Analysis of the quality of prenatal data of pregnant women attended at Healthcare Services in the city of São Paulo between 2012 and 2020

OBJECTIVE

To analyze the quality of data collected during prenatal care recorded in the Integrated Health Care Management System (SIGA) of the Municipal Department of Health of São Paulo from 2012 to 2020.

METHODS

Descriptive study using SIGA data and the variables: maternal height (cm), weight (kg) measured throughout pregnancy, gestational age at prenatal consultation, systolic (SBP) and diastolic (DBP) blood pressure (in mmHg), and body mass index (BMI) at the beginning of pregnancy (up to 8 weeks). Quality analysis was carried out by calculating the indicators: percentage of incompleteness and zero values of all variables studied, percentage of implausible values for height, weight, BMI; preference for terminal digit of weight and height, and normality of distributions.

RESULTS

The database of pregnant women made available for analysis included 8,046,608 records and 1,174,115 women. The percentage of incompleteness and zero values was low (<1%) in all original variables of the system. There are more records at the end of pregnancy. For the four original variables of interest in the database (weight, height, SBP, DBP), there is a clear preference for the terminal digit. The variables of interest did not present an approximately normal distribution during the evaluated period.

CONCLUSION

The quality analysis showed the need for improving the standardization of information collection and recording, the rounding of measurements and the need for encouraging pregnant women to start prenatal care as soon as possible, in such a way that it is important to invest in data quality, through educational resources for professionals who work in health care.

Achievement of appropriate cesarean rates using Robson's 10-Group classification system in Brazilian private practice

BACKGROUND

Increasing cesarean section (CS) rates are a global concern because they are related to higher maternal and neonatal complication rates and do not provide positive childbirth experiences. In 2019, Brazil ranked second globally, given its overall CS rate of 57%. According to the World Health Organization (WHO), populational CS rates of 10-15% are associated with decreased maternal, neonatal, and infant mortality rates. This study aimed to investigate whether multidisciplinary care following evidence-based protocols associated with a high motivation of both women and professionals for a vaginal birth leads to less overuse of CS in a Brazilian private practice (PP).

METHODS

This cross-sectional study evaluated CS rates by Robson group for women who sought vaginal birth in a private practice in Brazil comparing with Swedish data. Collaborative care of midwives and obstetricians who adopted evidence-based guidelines was offered. CS rates, overall and by Robson group, contribution of each Robson group to the overall CS rate, clinical and nonclinical interventions, vaginal birth, pre-labor CS, and intrapartum CS proportions were estimated. The expected CS rate was calculated using the World Health Organization C-model tool. The analysis used Microsoft Excel and R Studio (version 1.2.1335. 2009-2019).

RESULTS

The PP overall CS rate was 15.1% (95%CI, 13.4-17.1%) versus the 19.8% (95%CI, 14.8-24.7%) rate expected by the WHO C-model tool. The population included 43.7% women in Robson Group 1 (nulliparous, single, cephalic, at term, spontaneous labor), 11.4% in Group 2 (nulliparous, single, cephalic, at term, induced labor or CS before labor), and 14.9% in Group 5 (multiparous women with previous CS), the greatest contributors to higher CS rates (75.4% of them). The Swedish overall CS rate was 17.9% (95%CI, 17.6-18.1%) in a population of 27% women in Robson Group 1, 10.7% in Group 2, and 9.2% in Group 5.

CONCLUSIONS

Multidisciplinary care following evidence-based protocols, associated with high motivation of both women and professionals for vaginal birth, may lead to a significant and safe reduction of CS rates even in contexts such as Brazil, with high medicalization of obstetric care and excess CS.

Gestational age: comparing estimation methods and live births' profile

OBJECTIVE

To identify factors associated with the definition of the gestational age (GA) estimation method recorded in the live birth certificate (LBC), and to compare the results obtained according to the method in the city of São Paulo (CSP), between 2012 and 2019.

METHODS

Cross-sectional population-based study using the Live Birth Information System. Descriptive and comparative analysis was performed according to the GA estimation method, followed by a univariate and multivariate logistic regression model to identify the predictor variables of the method used.

RESULTS

The estimation of GA by the date of the last menstrual period (LMP) (39.9%) was lower than that obtained by other methods (OM) (60.1%) - physical examination and ultrasound, between 2012-2019. LMP registration in the LBC increased with the mother's age, it was higher among women who were white, more educated and with partners, in cesarean sections and with private funding. In the logistic regression, public funding was 2.33 times more likely than private funding to use OM. The proportion of preterm infants (<37 weeks) with GA by LMP was 26.5% higher than that obtained by OM. Median birth weight was higher among preterm infants with GA estimated by LMP.

CONCLUSION

Prematurity was higher with the GA estimated by LMP in the CSP, which may indicate overestimation by this method. The source of funding was the most explanatory variable for defining the GA estimator method at the LBC. The results point to the need for caution when comparing the GA obtained by different methods.

Clusters of high-risk, low-risk, and temporal trends of breast and cervical cancer-related mortality in São Paulo, Brazil, during 2000-2016

PURPOSE

Studying breast and cervical cancers in space and time and verifying divergences of different territorially established socioeconomic profiles.

METHODS

Ecological study using spatial scanning (with socioeconomic characterization), space-time, and spatial variation of temporal trends, in order to identify significant clusters of high- and low-risk or temporal trends, of deaths from breast cancer and cervical cancer, in the city of São Paulo, Brazil, during 2000-2016.

RESULTS

High-risk spatial clusters were identified in the central areas, and low-risk clusters were identified in the peripheral areas, which were associated with better and worse socioeconomic conditions, respectively. As for cervical cancer, the pattern was the opposite. High-risk space-time clusters occurred in the early years of the study, whereas low-risk clusters occurred in the most recent years. For breast cancer, the central areas showed a temporal trend of decreasing mortality and the peripheral areas showed an increasing trend. While for cervical cancer, in general, the temporal trend was for the identified clusters to fall.

CONCLUSIONS

It is expected that this study will provide insights for the formulation of public policies to implement prevention and control measures, in order to reduce mortality and inequalities related to breast and cervical cancers.

Intra-urban spatial variability of breast and cervical cancer mortality in the city of São Paulo: analysis of associated factors

OBJECTIVE

To identify spatial variability of mortality from breast and cervical cancer and to assess factors associated in the city of São Paulo.

METHODS

Between 2009 and 2016, 10,124 deaths from breast cancer and 2,116 deaths from cervical cancer were recorded in the Mortality Information System among women aged 20 years and over. The records were geocoded by address of residence and grouped according to Primary Health Care coverage areas. A spatial regression modeling was put together using the Bayesian approach with a Besag-York-Mollié structure to verify the association of deaths with selected indicators.

RESULTS

Mortality rates from these types of cancer showed inverse spatial patterns. These variables were associated with breast cancer mortality: travel time between one and two hours to work (RR - relative risk: 0.97; 95%CI - credible interval: 0.93-1.00); women being the head of the household (RR 0.97; 95%CI 0.94-0.99) and deaths from breast cancer in private health institutions (RR 1.04; 95%CI 1.00-1.07). The following variables were associated with mortality from cervical cancer: travel time to work between half an hour and one hour (RR 0.92; 95%CI 0.87-0.98); per capita household income of up to 3 minimum wages (RR 1.27; 95%CI 1.18-1.37) and ratio of children under one year of age related to the female population aged 15 to 49 years (RR 1.09; 95%CI 1.01-1.18).

CONCLUSION

The predicted RR for mortality from these cancers were calculated and associated with the socioeconomic conditions of the areas covered.

Gestational age: comparing estimation methods and live births’ profile

RESUMO Objetivo: Identificar fatores associados à definição do método estimador da idade gestacional (IG) registrado na declaração de nascido vivo (DNV) e comparar os resultados obtidos segundo método no município de São Paulo, entre 2012 e 2019. Métodos: Estudo transversal de base populacional utilizando o Sistema de Informações sobre Nascidos Vivos. Realizou-se análise descritiva e comparativa segundo método de estimativa da IG, seguida de modelo de regressão logística uni e multivariada para identificar as variáveis preditoras do método utilizado. Resultados: A estimativa da IG pela data da última menstruação (DUM) (39,9%) foi inferior à obtida por outros métodos (OM) (60,1%) — exame físico e ultrassonografia, entre 2012-2019. O registro da DUM na DNV aumentou com a idade da mãe, foi maior entre as brancas, mais escolarizadas e com companheiro, nas cesarianas e nos partos realizados com financiamento privado. Na regressão logística, o financiamento público apresentou chance 2,33 vezes maior que o privado para uso de OM. A proporção de prematuros (<37 semanas) com IG pela DUM foi 26,5% maior do que a obtida por OM. A mediana de peso ao nascer foi maior entre prematuros com IG estimada pela DUM. Conclusão: A prematuridade foi mais elevada com a IG estimada pela DUM no MSP, o que pode indicar superestimação por este método. A fonte de financiamento foi a variável mais explicativa para definição do método estimador da IG na DNV. Os resultados apontam a necessidade de cautela ao comparar a IG obtida por métodos diferentes.

Intra-urban spatial variability of breast and cervical cancer mortality in the city of São Paulo: analysis of associated factors

ABSTRACT Objective: To identify spatial variability of mortality from breast and cervical cancer and to assess factors associated in the city of São Paulo. Methods: Between 2009 and 2016, 10,124 deaths from breast cancer and 2,116 deaths from cervical cancer were recorded in the Mortality Information System among women aged 20 years and over. The records were geocoded by address of residence and grouped according to Primary Health Care coverage areas. A spatial regression modeling was put together using the Bayesian approach with a Besag-York-Mollié structure to verify the association of deaths with selected indicators. Results: Mortality rates from these types of cancer showed inverse spatial patterns. These variables were associated with breast cancer mortality: travel time between one and two hours to work (RR – relative risk: 0.97; 95%CI – credible interval: 0.93–1.00); women being the head of the household (RR 0.97; 95%CI 0.94–0.99) and deaths from breast cancer in private health institutions (RR 1.04; 95%CI 1.00–1.07). The following variables were associated with mortality from cervical cancer: travel time to work between half an hour and one hour (RR 0.92; 95%CI 0.87–0.98); per capita household income of up to 3 minimum wages (RR 1.27; 95%CI 1.18–1.37) and ratio of children under one year of age related to the female population aged 15 to 49 years (RR 1.09; 95%CI 1.01–1.18). Conclusion: The predicted RR for mortality from these cancers were calculated and associated with the socioeconomic conditions of the areas covered.

Neonatal mortality by gestational age in days in infants born at term: A cohort study in Sao Paulo city, Brazil

Birth at term comprises a period with heterogeneous neonatal outcomes that tend to be worse for infants born earlier. However, few studies have analyzed this period, in which each day can make a difference. Therefore, we aim to assess neonatal mortality (NM) according to gestational age (GA) at birth measured in days in term liveborn infants born in 2012-2017 in São Paulo, the largest city in Latin America. This population-based cohort study assessed term liveborn infants followed until the end of the neonatal period. We analyzed 7 models for NM according to GA in days: crude NM adjusted for maternal and prenatal variables, NM additionally adjusted for type of birth and type of hospital, and adjusted NM stratified by type of birth (cesarean and vaginal) and by type of hospital (public and private). We included 440,119 live infants born at 259-293 days of gestation. The median GA at birth was 274 days. In all models, NM was higher for infants born early term, decreasing in infants born full term and rising again in infants born late term. In the unadjusted model, hazard ratios of NM changed daily, decreasing from 3.34 to 1.00 on day 278 and increasing again thereafter. In the stratified analysis according to type of hospital, being born in a public hospital was associated with a reduced risk of NM for infants born at 278-283 days of pregnancy. There was a decrease in GA related to obstetric interventions, especially cesarean sections, which increased NM. The loss of days of pregnancy was larger in private hospitals. Increasing the granularity of GA to days is feasible and has the potential to drive public policies. To the best of our knowledge, this is the first Brazilian study on GA in days using a national live births database.

Reproductive health and rights, and public policies in Brazil: revisiting challenges during covid-19 pandemics

We revisit the debates on reproductive health and rights (RHR) and public policies in Brazil, with focus on contraception, abortion and maternity care. These were part of a broader political agenda for re-democratisation, and for health sector reform, with the creation of the Women's Integral Health Program (PAISM) in 1983, and of the Universal Health System (SUS) in 1988. The momentum created by ICPD in Cairo (1994) was essential to institutionalise the language of RHR. Not without resistance and organised activism, recent years of right-wing governments brought a disinvestment in most public policies for women's rights. Some components of the RHR agenda are more mainstreamed, such as fertility regulation, especially hormonal and long term-methods. The limited legal rights to abortion are poorly institutionalised and constantly threatened. Maternal care tends to be highly medicalised and frequently abusive. The covid-19 pandemic accelerated social and public health disruption. The article addresses notions such as reproductive justice and institutional violence, present in the early days of women's health movement, in order to highlight important premises that were diluted in the debate on reproductive rights and autonomy. The historical analysis of how these concepts evolved locally and globally can allow a better understanding of present challenges.

Pink October and mammograms: when health communication misses the target

Breast cancer is the most frequently diagnosed type of cancer and is the leading cause of death from cancer in the female population. Screening mammograms and early treatment are the most frequently used means to attempt to reduce this mortality and are promoted during Pink October, an annual awareness-raising campaign. However, recent studies have correlated the increase in screening with higher morbidity and mortality, due to overdiagnosis and overtreatment. The current study assessed searches related to breast cancer and mammogram in Google Trends from 2004 to 2019 in terms of trend, seasonality, and distribution in Brazilian states. The study also evaluatedH the correlation between the number of searches in Google Trends and the number of screening mammograms. The two series showed a seasonal pattern with peaks in October, and there was an excess in tests performed outside the recommended age bracket. Pink October transmitted and popularized health information and induced behaviors related to this information, which are three desirable aspects in health communication and education. However, the campaign also generated an excess in screening mammograms and did not encourage autonomy and free and informed consent. Pink October revealed both the potential of mass communication in health and the need for messages to be aligned with the best available scientific evidence.

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

BACKGROUND

In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

OBJECTIVE

This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

METHODS

A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

RESULTS

The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

CONCLUSIONS

This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic.

TRIAL REGISTRATION

The Brazilian Clinical Trials Registry U1111-1255-8683; http://www.ensaiosclinicos.gov.br/rg/RBR-3g5f9f/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25016.

A change laboratory for maternity care in Brazil: Pilot implementation of Mother Baby Friendly Birthing Initiative

Disrespectful and abusive treatment of women during childbirth is a worldwide problem. This research aimed to develop and implement a Mother Baby-Friendly Hospital Initiative (MBFHI) in an academic maternity hospital in Brazil and evaluate how change could be sustained. Change Laboratory principles guided a process of action research, which was conducted between 2017 and 2019. Clinicians and managers joined the researchers in discussion sessions to redesign routines and care pathways. Observation, interviews, focus groups, and historical and documentary analysis provided information about the existing activity system, which we analysed qualitatively using MBFHI criteria to identify themes. Evidence of inappropriate obstetric interventions and impersonal interactions between clinicians and patients stimulated us to devise innovative solutions. The challenges identified by this exercise included: poor infrastructure and ambience; difficulty adhering to evidence-based protocols; social and professional hierarchies; and clinicians being poorly educated about women's rights. Although challenges remained, positive changes included a friendlier environment, improved patient privacy, and fewer unnecessary procedures. Resources released by these changes allowed us, collaboratively, to track the further implementation and sustainability of change. We conclude that the Change Laboratory can help motivated clinicians and managers humanise patients' experiences, make care more evidence-based, and expand learning of mother-friendly maternity care. Tensions and contradictions between education and patient care reported here may resonate in settings other than maternity care.

Spatial pattern of mortality from breast and cervical cancer in the city of São Paulo

OBJECTIVE

To verify the spatial pattern of mortality from breast and cervical cancer in areas of primary health care, considering socioeconomic conditions.

METHODS

This is an ecological study, from January 2000 to December 2016. The study area is the municipality of São Paulo, Brazil, and its 456 coverage areas of primary health units. Information on deaths of women aged 20 years or over were geocoded according to residence address. We calculated mortality rates, standardized by age, and smoothed by the local empirical Bayesian method, and grouped into three or two years to reduce the random fluctuation of the data. In addition, bivariate global and local Moran indexes were calculated to verify the existence of spatial agglomeration of standardized mortality rates with a domain of socioeconomic condition, elaborated based on the Índice Paulista de Vulnerabilidade Social (IPVS - São Paulo Index of Social Vulnerability).

RESULTS

The success rate of geocoding was 98.9%. Mortality from breast cancer, without stratification by time, showed a pattern with higher rates located in central regions with better socioeconomic conditions. It showed a decrease at the end of the period and a change in spatial pattern, with increased mortality in peripheral regions. On the other hand, mortality from cervical cancer remained with the highest rates in peripheral regions with worse socioeconomic conditions, despite being reduced over time.

CONCLUSION

The spatial pattern of mortality from the studied cancers, over time, suggests association with the best socioeconomic conditions of the municipality, either as protection (cervical) or risk (breast). This knowledge may direct resources to prevent and promote health in the territories.

Using the Maternity Safety Thermometer to estimate harm-free care in Southeast Brazil: A hospital-based cohort

BACKGROUND

High rates of unnecessary cesareans and interventions in vaginal births contribute to stagnant maternal and neonatal mortality rates in Brazil. We used the Maternity Safety Thermometer (MST) to assess the prevalence of harm during maternity care.

METHODS

This secondary analysis of the "Birth in Brazil" survey included a representative sample of 10 155 women who gave birth in public and private hospitals in southeastern Brazil. The main outcomes were perineal and abdominal trauma, maternal infection and hemorrhage, newborn vitality, and women's perception of safety. We calculated the odds ratios (OR) for the number of MST harms (dependent variable).

RESULTS

About 81.6% of the women with vaginal births had sutures for perineal trauma (87.7% of these due to episiotomies). Poor perception of safety was reported by 83.1% of women, and 69.5% of all infants not admitted to the NICU were separated from their mother after birth. The overall rate of cesarean birth was 52.6%, and 7.5% of term infants were admitted to the NICU. In public settings, having an intrapartum cesarean significantly increased the chances of one (OR 2.21; 95% CI 1.20-4.07), or two or more (4.08 [2.27-7.32]) harms. In private settings, cesarean deliveries without labor were also associated with higher chances of one (4.26 [2.65-6.85]), or two or more (4.60 [2.35-9.02]) harms. Only 2% of the women had harm-free care.

CONCLUSIONS

In southeastern Brazil, there is a high prevalence of preventable harm during maternity care.

'We are not infertile': challenges and limitations faced by women in same-sex relationships when seeking conception services in São Paulo, Brazil

The use of reproductive technologies has expanded beyond cases of infertility, and opportunities for individuals of different sexual orientations to use such technologies for conception have increased. The authors examined the challenges and limitations faced by women in same-sex relationships seeking conception services in São Paulo, Brazil. They interviewed 16 women in same-sex relationships who conceived children using reproductive technologies. Access to public health services for conception remains limited and exclusive to infertile heterosexual couples. Women in same-sex relationships are forced to select between costly medical treatments in the private sector, or self-insemination with sperm from a known donor. In this study, individuals reported that they experienced adverse effects of treatments; were treated with technologies for infertility when they were, in fact, fertile; and were exposed to unnecessary and invasive interventions. Growing political conservatism and the reduction of investment in public health services are factors that can directly affect sexual and reproductive health, including that of lesbians. Public policies that enable same-sex couples to conceive have yet to be developed in many countries, and a clearer articulation of the right to evidence-informed, rights-based care, consistent with national and international guidelines is a much-needed next step.

Violência obstétrica: influência da Exposição Sentidos do Nascer na vivência das gestantes

Resumo O excesso de intervenções no parto no Brasil tem sido reportado como violência obstétrica e contribui para os índices elevados morbi-mortalidade materna e neonatal. A exposição Sentidos do Nascer busca incentivar o parto normal para promover a saúde e melhorar a experiência de parir e nascer no País. Este artigo analisa o perfil e a experiência de parto de 555 mulheres que visitaram a exposição durante a gestação, com enfoque na percepção sobre violência obstétrica. A violência obstétrica foi reportada por 12,6% das mulheres e associada ao estado civil, à menor renda, à ausência de companheiro, ao parto em posição litotômica, à realização da manobra de Kristeller e à separação precoce do bebê após o parto. Predominaram nos relatos de violência obstétrica: intervenção não consentida/aceita com informações parciais, cuidado indigno/abuso verbal; abuso físico; cuidado não confidencial/privativo e discriminação. A visita à exposição aumentou o conhecimento das gestantes sobre violência obstétrica. Entretanto, o reconhecimento de procedimentos obsoletos ou danosos na assistência ao parto como violência obstétrica foi ainda baixo. Iniciativas como esta podem contribuir para ampliar o conhecimento e a mobilização social sobre as práticas na assistência ao parto e nascimento.

Caesarean birth rates in public and privately funded hospitals: a cross-sectional study

OBJECTIVE

To examine maternal and obstetric factors influencing births by cesarean section according to health care funding.

METHODS

A cross-sectional study with data from Southeastern Brazil. Caesarean section births from February 2011 to July 2012 were included. Data were obtained from interviews with women whose care was publicly or privately funded, and from their obstetric and neonatal records. Univariate and multivariate analyses were conducted to generate crude and adjusted odds ratios (OR) with 95% confidence intervals (95%CI) for caesarean section births.

RESULTS

The overall caesarean section rate was 53% among 9,828 women for whom data were available, with the highest rates among women whose maternity care was privately funded. Reasons for performing a c-section were infrequently documented in women's maternity records. The variables that increased the likelihood of c-section regardless of health care funding were the following: paid employment, previous c-section, primiparity, antenatal and labor complications. Older maternal age, university education, and higher socioeconomic status were only associated with c-section in the public system.

CONCLUSIONS

Higher maternal socioeconomic status was associated with greater likelihood of a caesarean section birth in publicly funded settings, but not in the private sector, where funding source alone determined the mode of birth rather than maternal or obstetric characteristics. Maternal socioeconomic status and private healthcare funding continue to drive high rates of caesarean section births in Brazil, with women who have a higher socioeconomic status more likely to have a caesarean section birth in all birth settings.

Breast cancer mortality and associated factors in São Paulo State, Brazil: an ecological analysis

OBJECTIVE

Identify the factors associated with the age-standardised breast cancer mortality rate in the municipalities of State of São Paulo (SSP), Brazil, in the period from 2006 to 2012.

DESIGN

Ecological study of the breast cancer mortality rate standardised by age, as the dependent variable, having each of the 645 municipalities in the SSP as the unit of analysis.

SETTINGS

The female resident population aged 15 years or older, by age group and municipality, in 2009 (mid-term), obtained from public dataset (Informatics Department of the Unified Health System).

PARTICIPANTS

Women 15 years or older who died of breast cancer in the SSP were selected for the calculation of the breast cancer mortality rate, according to the municipality and age group, from 2006 to 2012.

MAIN OUTCOME MEASURES

Mortality rates for each municipality calculated by the direct standardisation method, using the age structure of the population of SSP in 2009 as the standard.

RESULTS

In the final linear regression model, breast cancer mortality, in the municipal level, was directly associated with rates of nulliparity (p<0.0001), mammography (p<0.0001) and private healthcare (p=0.006).

CONCLUSIONS

The findings that mammography ratio was associated, in the municipal level, with increased mortality add to the evidence of a probable overestimation of benefits and underestimation of risks associated with this form of screening. The same paradoxical trend of increased mortality with screening was found in recent individual-level studies, indicating the need to expand informed choice for patients, primary prevention actions and individualised screening. Additional studies should be conducted to explore if there is a causality link in this association.

Desigualdades sociodemográficas e na assistência à maternidade entre puérperas no Sudeste do Brasil segundo cor da pele: dados do inquérito nacional Nascer no Brasil (2011-2012)

Resumo Historicamente, no Brasil, os indicadores de saúde de mães e bebês segundo cor da pele mostram quadro desfavorável às negras (pretas e pardas). Na última década, a redução das disparidades de renda e escolaridade, assim como a universalização da assistência à saúde, podem ter alterado esse quadro, em alguma medida. O objetivo deste artigo foi analisar as mudanças nas desigualdades sociodemográficas e na assistência à maternidade no Sudeste do Brasil, segundo raça/cor, na última década. Utilizamos dados do inquérito nacional Nascer no Brasil (2011-2012). Análise estatística descritiva foi realizada para a caracterização sociodemográfica, do acesso à assistência pré-natal, antecedentes clínicos e obstétricos, e características da assistência ao parto. Encontramos diferenças desfavoráveis às pretas e pardas quanto à escolaridade, renda e ao trabalho remunerado; as brancas tinham mais planos de saúde privados e maior idade. As pretas e pardas tiveram menor número de consultas, menos ultrassonografias, mais cuidado pré-natal considerado inadequado, maior paridade e mais síndromes hipertensivas. No parto, tiveram menos acompanhantes, mais partos vaginais, embora a cesárea tenha dobrado entre as negras, que com mais frequência entraram em trabalho de parto e tiveram filhos nascidos de termo pleno. Não houve diferença estatisticamente significativa quanto à situação conjugal, intercorrências da gestação, diabetes mellitus, anemias, sífilis, HIV, peregrinação para o parto, near miss materno ou neonatal e na maioria das intervenções no parto vaginal. Ainda que importantes disparidades persistam, houve alguma redução das diferenças sociodemográficas e um aumento do acesso, tanto a intervenções adequadas quanto às desnecessárias e potencialmente danosas.

The Enlighten Campinas Program: the construction of an intersectoral and interinstitutional policy to confront violence as a social problem

Resumo A inclusão da temática violência na agenda da promoção da saúde demanda a reorientação nas linhas de cuidado do sistema de serviços e a consolidação de ações voltadas para indivíduos e coletividades, em uma perspectiva de trabalho intersetorial, multidisciplinar, integrado e em redes que contemple a reorganização das práticas para acolher esta questão como um determinante de saúde. O objetivo deste artigo é compartilhar a experiência da implementação do Programa Iluminar Campinas – uma política local de promoção da saúde de um município de grande porte –que articulou o setor saúde em uma ampla rede intersetorial e interinstitucional para ofertar cuidados às pessoas que sofreram violência. As perspectivas teóricas do estudo foram o Construcionismo Social e a Teoria Ator Rede (TAR) e a metodologia envolveu a análise de documentos, entrevistas e observações de eventos do Programa Iluminar.

A vagina-escola: seminário interdisciplinar sobre violência contra a mulher no ensino das profissões de saúde

O ensino de obstetrícia no Brasil tradicionalmente requer que o aluno realize um certo número de procedimentos para que seja avaliado, o que levou a uma cultura de ensino do uso não informado, não consentido, das vaginas das parturientes mais pobres, usuárias do SUS, pelos alunos de medicina e outras profissões, para o treinamento de habilidades cirúrgicas. Tais abusos permanecem normalizados por uma cultura institucional que não os reconhece como violações de direitos, promovendo um ensino de habilidades descolado do ensino de valores e dos direitos das usuárias. Para promover um diálogo entre os setores envolvidos, realizamos em março de 2015 o evento “A Vagina-escola: seminário sobre violência contra a mulher no ensino das profissões de saúde”. O seminário foi especialmente oportuno por acompanhar a recente declaração da Oorganização Mundial de Saúde (OMS) “Prevenção e eliminação de abusos, desrespeito e maus-tratos durante o parto em instituições de saúde”, reforçando a urgência do tema na Saúde Coletiva.

We need to "ikarar the kutipados": intercultural understanding and health care in the Peruvian Amazon

The scope of this qualitative research was to describe and analyze how the Kukamas Kukamirias indigenous population from the Peruvian Amazon perceives and evaluates the healthcare offered by health workers at the local San Regis health post. An ethnographic-based study was conducted among the San Regis community on the Marañon River in the Loreto district of Peru, including interviews and participative observations with female and male patients as well as with traditional healers and professional health workers. An intercultural perspective is adopted to discuss the evaluations made by the Kukamas Kukamirias about the healthcare offered by professionals at their local health post. Issues examined include the intercultural matches and mismatches that affect vulnerable groups of the population in their interactions with the health services. The frequent preference shown for traditional treatment implies a close relationship between the healer and the person who is sick. This means that conventional forms of healthcare should be seen from an intercultural perspective and taken into account when organizing and articulating health services.

Incidence of maternal near miss in hospital childbirth and postpartum: data from the Birth in Brazil study

This study evaluated data on the incidence of maternal near miss identified on World Health Organization (WHO) criteria from the Birth in Brazil survey. The study was conducted between February 2011 and October 2012. The results presented are estimates for the study population (2,337,476 births), based on a sample of 23,894 women interviewed. The results showed an incidence of maternal near miss of 10.21 per 1,000 live births and a near-miss-to-mortality ratio of 30.8 maternal near miss to every maternal death. Maternal near miss was identified most prevalently by clinical criteria, at incidence of 5.2 per 1,000 live births. Maternal near miss was associated with maternal age 35 or more years (RR=1.6; 95%CI: 1.1-2.5), a history of previous cesarean delivery (RR=1.9; 95%CI: 1.1-3.4) and high-risk pregnancy (RR=4.5; 95%CI: 2.8-7.0). incidence of maternal near miss was also higher at hospitals in capital cities (RR=2.2; 95%CI: 1.3-3.8) and those belonging to Brazil's national health service, the Brazilian Unified National Health System (SUS) (RR=3.2; 95%CI: 1.6-6.6). Improved quality of childbirth care services can help reduce maternal mortality in Brazil.

Social inequalities and women's satisfaction with childbirth care in Brazil: a national hospital-based survey

The objective is to identify factors associated with women's satisfaction towards the care provided by the health professionals during hospital assisted delivery and identify how those factors influence their general levels of satisfaction. The cohort hospital based study was carried out in connection with the Birth in Brazil research. 15,688 women were included, interviewed at home, through the phone, from March 2011 to February 2012. All the variables that compose the professional/pregnant woman relationship (waiting time, respect, privacy, clarity of explanations, possibility of asking questions and participating in the decisions) and schooling remained independently associated with general satisfaction towards delivery care, in the adjusted model. The white women assisted in the southeastern and southern regions of the country, by the private sector and with a companion present gave a better evaluation of the care provided. Women value the way in which they are assisted by the health professionals, and there are inequalities in the way they are treated based on skin color, geographic region and financial situation.

Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa nacional Nascer no Brasil

As evidências sobre os benefícios do apoio contínuo durante o parto levou à recomendação de que este apoio deve ser oferecido a todas as mulheres. No Brasil, ele é garantido por lei desde 2005, mas os dados sobre a sua implementação são escassos. Nosso objetivo foi estimar a frequência e fatores sociodemográficos, obstétricos e institucionais associados à presença de acompanhantes durante o parto na pesquisa Nascer no Brasil. Foi feita análise estatística descritiva para a caracterização dos acompanhantes (em diferentes momentos do tempo da internação), fatores maternos e institucionais; as associações foram investigadas em modelos bi e multivariada. Vimos que 24,5% das mulheres não tiveram acompanhante algum, 18,8% tinham companhia contínua, 56,7% tiveram acompanhamento parcial. Preditores independentes de não ter algum, ou parcial, foram: menor renda e escolaridade, cor parda da pele, usar o setor público, multiparidade e parto vaginal. A implementação do acompanhante foi associada com ambiência adequada e regras institucionais claras sobre os direitos das mulheres ao acompanhante.

Hierarquias reprodutivas: maternidade e desigualdades no exercício de direitos humanos pelas mulheres

A partir da concepção contemporânea de direitos humanos, o texto discute os direitos reprodutivos e o exercício da maternidade. Após histórico e definição dos direitos reprodutivos e dos direitos sexuais, o artigo trata da maternidade voluntária, segura, socialmente amparada e prazerosa, para propor uma reflexão sobre 'hierarquias reprodutivas'. Defende-se que diferentes aspectos das mães - tal como raça, classe social, idade e parceria sexual - determinam a legitimidade e aceitação social destas maternidades, e, portanto, suas vivências. Quanto maior o número de aspectos 'negativos' presentes na mulher (ou casal) ao exercitar a maternidade e/ou a reprodução e cuidado com os filhos, mais próxima da base da pirâmide hierárquica estará e, ainda, maior dificuldade encontrará no exercício de seus direitos humanos. O texto conclui que são necessárias políticas públicas de suporte social à maternidade para as mulheres que assim escolham, indistintamente, visando promover o exercício de seus direitos humanos.

Centros de Parto no Brasil: revisão da produção científica

Este artigo consiste em uma revisão narrativa com o objetivo de identificar a produção científica brasileira relacionada ao processo assistencial e aos resultados maternos e perinatais em centro de parto normal (CPN). As publicações foram recuperadas nas bases de dados e portais de periódicos PubMed/MEDLINE, CINAHAL, SciELO e REVENF. Incluíram-se, também, publicação em livro e produção não publicada de grupo de pesquisa. Foram selecionados oito estudos do tipo descritivo, dois transversais e dois casos-controle, realizados com 5.407 mulheres e 5.395 recém-nascidos, divulgados entre 2005 e 2009. Os estudos analisaram variáveis sócio-demográficas e obstétricas, práticas na assistência ao parto e nascimento e remoções maternas e neonatais para o hospital. A produção científica sobre CPN apresenta dados da última década, relativos a sete serviços. São, principalmente, estudos descritivos, com foco nas práticas obstétricas e nos resultados maternos, com ênfase menor na assistência neonatal.

Evidências científicas no controle da dor no período neonatal

Objetivo: Identificar as revisões sistemáticas referentes ao controle da dor no neonato, catalogadas na Biblioteca Cochrane. Métodos: Utilizou-se os descritores pain e neonate. Resultados: Identificou-se seis publicações. Os temas abordados foram: dor resultante de procedimentos (uma revisão); métodos não-farmacológicos para o alívio da dor (duas) e métodos farmacológicos para analgesia (três). Conclusões: As revisões, de modo geral, apontam para a necessidade de condução de novos estudos clínicos, com amostras significativas e delineamentos adequados, para que mais evidências permitam instituir adequado controle da dor neonatal na prática clínica.

Humanização da assistência ao parto no Brasil: os muitos sentidos de um movimento

Este texto recupera as origens do termo humanização do parto, o reconhecimento da sua assistência ao parto como evento desumanizante, a crítica técnica à assistência, o surgimento de um movimento nacional e internacional de humanização do parto, as políticas de humanização do parto desenvolvidas no Brasil, e as relações entre a crítica à assistência e a criação do movimento pela medicina baseada em evidências (MBE). Com base em um estudo de duas maternidades "humanizadas" do SUS, discute os diferentes (às vezes contraditórios) sentidos do termo, e seu alcance em questionar a cultura técnico-assistencial, a anatomia, a fisiologia femininas, e as relações de gênero. Entre os diferentes sentidos estão: o uso da MBE, o respeito aos direitos (reprodutivos e sexuais, ao acesso universal e ao consumo de tecnologia), o tratamento acolhedor e respeitoso, o manejo da dor do parto e a prevenção da dor iatrogênica, novas atribuições profissionais e disputas corporativas; a relação custo-benefício etc. Longe de querer achar a "humanização certa", busca-se compreender nos diferentes sentidos um diálogo, tenso e produtivo, entre atores sociais em disputa.