ABSTRACT

Objective:

To identify the factors associated with Upright Delivery (UD) performed in hospitals linked to the Rede Cegonha (RC) in Brazil.

Methods:

Cross-sectional study with 3,073 parturients who had vaginal delivery in 606 health facilities in Brazil, located in health regions with a regional action plan approved in the RC. Socioeconomic, demographic, and obstetric characteristics of the parturients, organizational and management aspects of maternity hospitals, and work processes in childbirth care were evaluated. The multivariate logistic regression model with a hierarchical approach was adjusted to identify the variables associated with UD (outcome), estimating Odds Ratios (OR) with a significance level of 5%.

Results:

Of the evaluated parturient, 6.7% gave birth in the vertical position. The following were associated with a greater chance of PPV: being black (OR=2.07); having 13 or more years of study (OR=3.20); giving birth in a high-risk hospital (OR=1.58); giving birth in PPP rooms (which assisted with labor, delivery, and puerperium in the same environment) in Obstetric Centers (OR=2.07) or in-hospital Normal Delivery Centers (OR=1.62); being assisted by an obstetrician nurse (OR=1.64) or by a midwife (OR=7.62) when compared to a doctor; receiving massage during labor and delivery (OR=1.89); using a stool (OR=4.16) and among women who did not ask for/not receive analgesia (OR=3.15).

Conclusion:

The UD is an event related to racial aspects and the education of the parturient, being stimulated in health establishments where good practices of childbirth care are implemented, with adequate ambiance, and with multidisciplinary teams comprising midwives and obstetric nurses.

Keywords:
Parturition; Natural birth; Maternal health; Maternal-child health services

INTRODUCTION

In obstetrics, the phenomenon of horizontalization of childbirth occurred concomitantly with the process of medicalization and institutionalization of birth. The adoption of this position, although convenient for health professionals, as it facilitates obstetric interventions, is not always beneficial for parturients¹1 Schettini NJC, Griboski RA, Faustino AM. Partos normais assistidos por enfermeiras obstétricas: posição materna e a relação com lacerações perineais espontâneas. Rev Enferm UFPE on line 2017; 11(Supl 2): 932-40. https://doi.org/10.5205/1981-8963-V11I2A13462P932-940-2017.
https://doi.org/10.5205/1981-8963-V11I2A... . Brazilian public policies²2 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: Ministério da Saúde [Internet]. 2017. [cited on Jun. 5, 2022]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf
https://bvsms.saude.gov.br/bvs/publicaco... –⁴4 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria no 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS) a Rede Cegonha [Internet]. Diário Oficial da União, 27 jun. 2011; Seção 1; 2011. [cited on Jun. 20, 2022]. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011_comp.html
https://bvsms.saude.gov.br/bvs/saudelegi... , guided by recommendations from international bodies⁵5 World Health Organization. Intrapartum care for a positive childbirth experience. Geneva: WHO [Internet]. 2018. [cited on Jun. 05, 2022]. Available at: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf
https://apps.who.int/iris/bitstream/hand... , encourage the adoption of good practices in labor and birth care and determine that delivery in the upright birth position (UBP) is encouraged by professionals who assist parturients.

These guidelines highlight the importance of freedom of position during labor, giving the pregnant woman the opportunity to choose the position that is most comfortable for her, encouraging non-supine postures. In this sense, the adoption of UBP is encouraged because there is evidence of its benefits, such as reduced indication of cesarean sections⁶6 Gams B, Neerland C, Kennedy S. Reducing primary cesareans: an innovative multipronged approach to supporting physiologic labor and vaginal birth. J Perinat Neonatal Nurs 2019; 33(1): 52-60. https://doi.org/10.1097/JPN.0000000000000378
https://doi.org/10.1097/JPN.000000000000... , episiotomy and other obstetric interventions⁷7 Pervin J, Aktar S, Nu UT, Rahman M, Rahman A. Associations between improved care during the second stage of labour and maternal and neonatal health outcomes in a rural hospital in Bangladesh. Midwifery 2018; 66: 30-5. https://doi.org/10.1016/j.midw.2018.07.010
https://doi.org/10.1016/j.midw.2018.07.0... , cervical tear⁷7 Pervin J, Aktar S, Nu UT, Rahman M, Rahman A. Associations between improved care during the second stage of labour and maternal and neonatal health outcomes in a rural hospital in Bangladesh. Midwifery 2018; 66: 30-5. https://doi.org/10.1016/j.midw.2018.07.010
https://doi.org/10.1016/j.midw.2018.07.0... –⁹9 Hemmerich A, Diesbourg T, Dumas GA. Development and validation of a computational model for understanding the effects of an upright birthing position on the female pelvis. J Biomech 2018; 77: 99-106. https://doi.org/10.1016/j.jbiomech.2018.06.013
https://doi.org/10.1016/j.jbiomech.2018.... and blood loss⁷7 Pervin J, Aktar S, Nu UT, Rahman M, Rahman A. Associations between improved care during the second stage of labour and maternal and neonatal health outcomes in a rural hospital in Bangladesh. Midwifery 2018; 66: 30-5. https://doi.org/10.1016/j.midw.2018.07.010
https://doi.org/10.1016/j.midw.2018.07.0... , shorter intrapartum period⁷7 Pervin J, Aktar S, Nu UT, Rahman M, Rahman A. Associations between improved care during the second stage of labour and maternal and neonatal health outcomes in a rural hospital in Bangladesh. Midwifery 2018; 66: 30-5. https://doi.org/10.1016/j.midw.2018.07.010
https://doi.org/10.1016/j.midw.2018.07.0... ,¹⁰10 Berta M, Lindgren H, Christensson K, Mekonnen S, Adefris M. Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis. BMC Pregnancy Childbirth 2019; 19(1): 466. https://doi.org/10.1186/s12884-019-2620-0
https://doi.org/10.1186/s12884-019-2620-... , less need for epidural anesthesia¹¹11 Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2013; 8: CD003934. https://doi.org/10.1002/14651858.CD003934.pub4
https://doi.org/10.1002/14651858.CD00393... and greater satisfaction in the delivery experience¹²12 Li YP, Yeh CH, Lin SY, Chen TC, Yang YL, Lee CN, et al. A proposed mother-friendly childbirth model for Taiwanese women, the implementation and satisfaction survey. Taiwan J Obstet Gynecol 2015; 54(6): 731-6. https://doi.org/10.1016/j.tjog.2015.10.009
https://doi.org/10.1016/j.tjog.2015.10.0... , when compared to women who experienced the supine or lithotomous position.

However, evidence on factors associated with UBP is still limited. Expanding knowledge about these relationships can contribute to strengthening strategies that guarantee women the opportunity to choose the most convenient birthing position and, above all, the freedom to refuse unnecessary interventions. Therefore, this study aimed to identify the factors associated with UBP performed in public hospitals affiliated to the Unified Health System (Sistema Único de Saúde – SUS), linked to Rede Cegonha, in Brazil.

METHODS

This is a cross-sectional study carried out with data from the research entitled “Assessment of Delivery and Childbirth Care in Maternity Hospitals in the Scope of the Stork Network” (Avaliação das Boas Práticas na Atenção ao Parto e Nascimento em Maternidades non Âmbito da Rede Cegonha)¹³13 Vilela MEA, Leal MC, Thomaz EBAF, Gomes MASM, Bittencourt SDA, Gama SGN, et al. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Ciênc Saúde Coletiva 2021; 26(3): 789-800. https://doi.org/10.1590/1413-81232021263.10642020
https://doi.org/10.1590/1413-81232021263... ,¹⁴14 Bittencourt SDA, Vilela MEA, Marques MCO, Santos AM, Silva CKRT, Domingues RMSM, et al. Atenção ao parto e nascimento em Maternidades da Rede Cegonha/Brasil: avaliação do grau de implantação das ações. Ciênc Saúde Coletiva 2021; 26(3): 801-21. https://doi.org/10.1590/1413-81232021263.08102020
https://doi.org/10.1590/1413-81232021263... , which enabled the evaluation of various dimensions of delivery and birth care, including access and quality of services, management models, reception, resolution and good practices during childbirth and labor.

The research was carried out in public and mixed hospitals (private ones with SUS contracts) in Brazil located in health regions with an action plan by the Rede Cegonha, which, in 2015, carried out:

1. 500 or more deliveries⁴4 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria no 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS) a Rede Cegonha [Internet]. Diário Oficial da União, 27 jun. 2011; Seção 1; 2011. [cited on Jun. 20, 2022]. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011_comp.html
   https://bvsms.saude.gov.br/bvs/saudelegi... , regardless of the release of resources (581 maternity hospitals); or

2. Less than 500 births, with release of resources (25 maternity hospitals), totaling 606 maternity hospitals.

Data collection was carried out between December 2016 and October 2017, through individual, face-to-face interviews with all postpartum women who gave birth in the health facilities included in the research during the evaluation days of each maternity hospital. The sample was stratified by large geographic region. Thus, the number of days for data collection was defined according to the volume of deliveries in hospitals in each region, setting the North Region at six days, the Northeast and Southeast at two days, the South Region at five days, and seven days in the Midwest. Sample size was calculated based on a cesarean rate of 50%, to detect differences of 5%, with a significance level of 5% and power of 80%, totaling 10,473 postpartum women. The sampling plan generated an overrepresentation of the North, South, and Midwest regions, which was corrected by a calibration procedure¹⁵15 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saúde Pública 2019; 35(7): e00223018. https://doi.org/10.1590/0102-311x00223018
https://doi.org/10.1590/0102-311x0022301... . For the interviews, a semi-structured questionnaire was used as an instrument for data collection. Data on the characteristics of the health establishment were obtained from the National Registry of Health Establishments (Cadastro Nacional de Estabelecimentos de Saúde – CNES), referring to the year 2015.

For the present study, women who had vaginal delivery in the evaluated maternity hospitals were considered, excluding those who had a twin pregnancy, stillbirth, made use of forceps and observations with ignored information, totaling 3,073 puerperal women analyzed.

Considering the complexity of the phenomenon studied, a theoretical model was constructed to explain the relationships between the dependent and the explanatory variables through three levels: distal, intermediate, and proximal (Figure 1). At the distal level, the geographic region where the birth took place (North, Northeast, Southeast, Midwest or South) was considered.

The intermediate level included three blocks:

Block 1: Sociodemographic variables and obstetric information of the puerperal woman, including age group (19 or less, 20 to 29, 30 to 39, 40 or more), self-reported race/color (white, black, brown, yellow/oriental, indigenous), education (0 to 5 years, 6 to 9 years, 10 to 12 years, 13 years or more), and number of deliveries (primiparous, one previous delivery, two previous deliveries, three or more deliveries);

Block 2: Characteristics of the maternity, including type of maternity management (shared, state, municipal), total deliveries performed in 2015 (0 to 2,500, 2,501 to 5,000, more than 5,000), being a high-risk hospital (yes, no), accredited to the Baby-Friendly Hospital Initiative (Iniciativa Hospital Amigo da Criança – IHAC) (yes, no), having a room for prepartum, delivery, and postpartum assistance in the same environment (PPP room) in an obstetric center (OC) (none, 1 or more), or in-hospital normal delivery center (NDC) (none, 1 or more)]; and

Block 3: Variables of the professional responsible for the delivery, considering which professional attended the delivery (obstetrician, obstetric nurse, midwife, without assistance). At the proximal level, the characteristics of care provided during labor and delivery were considered: presence of a companion (yes, no); having privacy respected (yes, no); food offer (yes, no); walking allowed during labor (yes, no); offer of a bath with warm water (yes, no); birth ball (yes, no); massage (yes, no); sitting cowboy style (yes, no); stool (yes, no), and analgesia (asked and received analgesia, asked and did not receive, did not ask and received, did not ask and did not receive).

The outcome analyzed in this study was the UBP, obtained by the question “What was the position you were in to have the baby?” with eight answer options:

1. Lying on back with legs raised (gynecological position);

2. Lying flat on the bed;

3. Side-lying on the bed;

4. Recumbent;

5. Upright position, sitting;

6. Upright position, squatting;

7. Upright position, standing;

8. All fours.

The variable was dichotomized (yes, no), considering the UBP those who responded to the options upright, sitting, squatting or standing.

For data analysis, the R Studio software (version 2022.07.0) was used. A descriptive analysis of the data was initially performed, calculating absolute and relative frequencies. The associations between the explanatory variables and the outcome were estimated in crude and adjusted analyses, using a logistic regression model to calculate the odds ratio (OR) and respective 95% confidence intervals (95%CI). Modeling with a hierarchical approach was used to fit the models. At each level, only the variables that presented p≤0.20 in the crude analysis were included. Variables with a value of p≤0.10 remained in the adjusted model when inserted into the model at their respective hierarchical levels. Thus, initially, the association between the variables of the distal level and the outcome was estimated, remaining in the adjusted model (which goes to the subsequent levels) those with p-value≤0.10. Then, to this model with the variables that came from the distal level, the variables of the intermediate level were inserted, remaining in the model the variables that came from the distal level (regardless of the new p-value) and also those from the intermediate level whose p-value was less than or equal to 0.10. Finally, the process was repeated, inserting the variables from the proximal level into the model, adjusted for the variables that came from the distal and intermediate levels. Thus, the adjusted associations were considered at their respective levels adjusted for the variables of the previous levels¹⁶16 Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997; 26(1): 224-7. https://doi.org/10.1093/ije/26.1.224
https://doi.org/10.1093/ije/26.1.224... . The input sequence of the variables in the models followed the hierarchical order shown in Figure 1.

The research was approved by the Ethics Committees in Research with Human Beings of Universidade Federal do Maranhão and Escola Nacional de Saúde Pública Sérgio Arouca, CAAE 56389713.5.3001.5240, on December 14^th, 2016. All precautions were taken to ensure confidentiality of information, safeguarding the ethical principles of autonomy, justice, beneficence and non-maleficence, privacy, and confidentiality. All postpartum women were previously informed about the study, and those who agreed and signed the informed consent were included. The study followed the guidelines of the STROBE Statement.

RESULTS

Of the 3,073 women who participated in the present study, 208 (6.7%) gave birth in the upright position. The highest percentage of delivery in the vertical position was observed in women between 20 and 29 years old (7.1%), self-declared black (10.9%), with 13 years or more of schooling (11.0%), primiparous (7.2%) and in the southern region of the country (9.2%). The highest percentage of UBP was among shared management hospitals (9.3%), with more than 5,000 deliveries in 2015 (11.2%), in high-risk hospitals (9.3%), with one or more PPP rooms in obstetric centers (10.4%) or in in-hospital normal delivery centers (9.8%). UBP were mostly performed by midwives (32.6%), without the assistance of a professional (28.1%) or by obstetric nurses (8.8%). As for good practices in labor and delivery care, delivery in an upright position was more prevalent among women who were accompanied (6.9%), walked around during labor (7.6%), took a bath with warm water (9.0%), used a birth ball (10.4%), received a massage (11.8%), sat in a cowboy style (11.6%), used a stool (22.1%), and did not ask for and did not received analgesia (7.5%) (Table 1).

In the unadjusted analysis, UBP was associated with: self-declared black mothers compared to white ones (OR=2.13); having 10 to 12 years of schooling (OR=2.05) or ≥13 (OR=3.13) compared to those with up to five years of study; giving birth in a hospital with 5,000 or more deliveries per year (OR=1.99); giving birth in a referral hospital for high-risk pregnancy (OR=1.67), which has a PPP room in the obstetric center (OR=1.95) or in-hospital NDC (OR=1.65); being assisted in childbirth by an obstetrician nurse (OR=1.72), midwife (OR=8.65) or even giving birth without the presence of a professional (OR=6.99) when compared to being assisted by a doctor. All variables at the proximal level (good practices in childbirth care) were associated with UBP, except for the presence of a companion. After adjusting the models, an increase in the chance of UBP was identified in black women (OR=2.07; 95%CI 1.29–3.30); with 13 or more years of schooling (OR=3.20; 95%CI 1.36–7.53); who gave birth in a high-risk hospital (OR=1.58; 95%CI 1.10–2.27), in a PPP in the OC (OR=2.07; 95%CI 1.45–2.96) or in an intra-hospital NDC PPP room (OR=1.62; 95%CI 1.08–2.43). Being assisted by an obstetrician nurse (OR=1.64; 95%CI 1.15–2.32) or by a midwife (OR=7.62; 95%CI 2.26–25.68). Receiving a massage (OR=1.91; 95%CI 1.33–2.76) and use a stool (OR=4.35; 95%CI 2.94–6.44) during labor and delivery; and not asking for and not receiving analgesia (OR=3.33; 95%CI 1.22–9.24) also increased the chance of giving birth in the upright position (Table 2).

DISCUSSION

This population-based study, carried out in 606 health facilities linked to the Rede Cegonha in all federal units in Brazil, included 3,073 postpartum women who gave birth through the normal route. It was evidenced that only 6.7% of these deliveries were in upright positions. The factors that were positively associated with UBP were: being a black woman, having 13 or more years of schooling, giving birth in a referral hospital for high-risk pregnancy, having a PPP room in an obstetric center or in-hospital NDC, and being assisted by an obstetric nurse or by a midwife. Offering good practices — such as receiving massage, using a stool during labor and delivery, and not asking for/not receiving analgesia — was associated with a greater chance of giving birth in an upright position.

The low frequency of vaginal delivery in the upright position observed in this study represents the continuation of a pattern already presented in the Nascer no Brasil research, in which less than 9% of deliveries in the country in 2011 and 2012 occurred in a non-lithotomic position¹⁷17 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saúde Pública 2014; 30(Suppl 1): S17-S32. https://doi.org/10.1590/0102-311X00151513
https://doi.org/10.1590/0102-311X0015151... . This outcome is similar to the experience of childbirth in American women, in which 91% of vaginal deliveries performed in hospitals were conducted in supine positions. This high prevalence of deliveries in the supine position is due to the care model practiced in the United States and Brazil, which prioritizes curative and hospital measures for the care of their population and where cesarean section is the most common surgical procedure among women¹⁸18 Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Major survey findings of listening to mothers (SM) III: pregnancy and birth: report of the Third National U.S. Survey of Women's Childbearing Experiences. J Perinat Educ 2014; 23(1): 9-16. https://doi.org/10.1891/1058-1243.23.1.9
https://doi.org/10.1891/1058-1243.23.1.9... –²⁰20 Leal MC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, et al. Saúde reprodutiva, materna, neonatal e infantil nos 30 anos do Sistema Único de Saúde (SUS). Ciênc Saúde Colet 2018; 23(6): 1915-28. https://doi.org/10.1590/1413-81232018236.03942018
https://doi.org/10.1590/1413-81232018236... .

The findings of the aforementioned study are not consistent with the actions of the government and the efforts of civil society to improve delivery and birth care in recent decades in Brazil²2 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: Ministério da Saúde [Internet]. 2017. [cited on Jun. 5, 2022]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf
https://bvsms.saude.gov.br/bvs/publicaco... –⁵5 World Health Organization. Intrapartum care for a positive childbirth experience. Geneva: WHO [Internet]. 2018. [cited on Jun. 05, 2022]. Available at: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf
https://apps.who.int/iris/bitstream/hand... . This situation probably reflects the culture of medicalization of childbirth, which is still very strong in the country, despite efforts to encourage natural childbirth²¹21 Gomes SC, Teodoro LPP, Pinto AGA, Oliveira DR, Quirino GS, Pinheiro AKB. Rebirth of childbirth: reflections on medicalization of the Brazilian obstetric care. Rev Bras Enferm 2018; 71(5): 2594-8. https://doi.org/10.1590/0034-7167-2017-0564
https://doi.org/10.1590/0034-7167-2017-0... .

Differently from what was observed in this study, Andrade et al.²²22 Andrade PON, Silva JQP, Diniz CMM, Caminha MFC. Fatores associados à violência obstétrica na assistência ao parto vaginal em uma maternidade de alta complexidade em Recife, Pernambuco. Rev Bras Saude Mater Infant 2016; 16(1): 29-37. https://doi.org/10.1590/1806-93042016000100004
https://doi.org/10.1590/1806-93042016000... found that 61% of deliveries performed in 2014 in a hospital in Pernambuco, a reference for the Ministry of Health (MoH), occurred in a non-supine position. This result differs from the national reality and reflects the joint effort of managers and professionals to change the scenario of obstetric care. They are also similar to that found in Scandinavian countries, where 65% of women tend to give birth in non-supine positions²³23 Edqvist M, Blix E, Hegaard HK, Ólafsdottir OÁ, Hildingsson I, Ingversen K, et al. Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth. BMC Pregnancy Childbirth 2016; 16(1): 196. https://doi.org/10.1186/s12884-016-0990-0
https://doi.org/10.1186/s12884-016-0990-... and indicate that the process of change in the model of childbirth care in Brazil, stimulated by Rede Cegonha, is under development, but little implemented in some recommendations.

The adoption of vertical positions in the first and second stages of labor has been identified as beneficial for both the mother and the baby, as they are associated with a reduction in obstetric interventions, such as cesarean section, use of episiotomies and forceps, shorter length of time of labor, and less negative effects on the health of mother and baby⁶6 Gams B, Neerland C, Kennedy S. Reducing primary cesareans: an innovative multipronged approach to supporting physiologic labor and vaginal birth. J Perinat Neonatal Nurs 2019; 33(1): 52-60. https://doi.org/10.1097/JPN.0000000000000378
https://doi.org/10.1097/JPN.000000000000... –¹¹11 Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2013; 8: CD003934. https://doi.org/10.1002/14651858.CD003934.pub4
https://doi.org/10.1002/14651858.CD00393... . From this perspective, the recommendations of the World Health Organization (WHO) and the MoH encourage the adoption of practices that promote a safe, quality vaginal delivery in which women are free to assume the position that is most comfortable for them, being encouraged by the professionals who assist them to try non-supine positions during childbirth²2 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: Ministério da Saúde [Internet]. 2017. [cited on Jun. 5, 2022]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁵5 World Health Organization. Intrapartum care for a positive childbirth experience. Geneva: WHO [Internet]. 2018. [cited on Jun. 05, 2022]. Available at: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf
https://apps.who.int/iris/bitstream/hand... .

The distribution of UBP in Brazilian geographic regions was heterogeneous, with a higher proportion in the Southeast and Northeast regions and lower frequency in the Center-West region, consistent with the results of the Nascer no Brasil survey, in which deliveries in the lithotomy position were more frequent in the Midwest and less frequent in the Northeast¹⁷17 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saúde Pública 2014; 30(Suppl 1): S17-S32. https://doi.org/10.1590/0102-311X00151513
https://doi.org/10.1590/0102-311X0015151... .

Being black, compared to white women, increased the chances of giving birth in an upright position. The literature does not describe significant differences regarding the race/color of women and the position of delivery performed within the scope of SUS, when analyzed according to education and income²⁴24 Theophilo RL, Rattner D, Pereira ÉL. The vulnerability of afro-brazilian women in perinatal care in the Unified Health System: analysis of the active ombudsman survey. Ciênc Saúde Colet 2018; 23(11): 3505-16. https://doi.org/10.1590/1413-812320182311.31552016
https://doi.org/10.1590/1413-81232018231... . Racial differences were identified in relation to some unnecessary interventions, characterizing obstetric violence²⁵25 Diniz CSG, Batista LE, Kalckmann S, Schlithz AOC, Queiroz MR, Carvalho PCA. 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). Saúde Soc 2016; 25(3): 561-72. https://doi.org/10.1590/S0104-129020162647
https://doi.org/10.1590/S0104-1290201626... ,²⁶26 Alves MTSSB, Chagas DC, Santos AM, Simões VMF, Ayres BVS, Santos GL, et al. Desigualdade racial nas boas práticas e intervenções obstétricas no parto e nascimento em maternidades da Rede Cegonha. Ciênc Saúde Coletiva 2021; 26(3): 837-46. https://doi.org/10.1590/1413-81232021263.38982020
https://doi.org/10.1590/1413-81232021263... . It is possible that the result identified is reflecting both cultural aspects related to the choice to give birth in an upright position among Afro descendants, as well as a different form of discrimination, as discussed by Alves et al.²⁶26 Alves MTSSB, Chagas DC, Santos AM, Simões VMF, Ayres BVS, Santos GL, et al. Desigualdade racial nas boas práticas e intervenções obstétricas no parto e nascimento em maternidades da Rede Cegonha. Ciênc Saúde Coletiva 2021; 26(3): 837-46. https://doi.org/10.1590/1413-81232021263.38982020
https://doi.org/10.1590/1413-81232021263... . For these authors, some good practices are more performed in black women because, in the interventionist model of care, which is still hegemonic in Brazil, unnecessary interventions, including elective cesarean section and delivery in the supine position, are routinely performed, and the least amount of them is performed in black women would be better interpreted as evidence of racial discrimination and a certain “carelessness” with these women.

The higher level of education of the parturients increased the chances of carrying out the UBP. This association may have occurred because women with more years of schooling have greater understanding and greater access to information about labor and delivery, making them less vulnerable to practices considered inappropriate¹⁷17 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saúde Pública 2014; 30(Suppl 1): S17-S32. https://doi.org/10.1590/0102-311X00151513
https://doi.org/10.1590/0102-311X0015151... ,²²22 Andrade PON, Silva JQP, Diniz CMM, Caminha MFC. Fatores associados à violência obstétrica na assistência ao parto vaginal em uma maternidade de alta complexidade em Recife, Pernambuco. Rev Bras Saude Mater Infant 2016; 16(1): 29-37. https://doi.org/10.1590/1806-93042016000100004
https://doi.org/10.1590/1806-93042016000... .

Being treated in a high-risk hospital and in an obstetric center or in-hospital normal delivery center with PPP rooms increased the chances of UBP. These results reflect the changes that occurred with the implementation of the Rede Cegonha, which allowed, through the environment, the modification of physical spaces aimed at childbirth care, making it possible to implement good practices and educational interventions that improved childbirth care and delivery⁴4 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria no 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS) a Rede Cegonha [Internet]. Diário Oficial da União, 27 jun. 2011; Seção 1; 2011. [cited on Jun. 20, 2022]. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1459_24_06_2011_comp.html
https://bvsms.saude.gov.br/bvs/saudelegi... ,²⁷27 Côrtes CT, Oliveira SMJV, Santos RCS, Francisco AA, Riesco MLG, Shimoda GT. Implementação das práticas baseadas em evidências na assistência ao parto normal. Rev Latino-Am Enfermagem. 2018; 26: e2988. https://doi.org/10.1590/1518-8345.2177.2988
https://doi.org/10.1590/1518-8345.2177.2... .

Another relevant factor in this study was the professional responsible for the delivery. Having the birth assisted by obstetric nurses or midwives, when compared to the doctor, was associated with greater chances of performing UBP, and the latter further increase the chances of delivery in this position. These professionals are indicated by the National Guidelines for Assistance to Normal Childbirth²2 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: Ministério da Saúde [Internet]. 2017. [cited on Jun. 5, 2022]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf
https://bvsms.saude.gov.br/bvs/publicaco... as the most suitable for assisting low-risk postpartum women. In addition, evidence shows that the presence of the nursing team is associated with better results in childbirth care¹⁵15 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, et al. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saúde Pública 2019; 35(7): e00223018. https://doi.org/10.1590/0102-311x00223018
https://doi.org/10.1590/0102-311x0022301... ,²²22 Andrade PON, Silva JQP, Diniz CMM, Caminha MFC. Fatores associados à violência obstétrica na assistência ao parto vaginal em uma maternidade de alta complexidade em Recife, Pernambuco. Rev Bras Saude Mater Infant 2016; 16(1): 29-37. https://doi.org/10.1590/1806-93042016000100004
https://doi.org/10.1590/1806-93042016000... ,²⁸28 Gama SGN, Viellas EF, Torres JA, Bastos MH, Brüggemann OM, Theme Filha MM, et al. Labor and birth care by nurse with midwifery skills in Brazil. Reprod Health 2016; 13(Suppl 3): 123. https://doi.org/10.1186/s12978-016-0236-7
https://doi.org/10.1186/s12978-016-0236-... .

Despite the low number of women in this condition (n=7), in this study, a greater chance of adopting the upright position was observed among women who gave birth without professional assistance, compared to those who received assistance from a medical professional. This result is possibly due to the fact that these women were walking or sitting at the time of delivery, which made an adequate diagnosis of labor impossible. In addition, a previous study points out that women who opted for UBP demand less assistance and fewer interventions, in addition to not being influenced by traditional medical training, which tends to consider the supine position as the most convenient²⁷27 Côrtes CT, Oliveira SMJV, Santos RCS, Francisco AA, Riesco MLG, Shimoda GT. Implementação das práticas baseadas em evidências na assistência ao parto normal. Rev Latino-Am Enfermagem. 2018; 26: e2988. https://doi.org/10.1590/1518-8345.2177.2988
https://doi.org/10.1590/1518-8345.2177.2... . However, it is necessary to emphasize that the recommendation of the Ministry of Health is that low-risk childbirth should be assisted by a doctor, obstetric nurse or midwife, the last two being related to less intervention and greater satisfaction of women²2 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: Ministério da Saúde [Internet]. 2017. [cited on Jun. 5, 2022]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

The performance of some non-pharmacological measures, such as receiving massage and using the stool, were associated with greater chances of performing UBP. A systematic review²⁹29 Gayeski ME, Brüggemann OM. Métodos não farmacológicos para alívio da dor no trabalho de parto: uma revisão sistemática. Texto Contexto Enferm 2010; 19(4): 774-82. https://doi.org/10.1590/S0104-07072010000400022
https://doi.org/10.1590/S0104-0707201000... points out that the performance of comfort massage, by professionals or partners, proved to be effective when applied at the beginning of the latent phase of childbirth, promoting a reduction in the levels of stress and pain, in addition to providing an opportunity for the active participation of the companion. This comfort measure encourages relaxation, improves blood flow and tissue oxygenation, contributing to a more satisfying birthing experience. Furthermore, the use of a stool during labor encourages a change in the parturient's posture and has been shown to be efficient in increasing the rate of dilation, promoting pain relief and facilitating fetal descent²2 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: versão resumida. Brasília: Ministério da Saúde [Internet]. 2017. [cited on Jun. 5, 2022]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_nacionais_assistencia_parto_normal.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ,⁵5 World Health Organization. Intrapartum care for a positive childbirth experience. Geneva: WHO [Internet]. 2018. [cited on Jun. 05, 2022]. Available at: https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf
https://apps.who.int/iris/bitstream/hand... . This data was also pointed out by a study that evaluated the perception of puerperal women about non-invasive care technologies during childbirth³⁰30 Ribeiro IAP, Pereira PSL, Gomes IS, Morais JC, Gouveia MTO, Nascimento MVF, et al. Tecnologias não invasivas de cuidado: percepção das puérperas. Rev Enferm UFPE on line 2018; 12(8): 2129-36. https://doi.org/10.5205/1981-8963-v12i8a236584p2129-2136-2018
https://doi.org/10.5205/1981-8963-v12i8a... .

Not asking for and not receiving analgesia was associated with higher odds of UBP. Thus, it is understood that the adoption of this position contributed to the reduction of the need for analgesia, a benefit already described in the literature¹¹11 Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2013; 8: CD003934. https://doi.org/10.1002/14651858.CD003934.pub4
https://doi.org/10.1002/14651858.CD00393... .

A limitation of the present research refers to the fact that only hospitals in health regions that had plans approved by Rede Cegonha were included. It is possible that, with the inclusion of other hospitals, the prevalence of UBP in Brazil would be even lower. As strengths, we emphasize the fact that this is data from an evaluative research of a national character, with representation for the macro-regions of Brazil. The evaluated maternity hospitals, together, perform 65% of deliveries in Brazil³¹31 Brasil. Minstério da Saúde. Cadastro Nacional de Estabelecimentos de Saúde – CNES [Internet]. [cited on Apr. 20, 2022]. Available at: http://cnes2.datasus.gov.br
http://cnes2.datasus.gov.br... . This was the first nationwide survey carried out after the implementation of the Rede Cegonha within SUS. These data allow comparing the reality of maternal and child care before and after the implementation of this strategy. We emphasize that the study used different techniques and data collection instruments, validated by experts in the area of maternal and child health, and was carried out with puerperal women soon after childbirth and with all women who gave birth at the time of the interviews, thus reducing memory and selection bias.

Factors associated with birth in the vertical position were black women, with 13 or more years of schooling, assisted by an obstetrician nurse or midwife, who received massage, used a stool during labor and delivery, and did not ask for and did not received analgesia. Finally, delivery in the upright position, despite being more indicated because it requires fewer interventions, still has low adherence in Brazil. The low prevalence of adopting this position points to the need to promote the strengthening of these practices in the daily routine of health services, together with professionals who are inserted in this context. It is also important to emphasize the importance of the effective implementation of environments with physical structure and resources consistent with the needs of these women.

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