Birth In Brazil Study Research Articles

Influência do tipo de parto na satisfação com a internação para o parto na pesquisa Nascer no Brasil

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.

Magnitude and characteristics of late-term and post-term births: analysis of maternal and neonatal complications in Brazil, 2011

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.

Using Non-inferiority Margins to Define Optimal Gestational Weight Gain Ranges Based on Reducing the Risk of Occurrence of Adverse Neonatal Outcomes

ObjectivesTo identify optimal gestational weight gain (GWG) ranges to prevent adverse neonatal outcomes based on the new Brazilian GWG charts. MethodsData from 9,294 women from the Brazilian Maternal and Child Nutrition Consortium and Birth in Brazil study were used. Women aged ≥18 years, free of hypertensive disorders, diabetes in pregnancy, or diseases affecting GWG, were selected. Total GWG was calculated as last measured prenatal weight minus self-reported pre-pregnancy weight. Total GWG was standardized to gestational age-specific z scores according to the Brazilian GWG charts. A composite outcome was defined as the occurrence of any of small-for-gestational-age birth (SGA, birthweight < 10th percentile), large-for-gestational-age birth (LGA > 90th percentile) according to INTERGROWTH-21st charts, or preterm birth (birth < 37 weeks). We weighted each outcome in a composite index using previously-published weights to account for its relative seriousness. Logistic and Poisson regressions were performed with GWG z scores as exposure and independent outcomes and the composite outcome, respectively. Models were adjusted for maternal age, education, pre-pregnancy BMI, and smoking during pregnancy. GWG ranges associated with the lowest risk of the composite outcome were identified using the non-inferiority margins approach (20%). ResultsThe median total GWG was 12.5 kg (IQR 9–16), and 6.2% of the neonates were SGA, 16.6% LGA, and 10.5% were preterm. Higher GWG z scores were associated with an increase in LGA probabilities and preterm birth compared with neonates born with appropriate weight and ≥37 weeks, respectively. Lower z scores were associated with an increase in SGA probability. The non-inferiority margins analysis showed that to prevent the occurrence of these adverse outcomes, women with underweight, normal-weight, overweight, or obesity should gain between 6.5–14.1 kg, 6.4–13.8 kg, 2.2–12.1 kg, and –2.2–8.9 kg, respectively. ConclusionsTotal GWG ranges associated with lower risk of adverse neonatal outcomes were identified using non-inferiority margins. The next step must incorporate maternal outcomes in this analysis. Funding SourcesBrazilian National Research Council, Brazilian Ministry of Health, Bill and Melinda Gates Foundation.

Twin pregnancy and perinatal outcomes: Data from ‘Birth in Brazil Study’

Twin pregnancies account for 0.5-2.0% of all gestations worldwide. They have a negative impact on perinatal health indicators, mainly owing to the increased risk for preterm birth. However, population-based data from low/middle income countries are limited. The current paper aims to understand the health risks of twins, compared to singletons, amongst late preterms and early terms. Data is from "Birth in Brazil", a national inquiry into childbirth care conducted in 2011/2012 in 266 maternity hospitals. We included women with a live birth or a stillborn, and excluded births of triplets or more, totalling 23,746 singletons and 554 twins. We used multiple logistic regressions and adjusted for potential confounders. Twins accounted for 1.2% of gestations and 2.3% of newborns. They had higher prevalence of low birth weight and intrauterine growth restriction, when compared to singletons, in all gestational age groups, except in the very premature ones (<34 weeks). Amongst late preterm's, twins had higher odds of jaundice (OR 2.7, 95% CI 1.8-4.2) and antibiotic use (OR 1.8, 95% CI 1.1-3.2). Amongst early-terms, twins had higher odds of oxygen therapy (OR 2.7, 95% CI 1.3-5.9), admission to neonatal intensive care unit (OR 3.1, 95% CI 1.5-6.5), transient tachypnoea (OR 3.7, 95% CI 1.5-9.2), jaundice (OR 2.8, 95% CI 1.3-5.9) and antibiotic use (OR 2.2, 95% CI 1.14.9). In relation to birth order, the second-born infant had an elevated likelihood of jaundice, antibiotic use and oxygen therapy, than the first-born infant. Although strongly mediated by gestational age, an independent risk remains for twins for most neonatal morbidities, when compared to singletons. These disadvantages seem to be more prominent in early-term newborns than in the late preterm ones.

Risk stratification for small for gestational age for the Brazilian population: a secondary analysis of the Birth in Brazil study

Risk-stratification screening for SGA has been proposed in high-income countries to prevent perinatal morbidity and mortality. There is paucity of data from middle-income settings. The aim of this study is to explore risk factors for SGA in Brazil and assess potential for risk stratification. This population-based study is a secondary analysis of Birth in Brazil study, conducted in 266 maternity units between 2011 and 2012. Univariate and multivariate logistic regressions were performed, and population attributable fraction estimated for early and all pregnancy factors. We calculated absolute risk, odds ratio, and population prevalence of single or combined factors stratified by parity. Factors associated with SGA were maternal lupus (ORadj 4.36, 95% CI [2.32–8.18]), hypertensive disorders in pregnancy (ORadj 2.72, 95% CI [2.28–3.24]), weight gain < 5 kg (ORadj 2.37, 95% CI [1.99–2.83]), smoking at late pregnancy (ORadj 2.04, 95% CI [1.60–2.59]), previous low birthweight (ORadj 2.22, 95% CI [1.79–2.75]), nulliparity (ORadj 1.81, 95% CI [1.60–2.05]), underweight (ORadj 1.61, 95% CI [1.36–1.92]) and socioeconomic status (SES) < 5th centile (ORadj 1.23, 95% CI [1.05–1.45]). Having two or more risk factors (prevalence of 4.4% and 8.0%) was associated with a 2 and fourfold increase in the risk for SGA in nulliparous and multiparous, respectively. Early and all pregnancy risk factors allow development of risk-stratification for SGA. Implementation of risk stratification coupled with specific strategies for reduction of risk and increased surveillance has the potential to contribute to the reduction of stillbirth in Brazil through increased detection of SGA, appropriate management and timely delivery.

Pregestational overweight and obesity and symptoms of postpartum depression: Data from the Birth in Brazil Study

Relationship between pregestational overweight and obesity and symptoms of postpartum depression (PPD) has been documented in developed countries. In middle and low-income countries the studies are scarce and the pattern of findings is more mixed. Our objective is to assess the effect of pregestational overweight and obesity on development symptoms of PPD in a nationwide Brazilian study. The study included 23,894 puerperal women, from 2011 to 2012. The Edinburgh Postnatal Depression Scale (EPDS) was applied from 6 to 18 months postpartum, with ≥13 points as the cutoff. Classification of pregestational nutritional status followed the method recommended by the Institute of Medicine. Confounding variables were identified using directed acyclic graph (DAG), and propensity score estimated the effect of nutritional status on PPD symptoms. Prevalence of PPD was 26.3%. Women with excess weight represented nearly 32% of the sample. In the crude analysis, women with pregestational obesity showed 23% higher odds of developing symptoms of PPD when compared to those with normal weight (OR=1.23 CI 95% 1.04-1.45). There was a loss of statistical significance after propensity score analysis (OR=1.14 CI 95% 0.91-1.42). The symptoms of PPD were measured in a single moment, and sensitivity analysis revealed the existence of omitted or non-measured variables potentially modifying these estimates. Although we did not find a relationship between pregestational nutritional status and depressive symptoms, the results are important because of the problem's magnitude. Future studies should aim at a more comprehensive understanding of the complex relationship between the variables.

Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study

BackgroundMany 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. Methodsnational 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. ResultsDisrespect 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. ConclusionDisrespect 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.

Economic and racial inequalities in the prenatal care of pregnant teenagers in Brazil, 2011-2012

Abstract Objectives: to analyze the prenatal care of pregnant teenagers interviewed in the post-partum period in Brazilian maternity hospitals, according to economic status and skin color. Methods: data were obtained from the Birth in Brazil study, a national hospital-based survey in 2011 and 2012. Information was obtained from interviews with the postpartum women and from data collected from their prenatal cards. Multivariate logistic regression was used to verify whether maternal and prenatal care characteristics were associated with ina-dequate prenatal care. Results: a total of 3,317 teenage mothers were interviewed in the postpartum period, 84.4% of whom had received inadequate prenatal care, with worse results for lower-income, lower-schooling, and multiparous teens. In the same way, it became evident the higher proportion of black teenagers and those from economic classes D/E among those who failed to receive routine laboratory tests, who received little orientation on the pregnancy, labor, and childbirth, and who were forced to go from one maternity hospital to another before being admitted to give birth. Conclusions: strategies targeted to the most vulnerable pregnant teenagers should be implemented in order to achieve greater equality in teenagers’ prenatal care, seeking to assure easier access, earlier initiation of care, and greater case-resolution capacity

Advanced maternal age and factors associated with neonatal near miss in nulliparous and multiparous women

The early neonatal period accounts for approximately half of the deaths of young children under one year of age, and the neonatal near miss can recognize factors causing this high number of deaths. Thus, the aim of this study is to determine whether advanced maternal age increases the chance of neonatal near miss, in addition is to identify which factors are associated with the neonatal near miss, stratified by parity. Data are from the 2011-2012 Birth in Brazil study, which used a national population-based sample of 15,092 newborns of women between 20-29 and 35 years of age or more (advanced maternal age). Multiple logistic regression was performed to test the association between neonatal near miss and prenatal and childbirth variables, pre-gestational diseases, obstetric history and socioeconomic characteristics, stratified by parity. Advanced maternal age was to be statistically associated with neonatal near miss in nulliparous (OR = 1.62; 95%CI: 1.05-2.50) and multiparous (OR = 1.51; 95%CI: 1.20-1.91) when compared to women 20-29 years of age. For nulliparous women, the main variables statistically associated with neonatal near miss were multiple gestation (OR = 8.91) and hypertensive disease (OR = 2.57), whereas forceps-assisted vaginal delivery (OR = 7.19) and multiple gestation (OR = 4.47) were the variables associated for multiparous women. Neonatal near miss has been shown to be connected with access to health services for childbirth, gestational complications and maternal characteristics, mainly advanced maternal age. Therefore, to properly monitor and classify maternal gestational risk, to control gestational complications during prenatal care, and to correctly refer these women to childbirth care should be priority strategies for healthcare services.

Progress in childbirth care in Brazil: preliminary results of two evaluation studies.

This article aims to describe the preliminary results of two evaluations studies, one about the Stork Network program and the other about the Adequate Birth program, called Stork Network Assessment and Healthy Birth, and to identify possible improvements in comparison to the Birth in Brazil study. Both studies used a cross-sectional design and were conducted in 2017. The Stork Network Assessment study included all 606 public and mixed maternity hospitals from the Stork Network and a total of 10,675 postpartum women. The Healthy Birth study included a convenience sample of 12 private hospitals and 4,798 women. Indicators of labour and childbirth care were: presence of a companion person, care by obstetric nurse, use of partograph, use of non-pharmacological methods, walking during labor, eating, use of peripheral venous catheter, position for delivery, episiotomy, and Kristeller maneuver. The indicators were compared to those verified in Birth in Brazil, a nationwide population-based study in 2011-2012, before the start of the two intervention programs. Comparisons used the chi-square test for independent samples and 95% confidence interval. There was a significant increase in the number of women with access to appropriate technology for labour and childbirth from 2011 to 2017 and a reduction in harmful practices. The private sector also showed a decrease in cesarean rates and an increase in gestational age at birth. The study's results show that properly conducted public policies can change the scenario of care for labor and childbirth, helping to reduce in negative maternal and neonatal outcomes.

Evaluation of data from the Brazilian Information System on Live Births (SINASC)

This study is a quantitative and qualitative assessment of data from the Brazilian Information System on Live Births (SINASC) in Brazil. Coverage of the data by municipality was estimated as the ratio between reported and estimated live births. Data quality in the SINASC was assessed via probabilistic linkage with the database from the Birth in Brazil study, 2011-2012, and kappa coefficients of agreement were calculated. In 2013, data coverage was high and homogeneous in all states of Brazil. However, the analysis according to municipalities (counties) showed greater spatial heterogeneity. As for completeness of information in SINASC, kappa coefficients were statistically different from zero for all the tested variables (p < 0.001), and marginal distributions of all the variables were similar in the two databases. Gestational age was the variable with the worst agreement, with a kappa value of 0.461. The indicator that describes the inconsistencies, measured by the sum of the square of the differences between the reported and expected prematurity rates by birthweight bracket, showed the highest value in the North of Brazil and the lowest in the South, pointing to geographic inequalities in measurement of gestational age.

Elective repeat cesarean delivery in women eligible for trial of labor in Brazil.

To assess the hospital, maternal, and obstetric characteristics associated with elective repeat cesarean delivery (ERCD) among women eligible for trial of labor after cesarean (TOLAC) delivery in Brazil. The present data were retrieved from the Birth in Brazil study, a national hospital-based cohort study conducted during 2011-2012. Data were collected from medical records and by interview. Univariate and hierarchical multiple logistic regression analyses were performed to analyze factors associated with ERCD among women with a previous cesarean delivery who were eligible for TOLAC. Among 2295 women considered eligible for TOLAC, 1516 (66.1%) had an ERCD; the overall cesarean delivery rate was 79.4%. In the private sector, almost all deliveries (95.3%) were performed by ERCD. In the public sector, ERCD was associated with socioeconomic (more years of schooling), obstetric (women's preference, no previous vaginal delivery, macrosomia), and hospital (mixed hospital, location in noncapital city, fewer than 1500 deliveries per year) characteristics. The ERCD rate in Brazil was high even in a low-risk group, indicating that nonclinical factors may be driving the decision for cesarean delivery. Efforts aiming to reduce cesarean deliveries in Brazil should target women with a previous cesarean delivery.

Mother to child transmission of HIV in Brazil: Data from the "Birth in Brazil study", a national hospital-based study.

Aimsto 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.MethodsDescriptive 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.ResultsMTCT 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.ConclusionBrazil 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.

Prevalence of syphilis and HIV infection during pregnancy in incarcerated women and the incidence of congenital syphilis in births in prison in Brazil

Abstract: This study aimed to estimate the prevalence of syphilis and HIV infection during pregnancy, the mother to child transmission of syphilis and the incidence of congenital syphilis in incarcerated women in Brazil; to compare these rates to those observed in pregnant women outside of jail; and to verify the maternal factors associated with syphilis infection during pregnancy in free and incarcerated women. We used data from two nationwide studies conducted during the period 2011-2014. The Birth in Brazil study included 23,894 free women cared for in 266 hospitals. The Maternal and Infant Health in Prisons study included 495 incarcerated pregnant women or mothers living with their children, according to a census conducted in 33 female prisons. The same case definitions and data collection methods were used in both studies. The chi-square test was used to compare the characteristics of incarcerated and free women with a significance of 0.05. For incarcerated women, the estimated prevalence of syphilis during pregnancy was 8.7% (95%CI: 5.7-13.1) and for HIV infection 3.3% (95%CI: 1.7-6.6); the estimated mother to child transmission of syphilis was 66.7% (95%CI: 44.7-83.2) and the incidence of congenital syphilis was 58.1 per 1,000 living newborns (95%CI: 40.4-82.8). Incarcerated women had a greater prevalence of syphilis and HIV infection during pregnancy, lower quality of antenatal care and higher levels of social vulnerability. Syphilis infection showed to be an indicator of social vulnerability in free women, but not in incarcerated women. Health initiatives in prison are necessary to reduce healthcare inequalities and should include adequate antenatal and birth care.

Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil.

BackgroundCesarean 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.MethodsThis 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.ResultsAfter 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.ConclusionCesarean 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.

Prevalence of syphilis in pregnancy and prenatal syphilis testing in Brazil: birth in Brazil study.

OBJECTIVE Determine the coverage rate of syphilis testing during prenatal care and the prevalence of syphilis in pregnant women in Brazil.METHODS This is a national hospital-based cohort study conducted in Brazil with 23,894 postpartum women between 2011 and 2012. Data were obtained using interviews with postpartum women, hospital records, and prenatal care cards. All postpartum women with a reactive serological test result recorded in the prenatal care card or syphilis diagnosis during hospitalization for childbirth were considered cases of syphilis in pregnancy. The Chi-square test was used for determining the disease prevalence and testing coverage rate by region of residence, self-reported skin color, maternal age, and type of prenatal and child delivery care units.RESULTS Prenatal care covered 98.7% postpartum women. Syphilis testing coverage rate was 89.1% (one test) and 41.2% (two tests), and syphilis prevalence in pregnancy was 1.02% (95%CI 0.84;1.25). A lower prenatal coverage rate was observed among women in the North region, indigenous women, those with less education, and those who received prenatal care in public health care units. A lower testing coverage rate was observed among residents in the North, Northeast, and Midwest regions, among younger and non-white skin-color women, among those with lower education, and those who received prenatal care in public health care units. An increased prevalence of syphilis was observed among women with < 8 years of education (1.74%), who self-reported as black (1.8%) or mixed (1.2%), those who did not receive prenatal care (2.5%), and those attending public (1.37%) or mixed (0.93%) health care units.CONCLUSIONS The estimated prevalence of syphilis in pregnancy was similar to that reported in the last sentinel surveillance study conducted in 2006. There was an improvement in prenatal care and testing coverage rate, and the goals suggested by the World Health Organization were achieved in two regions. Regional and social inequalities in access to health care units, coupled with other gaps in health assistance, have led to the persistence of congenital syphilis as a major public health problem in Brazil.

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.