Maternal health in Brazil: priorities and challenges

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Developing strategies to be added to the protocol for antenatal care: An exercise and birth preparation program

OBJECTIVES: To describe the implementation process of a birth preparation program, the activities in the protocol for physical and birth preparation exercises, and the educational activities that have been evaluated regarding effectiveness and women's satisfaction. The birth preparation program described was developed with the following objectives: to prevent lumbopelvic pain, urinary incontinence and anxiety; to encourage the practice of physical activity during pregnancy and of positions and exercises for non-pharmacological pain relief during labor; and to discuss information that would help women to have autonomy during labor. METHODS: The program comprised the following activities: supervised physical exercise, relaxation exercises, and educational activities (explanations of lumbopelvic pain prevention, pelvic floor function, labor and delivery, and which non-pharmacological pain relief to use during labor) provided regularly after prenatal consultations. These activities were held monthly, starting when the women joined the program at 18–24 weeks of pregnancy and continuing until 30 weeks of pregnancy, fortnightly thereafter from 31 to 36 weeks of pregnancy, and then weekly from the 37th week until delivery. Information and printed materials regarding the physical exercises to be performed at home were provided. Clinicaltrials.gov: NCT01155804. RESULTS: The program was an innovative type of intervention that systematized birth preparation activities that were organized to encompass aspects related both to pregnancy and to labor and that included physical, educational and home-based activities. CONCLUSIONS: The detailed description of the protocol used may serve as a basis for further studies and also for the implementation of birth preparation programs within the healthcare system in different settings

Maternal mortality in Campinas: evolution, under-registration and avoidanc

CONTEXT: Up until a few years ago, maternal mortality did not merit much attention as a worldwide public health issue. The health and social development indicator almost exclusively used was infant death.OBJECTIVE: To study the number, characteristics, basic causes and avoidance of maternal mortality (MM) among women living in the city of Campinas, which occurred between 1985 and 1991, identified from all death certificates of women aged 10 through 49 years. DESIGN: Retrospective and descriptive population-based study. SETTING: University Referal Center.SAMPLES: All eligible death certificates classified as declared and presumed maternal deaths according to the Laurenti criteria for the cause of death were selected and complementary studies of the clinical records were performed. MAIN MEASURES: Day of the week and place of occurrence of death; period of occurrence; transfer from another hospital; number of days from delivery/abortion to death; blood transfusion; opportunity for transfusion; complications; autopsy; basic cause of death.RESULTS: Initially 39 declared maternal deaths were identified and a total of 62 were confirmed by the end of the study. This corresponds to an under-registration rate of 37.1% and to an MM ratio of 45.5 per 100,000 live births. Around three-fourths of these maternal deaths were due to a direct obstetrical cause and were considered avoidable.CONCLUSION: Maternal mortality still is high in the municipality of Campinas, although lower than the mean estimated for Brazil. The predominance of direct obstetric causes and avoidable deaths reinforces the need for public health interventions directed towards avoiding themOBJETIVOS: Estudar o número e as características das mortes maternas, suas causas e evitabilidade, entre mulheres residentes no município de Campinas no período de 1985 a 1991, identificadas entre todas as declarações de óbito de mulheres com idade entre 10 e 49 anos. TIPO DE ESTUDO: Estudo descritivo de base populacional, retrospectivo. MÉTODO: Selecionaram-se, dentre todas as D.O. elegíveis ao estudo, as classificadas quanto à causa básica do óbito como mortes maternas declaradas e presumíveis, segundo os critérios de Laurenti, que foram complementarmente estudadas através de seus prontuários clínicos. RESULTADOS: Identificaram-se 39 mortes maternas declaradas e um total de 62 confirmadas ao fim do estudo, correspondendo a uma subenumeração de 37,1% e a uma RMM de 45,5 por 100.000 NV. Cerca de três quartos dos óbitos maternos aconteceram por uma causa obstétrica direta e foram considerados evitáveis. CONCLUSÃO:A mortalidade materna ainda é elevada no município de Campinas, embora bem menor que a média estimada para o Brasil. O predomínio de causas obstétricas diretas e de óbitos evitáveis reforça a necessidade de medidas de saúde pública para evitá-los.51

Brazilian doctors' perspective on the second opinion strategy before a C-section

OBJECTIVE: To describe the opinion of doctors who participated in the Latin American Study on Cesarean section in Brazil regarding the second opinion strategy when faced with the decision of performing a C-section. METHODS: Seventy-two doctors from the hospitals where the study took place (where the second opinion was routinely sought) and 70 from the control group answered a pre-tested self-administered structured questionnaire. Descriptive tables were prepared based on the frequency of relevant variables on opinion of physicians regarding: effectiveness of the application of the second opinion strategy; on whether they would recommend implementation of this strategy and reasons for not recommending it in private institutions; feasibility of the strategy implementation and reasons for not considering this implementation feasible in private institutions. RESULTS: Half of the doctors from the intervention hospitals (50%) and about two thirds of those in the control group (65%) evaluated the second opinion as being or having the potential of being effective/very effective in their institutions. The great majority of those interviewed from both intervention and control hospitals considered this strategy feasible in public (87% and 95% respectively) but not in private hospitals (64% and 70% respectively), mainly because in the latter the doctors would not accept interference from a colleague in their decision-making process. CONCLUSION: Although the second opinion strategy was perceived as effective in reducing C-section rates, doctors did not regard it feasible outside the public health system in Brazil.OBJETIVO: Descrever a opinião dos médicos que participaram no Brasil do Estudo Latino-Americano de Cesárea sobre a estratégia da segunda opinião antes de decidir fazer uma cesárea. MÉTODOS: Setenta e dois médicos dos hospitais do grupo de intervenção, onde se implantou a estratégia da segunda opinião, e 70 do grupo controle auto-responderam um questionário estruturado e pré-testado. Prepararam-se tabelas descritivas para apresentar a freqüência das variáveis mais relevantes sobre a opinião dos médicos a respeito: da efetividade da implementação da estratégia da segunda opinião; se recomendariam ou não a sua implementação e as razões para não a recomendarem em instituições privadas; a factibilidade da sua implementação e as razões para não a considerarem factível em instituições privadas. RESULTADOS: Metade dos médicos dos hospitais de intervenção (50%) e cerca de dois terços do grupo controle (65%) consideraram que a estratégia da segunda opinião havia sido ou poderia ser eficaz para reduzir o número de cesáreas na instituição em que eles trabalhavam. A grande maioria dos médicos que responderam o questionário nos hospitais de intervenção e controle considerou que a estratégia seria factível em instituições públicas (87% e 95% respectivamente), mas não nas privadas (64% e 70% respectivamente), principalmente porque nessas últimas os médicos não aceitariam a interferência de um colega sobre a sua decisão de fazer uma cesárea. CONCLUSÃO: Embora a estratégia da segunda opinião tenha sido percebida como capaz de reduzir as taxas de cesariana, os médicos não a consideraram factível fora do sistema público de saúde no Brasil

Perspectiva de médicos brasileiros sobre a estratégia da segunda opinião antes de realizar uma cesárea

OBJECTIVE: To describe the opinion of doctors who participated in the Latin American Study on Cesarean section in Brazil regarding the second opinion strategy when faced with the decision of performing a C-section. METHODS: Seventy-two doctors from the hospitals where the study took place (where the second opinion was routinely sought) and 70 from the control group answered a pre-tested self-administered structured questionnaire. Descriptive tables were prepared based on the frequency of relevant variables on opinion of physicians regarding: effectiveness of the application of the second opinion strategy; on whether they would recommend implementation of this strategy and reasons for not recommending it in private institutions; feasibility of the strategy implementation and reasons for not considering this implementation feasible in private institutions. RESULTS: Half of the doctors from the intervention hospitals (50%) and about two thirds of those in the control group (65%) evaluated the second opinion as being or having the potential of being effective/very effective in their institutions. The great majority of those interviewed from both intervention and control hospitals considered this strategy feasible in public (87% and 95% respectively) but not in private hospitals (64% and 70% respectively), mainly because in the latter the doctors would not accept interference from a colleague in their decision-making process. CONCLUSION: Although the second opinion strategy was perceived as effective in reducing C-section rates, doctors did not regard it feasible outside the public health system in Brazil.OBJETIVO: Descrever a opinião dos médicos que participaram no Brasil do Estudo Latino-Americano de Cesárea sobre a estratégia da segunda opinião antes de decidir fazer uma cesárea. MÉTODOS: Setenta e dois médicos dos hospitais do grupo de intervenção, onde se implantou a estratégia da segunda opinião, e 70 do grupo controle auto-responderam um questionário estruturado e pré-testado. Prepararam-se tabelas descritivas para apresentar a freqüência das variáveis mais relevantes sobre a opinião dos médicos a respeito: da efetividade da implementação da estratégia da segunda opinião; se recomendariam ou não a sua implementação e as razões para não a recomendarem em instituições privadas; a factibilidade da sua implementação e as razões para não a considerarem factível em instituições privadas. RESULTADOS: Metade dos médicos dos hospitais de intervenção (50%) e cerca de dois terços do grupo controle (65%) consideraram que a estratégia da segunda opinião havia sido ou poderia ser eficaz para reduzir o número de cesáreas na instituição em que eles trabalhavam. A grande maioria dos médicos que responderam o questionário nos hospitais de intervenção e controle considerou que a estratégia seria factível em instituições públicas (87% e 95% respectivamente), mas não nas privadas (64% e 70% respectivamente), principalmente porque nessas últimas os médicos não aceitariam a interferência de um colega sobre a sua decisão de fazer uma cesárea. CONCLUSÃO: Embora a estratégia da segunda opinião tenha sido percebida como capaz de reduzir as taxas de cesariana, os médicos não a consideraram factível fora do sistema público de saúde no Brasil.23323

Brazilian Doctors' Perspective On The Second Opinion Strategy Before A C-section.

To describe the opinion of doctors who participated in the Latin American Study on Cesarean section in Brazil regarding the second opinion strategy when faced with the decision of performing a C-section. Seventy-two doctors from the hospitals where the study took place (where the second opinion was routinely sought) and 70 from the control group answered a pre-tested self-administered structured questionnaire. Descriptive tables were prepared based on the frequency of relevant variables on opinion of physicians regarding: effectiveness of the application of the second opinion strategy; on whether they would recommend implementation of this strategy and reasons for not recommending it in private institutions; feasibility of the strategy implementation and reasons for not considering this implementation feasible in private institutions. Half of the doctors from the intervention hospitals (50%) and about two thirds of those in the control group (65%) evaluated the second opinion as being or having the potential of being effective/very effective in their institutions. The great majority of those interviewed from both intervention and control hospitals considered this strategy feasible in public (87% and 95% respectively) but not in private hospitals (64% and 70% respectively), mainly because in the latter the doctors would not accept interference from a colleague in their decision-making process. Although the second opinion strategy was perceived as effective in reducing C-section rates, doctors did not regard it feasible outside the public health system in Brazil.40233-

Mortality among childbearing-age women in Campinas, São Paulo (1985-1994)

To provide a profile of the main health problems in childbearing-age women, we studied all 3,086 death certificates from the SEADE Foundation for women from 10 to 49 years of age and residing in the municipality of Campinas, from January 1, 1985, to December 31, 1994. The primary cause of death was identified and classified according to the 10th review of the ICD. Population data were obtained from the Laboratory for Epidemiological Analyses and Research, UNICAMP. One-fourth of the deaths were cardiovascular in origin, one-fifth were from external causes, and almost 20% were due to neoplasms. Maternal mortality was the ninth cause of death. External causes predominated in the 10-to-34-year age group, as compared to cardiovascular diseases and neoplasms in the 35-to-49-year group. Most alarming were the predominance of traffic accidents among causes of death in women up to age 34 (greater than AIDS during the study period) and the high mortality rate from homicides.Com o fim de obter um perfil das principais doenças que afetam as mulheres em idade fértil, estudaram-se todas as 3.086 declarações de óbito de mulheres de 10 a 49 anos, residentes no Município de Campinas, Estado de São Paulo. Óbitos ocorridos entre primeiro de janeiro de 1985 e 31 de dezembro de 1994, fornecidos pela Fundação SEADE. A causa básica desencadeante do óbito foi identificada e classificada segundo a CID 10ª revisão. Os dados populacionais para o períodos foram obtidos do Laboratório de Análises e Pesquisas Epidemiológicas da UNICAMP. Um quarto dos óbitos foram por doenças cardiovasculares e um quinto por causas externas. A terceira causa, próxima a 20% do total, foi neoplasia. A mortalidade materna constituiu a nona causa de morte. As causas externas foram as principais causas de morte entre 10 e 34 anos. A partir dos 35 anos, predominaram as causas cardiovasculares e neoplasias. Chama a atenção o predomínio dos acidentes de trânsito como primeira causa de morte ate os 34 anos de idade, superando a AIDS durante o período estudado, assim como a alta mortalidade por homicídio.67167

Conhecimento, atitude e prática da mamografia entre usuárias do serviço público de saúde

OBJECTIVE: To evaluate knowledge, attitude and practice related to mammography among women users of local health services, identifying barriers to its performance. METHODS: A total of 663 women were interviewed at 13 local health centers in a city of Southeastern Brazil, in 2001. Interviewees were randomly selected at each center and they were representative from different socioeconomic conditions. The number of interviewees at each center was proportional to monthly mean appointments. For data analysis, answers were described as knowledge, attitude, practice and their respective adequacies and then they were correlated with control variables through the chi-square test. RESULTS: Only 7.4% of the interviewees had adequate knowledge on mammography, while 97.1% of women had an adequate attitude. The same was seen for the practice of mammography that was adequate in 35.7% of the cases. The main barrier to mammography was lack of referral by physicians working at the health center (81.8%). There was an association between adequacy of attitude and five years or more of education and being married. There was also an association between adequacy of mammography practice and being employed and family income up to four minimum wages. CONCLUSIONS: Women users of local health services had no adequate knowledge and practice related to mammography despite having an adequate attitude about this exam.OBJETIVO: Avaliar o conhecimento, a atitude e a prática do exame de mamografia entre as mulheres usuárias do serviço médico municipal, identificando as barreiras para seu acesso à realização do procedimento. MÉTODOS: Foram entrevistadas 663 mulheres de 13 centros de saúde municipais de Campinas, SP, em 2001. As entrevistadas foram incluídas de forma aleatória, representando diferentes estratos sociais. O número de entrevistas em cada centro de saúde foi proporcional ao número médio mensal de mulheres atendidas. As respostas foram descritas quanto ao conhecimento, atitude e prática e suas respectivas adequações. A adequação foi correlacionada com variáveis de controle utilizando o teste qui-quadrado. RESULTADOS: Apenas 7,4% das entrevistadas tinham conhecimento adequado sobre o exame de mamografia, embora a atitude frente a este procedimento tenha sido adequada em 97,1% das mulheres e a prática adequada em 35,7% das entrevistadas. A principal barreira para a realização da mamografia foi a não solicitação por parte dos médicos dos centros de saúde (81,8%). A adequação da atitude esteve relacionada à escolaridade igual ou superior a cinco anos e ser casada. A prática adequada da mamografia associou-se com o trabalho fora de casa e renda familiar igual ou superior a cinco salários mínimos. CONCLUSÕES: O conhecimento e a prática da mamografia entre as usuárias do serviço médico municipal foi inadequada, apesar da atitude adequada em relação ao procedimento

Misoprostol versus oxytocin for labor induction in term and post-term pregnancy: randomized controlled trial

CONTEXT: Misoprostol, a synthetic E1 methyl analog prostaglandin, is at present receiving attention as a cervical modifier and labor induction agent. However, there is still a need for better determination of its safety and effectiveness. OBJECTIVE: To compare intravaginal misoprostol versus intravenous oxytocin for cervical ripening and labor induction in pregnant women with unripe cervices. DESIGN: Randomized controlled trial. SETTING: The study was performed at the Leonor Mendes de Barros Maternity Hospital between November 1998 and December 2000. PARTICIPANTS: 210 pregnant women with intact membranes and indication for labor induction were selected. PROCEDURES: The women randomly received 25 µg of vaginal misoprostol every 4 hours, not exceeding 8 doses (105 women), or oxytocin in a continuous infusion (105 women). MAIN MEASUREMENTS: The main parameters measured were: latent period, time from induction to vaginal delivery, delivery route, occurrence of vaginal delivery with time, occurrence of uterine tonus alterations, hypoxia and neonatal morbidity. To verify the statistical significance of the differences between the groups, the chi-squared, Student t and log-rank tests were used. RESULTS: There were no significant differences between the groups concerning conditions for labor induction, age, parity, race, marital status, family income, initial Bishop Index and number of prenatal visits. The cesarean section rate, latent period and period from induction to vaginal delivery were significantly lower for the misoprostol group. With regard to uterine tonus alterations, tachysystole was significantly more common in the misoprostol group. However, there was no difference in hypoxia and neonatal morbidity between the groups. CONCLUSION: 25 µg of misoprostol used vaginally every 4 hours is safer and more efficient for cervical ripening and labor induction than oxytocin.CONTEXTO: Na atualidade, misoprostol, um metilanálogo sintético da prostaglandina E1, vem recebendo atenção como um agente maturador do colo e indutor do trabalho de parto. No entanto, ainda é necessário determinar melhor sua segurança e eficácia. OBJETIVO: Comparar misoprostol intravaginal versus ocitocina intravenosa para amadurecimento cervical e indução de parto em mulheres com colo uterino desfavorável. TIPO DE ESTUDO: Ensaio clínico controlado aleatorizado. LOCAL: Hospital e Maternidade Leonor Mendes de Barros, em São Paulo, SP, no período de novembro de 1998 a dezembro de 2000. PARTICIPANTES: 210 gestantes com membranas íntegras e indicação para indução do parto. PROCEDIMENTOS: As mulheres, após a aleatorização, receberam misoprostol vaginal na dose de 25 µg a cada quatro horas, não excedendo oito doses (105 mulheres) ou ocitocina em uma infusão contínua (105 mulheres). VARIÁVEIS ESTUDADAS: Período de latência, tempo da indução ao parto vaginal, tipo de parto, ocorrência de parto vaginal em função do tempo, ocorrência de alterações do tônus uterino, hipóxia e morbidade neonatal. Para verificar a significância estatística das diferenças entre os grupos, utilizaram-se os testes de qui -quadrado, log-rank e t de Student. RESULTADOS: Não houve diferença significativa entre os grupos referentes às indicações de indução, idade, paridade, raça, renda familiar, índice inicial de Bishop e número de consultas de pré-natal. A incidência de cesárea, o período de latência e o período da indução ao parto vaginal foram significativamente menores para o grupo de misoprostol. Das alterações do tônus uterino, a taquissistolia foi significativamente mais comum no grupo do misoprostol, entretanto hipóxia e morbidade neonatal não foram diferentes entre os grupos. CONCLUSÃO: 25 µg de misoprostol vaginal usados a cada quatro horas é seguro e mais eficiente para o amadurecimento cervical e indução do trabalho de parto do que a ocitocina.10210

[strategies Directed To Professionals For Reducing Unnecessary Cesarean Sections In Brazil].

Brazil is among the countries with the highest cesarean section rates, especially in the supplementary health sector. However, some characteristics are similar in both the public and private sectors in terms of the wishes and expectations of pregnant women regarding their delivery. There is a preference for vaginal delivery among women of all social, economic, and cultural levels, a fact that shifts the focus of the negative influence of this variable from women to other subjects involved in delivery care. No isolated factor is able to justify the complexity of making a decision for cesarean section, but the physician and the type of hospital are the main associated factors. The several harmful effects of a non-judicious performance of cesarean section are scientifically recognized. It is important to raise the awareness of doctors and of other health professionals about the real consequences of this decision, the ethical deviations when conducts are chosen without exclusively focusing on the patient`s health, and the need for constant updating for the management of the various possible conditions of childbirth.33252-6