and maternal characteristics related to essential newborn care in Brazil: a cross-sectional study.

OBJECTIVES: To assess the use of the WHO's Essential Newborn Care (ENC) programme items and to investigate how the non-use of such technologies associates with the mothers' characteristics and hospital structure. DESIGN: A cross-sectional observational health facility assessment. SETTING: This is a secondary analysis of the 'Birth in Brazil' study, a national population-based survey on postnatal women/newborn babies and of 266 publicly and privately funded health facilities (secondary and tertiary level of care). PARTICIPANTS: Data on 23 894 postnatal women and their newborn babies were analysed. MAIN OUTCOME MEASURES: The facility structure was assessed by evaluating the availability of medicines and equipment for perinatal care, a paediatrician on call 24/7, a neonatal intensive care unit (NICU) and kangaroo mother care. The use of each ENC item was assessed according to the health facility structure and the mothers' sociodemographic characteristics. RESULTS: The utilisation of ENC items is low in Brazil. The factors associated with failure in pregnant woman reference were: pregnant adolescents (ORadj 1.17; 95% CI 1.06 to 1.29), ≤7 years of schooling (ORadj 1.47; 95% CI 1.22 to 1.78), inadequate antenatal care (ORadj 1.67; 95% CI 1.47 to 1.89). The non-use of corticosteroids was more frequently associated with the absence of an NICU (ORadj 3.93; 95% CI 2.34 to 6,66), inadequate equipment and medicines (ORadj 2.16; 95% CI 1.17 to 4.01). In caesarean deliveries, there was a less frequent use of a partograph (ORadj 4,93; 95% CI 3.77 to 6.46), early skin-to-skin contact (ORadj 3.07; 95% CI 3.37 to 4.90) and breast feeding in the first hour after birth (ORadj 2.55; 95% CI 2.21 to 2.96). CONCLUSIONS: The coverage of ENC technologies use is low throughout Brazil and shows regional differences. We found a positive effect of adequate structure at health facilities on antenatal corticosteroids use and on partograph use during labour. We found a negative effect of caesarean section on early skin-to-skin contact and early breast feeding.

Birth in Brazil: national survey into labour and birth.

BACKGROUND: Caesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction. METHODS: Nationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients' medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson's groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design. DISCUSSION: This study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it's consequences on postnatal health.

Trajetória das mulheres na definição pelo parto cesáreo: estudo de caso em duas unidades do sistema de saúde suplementar do estado do Rio de Janeiro / The decision of women for cesarean birth: a case study in two units of the supplementary health care system of the State of Rio de Janeiro

No Brasil, as taxas de cesariana são bastante elevadas, principalmente nos serviços privados, estando provavelmente associadas a fatores socioeconômicos e culturais. O objetivo deste estudo foi descrever as características socioeconômicas, demográficas, culturais e reprodutivas de puérperas e os determinantes da decisão por parto cesáreo em duas unidades do sistema de saúde suplementar do Estado do Rio de Janeiro. A população foi composta por 437 puérperas que tiverem partos vaginais ou cesarianos nas duas unidades selecionadas. Os dados foram coletados por meio de entrevistas com as mães e consulta aos prontuários. Através de regressão logística não condicional, avaliaram-se os fatores associados à decisão por cesariana como via de parto, seguindo os modelos hierárquicos estabelecidos em três momentos definidos: no início, ao longo da gestação e no momento do parto. Observou-se que, embora 70 por cento das entrevistadas não relatassem preferência inicial pela cesariana, 90 por cento apresentaram esse tipo de parto. Verificou-se que, independente do desejo inicial da gestante, a interação com o serviço de saúde resultou na cesariana como via final de parto. Trabalhos educativos direcionados às gestantes e à população geral e mudanças no modelo de assistência ao parto podem ser estratégias promissoras para a reversão desse quadro.

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70 percent of the women had no initial preference for cesarean section, 90 percent of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.

[The decision of women for cesarean birth: a case study in two units of the supplementary health care system of the State of Rio de Janeiro]. / Trajetória das mulheres na definição pelo parto cesáreo: estudo de caso em duas unidades do sistema de saúde suplementar do estado do Rio de Janeiro.

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70% of the women had no initial preference for cesarean section, 90% of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.

Cesarianas desnecessárias: causas, conseqüências e estratégias para sua redução

Relatório de projeto de pesquisa sobre causas, conseqüências e estratégias de redução de cesarianas, no âmbito da saúde suplementar, produto de parceria entre a Agência Nacional de Saúde Suplementar e a Escola Nacional de Saúde Pública Sergio Arouca iniciada em 2006. O projeto foi dividido em três subprojetos que investigam o problema em três abordagens distintas: (1) análise da freqüência e adequação de indicação de partos cesáreos no Estado do Rio de Janeiro, com o objetivo de conhecer a trajetória da escolha/definição da via de parto operatória e avaliar a adequação das indicações de parto cesáreo; (2) análise da evolução das taxas de cesariana no Brasil nos últimos dez anos a partir dos dados do SINASC; e revisão sistemática da literatura de 2001 a 2006, para descrever as principais estratégias estudadas para reduzir cesarianas desnecessárias