Knowledge, attitudes and practices of Brazilian obstetricians in relation to childbirth care.

Objectives: to analyze the incidence of obstetric practices in labor and childbirth care at usual risk in a tertiary hospital. Methods: cross-sectional, descriptive study with a quantitative approach. Data were collected from 314 Monitoring Sheets of Labor and Childbirth Care of women who had their birth attended at the institution, from July 2017 to July 2018. The study was approved by the research ethics committee, with the embodied opinion number 2.822.707. Results: most women in the study were between 20 and 34 years old, coming from the city of Fortaleza, Ceará; had completed high school; and had unpaid work. The prevalence of good practices was identified: umbilical cord clamping in a timely manner (81.5%), immediate skin-to-skin contact (73.9%), breastfeeding in the childbirth room (74.2%), freedom of position and movement (72.3%), completion of the partograph (66.6%), presence of a companion (66.2%), offer of a liquid diet (65%), and non-pharmacological methods for pain relief (54.8%). As for interventional practices, we identified: venoclysis (42.4%), oxytocin infusion (29%), and amniotomy (11.1%). Conclusions: advances in the adoption of good practices based on scientific evidence are noteworthy; however, the technocratic model of childbirth care for women at normal risk persists.

International caesarean section rates: the rising tide.

Aguiar CA. Praticas obstetricas e a questao das cesarianas intraparto na rede publica de saude de Sao Paulo./Obstetric practices and the question of intrapartum caesarean section in public health system of Sao Paulo [dissertation]. Sao Paulo (BR): Faculdade de Saude Publica da Universidade de Sao Paulo; 2011. Background The obstetrical practices have been determined by the notion of risk, resulting in high rates of intrapartum interventions and cesarean sections in the country. The recommendations of this surgery have not followed a wellfounded clinical and obstetric criterion in different assistance scenarios, reducing its protective potential. Objectives – Identify and compare the recommendations for intrapartum caesarean sections in women with low-risk pregnancies from the assistance and the events that preceded the birth, in two models of care (Center for Childbirth and Obstetric Center); and characterize the study sites regarding the health team, protocol practices and the structure to assist the woman and the baby. Methods A cross sectional study carried out by secondary data collection in two public hospitals in Sao Paulo. The study included 158 pregnant women with low-risk pregnancies, submitted to intrapartum cesarean section in 2010. For data analysis, we estimated the Odds Ratio. Results – The findings were discussed from the Evidence-Based Medicine. The best results were associated with a hospital that has a Childbirth Center, with statistical significance in the timely admission of the mother, in the presence of a companion, the use of partogram and non-pharmacological methods for pain relief. There were records of obstetrical practices in a way questionable in both institutions, such as use of oxytocin and amniotomy. As for complications, the most frequent were: fetal distress, meconium, functional dystocia and cephalopelvic disproportion, although part of these records have diverged from findings reported in the course of labor. Conclusion: Weaknesses in obstetric practices were present in both institutions, although the Hospital Childbirth Center has demonstrated a more personalized and less restrictive care to women. It was noted the presence of unnecessary interventions, aiming at the acceleration of labor, which shows resistance of professionals and institutions to the evidence-based medicine, and also to the recommendations and guidelines of the Ministry of Health and World Health Organization. Descriptors: Cesarean Section; Labor; Delivery of Health Care; Delivery Rooms.

BackgroundThe “Adequate Childbirth Program” (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation.MethodThis study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software.ResultsThe three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals.ConclusionsAfter the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it’s harmful.

Purpose: To analyze the Cesarean Section (CS) rate in Brazilian women according to category of health insurance and individual characteristics associated with the mode of delivery.Materials and methods: A cross-sectional study was performed in three maternity services (one public tertiary referral center, one maternity service for both public and private care, and one private maternity service) in Campinas city, Brazil. Eligibility criteria were: inpatient during the immediate postpartum period, hospital birth, single pregnancy, and live newborn. Sociodemographic and anthropometric data, reproductive history, pregnancy planning, and prenatal care information was obtained from participants. Comorbidities, type of birth, and newborn data were collected from medical records. The mode of delivery was categorized as either CS or vaginal delivery.Results: A total of 1276 women were included in this study. The overall CS rate was 57.5%. CS rates were 41.6, 54.8, and 90.1% for public, mixed (public and private), and private maternity services, respectively. Mean age was higher in women who had a CS (28.0 ± 6.0 years versus 25.9 ± 6.5 years, p < .0001) as was the mean Body Mass Index (25.2 ± 5.3 kg/m2 versus 23.8 ± 4.5 kg/m2, p < .0001). CS was related to higher education, employment, white skin color, planned pregnancy, antenatal care in a private service, and primiparity.Conclusions: The overall CS rate was high (greater than 50%); in the private service, almost all participants had a CS delivery (90.1%). Better socioeconomic conditions and primiparity were associated with higher CS rates in Brazil. Political pressure for the management of unnecessary CSs is vital in Brazil. Together with the provision of real incentives for normal deliveries in public and, most importantly, private services.

To assess the cesarean section rate and compare the risk profiles of cesarean delivery in nulliparous women between private and non-private service. The computerized delivery records, collected from June 2006 to May 2009 at Rajavithi Hospital were retrospectively reviewed. Of these, 11,049 term singleton nulliparous pregnant women without maternal chronic medical disease were divided into two groups; private and non-private group. Demographic data, cesarean section rate, indication for cesarean section, time of delivery, maternal and neonatal outcomes were assessed and analyzed. The cesarean section rate was markedly different between both groups. The cesarean rates of all pregnant women, women in private group and non-private group were 25.7% (2,841 out of 11,049), 67.3% (1,187 out of 1,765), and 17.8% (1,654 out of 9,284), respectively. The private group's odds of having a cesarean delivery was 9.44 times [95% confidence interval (95% CI) 8.372-10.655] higher than the non-private group's after adjusting for background differences (maternal age, race, gestational age and birth weight). The most common indications for cesarean delivery in private group were elderly gravida, unfavorable cervix and cephalopelvic disproportion. The private group had significantly higher operation rate in the office hours than that of non-private group (70.1 vs. 41.8%; p < 0.0001). After adjusted for background differences, postpartum hemorrhage was significant higher in private group. Conversely, there was fewer admission to neonatal intensive care unit in private group. Low Apgar score at 5 min and perinatal death were not statistically significant in both groups. No cesarean hysterectomy and maternal death in both groups were noted. Private patients had a significantly higher rate of cesarean section than non-private patients. NICU admission was significantly lower in the private group, but postpartum hemorrhage was significantly higher. There were no significant differences in maternal mortality, low Apgar score at 5 min, perinatal death in both group. This study suggests that a significant number of cesarean sections among private services may be unnecessary. To safely reduce a cesarean section rate, an appropriate policy and guideline for auditing cesarean section among private service should be developed.

BackgroundIn 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.MethodsCross-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.Results4798 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.ConclusionsThere 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.

Caesarean section (CS) rates have increased globally, with substantial variations across healthcare settings. Monitoring CS rates using Robson's Ten Group Classification System (RTGCS) provides insights into obstetric practices. This study examines the variation in CS rates among women classified in Groups 1 to 4 of the RTGCS across hospitals in four low- and middle-income countries (LMICs) and explores hospital-level factors associated with these variations. This observational study analyzed CS rates in 32 hospitals (8 per country) in Argentina, Burkina Faso, Thailand, and Vietnam. Data were collected from hospital records between January and December 2020. A meta-analysis assessed hospital-level heterogeneity in CS rates, and meta-regression models explored potential determinants, including hospital characteristics such as staffing levels, equipment availability, and birth volume. The overall CS rate in the 32 hospitals was 45.4%, with nearly half (46.5%) of CS performed on women in Groups 1 to 4. There was substantial heterogeneity in CS rates among hospitals (I2 > 75%, p < 0.001). Factors associated with variations included country differences, staffing levels (midwife-to-delivery and doctor-to-delivery ratios at night), the presence of functional equipment (ultrasound and cardiotocograph), birth volume, and the possibility of labor companionship. Hospitals with higher birth volumes and greater staff availability had higher CS rates, while those permitting companionship during labor exhibited lower rates. Hospital characteristics appear to influence CS rates among low-risk groups, highlighting the need to consider institutional factors when implementing CS reduction strategies. Routine monitoring using the RTGCS, alongside tailored interventions addressing hospital-specific challenges, could support efforts to optimize CS use in LMICs. Further research is needed to confirm the role of organizational factors and guide policy decisions. The QUALI-DEC trial is registered with the Current Controlled Trials database (ISRCTN67214403), registration date: 30/03/2020.

The Over Roofing Rates of Caesarean Section

Introduction: The prolongation of the second stage of labor in pregnant women, in order to reduce the rate of cesarean sections, constitutes a scientific and clinical dilemma. This controversy is generated because the increase in the prolonged second stage time can increase the maternal and neonatal risks. Objective: To analyze differences in maternal and neonatal outcomes between pregnant women who have a prolonged vs non-prolonged delivery. To study those pregnant women who have prolonged second stage (&gt;180 minutes) and identify differences between them according to mode of delivery (non-operative, operative or cesarean delivery). Material and methods: Prospective cohort study of all nulliparous pregnant women treated at the Hospital Universitario de Fuenlabrada between January 1, 2018 and December 31, 2019. Differences in pregnant women with prolonged versus non-prolonged delivery are analyzed. Those cases in which the prolonged second stage period was equal to or greater than 180 minutes were selected and differences according to the mode of delivery were studied. During the study period, 944 women met the inclusion criteria, of which 445 (47.1%) had prolonged second stage periods equal to or greater than 180 minutes. Results: Prolonged second stage is associated with a higher rate of operative delivery 44.5% vs. 28.1% and a higher rate of cesarean section 6.7% vs. 2% (p: 0.000), a higher rate of shoulder dystocia 3.8% vs. 1.6%, greater weight at birth of the newborn 3279 g vs 3119 g and greater perinatal trauma 13.3 vs 6.6% compared with non-prolonged second stage delivery. By selecting only pregnant women with prolonged delivery, we observed a higher rate of complications of surgical wound in caesarean sections 13.3%, vs 1.5% in operative delivery and 0% in spontaneous vaginal delivery and a higher rate of grade III-IV degree perineal lacerations in deliveries eutocic and instrumental. With respect to the neonate, a greater weight of the newborn is observed in caesarean sections 3445 grams compared to eutocic deliveries 3230 grams and operative delivery 3275 grams (p: 0.001), a higher rate of type III resuscitation in those neonates born by caesarean section 26, 7% vs 4.2% in spontaneous vaginal delivery and 5.6% in operative delivery and a higher rate of admission to the neonatal ICU in caesarean sections 26.7% vs 6.9% spontaneous vaginal delivery and 9.1% operative delivery (p: 0.002) . Conclusion: A higher rate of operative delivery and cesarean sections has been observed in pregnant women with prolonged second stage, as well as a higher rate of shoulder dystocia, newborn weight, and perinatal trauma compared with non-prolonged delivery. When studying the cohort of pregnant women with prolonged second stage, there is a higher rate of cesarean section in pregnant women with a previous suspicion of fetal macrosomia, a higher weight of the newborn at birth, a higher rate of type III neonatal resuscitation and admission of the newborn to the neonatal ICU in pregnant women. that end in caesarean section with respect to spontaneous vaginal delivery or operative delivery.

Childbirth care practices in public sector facilities in Jeddah, Saudi Arabia: A descriptive study

To determine the relationship between cervical cerclage and delivery by Caesarean section secondary due to cervical dystocia. This is a retrospective cohort study of patients who were high risk for preterm birth and some of them underwent cervical cerclage and others did not. Our study included 144 women who underwent cerclage (cerclage group) and 152 who had no cerclage insertion (no cerclage group). There was significant difference in the overall emergency Caesarean section rate between the groups (RR 2.02.95%CI 1.33–3.07). Cervical dystocia as an indication for emergency Caesarean section was more prevalent in cerclage group (RR 3.08.95%CI 0.81–11.61). BMI has no significant impact on the rate of emergency Caesarean section for cervical dystocia in cerclage group. Primigravida women with cerclage had a significantly higher rate of emergency Caesarean section and these decrease rate as the number of pregnancies increase (p < 0.05). In our study we found that women who underwent cervical cerclage had higher risk of emergency Caesarean section in general. We did not find positive correlation between cervical dystocia and cerclage. Low parity may play important factor in higher rate of Caesarean section after cerclage. As the parity increases, the risk for surgical delivery decreases. BMI has no influence on Caesarean section rate in pregnancies with cerclage. Whether cerclage indeed influence the rate of cervical dystocia should be further evaluated by larger studies. Cerclage (N-144) No Cerclage (N-152)

To compare the clinical indications for delivery by cesarean section (CS) in singleton pregnancies in two Danish counties with different CS rates, and to describe the relation between CS in the two counties and parity, mother's age, type of delivery department, gestational age at birth, and birthweight. A population-based, follow-up study based on antecedent data. Two Danish counties, where women deliver in obstetric as well as surgical departments, with a CS rate of 8.3% and 15.2%, respectively. All pregnant women in the two counties who delivered in 1989. Comparison of the rates of CS in the two counties carried out for five well-defined clinical indications: Previous cesarean section, breech presentation, dystocia, fetal distress, and other. SECONDARY MEASURES: Neonatal and maternal outcomes. In the county with the higher frequency of CS, all indications for CS were used significantly more often, except from 'fetal distress' in primiparous women. In this county 'breech presentation' was the commonest indication among primiparous women, whereas 'fetal distress' was the most common in the county with the lower CS rate. For multiparous women the highest CS rates in both counties were found among women who had had a previous CS. The major difference between the two counties was the threefold greater risk of CS indicated by 'dystocia' among multiparous women in the county with the higher CS rate. The regional differences in CS could not be explained by differences between the two populations or by an increased rate of a single indication, but could be due to differences in obstetric practice or expectations or demands from the pregnant women.

The high caesarean section (CS) rate has been of great public concern around the world. Yet, large-scale studies of dissecting such a high CS rate are few in the Chinese population. We carried out a cross-sectional survey randomly selecting 10,855 births from 20 hospitals in Shanghai from January to June, 2016. Labor and delivery information was extracted from medical records. The Robson classification system for CS was used to classify all women into ten groups. The overall CS rate was 41.5%. Prelabor CS in nulliparous, term singleton vertex women was the predominant contributor (37.4%) to the total CS and accounted for the second highest proportion of total births (15.5%) in all hospital types. The vast majority of women with a previous CS had a repeat CS (96.6%). CS rate was still high in Shanghai. Nulliparous women in low risk and having CS before labour, often without any medical indication, was a major contributor to the high CS rate.

Clinicians’ views regarding caesarean section rates in Switzerland: A cross-sectional web-based survey