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Background: The study aims to assess agreement between data obtained from interviews with postpartum women and their health records about labor and birth characteristics, newborn care, and reasons for cesarean birth. Methods: The present study analyzes the Birth in Brazil study dataset, a nationwide hospital‐based survey that included 23,894 postpartum women. Reliability was assessed using kappa coefficients and 95% confidence intervals. We also calculated the proportion of specific agreement: the observed proportion of positive agreement (Ppos) and the observed proportion of negative agreement (Pneg). Results: In terms of labor and birth characteristics, more significant discrepancies in prevalence were observed for fundal pressure (1.4%–42.6%), followed by amniotomy, and augmentation. All of these variables were reported more frequently by women. Reliability was nearly perfect only for mode of delivery (kappa 0.99–1.00, Ppos and Pneg >99.0%). Higher discrepancies in reasons for cesarean prevalence were observed for previous cesarean birth (CB) (3.9%–10.4%) and diabetes mellitus (0.5%–8.5%). Most kappa coefficients for CB reasons were moderate to substantial. Lower coefficients were seen for diabetes mellitus, induction failure, and prelabor rupture of membranes and Pneg was consistently higher than Ppos. Discussion: Our findings raise relevant questions about the quality of information shared with women during and after the process of care for labor and birth, as well as the information recorded in medical charts. Not having access to full information about their own health status at birth may impair women's health promotion behaviors or clear disclosure of risk factors in future interactions with the healthcare system. [ABSTRACT FROM AUTHOR]

The high incidence of Zika virus (ZIKV) infection in the period of 2015–2016 in Brazil may have affected linear height growth velocity (GV) in children exposed in utero to ZIKV. This study describes the growth velocity and nutritional status based on the World Organization (WHO) standards of children exposed to ZIKV during pregnancy and followed up in a tertiary unit, a reference for tropical and infectious diseases in the Amazon. Seventy-one children born between March 2016 and June 2018 were monitored for anthropometric indices: z-score for body mass index (BMI/A); weight (W/A); height (H/A) and head circumference (HC/A); and growth velocity. The mean age at the last assessment was 21.1 months (SD ± 8.93). Four children had congenital microcephaly and severe neurological impairment. The other 67 were non-microcephalic children (60 normocephalic and 7 macrocephalic); of these; 24.2% (16 children) had neurological alterations, and 28.8% (19 children) had altered neuropsychomotor development. Seventeen (24.2%) children had inadequate GV (low growth velocity). The frequencies of low growth among microcephalic and non-microcephalic patients are 25% (1 of 4 children) and 23.9% (16 of 67 children); respectively. Most children had normal BMI/A values during follow-up. Microcephalic patients showed low H/A and HC/A throughout the follow-up, with a significant reduction in the HC/A z-score. Non-microcephalic individuals are within the regular ranges for H/A; HC/A; and W/A, except for the H/A score for boys. This study showed low growth velocity in children with and without microcephaly, highlighting the need for continuous evaluation of all children born to mothers exposed to ZIKV during pregnancy. [ABSTRACT FROM AUTHOR]

Background: In 2015, a quality improvement (QI) intervention to reduce cesarean sections (CS)—the Adequate Childbirth Project (PPA)—was implemented in the private sector in Brazil. This analysis aims to compare safety care measures and adverse outcomes between women exposed to the PPA intervention to those receiving standard care. Methods: The analysis included a convenience sample of 12 private hospitals that participated in the PPA (2017–2018). Data collection was performed through chart review and interviews. Differences in 15 outcomes were examined using Pearson's chi-square test and multiple logistic regressions. Results: The final weighted sample was comprised of 4789 births, 2570 in the PPA group (53.5%) and 2227 in the standard care group (46.5%). CS rate was significantly lower in the PPA group (67.3% vs 88.8%). After adjusting for potential confounders, PPA model was associated with decreased overall CS rate (OR = 0.30, 95% CI 0.24 to 0.36), as well as prelabor (OR = 0.41, 0.34 to 0.48) and repeated CS (OR = 0.45, 0.29 to 0.70). In terms of other safety care measures, women in the PPA model had an increased chance of absence of antibiotic prophylaxis in Group B Streptococcus (GBS) + women (OR = 4.63, 1.33 to 16.14) and for CSs (OR = 1.75, 1.38 to 2.22), while those with severe hypertension were less likely to not receiving magnesium sulphate (OR = 0.27, 0.09 to 0.77). Regarding obstetric and neonatal outcomes, PPA model was associated with a decreased chance of having an obstetric anal sphincter injury (OASI) following an episiotomy (OR = 0.34, 0.13 to 0.89), requiring antibiotics other than routine prophylaxis (OR = 0.84, 0.70 to 0.99), having a late preterm (OR = 0.36, 0.27 to 0.48) or early term baby (OR = 0.81, 0.70 to 0.94). There were no statistically significant differences for other outcomes. Conclusions: The PPA intervention was able to reduce CS rates, late preterm and early term deliveries without increasing the chance of adverse outcomes. The bidirectional effect on safety care measures reinforces that QI initiatives includes closer observation of routine care when implementing interventions to reduce C-section rates. Plain Language Summary: Cesarean section rates in Brazil are among the highest in the world, particularly in private hospitals. In 2015, a quality improvement project was implemented in private hospitals aiming to reduce the cesarean section (CS) rates (the Adequate Childbirth Project—PPA). In the 2017–2018 period, the Healthy Birth Study (HBS) was proposed to assess the effect of the PPA project in CS rates, as well as use of obstetric interventions, adoption of good practices during labor and birth care and outcomes for both women and their babies. This article presents the comparison of 4873 births analyzed in the HBS, 2589 who were exposed to the PPA project and 2284 who received standard care. The analysis aim was to compare CS rates at the same time to assess if women who were part of the PPA intervention were less likely to have a negative event for themselves or their babies. A group of 15 measures of safety of obstetric care and negative outcomes for women and their babies was compared. Women who were exposed to the PPA intervention had a lower chance of CS, late preterm and early term deliveries. At the same time, the PPA group did not have worse outcomes for women or babies. In terms of safety care, the PPA intervention was associated with both positive and negative effects. For instance, women exposed to the PPA group had a higher chance of not receiving antibiotics to prevent infections when they needed, when compared to standard care. [ABSTRACT FROM AUTHOR]

Background: In 2015, a quality improvement project—the "Adequate Childbirth Project" (Projeto Parto Adequado, or PPA)—was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals. Methods: Cross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test. Results: 4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including "oral fluid and food", "maternal mobility and position", "monitoring of labor", "use of non-pharmacological methods for pain relief" and "epidural analgesia for pain relief" in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors. Conclusions: There was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges. Plain Language Summary: Brazil has a high rate of cesarean sections with low participation of nurse-midwives in childbirth care. Nurse-midwife care is associated with less use of interventions, lower proportions of cesarean sections and greater women's satisfaction. In 2015, a quality improvement project, called the "Adequate Childbirth Project" (Projeto Parto Adequado, PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean sections. One of its components is the expansion of nurse-midwives in labor and childbirth care. In this study, we evaluated the results of PPA on childbirth care by nurse-midwives. Data were collected in 12 hospitals with interviews with 4798 women. Women assisted in the PPA model of care had a higher proportion of labor and vaginal birth, but there was no increase in the proportion of women assisted by nurse-midwives, neither during labor nor vaginal birth. The use of recommended practices was adequate, except for the use of epidural analgesia, with greater use of some recommended practices in women assisted by nurse-midwives compared to those seen only by doctors. However, we observed excessive use of non-recommended practices during labor, both by doctors and nurses. We can conclude that there was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and a greater use of recommended practices in women assisted by nurse-midwives, but without an increase in the proportion of women assisted by nurses. The expansion of nurse-midwives' participation in childbirth care and the reduction of non-recommended practices therefore continue to be challenges. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: In 2015, a quality improvement project—the "Adequate Childbirth Project" (Projeto Parto Adequado, or PPA)—was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals. Methods: Cross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test. Results: 4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including "oral fluid and food", "maternal mobility and position", "monitoring of labor", "use of non-pharmacological methods for pain relief" and "epidural analgesia for pain relief" in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors. Conclusions: There was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges. Plain Language Summary: Brazil has a high rate of cesarean sections with low participation of nurse-midwives in childbirth care. Nurse-midwife care is associated with less use of interventions, lower proportions of cesarean sections and greater women's satisfaction. In 2015, a quality improvement project, called the "Adequate Childbirth Project" (Projeto Parto Adequado, PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean sections. One of its components is the expansion of nurse-midwives in labor and childbirth care. In this study, we evaluated the results of PPA on childbirth care by nurse-midwives. Data were collected in 12 hospitals with interviews with 4798 women. Women assisted in the PPA model of care had a higher proportion of labor and vaginal birth, but there was no increase in the proportion of women assisted by nurse-midwives, neither during labor nor vaginal birth. The use of recommended practices was adequate, except for the use of epidural analgesia, with greater use of some recommended practices in women assisted by nurse-midwives compared to those seen only by doctors. However, we observed excessive use of non-recommended practices during labor, both by doctors and nurses. We can conclude that there was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and a greater use of recommended practices in women assisted by nurse-midwives, but without an increase in the proportion of women assisted by nurses. The expansion of nurse-midwives' participation in childbirth care and the reduction of non-recommended practices therefore continue to be challenges. [ABSTRACT FROM AUTHOR]

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Background: There is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances.Methods and Findings: We conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available.Conclusions: In this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality. [ABSTRACT FROM AUTHOR]

The article analyzes the opinions of a group of women regarding the standard of care at maternity facilities attached to the Ministry of Health's Programa Rede Cegonha or Stork Network Program. The women's views were obtained from a questionnaire administered to 10,665 puerperal women between 2016 and 2017 as part of the survey Evaluation of good labor and childbirth care practices in maternity facilities covered by the Rede Cegonha, conducted by the Oswaldo Cruz Foundation and Maranhão Federal University. Consisting mainly of closed-ended questions, the questionnaire contained an optional open-ended question at the end that allowed women to talk freely about the standard of care received in the maternity facility. Of the 10,665 puerperal women interviewed, 2,069 gave their opinions. We undertook a critical reading of the opinions identifying four core themes, which were discussed in the light of the relevant literature: puerperal woman/health team relationship; puerperal women's right to information; presence of a companion; and quality of hospital services and facilities. Giving both praise and criticism, all the women reiterated the importance of improving the quality of public health services to ensure the humanization of childbirth in Brazil. [ABSTRACT FROM AUTHOR]

This article compares the findings of "Avaliação da Rede Cegonha" (ARC - Stork Network Assessment), an evaluative study on the Rede Cegonha (RC - Stork Network) program, with Nascer no Brasil (NB - Born in Brazil), a national survey on labor and birth, conducted in 2011-12, before the start implementation of RC. ARC was conducted in 2017, in 606 maternity hospitals involved in RC and NB included a sample with national representation of 266 hospitals. In the current analysis, we included the 136 SUS hospitals that participated in both studies, totaling 3,790 and 12,227 puerperal women. We perform comparisons of best practices and interventions in the management of labor and delivery using Pearson's chi-square test for independent samples. The prevalence of best practices was, on average, 150% higher in ARC than in NB, with a greater relative increase in less developed regions, for older, brown and black women and less educated. Regarding interventions, there was an average reduction of 30% between NB and ARC, with a greater relative reduction in less developed regions and less educated women. There was a significant improvement in the scenario of care for labor and childbirth, with a reduction in regional, educational and racial inequalities in access to appropriate technologies, suggesting that the RC intervention was effective. [ABSTRACT FROM AUTHOR]

Gestational smoking is associated with various adverse maternal and fetal outcomes. Over the last three decades, despite considerable advances in tobacco control policy in Brazil, gestational smoking has caused a considerable number of fetal deaths and disabilities. The aim of this study is to estimate the prevalence of pre-gestational and gestational smoking and to identify the factors associated with smoking cessation up to the 20th gestational week. Methods: “Birth in Brazil” was a nationwide hospital-based study conducted from February 2011 to October 2012. Smoking prevalence and smoking cessation during pregnancy was estimated through face-to-face interviews with postpartum women during hospitalization for birth care. We performed multivariate logistic regression to verify the factors associated with smoking cessation up to the 5th month of pregnancy. Results: prevalence of pre-gestational smoking of 16.1% (CI 95% 15.3%-16.9%); prevalence of smoking any time during pregnancy of 9.6% (CI 95% 9.0%-10.3%); and prevalence of smoking cessation up to the 5th month of pregnancy of 56.7% (CI 95% 54.0%-59.4%). The factors associated with smoking cessation were residence in the North, Northeast, and Central-West of Brazil, having received at least one prenatal consultation (OR 3.51 CI 95% 1.85–6.67), more years of schooling (15 or more vs less than 7 years of schooling OR 5.54 CI 95% 2.97–10.34), living with a partner (OR 1.35 CI 95% 1.01–1.79), no children prior to the index pregnancy (OR 2.77 CI 95% 2.13–3.61), and absence of alcohol use (1.74 CI 95% 1.39–2.18) or of suspected alcohol abuse (OR 1.62 CI 95% 1.07–2.45). Conclusion: The estimated smoking rate during pregnancy in Brazil is still high and is associated with factors of increased maternal social vulnerability, which may contribute to the increased occurrence of unfavorable perinatal outcomes. [ABSTRACT FROM AUTHOR]

Aims: to estimate the mother to child transmission (MTCT) of HIV among infected pregnant women identified in the "Birth in Brazil" study and to evaluate care practices provided in order to identify missed opportunities at preventing the MTCT of HIV infection in the country. Methods: Descriptive study using data obtained from the consultation of different databases: the “Birth in Brazil” study database and the Brazilian National Information Systems (NIS) databases. We used cases of pregnant women infected with HIV identified in the “Birth in Brazil” study, and cases of AIDS in children under 5 years old identified in the NIS, to estimate the MTCT of HIV infection in the country, with a 95% confidence interval. We also estimated the HIV cascade (HIV diagnosis; use of antiretroviral treatment (ART) during pregnancy, labour, and for the newborn; adequate care during childbirth considering viral load at birth; and no breastfeeding) using data from the same sources. Results: MTCT of HIV of 2.0% (95% CI 0.3%-13.8%). At birth, 84.0% of HIV infected woman showed a positive HIV diagnosis, 74.9% received combined ART during pregnancy, 80.7% received ART during childbirth, 77.1% received adequate care during childbirth, 86.8% of newborns received ART within the first 24 hours after birth, and 2.8% of newborns were breastfed. Considering all steps, 61.3% of the women (95% CI 48.3%-72.8%) received all available medical interventions. In the analysis restricted to women identified in the NIS, 65.3% (95% CI 48.0%-79.3%) of HIV infected women received all available medical interventions. Conclusion: Brazil has healthcare policies that guarantee free access to tests, ART and substitutes for maternal milk. However, missed opportunities to prevent MTCT of HIV were identified in at least one-third of women and may be making it difficult to reach HIV-elimination targets especially in the less developed country regions. [ABSTRACT FROM AUTHOR]

Background: The rate of preterm birth has been increasing worldwide, including in Brazil. This constitutes a significant public health challenge because of the higher levels of morbidity and mortality and long-term health effects associated with preterm birth. This study describes and quantifies factors affecting spontaneous and provider-initiated preterm birth in Brazil. Methods: Data are from the 2011-2012 "Birth in Brazil" study, which used a national population-based sample of 23,940 women. We analyzed the variables following a three-level hierarchical methodology. For each level, we performed non-conditional multiple logistic regression for both spontaneous and provider-initiated preterm birth. Results: The rate of preterm birth was 11.5 %, (95 % confidence 10.3 % to 12.9 %) 60.7 % spontaneous - with spontaneous onset of labor or premature preterm rupture of membranes - and 39.3 % provider-initiated, with more than 90 % of the last group being pre-labor cesarean deliveries. Socio-demographic factors associated with spontaneous preterm birth were adolescent pregnancy, low total years of schooling, and inadequate prenatal care. Other risk factors were previous preterm birth (OR 3.74; 95 % CI 2.92-4.79), multiple pregnancy (OR 16.42; 95 % CI 10.56-25.53), abruptio placentae (OR 2.38; 95 % CI 1.27-4.47) and infections (OR 4.89; 95 % CI 1.72-13.88). In contrast, provider-initiated preterm birth was associated with private childbirth healthcare (OR 1.47; 95 % CI 1.09-1.97), advanced-age pregnancy (OR 1.27; 95 % CI 1.01-1.59), two or more prior cesarean deliveries (OR 1.64; 95 % CI 1.19-2.26), multiple pregnancy (OR 20.29; 95 % CI 12.58-32.72) and any maternal or fetal pathology (OR 6.84; 95 % CI 5.56-8.42). Conclusion: The high proportion of provider-initiated preterm birth and its association with prior cesarean deliveries and all of the studied maternal/fetal pathologies suggest that a reduction of this type of prematurity may be possible. The association of spontaneous preterm birth with socially-disadvantaged groups reaffirms that the reduction of social and health inequalities should continue to be a national priority. [ABSTRACT FROM AUTHOR]

Background: Cesarean section (CS) rates are increasing worldwide but there is some concern with this trend because of potential maternal and perinatal risks. The Robson classification is the standard method to monitor and compare CS rates. Our objective was to analyze CS rates in Brazil according to source of payment for childbirth (public or private) using the Robson classification. Methods: Data are from the 2011-2012 "Birth in Brazil" study, which used a national hospital-based sample of 23,940 women. We categorized all women into Robson groups and reported the relative size of each Robson group, the CS rate in each group and the absolute and relative contributions made by each to the overall CS rate. Differences were analyzed through chi-square and Z-test with a significance level of < 0.05. Results: The overall CS rate in Brazil was 51.9 % (42.9 % in the public and 87.9 % in the private health sector). The Robson groups with the highest impact on Brazil's CS rate in both public and private sectors were group 2 (nulliparous, term, cephalic with induced or cesarean delivery before labor), group 5 (multiparous, term, cephalic presentation and previous cesarean section) and group 10 (cephalic preterm pregnancies), which accounted for more than 70 % of CS carried out in the country. High-risk women had significantly greater CS rates compared with low-risk women in almost all Robson groups in the public sector only. Conclusions: Public policies should be directed at reducing CS in nulliparous women, particularly by reducing the number of elective CS in these women, and encouraging vaginal birth after cesarean to reduce repeat CS in multiparous women. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The participation of nurses and midwives in vaginal birth care is limited in Brazil, and there are no national data regarding their involvement. The goal was to describe the participation of nurses and nurse-midwives in childbirth care in Brazil in the years 2011 and 2012, and to analyze the association between hospitals with nurses and nurse-midwives in labor and birth care and the use of good practices, and their influence in the reduction of unnecessary interventions, including cesarean sections. Methods: Birth in Brazil is a national, population-based study consisting of 23,894 postpartum women, carried out in the period between February 2011 and October 2012, in 266 healthcare settings. The study included all vaginal births involving physicians or nurses/nurse-midwives. A logistic regression model was used to examine the association between the implementation of good practices and suitable interventions during labor and birth, and whether care was a physician or a nurse/nurse-midwife led care. We developed another model to assess the association between the use of obstetric interventions during labor and birth to the personnel responsible for the care of the patient, comparing hospitals with decisions revolving exclusively around a physician to those that also included nurses/nurse-midwives as responsible for vaginal births. Results: 16.2 % of vaginal births were assisted by a nurse/nurse-midwife. Good practices were significantly more frequent in those births assisted by nurses/nurse-midwives (ad lib. diet, mobility during labor, non-pharmacological means of pain relief, and use of a partograph), while some interventions were less frequently used (anesthesia, lithotomy position, uterine fundal pressure and episiotomy). In maternity wards that included a nurse/nurse-midwife in labour and birth care, the incidence of cesarean section was lower. Conclusions: The results of this study illustrate the potential benefit of collaborative work between physicians and nurses/nurse-midwives in labor and birth care. The adoption of good practices in managing labor and birth could be the first step toward more effective obstetric and midwifery care in Brazil. It may be easier to introduce new approaches rather than to eliminate old ones, which may explain why the reduction of unnecessary interventions during labor and birth was less pronounced than the adoption of new practices [ABSTRACT FROM AUTHOR]

Background: Breastfeeding in the first hour after birth is important for the success of breastfeeding and in reducing neonatal mortality. Government policies are being developed in this direction, highlighting the accreditation of hospitals in the Baby-Friendly Hospital (BFH) initiative. The aim of this study was to analyze the association between delivery in a BFH (main exposure), compared to non BFH, and timely initiation of breastfeeding (outcome). Methods: Data came from the "Birth in Brazil" survey, a nationwide hospital-based study of postpartum women and their newborns, coordinated by the Oswaldo Cruz Foundation. A sample of 22,035 mothers/babies was analyzed through a hierarchical theoretical model on three levels, and all analyzes considered the complex sample design. Odds ratios were obtained by logistic regression, with a 99 % CI. Results: Among all births, 40 % occurred in hospitals accredited or in accreditation process for the BFHI and 52 % of women underwent caesarean section. In the final model, at the distal level, mothers less than 35 years old, and those who lived in the North Region, had a higher chance of timely initiation of breastfeeding. At the intermediate level, prenatal care in the public sector and advice on breastfeeding during pregnancy were directly associated with the outcome. At the proximal level, being born in a Baby-Friendly Hospital and vaginal delivery increased the chance of timely initiation of breastfeeding, while prematurity and low birth weight reduced the chance of the outcome. [ABSTRACT FROM AUTHOR]

Background: Maternal near-miss (MNM) audits are considered a useful approach to improving maternal healthcare. The aim of this study was to evaluate the factors associated with maternal near-miss cases in childbirth and the postpartum period in Brazil. Methods: The study is based on data from a nationwide hospital-based survey of 23,894 women conducted in 2011-2012. The data are from interviews with mothers during the postpartum period and from hospital medical files. Univariate and multivariable logistic regressions were performed to analyze factors associated with MNM, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals (95 % CI). Results: The estimated incidence of MNM was 10.2/1,000 live births (95 % CI: 7.5-13.7). In the adjusted analyses, MNM was associated with the absence of antenatal care (OR: 4.65; 95 % CI: 1.51-14.31), search for two or more services before admission to delivery care (OR: 4.49; 95 % CI: 2.12-9.52), obstetric complications (OR: 9.29; 95 % CI: 6.69-12.90), and type of birth: elective C-section (OR: 2.54; 95 % CI: 1.67-3.88) and forceps (OR: 9.37; 95 % CI: 4.01-21.91). Social and demographic maternal characteristics were not associated with MNM, although women who self-reported as white and women with higher schooling had better access to antenatal and maternity care services. Conclusion: The high proportion of elective C-sections performed among women in better social and economic situations in Brazil is likely attenuating the benefits that could be realized from improved prenatal care and greater access to maternity services. Strategies for reducing the rate of MNM in Brazil should focus on: 1) increasing access to prenatal care and delivery care, particularly among women who are at greater social and economic risk and 2) reducing the rate of elective cesarean section, particularly among women who receive services at private maternity facilities, where C-section rates reach 90 % of births. [ABSTRACT FROM AUTHOR]

Background: The rate of cesarean delivery (CD) in Brazil has increased over the past 40 years. The CD rate in public services is three times above the World Health Organization recommended values. Among strategies to reduce CD, the most important is reduction of primary cesarean. This study aimed to describe factors associated with CD during labor in primiparous women with a single cephalic pregnancy assisted in the Brazilian Public Health System (SUS). Methods: This study is part of the Birth in Brazil survey, a national hospital-based study of 23,894 postpartum women and their newborns. The rate of CD in primiparous women was estimated. Univariate and multivariable logistic regression was performed to analyze factors associated with CD during labor in primiparous women with a single cephalic pregnancy, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals. Results: The analyzed data are related to the 2814 eligible primiparous women who had vaginal birth or CD during labor in SUS hospitals. In adjusted analyses, residing in the Southeast region was associated with lower CD during labor. Occurrence of clinical and obstetric conditions potentially related to obstetric emergencies before delivery, early admission with < 4 cm of dilatation, a decision late in pregnancy for CD, and the use of analgesia were associated with a greater risk for CD. Favorable advice for vaginal birth during antenatal care, induction of labor, and the use of any good practices during labor were protective factors for CD. The type of professional who attended birth was not significant in the final analyses, but bivariate analysis showed a higher use of good practices and a smaller proportion of epidural analgesia in women cared for by at least one nurse midwife. Conclusions: The CD rate in primiparous women in SUS in Brazil is extremely high and can compromise the health of these women and their newborns. Information and support for vaginal birth during antenatal care, avoiding early admission, and promoting the use of good practices during labor assistance can reduce unnecessary CD. Considering the experience of other countries, incorporation of nurse midwives in childbirth care may increase the use of good practices during labor. [ABSTRACT FROM AUTHOR]

Background: In Brazil, hospital childbirth care is available to all, but differences in access and quality of care result in inequalities of maternal health. The objective of this study is to assess the infrastructure and staffing of publicly financed labor and birth care in Brazil and its adequacy according to clinical and obstetric conditions potentially associated with obstetric emergencies. Methods: Nationwide cross-sectional hospital-based study "Birth in Brazil: national survey into labor and birth" conducted in 2011-2012. Data from 209 hospitals classified as public (public funding and management) or mixed (public or private funding and private management) that generate estimates for 1148 Brazilian hospitals. Interview with hospital managers provided data for the structure adequacy assessment covering four domains: human resources, medications, equipment for women emergency care and support services. We conducted analysis of the structure adequacy rate according to type of hospital (public or mixed), availability of ICU and the woman obstetric risk using the X2 test to detect differences in categorical variables with the level of statistical significance set at p <0.05. Results: Global rate of adequacy of 34.8 %: 42.2 % in public hospitals and 29.0 % in mixed hospitals (p < 0.001). Public and mixed hospitals with ICU had higher scores of adequacy than hospitals without ICU (73.3 % x 24.4 % public hospitals; 40.3 % x 10.6 % mixed hospitals). At a national level, 32.8 % of women with obstetric risk were cared for in hospitals without ICU and 29.5 % of women without risk were cared for in hospitals with ICU. Inequalities were observed with the North, Northeast and non-capital regions having the lower rates of hospitals with ICU. Conclusions: The majority of maternity wards across the country have a low rate of adequacy that can affect the quality of labor and birth care. This holds true for women at high obstetric risk, who suffer the possibility of having their care compromised by failures of hospital infrastructure, and for women at low obstetric risk, who may not receive the appropriate care to support the natural evolution of their labor when in a technological hospital environment. [ABSTRACT FROM AUTHOR]

Background: Unintended pregnancy, a pregnancy that have been either unwanted or mistimed, is a serious public health issue in Brazil. It is reported for more than half of women who gave birth in the country, but the characteristics of women who conceive unintentionally are rarely documented. The aim of this study is to analyse the prevalence and the association between unintended pregnancy and a set of sociodemographic characteristics, individual-level variables and history of obstetric outcomes. Methods: Birth in Brazil is a cross-sectional study with countrywide representation that interviewed 23,894 women after birth. The information about intendedness of pregnancy was obtained after birth at the hospital and classified into three categories: intended, mistimed or unwanted. Multinomial regression analysis was used to estimate the associations between intendedness of a pregnancy, and sociodemographic and obstetric variables, calculating odds ratios and 95 % confidence intervals. All significant variables in the bivariate analysis were included in the multinomial multivariate model and the final model retaining variables that remained significant at the 5 % level. Results: Unintended pregnancy was reported by 55.4 % of postpartum women. The following variables maintained positive and significant statistical associations with mistimed pregnancy: maternal age < 20 years (OR = 1.89, 95 % CI: 1.68-2.14); brown (OR = 1.15, 95 % CI: 1.04-1.27) or yellow skin color (OR = 1.56, 95 % CI: 1.05-2.32); having no partner (OR = 2.32, 95 % CI: 1.99-2.71); having no paid job (OR = 1.15, 95 % CI: 1.04-1.27); alcohol abuse with risk of alcoholism (OR = 1.25, 95 % CI: 1.04-1.50) and having had three or more births (OR = 2.01, 95 % CI: 1.63-2.47). The same factors were associated with unwanted pregnancy, though the strength of the associations was generally stronger. Women with three or more births were 14 times more likely to have an unwanted pregnancy, and complication in the previous pregnancies and preterm birth were 40 % and 19 % higher, respectively. Previous neonatal death was a protective factor for both mistimed (OR = 0.61, 95 % CI: 0.44-0.85) and unwanted pregnancy (OR = 0.44, 95 % CI: 0.34-0.57). Conclusions: This study confirms findings from previous research about the influence of socioeconomic and individual risk factors on unintended pregnancy. It takes a new approach to the problem by showing the importance of previous neonatal death, preterm birth and complication during pregnancy as risk factors for unintended pregnancy. [ABSTRACT FROM AUTHOR]

Background: A large proportion of the rise in prematurity worldwide is owing to late preterm births, which may be due to the expansion of obstetric interventions, especially pre-labour caesarean section. Late preterm births pose similar risks to overall prematurity, making this trend a concern. In this study, we describe factors associated with provider-initiated late preterm birth and verify differences in provider-initiated late preterm birth rates between public and private health services according to obstetric risk. Methods: This is a sub-analysis of a national population-based survey of postpartum women entitled “Birth in Brazil”, performed between 2011 and 2012. We included 23,472 singleton live births. We performed non-conditional multiple logistic regressions assessing associated factors and analysing differences between public and private health services. Results: Provider-initiated births accounted for 38% of late preterm births; 32% in public health services and 61% in private health services. They were associated with previous preterm birth(s) and maternal pathologies for women receiving both public and private services and with maternal age ≥35 years for women receiving public services. Women receiving private health services had higher rates of provider-initiated late preterm birth (rate of 4.8%) when compared to the ones receiving public services (rate of 2.4%), regardless of obstetric risk–adjusted OR of 2.3 (CI 1.5–3.6) for women of low obstetric risk and adjusted OR of 1.6 (CI 1.1–2.3) for women of high obstetric risk. Conclusion: The high rates of provider-initiated late preterm birth suggests a considerable potential for reduction, as such prematurity can be avoided, especially in women of low obstetric risk. To promote healthy births, we advise introducing policies with incentives for the adoption of new models of birth care. [ABSTRACT FROM AUTHOR]

Background: Cesarean delivery rates continue to increase worldwide and reached 57% in Brazil in 2014. Although the safety of this surgery has improved in the last decades, this trend is a concern because it carries potential risks to women’s health and may be a modifiable risk factor of maternal mortality. This paper aims to investigate the risk of postpartum maternal death directly associated with cesarean delivery in comparison to vaginal delivery in Brazil. Methods: This was a population-based case—control study performed in eight Brazilian states. To control for indication bias, deaths due to antenatal morbidity were excluded. We included 73 cases of postpartum maternal deaths from 2009–2012. Controls were selected from the Birth in Brazil Study, a 2011 nationwide survey including 9,221 postpartum women. We examined the association of cesarean section and postpartum maternal death by multivariate logistic regression, adjusting for confounders. Results: After controlling for indication bias and confounders, the risk of postpartum maternal death was almost three-fold higher with cesarean than vaginal delivery (OR 2.87, 95% CI 1.63–5.06), mainly due to deaths from postpartum hemorrhage and complications of anesthesia. Conclusion: Cesarean delivery is an independent risk factor of postpartum maternal death. Clinicians and patients should consider this fact in balancing the benefits and risks of the procedure. [ABSTRACT FROM AUTHOR]

Background: In Brazilian private hospitals, caesarean section (CS) is almost universal (88%) and is integrated into the model of birth care. A quality improvement intervention, "Adequate Birth" (PPA), based on four driving components (governance, participation of women and families, reorganisation of care, and monitoring), has been implemented to help 23 hospitals reduce their CS rate. This is a protocol designed to evaluate the implementation of PPA and its effectiveness at reducing CS as a primary outcome of birth care. Methods: Case study of PPA intervention conducted in 2017/2018. We integrated quantitative and qualitative methods into data collection and analysis. For the quantitative stage, we selected a convenient sample of twelve hospitals. In each of these hospitals, we included 400 women. This resulted in a total sample of 4800 women. We used this sample to detect a 2.5% reduction in CS rate. We interviewed managers and puerperal women, and extracted data from hospital records. In the qualitative stage, we evaluated a subsample of eight hospitals by means of systematic observation and semi-structured interviews with managers, health professionals and women. We used specific forms for each of the four PPA driving components. Forms for managers and professionals addressed the decision-making process, implemented strategies, participatory process in strategy design, and healthcare practice. Forms for women and neonatal care addressed socio-economic, demographic and health condition; prenatal and birth care; tour of the hospital before delivery; labour expectation vs. real experience; and satisfaction with care received. We will estimate the degree of implementation of PPA strategies related to two of the four driving components: "participation of women and families" and "reorganisation of care". We will then assess its effect on CS rate and secondary outcomes for each of the twelve selected hospitals, and for the total sample. To allow for clinical, socio-demographic and obstetric characteristics in women, we will conduct multivariate analysis. Additionally, we will evaluate the influence of internal context variables (the PPA driving components "governance" and "monitoring") on the degree of implementation of the components "participation of women and families" and "reorganisation of care", by means of thematic content analysis. This analysis will include both quantitative and qualitative data. Discussion: The effectiveness of quality improvement interventions that reduce CS rates requires examination. This study will identify strategies that could promote healthier births. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: to estimate neonatal and post-neonatal mortality rates (NMR and PNMR) of a sample of births in the municipality of Rio de Janeiro, 1999-2001, and to compare them according to the type of maternity and access to hospital delivery and to describe deaths according to their primary cause. Methods: the identification of infant deaths in the Mortality Information System (MIS) was accomplished through a probabilistic record linkage method. Bivari ate analysis was applied with calculation of relative risks (RR) and respective 95% confidence intervals. Results: neonatal and post-natal mortality rates were seven and six times higher in public than in private maternities respectively. For puerperal women non-resident in the municipality and those who were denied hospital admittance in other maternity hospitals, IMR was twice as high. High IMR caused by affections of the perinatal period (PPA) even in children weighing over 1500 grams (2.3 of 1.000 born alive infants). Neonatal deaths by PPA were six times more frequent in public maternity hospitals than in private ones. Conclusions: the enormous differences in neonatal and post-neonatal mortality rates between public and private hospitals point towards the need for reduction of social inequalities and improvement of the access to healthcare as fundamental issues to be approached in the municipality of Rio de Janeiro. [ABSTRACT FROM AUTHOR]

Background: Depression is one of the most common postpartum mental disorders. Many sociodemographic and individuals risk factors are associated with maternal depression but the impact of high levels of birth intervention is unclear. The Brazilian context is characterized by excessive intervention and frequent non-compliance with recommended obstetric protocols. This study therefore examined the impact of sociodemographic, individual, and obstetric risk factors in postpartum depression.Methods: The Birth in Brazil research study is a national study of 23,894 postpartum women. Information about depression was obtained by telephone interview at 6-18 months after birth and was measured using the Edinburgh Postnatal Depression Scale.Results: The prevalence of probable cases of depression was 26.3%. A multiple logistic regression model identified significant sociodemographic and individual risk factors as: brown skin color (OR=1.15 CI 1.01-1.31), lower economic class (OR=1.70 CI 1.41-2.06), alcohol use (OR=1.41 CI 1.09-1.84) and a history of mental disorders (OR=3.13 CI 1.80-5.44). Significant obstetric factors were unplanned pregnancy (OR=1.22 CI 1.05-1.43 for wanted later and OR=1.38 CI 1.20-1.60 for never wanted), multiparity (OR=1.97 CI 1.58-2.47 for 3 or more children), and poor care during birth (OR=2.02 CI 1.28-3.20) or of the newborn (OR=2.16 CI 1.51-3.10). Obstetric interventions and complications were not associated with maternal depression.Limitations: Depression was measured only once so we are not able to examine the course over time. The associational and reverse causality cannot be ruled out for some variables.Conclusions: The prevalence of postpartum depression is high in Brazilian women six months after birth. Poor care of women and babies during birth is more important in postpartum depression than physical obstetric or neonatal intervention and complications. [ABSTRACT FROM AUTHOR]

Objectives: to evaluate the extent to which seven family health units in the municipality of Rio de Janeiro are equipped to provide prenatal care on nutrition. Methods: a cross-sectional study was carried out in 2008. Seven family health units were selected and their structure was observed directly. Seven health workers and 230 pregnant women were interviewed at these units. The building structure, material resources, referral system, human resources and norms and routines were examined at each unit. Results: direct observation and the interviews with the health workers ascertained that all the units had a suitable building structure and material resources. The norm that was least commonly complied with was the preventive maintenance of scales. The Ministry of Health's current prenatal card was found to have been implemented for 45% of the pregnant women. Access to ferrous sulfate and folic acid were reported by around 70% of pregnant women. There was found to be a shortfall in human resources and in referral of pregnant women to nutritionists. Conclusions: the study points out the importance of ensuring the minimum team size and installing Family Health Support Unites, when expanding the scope and improving the integration of prenatal care. [ABSTRACT FROM AUTHOR]

Objectives: to characterize features of care provided for malnourished children aged under five years admitted to hospitals affiliated to the Brazilian National Health Service in 2004. Methods: geographical, demographic data and information relating to diagnosis, results of care and admission to hospital available on the Brazilian National Health Service's Hospital Information System were analyzed. Results: the highest rate for admission to hospital for malnutrition was found in the Northeast region. Of all admissions to hospital for malnutrition in Brazil as a whole, 36.2% were registered as non-specific. The hospital mortality rate for malnutrition in Brazil was low, but moderate for children aged under six months and high when severe malnutrition was registered in the secondary diagnosis field. The hospital mortality rate for malnutrition was also high in 102 Brazilian municipalities. It is worth noting that 11.4% of children died within the first 24 hours following admission to hospital and the complementary outpatient treatment was recommended in 3.7% of Hospital Admissions Authorizations. Conclusions: the study revealed the importance of health workers recognizing the value of the nutritional status evaluation and correctly registering this as the cause of admission to hospital, and also integrating and ordering the various levels of care for malnourished children. [ABSTRACT FROM AUTHOR]

The aim of this review is to present the state of the art regarding obstetric violence in Brazil. The most commonly used terms are "obstetric violence," "disrespect and abuse," and "mistreatment". Concerning measurement, the most widely used instrument is based on the definition of "mistreatment," still in its early stages of evaluation and lacking adaptation to Brazil. The prevalence of obstetric violence varies widely in national studies due to methodological factors and the type of postpartum women considered. Regarding risk factors, adolescent or women over 35, non-white, with low education levels, users of the public health system (SUS), those who had vaginal birth or abortion, are at higher risk. Hierarchical relationships between the healthcare team and the family are also relevant, as well as inadequate hospital structures, bed shortages, and insufficient healthcare professionals, which contribute to obstetric violence. The consequences of this violence include an increased risk of postpartum depression and PTSD, reduced likelihood of attending postpartum and childcare consultations, and difficulties in exclusive breastfeeding. Interventions to mitigate obstetric violence should consider women's empowerment, healthcare professionals' training, monitoring obstetric violence, and legal support.

In 2021, an RDS survey was conducted among Venezuelan migrant women of reproductive age who migrated to two Brazilian cities (Manaus and Boa Vista) from 2018 to 2021. To start the RDS recruitment, we chose seeds non-randomly in both cities. The study variables were age, educational level, self-rated health, pregnancy, migratory status and use of health services. We estimated the prevalence, confidence intervals and homophily effects by variable category. We used a multivariate logistic regression model to identify the main factors associated with healthcare use. A total of 761 women were recruited in Manaus and 1268 in Boa Vista. Manaus showed more irregular migrants than Boa Vista. The main reasons for using health services were as follows: illness, disease prevention and prenatal care. The logistic regression model showed the use of health services was associated with educational level and healthcare needs but not with migratory status. The social inclusion of Venezuelan migrants is extremely relevant, although many challenges must be overcome. The strategy of the Brazilian Federal Government for providing humanitarian assistance to Venezuelan migrants should be expanded to include and facilitate their integration into labor markets, access to healthcare and education, benefiting both migrants and the Brazilian people by reducing social inequality.

The Maternal Mortality Study conducts a hospital investigation of maternal deaths that occurred in 2020/2021 in the maternity hospitals sampled by the Birth in Brazil II survey, with the following objectives: estimate the maternal mortality underreporting; calculate a correction factor and the corrected (MMR); validate the causes of maternal mortality reported in the death certificate (DC); and analyze the factors associated with maternal mortality. The Birth in Brazil II includes approximately 24,250 puerperal women distributed in 465 public, private, and mixed hospitals with ≥ 100 live births/year in the five macroregions of Brazil. The Maternal Mortality Study data will be completed using the same Birth in Brazil II questionnaire, from the consultation of hospital records. Trained obstetricians will fill out a new DC (redone DC) from independent analysis of this questionnaire, comparing it to official data. The database of the investigated deaths will be related to the deaths listed in the Mortality Information System of the Brazilian Ministry of Health, allowing the estimation of underreporting and calculation of the corrected MMR. To calculate the reliability of the causes of death, the kappa test and prevalence-adjusted kappa with 95% confidence interval will be used. A case-control study to estimate the risk factors for maternal mortality will be developed with the investigated deaths (cases) and the controls obtained in the Birth in Brazil II survey, using conditional multiple logistic regression models. We expect this research to contribute to the correction of the underreporting of maternal mortality and to a better understanding of the determinants of the persistence of a high MMR in Brazil.

Brazil has made advances in obstetric care in public and private hospitals; however, weaknesses in this system still require attention. The Brazilian Ministry of Health, aware of this need, funded the second version of the Birth in Brazil survey. This study aimed to evaluate: prenatal, labor and birth, postpartum, and abortion care, comparing the results with those of Birth in Brazil I; and analyze the main determinants of perinatal morbidity and mortality; evaluate the care structure and processes of obstetrics and neonatology services in maternity hospitals; analyze the knowledge, practices, and attitudes of health professionals who provide birth and abortion care; and identify the main barriers and facilitators related to care of this nature in Brazil. With a national scope and a 2-stage probability sample: 1-hospitals and 2-women, stratified into 59 strata, 465 hospitals were selected with a total planned sample of around 24,255 women - 2,205 for abortion reasons and 22,050 for labor reasons. Data collection was conducted using six electronic instruments during hospital admission for labor or abortion, with two follow-up waves, at two and four months. In order to expand the number of cases of severe maternal morbidity, maternal and perinatal mortality, three case control studies were incorporated into Birth in Brazil II. The fieldwork began in November 2021 and is scheduled to end in 2023. It will allow a comparison between current labor and birth care results and those obtained in the first study and will evaluate the advances achieved in 10 years.

In recent decades, several academic studies on abortion have been produced in Brazil, with different designs, objectives, and methodologies. However, due to the diversity of situations in which Brazilian women experience abortion, the complexity of this topic, and its modulations in different political and sociocultural contexts, it still challenges academicians and the fields of health and reproductive rights. In this article, we present methodological aspects of a qualitative study on health care itineraries of women in situations of abortion, a component of the Birth in Brazil II survey, whose objective is to discuss the effects of gender; race/ethnicity; social class; generational, regional, and territorial inequalities on care itineraries. We discuss the study design development, the construction of the theoretical framework and specific analytical axes, the development of interview instrument, definition of participant selection criteria, strategies to contact participants and conduct the interviews, management of field work and materials produced, analytical procedures, and ethical issues. In total, 120 narrative interviews were conducted in order to include a diversity of women and obtain detailed results from the quantitative analysis under Birth in Brazil II survey. The context of criminalization of abortion has an impact on the production of knowledge on this subject, creating challenges such as difficult access to women, women's anonymity, privacy and data confidentiality, creation of objective and subjective conditions so that they can narrate their experiences in depth. With this article, we seek to contribute to the debate about these challenges in abortion research in Brazil.

Pregnancy, parturition and birth bring major changes to the lives of mothers and fathers. This article presents a research protocol for estimating the prevalence of postpartum mental health outcomes in mothers and fathers, abuse and satisfaction in delivery/abortion care, and the correlations between them and socioeconomic, obstetric, and child health factors. As a 2-component research, it consists of a prospective cohort study with all postpartum women interviewed in the 465 maternity hospitals included at the Birth in Brazil II baseline survey conducted from 2021 to 2023, and a cross-sectional study with the newborns' fathers/partners. Interviews will be conducted via telephone or self-completion link sent by WhatsApp with the mother at 2 and 4 months after delivery/abortion. Partners will be approached three months after birth (excluding abortions, stillbirths and newborn death) using the telephone number informed by the mother at the maternity ward. Postpartum women will be inquired about symptoms of depression, anxiety and post-traumatic stress disorder, abuse during maternity care and quality of the mother-newborn bond. Maternal and neonatal morbidity, use of postnatal services, and satisfaction with maternity care are also investigated. Fathers will be asked to report on symptoms of depression and anxiety, and the quality of the relationship with the partner and the newborn. The information collected in this research stage may help to plan and improve care aimed at the postpartum health of the mother-father-child triad.

Brazil presents high maternal and perinatal morbidity and mortality. Cases of severe maternal morbidity, maternal near miss, and perinatal deaths are important health indicators and share the same determinants, being closely related to living conditions and quality of perinatal care. This article aims to present the study protocol to estimate the perinatal mortality rate and the incidence of severe maternal morbidity and maternal near miss in the country, identifying its determinants. Cross-sectional study integrated into the research Birth in Brazil II, conducted from 2021 to 2023. This study will include 155 public, mixed and private maternities, accounting for more than 2,750 births per year, participating in the Birth in Brazil II survey. We will collect retrospective data from maternal and neonatal records of all hospitalizations within a 30-day period in these maternities, applying a screening form to identify cases of maternal morbidity and perinatal deaths. Medical record data of all identified cases will be collected after hospital discharge, using a standardized instrument. Cases of severe maternal morbidity and maternal near miss will be classified based on the definition adopted by the World Health Organization. The perinatal deaths rate and the incidence of severe maternal morbidity and maternal near miss will be estimated. Cases will be compared to controls obtained in the Birth in Brazil II survey, matched by hospital and duration of pregnancy, in order to identify factors associated with negative outcomes. Results are expected to contribute to the knowledge on maternal morbidity and perinatal deaths in Brazil, as well as the development of strategies to improve care.

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

Background: The study aims to assess agreement between data obtained from interviews with postpartum women and their health records about labor and birth characteristics, newborn care, and reasons for cesarean birth., Methods: The present study analyzes the Birth in Brazil study dataset, a nationwide hospital-based survey that included 23,894 postpartum women. Reliability was assessed using kappa coefficients and 95% confidence intervals. We also calculated the proportion of specific agreement: the observed proportion of positive agreement (Ppos) and the observed proportion of negative agreement (Pneg)., Results: In terms of labor and birth characteristics, more significant discrepancies in prevalence were observed for fundal pressure (1.4%-42.6%), followed by amniotomy, and augmentation. All of these variables were reported more frequently by women. Reliability was nearly perfect only for mode of delivery (kappa 0.99-1.00, Ppos and Pneg >99.0%). Higher discrepancies in reasons for cesarean prevalence were observed for previous cesarean birth (CB) (3.9%-10.4%) and diabetes mellitus (0.5%-8.5%). Most kappa coefficients for CB reasons were moderate to substantial. Lower coefficients were seen for diabetes mellitus, induction failure, and prelabor rupture of membranes and Pneg was consistently higher than Ppos., Discussion: Our findings raise relevant questions about the quality of information shared with women during and after the process of care for labor and birth, as well as the information recorded in medical charts. Not having access to full information about their own health status at birth may impair women's health promotion behaviors or clear disclosure of risk factors in future interactions with the healthcare system., (© 2023 Wiley Periodicals LLC.)

Trend studies on the model of birth in Brazil show a scenario of successive linear increases in cesarean rates. However, they ignore possible changes in the temporal evolution of this delivery modality. Thus, this study aimed to evaluate possible inflection points in cesarean rates in Brazil, its macro-regions, and federated units, as well as to estimate projections for 2030. A time series with information on cesarean sections from 1994 to 2019 from the SUS Department of Informatics was used. Autoregressive integrated moving average and joinpoint regression models were used to obtain cesarean rate projections and trends, respectively. Caesarean rates showed a significant upward trend over the 26 study years at all levels of aggregation. On the other hand, when considering the formation of segments, a stabilization trend was observed both in the country and in the South and Midwest regions, starting in 2012. Rates tended to increase in North and Northeast and significantly decrease in Southeast. Projections show that in 2030, 57.4% of births in Brazil will be cesarean, with rates higher than 70% in Southeast and South regions.

This study aimed to describe maternal satisfaction with their experience during childbirth and birth and their association with sociodemographic, clinical and obstetric, and good practice characteristics during childbirth care. The sample included 2,069 women who wanted to express their opinions at the end of the interview of the Stork Network Assessment survey. Exploratory factor analysis was performed to summarize the variables of interest, creating latent variables, for input in the multiple logistic regression model. Six factors were created and tested in the model. Respect for the puerperal women was associated with satisfaction (vaginal delivery: 1.40; cesarean section: 1.47). Regarding those who underwent a cesarean section, satisfaction was associated with living in the Central-West (1.91) and South (2.00) regions and the presence of a companion during hospitalization (1.25). However, for women who had vaginal delivery, satisfaction was inversely associated with large hospitals (0.62) and undergoing interventions during labor and delivery (0.83), but positively with multiparity (1.98), receiving good care practices for labor and delivery (1.24), and having immediate contact with the newborn (1.20). The better understanding of the factors associated with mothers' care satisfaction for labor and delivery can improve care quality provided in public hospitals in the Brazil.

Objective: To estimate the prevalence of exclusive breastfeeding during maternity hospital stay (outcome) and to analyze the association between delivery in a Baby-Friendly Hospital (BFH) and the outcome. The hypothesis is that accreditation to this program improves exclusive breastfeeding during maternity hospital stay. Exclusive breastfeeding is essential in reducing neonatal morbidity and mortality., Methods: This study is based on secondary data collected by the "Birth in Brazil: National Survey into Labour and Birth", a population-based study, conducted with 21,086 postpartum women, from February 1, 2011, to October 31, 2012, in 266 hospitals from all five Brazilian regions. Face-to-face interviews were conducted mostly within the first 24 hours after birth, regarding individual and gestational characteristics, prenatal care, delivery, newborn's characteristics, and breastfeeding at birth. A theoretical model was created, allocating the exposure variables in three levels based on their proximity to the outcome. This hierarchical conceptual model was applied to perform a multiple logistic regression (with 95%CI and p < 0.05)., Results: In this study, 76.0% of the babies were exclusively breastfed from birth until the interview. Babies born in public (AOR = 1.73; 95%CI: 1.10-2.87), mixed (AOR = 2.48; 95%CI: 1.35-4.53) and private (AOR = 5.54; 95%CI: 2.38-12.45) BFHs were more likely to be exclusively breastfed during maternity hospital stay than those born in non-BFHs, as well as those born by vaginal birth (AOR = 2.16; 95%CI: 1.79-2.61), with adolescent mothers (AOR = 1.83; 95%CI: 1.47-2.26) or adults up to 34 years old (AOR =1 .31; 95%CI: 1.13-1.52), primiparous women (AOR = 1.51; 95%CI: 1.34-1.70), and mothers living in the Northern region of Brazil (AOR = 1.99; 95%CI: 1.14-3.49)., Conclusions: The Baby-Friendly Hospital Initiative promotes exclusive breastfeeding during hospital stay regarding individual and hospital differences.

This study aims to compare obstetric care in a birthing center and in hospitals of the Brazilian Unified National Health System (SUS) considering good practices, interventions, and maternal and perinatal results in the Southeast Region of Brazil. A cross-sectional study was conducted with comparable retrospective data from two studies on labor and birth. A total of 1,515 puerperal women of usual risk of birthing centers and public hospitals in the Southeast region were included. Propensity score weighting was used to balance the groups according to the following covariates: age, skin-color, parity, membrane integrity, and cervix dilation at hospitalization. Logistic regressions were used to estimate odds ratios (OR) and 95% confidence intervals (95%CI) between the place of birth and outcomes. In birthing centers, compared to hospitals, the puerperal woman had a higher chance of having a companion (OR = 86.31; 95%CI: 29.65-251.29), eating or drinking (OR = 862.38; 95%CI: 120.20-6,187.33), walking around (OR = 7.56; 95%CI: 4.65-12.31), using non-pharmacological methods for pain relief (OR = 27.82; 95%CI: 17.05-45.40), being in an upright position (OR = 252.78; 95%CI: 150.60-423.33), and a lower chance of using oxytocin (OR = 0.22; 95%CI: 0.16-0.31), amniotomy (OR = 0.01; 95%CI: 0.01-0.04), episiotomy (OR = 0.01; 95%CI: 0.00-0.02), and Kristeller maneuvers (OR = 0.01; 95%CI: 0.00-0.02). Also, in birthing centers the newborn had a higher chance of exclusive breastfeeding (OR = 1.84; 95%CI: 1.16-2.90) and a lower chance of airway (OR = 0.24; 95%CI: 0.18-0.33) and gastric aspiration (OR = 0.15; 95%: 0.10-0.22). Thus, birthing centers offers a greater supply of good practices and fewer interventions in childbirth and birth care, with more safety and care without influence on the outcomes.

Controversial results have been reported on the association between mode of delivery and patient satisfaction. This study investigates which mode of delivery leads to greater satisfaction with hospital admission for childbirth. A cohort study was conducted with data from the Birth in Brazil study, which began in 2011. A total of 23,046 postpartum women were included from a random sample of hospitals, selected by conglomerates with a three level stratification. At the first follow-up, 15,582 women were re-interviewed. Mode of delivery, dichotomized into vaginal or cesarean section, and confounders were collected before hospital discharge. The outcome maternal satisfaction, investigated as a 10-item unidimensional construct, was measured by the Hospital Birth Satisfaction Scale up to six months after discharge. We used a directed acyclic graph to define minimal adjustment variables for confounding. The effect of mode of delivery on satisfaction was estimated using a structural equation model with weighting by the inverse of the probability of selection, considering the complex sampling design. The weight was estimated considering the different sample selection probabilities, the losses to follow-up, and the propensity score, which was estimated in a logistic regression model. The analysis revealed no significant difference in satisfaction with hospitalization for childbirth between respondents who had vaginal delivery and cesarean section in the adjusted analysis (standardized coefficient = 0.089; p-value = 0.056). Therefore, women who had vaginal delivery and cesarean section were equally satisfied with their hospitalization for childbirth.

This study analyzed late-term and post-term birth, evaluating the maternal profile, its characteristics, and maternal and neonatal complications. A total of 23,610 babies were selected from the Birth in Brazil study (2011), and a descriptive analysis of the study population was performed. The association between late-term and post-term birth and their outcomes was performed using logistic regressions (p-value < 0.05). The prevalence found was 7.4% for late-term and 2.5% for post-term birth, both of which were more frequent in the North and Northeast regions, in adolescents, black women, with low schooling, multiparous, cared for by the public sector. Late term pregnancies had a higher chance of induction of vaginal delivery (OR = 2.02; 95%CI: 1.67-2.45), of cesarean section (OR = 1.32; 95%CI: 1.16-1.52), of severe laceration (OR = 3.75; 95%CI: 1.36-10.36), and of oxygen therapy for newborns (OR = 1.52; 95%CI: 1.02-2.26). In post-term pregnancies, newborns had a lower chance of breastfeeding at birth (OR = 0.74; 95%CI: 0.56-0.97) and during hospitalization (OR = 0.62; 95%CI: 0.40-0.97) and a higher chance of being born small for the gestational age (OR = 4.01; 95%CI: 2.83-5.70). The results using only ultrasound as a measure of gestational age confirmed the previous findings. Late-term and post-term pregnancies occur more frequently in the North and Northeast regions and in women with greater social vulnerability, being associated with maternal and neonatal complications.

This study aimed to describe cesarean and repeated cesarean section rates in Brazil according to gestational age (GA) at birth and type of hospital. This is an ecologic study using data from the Brazilian Information System on Live Births and the 2017 National Registry of Health Facilities. Overall and repeated cesarean section rates were calculated and analyzed according to GA, region of residence, and type of hospital. Spearman correlations were performed between cesarean and repeated cesarean section rates by GA subgroups at birth (≤ 33, 34-36, 37-38, 39-41, and ≥ 42 weeks) and analyzed according to the type of hospital. Overall and repeated cesarean section rates were 55.1% and 85.3%, respectively. More than 60% of newborns between 37-38 weeks were delivered via cesarean section. Private hospitals in all regions showed the highest cesarean section rates, especially those in the Central-West Region, with more than 80% at all GAs. The overall cesarean section rate was highly correlated with all cesarean section rates of GA subgroups (r > 0.7, p < 0.01). Regarding repeated cesarean sections, the overall rate was strongly correlated with the rates of 37-38 and 39-41 weeks in public/mixed hospitals, differing from private hospitals, which showed moderate correlations. This finding indicates the decision for cesarean section is not based on clinical factors, which can cause unnecessary damage to the health of both the mother and the baby. Then, changes in the delivery care model, strengthening public policies, and encouragement of vaginal delivery after a cesarean section in subsequent pregnancies are important strategies to reduce cesarean section rates in Brazil.

The objective was to estimate the proportion of women with a full-time companion in Brazilian maternities linked to the Rede Cegonha (RC) and to compare them between the macro-regions in Brazil. A nationwide study, carried out from December/2016 to October/2017. 10,665 puerperal women from all regions of Brazil participated in the study, who gave birth at one of 606 maternity hospitals with a regional action plan approved by RC. Proportions and respective 95% confidence intervals were estimated, adjusted for the cluster effect, by comparing the macro-regions using Wald's chi-square test. The presence of a full-time companion occurred in 71.2% of maternities, being higher among women aged 20-35 years, brown-skinned, with higher education, married, and assisted in vaginal delivery. Almost 30% of puerperal women did not have a full-time companion. In the Southeast and Midwest regions, self-declared black women, with less schooling and unmarried women were less accompanied. The moment of delivery had less presence of the companion (29.2%). Despite the advances, this right is still not fully fulfilled, pointing to the occurrence of social inequities among Brazilian macro-regions.

Objective: Describe and estimate the rate of recurrent preterm birth in Brazil according to the type of delivery, weighted by associated factors., Methods: We obtained data from the national hospital-based study "Birth in Brazil", conducted in 2011 and 2012, from interviews with 23,894 women. Initially, we used the chi-square test to verify the differences between newborns according to previous prematurity and type of recurrent prematurity. Sequentially, we applied the propensity score method to balance the groups according to the following covariates: maternal age, socio-economic status, smoking during pregnancy, parity, previous cesarean section, previous stillbirth or neonatal death, chronic hypertension and chronic diabetes. Finally, we performed multiple logistic regression to estimate the recorrence., Results: We analyzed 6,701 newborns. The rate of recurrence was 42.0%, considering all women with previous prematurity. Among the recurrent premature births, 62.2% were spontaneous and 37.8% were provider-initiated. After weighting by propensity score, we found that women with prematurity have 3.89 times the chance of having spontaneous recurrent preterm birth (ORaj = 3.89; 95%CI 3.01-5.03) and 3.47 times the chance of having provider-initiated recurrent preterm birth (ORaj = 3.47; 95%CI 2.59-4.66), compared to women who had full-term newborns., Conclusions: Previous prematurity showed to be a strong predictor for its recurrence. Thus, expanding and improving the monitoring and management of pregnant women who had occurrence of prematurity strongly influence the reduction of rates and, consequently, the reduction of infant morbidity and mortality risks in the country.

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., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)