Transcript Promoting evidence-informed obstetric care in Brazil: Challenges and Opportunities Dr Maria Helena Bastos, MD MSc Women’s Health Research Kings College London Thames Valley University.

Promoting evidence-informed
obstetric care in Brazil:
Challenges and Opportunities
Dr Maria Helena Bastos, MD MSc
Women’s Health Research
Kings College London
Thames Valley University
Overview
• Brazil is a middle-income country,
ranking 69 out of 177 countries on
UNDP's Human Development Index
(2006)
• 84 per cent of population lives in urban
areas (2004)
• Total fertility rate is 2.0 births per woman
(PNAD 2006)
• The under-five mortality rate - 56%
reduction from 1990 to 33‰ live births in
2005
• Continued poverty continues to be a
challenge for the government's economic
and social policies
Why do we need to look
beyond reproductive
health?
• Impressive progress in the region in
achieving lowered fertility and
improved reproductive outcomes
• Women’s rights perspective implies
that women should be viewed in own
right, not just in reproductive role
• Pregnancy and childbirth has
different consequences or
implications for women or some
subgroups of women
Policy and practice
• National Health System (SUS)
• Women’s health advocates launch national
initiative for Women’s Comprehensive
Health (PAISM)
• Some significant advances in the legal,
normative and regulatory frameworks,
guaranteeing a rights-based approach to
the provision of reproductive health care
• As part of the National Plan for the
Reduction of Maternal and Neonatal
Mortality, launched in 2004, Mortality
Committees are being established at
national, regional and municipal levels
Vital statistics in Brazil
• System of Information of Live Births
(SINASC) - implemented by the Brazilian
Ministry of Health in 1990
• Brazilian Death Information System
(SIM/MS) - low quality of information
provided in death certificates
• Hospital Information System (SIH/SUS) incomplete coverage and uncertainties
about reliability of data
What do we know?
• MMR is not compatible with the countries’
economic development
• Neonatal death constitutes the major
component of the infant mortality
• Great number of underreported fetal deaths
Hospital births (%)
90.41
94.43
99.22
98.97
99,03
Total: 96.76
SINASC/Datasus, 2004
Maternity care
organization
• ± 3 million births/year – 70% women
deliver in public hospitals
• Obstetric rather than maternity care
dominant
• Excessive care and over reliance on
unnecessary technology is common
• Obstetric and midwifery care does not
follow recognised evidence-based
guidelines
• Unnecessary caesarean section is
dominant in the private sector
Inequalities in childbirth
% ANC coverage by region, 2004
0
1 to 3
4 to 6
7 or +
70
60
50
40
30
20
10
0
North
Northeast Southeast
South
CentreWest
Sinasc/SVS/MS
ANC coverage and skin color,
2004
%
70
0
60
1 to 3
50
4 to 6
7 or +
40
30
20
10
0
White
Black
Yellow
Mixed
Indigineous
Sinasc/SVS/MS
Distribuition ANC according to skin
color in women with 12+ years of
education
90
0
1 to 3
4 to 6
7 and +
80
70
60
50
40
30
20
10
0
White
Black
Yellow
Mixed
Indigenous
Sinasc/SVS/MS
Maternal mortality
• According to the National
Demographic Health Survey (PNDS)
– in 1996, MMR was 160 per 100.000 live
births (modified sisterhood method)
– In 2000, MMR was 260
• Official MMR in 1998 was
approximately 65 per 100.000 live
births
Common causes of
maternal death in Brazil
•
•
•
•
Pre-eclampsia and eclampsia
Complications of unsafe abortion
Haemorrhage
Puerperal infection
Proportion of maternal deaths by
maternal skin color, 2004
12.1%
45.5%
41.4%
Mixed
Yellow
Indigenous
White
Black
SIM/SVS/MS - 2004
Trends in NMR by maternal skin
color, 1982-1993-2004, Pelotas
Barros, Victora et al, 2005
Death of women (10 to 49 years of age)
due to maternal causes according with
the occurrence period
Occurance
n
%
Pregnancy
24
21.1
Post-partum
72
63.2
(< 48 hours)
(34)
(29.8)
(48 hours – 42 days)
(38)
(33.4)
Maternal Deaths (WHO’s definition)
96
84.3
43 days – 1 year (Late maternal death)
16
14
1 year or more (Sequelae of maternal death)
2
1.7
Ignored
1
Total
115
100
Laurenti et al, WHO Brazilian Collaborating Center - 2003
Epidemiological transition
and the medicalization of
childbirth
• Operative delivery rates in Brazil are the
highest in the world - rates rose from
28% to 42.9% over 20 years, with a
staggering 82.4% in the private sector
• Rise in induction rates from 3% to 45%
• The amount of pain a woman
experiences during childbirth usually
reflects issues relating to class based on
differences in the quality of care
provided.
• The risks of medicalisation of childbirth
should not be ignored because they
might offset the gains resulting from
improved maternal health and survival of
newborn infants.
Proportions of Caesareans
(2003 - 2005)
Private sector
Public sector
Brazil Total
ANS, 2005
2005 WHO global survey
on maternal and perinatal
health in Latin America
• High rates of caesarean delivery do not
necessarily indicate good quality care
• Institutions that deliver a lot of babies by
caesarean should initiate a detailed and
rigorous assessment of the factors related to
their obstetric care and the perinatal
outcomes achieved vis-à-vis the case mix of
the population they serve; at present their
services might cause (iatrogenic) harm
Villar et al, 2005
Risk factors associated
with the high caesarean
section rates
•
•
•
•
Delivery in the private sector
Maternal education and white skin colour
More than seven antenatal consultations
Antenatal care with the doctor who
performed the delivery
• Being a first time mother (primipara)
• Previous caesarean section
• Arriving in the maternity before labour is
established
Freitas et al, 2005
Whose choice is it?
• In Brazil, many women prefer
caesarean sections because they
consider it good quality care
• Mothers accept that caesarean is
“just another way of giving birth”
• Women's power to acquire a
medicalised birth continues to have
an effect on birth outcome
• Brazilian doctors frequently use
their medical authority to persuade
women to "choose" delivery by
caesarean section
Behague et al, 2002
Potter et al, 2001
Government initiatives to
reduce caesarean births
• Galba de Araujo Award for
“humanized hospitals” of SUS
• Sponsors expansion of nursemidwifery education
• Incorporation of doula care (labour
and birth companions)
• Creation of Centres for Normal
Births (Birth centres)
• Pact for the Reduction of
Caesareans – limits to 25%
• Reduces payment of caesarean
births in relation to normal birth
Humanization of care in
Brazil
• Recognition of care in childbirth as
a “dehumanizing” event
• “Humanization” of care often
means:
– implementation of EBM
– respect for womens rights (sexual and
reproductive), and universal access to
available technology
– respectful treatment from providers
– availability of pain relief and prevention
of iatrogenic pain
– multiprofessional care
Policy implications
• Socio-spatial inequalities in the
adequacy of Ministry of Health data
systems on live births (SINASC) and
deaths (SIM) for estimating mortality
merits attention
• Policy makers should give special
attention to the needs of black/mixed
race women during antenatal and
delivery care
• Priorities to improve programmes on
education about sexual and reproductive
health, to extend availability of effective
family planning and safe abortion care,
and to improve the practice of evidencebased obstetric care
Challenges and
opportunities
• Unique opportunity to set framework for
maternity care
• Endorse pregnancy & childbirth as normal
life events
• Recommend tailored care packages
based on need
– Community focussed, nurse/midwife managed
care for healthy women
– Obstetric care for complex cases
• Focus on implementation not policy
• Stakeholder engagement
• Provide evidence relating to practitioners'
performance compared with that of their
peers
Thank you!