Abstract

The Rede Cegonha strategy was launched in 2011 by the federal government to improve pregnancy, delivery, postpartum care, and child development in the first two years of life, reduce maternal and child mortality, and expand women’s sexual and reproductive rights. We propose seven new maternal indicators to improve obstetric care evaluation in the next assessment cycle. The new indicators are the use of Robson’s classification to monitor cesarean rates, use of magnesium sulfate in cases of preeclampsia/eclampsia, pregnant women’s use of calcium supplements, blood transfusions and hysterectomy in delivery/puerperium, management of puerperal sepsis, IUD insertions in the postpartum/post-abortion period, and obstetricians’ continuing education. These indicators are based on robust scientific evidence and can reduce unnecessary cesarean sections, prevent maternal deaths and future unplanned pregnancies.

Key words
Maternal and child health services maternities; Health assessment

Introduction

The Rede Cegonha strategy was launched in 2011 by the federal government to improve pregnancy, childbirth, and postpartum care and promote the child’s healthy development in the first two years of life. It mainly aimed to reduce maternal and child mortality and expand women’s sexual and reproductive rights¹1 Brasil. Ministério da Saúde (MS). Portaria nº 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde-SUS-a Rede Cegonha. Diário Oficial da União 2011; 24 jul.. Rede Cegonha developed activities to train and qualify obstetric nurses, strategic professionals to change Brazilian obstetric and neonatal care²2 Organización Mundial de la Salud (OMS). Global strategic directions for strengthening nursing and midwifery 2016-2020 [Internet]. 2020 [cited 2020 Sep 18]. Available from: https://www.who.int/hrh/nursing_midwifery/global-strategy-midwifery-2016-2030/en/
https://www.who.int/hrh/nursing_midwifer... ^,33 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2016. [cited 2020 Sep 18]. Available from: s://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early
s://www.cochrane.org/CD004667/PREG_midwi... , and encouraged maternity hospitals to create Normal Childbirth Centers to humanize birth and offer pregnant women a private environment centered on women and the family⁴4 Brasil. Ministério da Saúde (MS). Orientações para elaboração de projetos arquitetônicos Rede Cegonha: ambientes de atenção ao parto e nascimento. Brasília: MS; 2018..

The first evaluation cycle of Rede Cegonha was performed in 2014-2015 in tripartite fashion with federal, state, and municipal managers. This first monitoring evaluated the maternity hospitals’ adherence to the agreed indicators: reception and risk classification, the pregnant women’s right to choose a companion, skin-to-skin contact of the puerperae and the newborn, and the occupancy rate of the high-risk reference obstetric beds. This instrument allowed evaluating and comparing the use of good care practices among maternity hospitals. This evaluation’s wide dissemination mobilized and encouraged maternity hospitals’ heads to promote necessary changes in their services.

The second evaluation cycle of Rede Cegonha occurred in 2016-2017 and was supported by the Oswaldo Cruz Foundation (Fiocruz) and the Federal University of Maranhão (UFMA)⁵5 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JA, Gama SGN, Domingues RMSM, Vilela MEA. Avanços na assistência ao parto no Brasil: resultados preliminares de dois estudos avaliativos. Cad Saude Publica 2019; 35(7):e00223018.. The five guidelines monitored in the participating maternity hospitals were reception in obstetrics and risk classification; good practices in labor, delivery, and postpartum care; care monitoring and maternal and neonatal mortality surveillance; participative management; and maternity hospital environment (Table 1).

In our view, the Rede Cegonha evaluation process contributed to the promotion of the necessary changes since managers were asked for an action plan based on the deficiencies found. Monitoring was critical, as municipal management does not have detailed assessment tools for maternal and child health in maternity hospitals. The proposed new indicators aim to intervene in the leading causes of maternal mortality and are described below.

1. Using Robson’s Classification to monitor cesarean rates

Guideline 2 of the second monitoring cycle assessed the hospital’s cesarean section rates in general, of high-risk pregnant women, primiparous women by age group, the main indications for cesarean sections, and the proportion of cesarean sections in women with previous cesarean section. We propose to use Robson’s classification for the next monitoring cycle. Robson’s classification (also known as the 10-group classification) has been recommended by the WHO since 2015 as a global standard instrument to assess, monitor, and compare cesarean rates over time in one and between different hospitals⁶6 Organização Mundial da Saúde (OMS). Declaração da OMS sobre Taxas de Cesáreas. Hum Reprod Program [Internet] 2015 [cited 2020 Sep 18];1-8. Available from: http://www.who.int/about/ licensing/copyright_ form/en/index.html).
http://www.who.int/about/ licensing/copy... . It has been widely used in several countries⁷7 Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, Tunçalp O, Mori R, Morisaki N, Ortiz-Panozo E, Hernandez B, Pérez-Cuevas R, Qureshi Z, Gülmezoglu AM, Temmerman M, WHO Multi-Country Survey on Maternal and Newborn Health Research Network. Use of the robson classification to assess caesarean section trends in 21 countries: A secondary analysis of two WHO multicountry surveys. Lancet Glob Heal [Internet]. 2015 May 1 [cited 2020 Sep 18];3(5):e260-270. Available from: https://pubmed.ncbi.nlm.nih.gov/25866355/
https://pubmed.ncbi.nlm.nih.gov/25866355... , but is barely employed in Brazil. Those responsible for the services often justify their high rates of cesarean sections because maternity hospitals are a reference in high-risk pregnancies. The use of Robson’s classification excludes this narrative, as it allows comparing cesarean rates in groups of similar pregnant women, such as, for example, with a single, term, cephalic fetus, with gestational age less than 37 weeks (Robson’s 10-group). The use of classification by Brazilian maternity hospitals will allow a more objective analysis of their cesarean rates, especially in groups 1 to 5 (pregnant women with a single, cephalic, term fetus), representing 70-80% of the obstetric population in most hospitals. The data analysis from each maternity hospital will allow managers to identify the need to improve or update their care protocols in groups with above-average cesarean rates⁸8 World Health Organization (WHO). Robson Classification: Implementation Manual. WHO [Internet]. 2020 [cited 2020 Sep 18]; Available from: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/robson-classification/en/
http://www.who.int/reproductivehealth/pu... .

2. Use of magnesium sulfate in women with severe preeclampsia or eclampsia

In the maternal and neonatal mortality surveillance guideline, both monitoring maternal death⁹9 Morse ML, Fonseca SC, Barbosa MD, Calil MB, Eyer FPC. Mortalidade materna no Brasil: O que mostra a produção científica nos últimos 30 anos? Cad Saude Publica 2011; 27(4):623-638. near-miss cases (women who almost died but survived a severe complication, which occurred during pregnancy, childbirth, or up to 42 days after the termination of pregnancy) is required¹⁰10 World Health Organization (WHO). Evaluating the quality of care for severe pregnancy complications. WHO [Internet]. 2017 [cited 2020 Sep 18]; Available from: http://www.who.int/reproductivehealth/publications/monitoring/9789241502221/en/
http://www.who.int/reproductivehealth/pu... , since near-death cases are more frequent situations than death. The analysis of these cases allows correcting inadequate care and preventing future maternal deaths. Reducing maternal mortality is one of the primary objectives of Rede Cegonha. Therefore, it is essential to evaluate the implementation of evidence-based protocols in the care of pregnant women with hypertensive syndromes, the leading cause of maternal death in Brazil⁹9 Morse ML, Fonseca SC, Barbosa MD, Calil MB, Eyer FPC. Mortalidade materna no Brasil: O que mostra a produção científica nos últimos 30 anos? Cad Saude Publica 2011; 27(4):623-638.. We propose to add the use of magnesium sulfate in pregnant women with severe preeclampsia and eclampsia as a new indicator. While scientific evidence shows that the use of magnesium sulfate reduces maternal mortality in severe preeclampsia and eclampsia cases¹¹11 Duley L, Henderson-Smart DJ, Walker GJ, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database Syst Rev [Internet]. 2010 Dec 8 [cited 2020 Sep 20];(12). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000127.pub2/full
https://www.cochranelibrary.com/cdsr/doi... , the use of this medication is resisted¹²12 Lotufo FA, Parpinelli MA, Osis MJ, Surita FG, Costa ML, Cecatti JG. Obstetrician's risk perception on the prescription of magnesium sulfate in severe preeclampsia and eclampsia: A qualitative study in Brazil. PLoS One [Internet]. 2017 Mar 1 [cited 2020 Sep 17];12(3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5354257/
https://www.ncbi.nlm.nih.gov/pmc/article... . Questions related to this indicator could include the percentage of magnesium sulfate use in pregnant women with severe preeclampsia or eclampsia, the time of use after diagnosis, and the adequacy of the dose and duration of medication use. Maternity managers should monitor professionals’ adherence to the protocol to avoid preventable maternal deaths⁹9 Morse ML, Fonseca SC, Barbosa MD, Calil MB, Eyer FPC. Mortalidade materna no Brasil: O que mostra a produção científica nos últimos 30 anos? Cad Saude Publica 2011; 27(4):623-638..

3. Use of calcium supplements during prenatal care

High-quality evidence¹³13 Hofmeyr GJ, Lawrie TA, Atallah ÁN, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems [Internet]. Vol. 2018, Cochrane Database of Systematic Reviews. [cited 2020 Sep 18]. Available from s://www.cochrane.org/CD001059/PREG_calcium-supplementation-during-pregnancy-preventing-blood-pressure-disorders-and-related-problems
s://www.cochrane.org/CD001059/PREG_calci... indicates that calcium supplementation during pregnancy can significantly reduce the risk of developing preeclampsia in pregnant women’s general population. It is even more effective in high-risk pregnant women and populations with low dietary calcium intake. As of 2014, the World Health Organization (WHO) has recommended the use of calcium supplements during pregnancy (1.5-2.0 g/day from the 20^th week) for all pregnant women in the population with low calcium diets (< less than 900 mg of elemental calcium per day)¹⁴14 World Health Organization (WHO). WHO recommendation: Calcium supplementation during pregnancy for the prevention of pre-eclampsia and its complications [Internet]. 2018 [cited 2020 Sep 18]. Available from: https://www.who.int/publications/i/item/9789240003118
https://www.who.int/publications/i/item/... . According to the results of the last national population survey, the typical diet consumed by adult Brazilian women (19-59 years old) contains an average of 546.4 mg/day of elemental calcium, and 90.7% of these women do not consume the minimum recommended amount for their age group¹⁵15 Instituto Brasilero de Geografia e Estatística (IBGE). Análise do Consumo Alimentar Pessoal no Brasil 2008-2009. Rio de Janeiro: IBGE; 2011.. Brazilian women have undoubtedly a low calcium diet and fit the WHO recommendation. The questions that could be asked for this indicator would be whether the pregnant woman received a prescription for calcium supplements during prenatal care and at what gestational age and dose.

4. Blood transfusion and hysterectomies in delivery and postpartum

Indicators monitoring the routine prophylactic use of oxytocin in the immediate postpartum period, the number of cases of blood transfusion and hysterectomies in the maternity hospitals are required in hemorrhagic syndromes. These data are essential for implementing the hemorrhagic syndromes protocol¹⁶16 Gallos ID, Papadopoulou c, Man R, Athanasopoulos N, Tobias A, Price MJ, Myfanwy J Williams, Virginia Diaz, Julia Pasquale, Monica Chamillard, Mariana Widmer, Özge Tunçalp, G Justus Hofmeyr, Fernando Althabe, Ahmet Metin Gülmezoglu, Joshua P Vogel , Oladapo OT, Coomarasamy A. Uterotonic agents for preventing postpartum haemorrhage: A network meta-analysis [Internet]. Cochrane Database of Syst Rev 2018 [cited 2020 Sep 18]; 12(12):CD011689. Available from: s://pubmed.ncbi.nlm.nih.gov/30569545/
s://pubmed.ncbi.nlm.nih.gov/30569545/... ^,1717 Organização Pan-Americana de Saúde (OPAS), Organização Mundial da Saúde (OMS Brasil). Zero Morte Materna por Hemorragia: a iniciativa da OPAS/OMS que está salvando vidas [Internet]. [cited 2020 Sep 18]. Available from: s://www.paho.org/bra/index.php?option=com_content&view=article&id=5528:zero-morte-materna-por-hemorragia-a-oficina-da-opas-oms-que-esta-salvando-vidas&Itemid=820
s://www.paho.org/bra/index.php?option=co... . We propose that the percentage of women receiving blood transfusions during labor and postpartum is monitored, offering the maternity manager assistance to improve the internal protocol and obtain a comparison parameter between other maternity hospitals. Using this indicator in near-death cases from hemorrhage is crucial, as they are frequent events, which can improve service deficiencies and avoid outcomes such as maternal death from hemorrhage⁹9 Morse ML, Fonseca SC, Barbosa MD, Calil MB, Eyer FPC. Mortalidade materna no Brasil: O que mostra a produção científica nos últimos 30 anos? Cad Saude Publica 2011; 27(4):623-638..

5. Adequate management of puerperal sepsis

Sepsis is a significant cause of maternal morbidity and mortality globally and the third leading cause of maternal mortality in Brazil. Evidence has shown an association between adherence to bundles and improved survival in patients with sepsis and septic shock¹⁸18 Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, Busani S, Girardis M. Effect of performance improvement programs on compliance with sepsis bundles and mortality: A systematic review and meta-analysis of observational studies [Internet]. PLoS One Public Library of Science 2015 [cited 2020 Sep 17]; 10(5):e0125827. Available from: s://pubmed.ncbi.nlm.nih.gov/25946168/
s://pubmed.ncbi.nlm.nih.gov/25946168/... . The central management of sepsis is the concept of being considered a medical emergency. As with acute myocardial infarction and stroke, early identification and appropriate immediate management in the early hours show better results. The guidelines state that these patients require urgent evaluation and treatment within the first hour, namely, “the golden hour”¹⁹19 Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyn TJ, Phillips GS, Lemeshow S, Osborn T, Terry KM, Levy MM. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med [Internet]. 2017 Jun 8 [cited 2020 Sep 17];376(23):2235-44. Available from: s://pubmed.ncbi.nlm.nih.gov/28528569/
s://pubmed.ncbi.nlm.nih.gov/28528569/... . Using this indicator allows evaluating the performance for the diagnosis and early therapy of the intervention package²⁰20 Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, Osborn T, Lemeshow S, Chiche JD, Artigas A, Dellinger RP. Surviving sepsis campaign: Association between performance metrics and outcomes in a 7.5-year study. Crit Care Med [Internet]. 2015 Jan 1 [cited 2020 Sep 17];43(1):3-12. Available from: ://journals.lww.com/00003246-201501000-00002
://journals.lww.com/00003246-201501000-0... and can improve near-death cases and puerperal infection-related maternal deaths.

6. Insertion of an IUD immediately after delivery or abortion

Unplanned and unwanted pregnancies are challenges to women and couples globally. Approximately 44% of global pregnancies are unplanned, and about 56% of unwanted pregnancies end in induced abortion²¹21 Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet [Internet]. 2014 Sep 22 [cited 2020 Sep 17];384(9947):980-1004. Available from: s://pubmed.ncbi.nlm.nih.gov/24797575/
s://pubmed.ncbi.nlm.nih.gov/24797575/... . In Brazil, the percentage of unplanned pregnancies follows developing countries’ trend, remaining above the world average. Per the Nascer no Brasil (“Born in Brazil”) survey²²22 Viellas EF, Domingues RMSM, Dias MAB, da Gama SGN, Filha MMT, da Costa JV, et al. Prenatal care in Brazil. Cad Saude Publica [Internet]. 2014 [cited 2020 Sep 18];30(Supl. 1):S85-100. Available from: ://dx.doi.org/10.1590/0102-311X00126013
://dx.doi.org/10.1590/0102-311X00126013... , more than 55% of Brazilian women who had children in 2011 and 2012 had not planned their pregnancy. Thus, reducing unplanned pregnancies is an essential factor in curbing maternal mortality²³23 Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet 2012; 380(9837):149-156..

The postpartum and post-abortion IUD’s immediate insertion should be routinely offered as a safe and effective option for expanding access to contraception²⁴24 Lopez LM, Bernholc A, Hubacher D, Stuart G, Van Vliet HA. Immediate postpartum insertion of intrauterine device for contraception [Internet]. Vol. 2015, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2015 [cited 2020 Aug 30]. Available from: ://doi.wiley.com/10.1002/14651858.CD003036.pub3
://doi.wiley.com/10.1002/14651858.CD0030... ^,2525 Okusanya BO, Oduwole O, Effa EE. Immediate postabortal insertion of intrauterine devices [Internet]. Cochrane Database Syst Rev 2014; [cited 2020 Aug 30]. Available from: ://doi.wiley.com/10.1002/14651858.CD001777.pub4
://doi.wiley.com/10.1002/14651858.CD0017... . Despite the higher expulsion rate of immediate insertion of the IUD in the postpartum period, the cost-benefit analysis data suggest the superiority of immediate placement in reducing unintended pregnancies, especially for women at greater risk of not attending the puerperal care visit.

Women face several barriers to access the IUD in health services²⁶26 Bahamondes L, Makuch MY, Monteiro I, Marin V, Lynen R. Knowledge and attitudes of Latin American obstetricians and gynecologists regarding intrauterine contraceptives. Int J Womens Health [Internet]. 2015 Jul 16 [cited 2020 Aug 30];7:717-22. Available from: /pmc/articles/PMC4509537/?report=abstract
/pmc/articles/PMC4509537/?report=abstrac... ^,2727 Gonzaga VAS, Borges ALV, Santos OA, Rosa PLFS, Gonçalves RFS. Organizational barriers to the availability and insertion of intrauterine devices in Primary Health Care Services. Rev Esc Enferm 2017; 51:e03270.. The period immediately after delivery or abortion is an opportunity to start contraception. The immediate insertion of the IUD in these periods has high acceptance rates, women are highly motivated to avoid a new pregnancy, the discomfort of standard insertion, and it is not necessary to run tests as they are certainly not pregnant. Therefore, the offer and insertion of copper IUDs in maternity hospitals immediately after delivery or abortion can be a strategy to expand its use, as the Mexican experience²⁸28 Potter JE, Hubert C, White K. The Availability and Use of Postpartum LARC in Mexico and Among Hispanics in the United States. Matern Child Health J 2017; 21(9):1744-1752..

The low prevalence of IUD use compared to other countries²⁹29 United Nations Population Division - Family Planning. Family Planning - United Nations Population Division. 2013 [cited 2020 Aug 30]; Available from: s://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2019.asp
s://www.un.org/en/development/desa/popul... , the support of several scientific societies³⁰30 Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo). Contracepção reversível de longa ação. São Paulo: Febrasgo; 2016 [cited 2020 Aug 30]. Available from: s://www.febrasgo.org.br/media/k2/attachments/03-CONTRACEPCAO_REVERSIVEL_DE_LONGA_ACAO.pdf
s://www.febrasgo.org.br/media/k2/attachm... ^,3131 Makins A, Taghinejadi N, Sethi M, Machiyama K, Thapa K, Perera G, Munganyizi PS, Bhardwaj A, Arulkumaran S. Factors influencing the likelihood of acceptance of postpartum intrauterine devices across four countries: India, Nepal, Sri Lanka, and Tanzania. Int J Gynecol Obstet 2018; 143(Supl. 1):13-19., and the Ministry of Health³²32 Brasil. Ministério da Saúde (MS). Manual Técnico para Profissionais de Saúde: DIU com Cobre TCu 380A. Brasília: MS; 2018. [cited 2020 Sep 18]. Available from: ://portaldeboaspraticas.iff.fiocruz.br/wp-content/uploads/2018/12/manual_diu_08_2018.pdf
://portaldeboaspraticas.iff.fiocruz.br/w... validate the inclusion of this new indicator. We propose the inclusion of this indicator in Guideline 2. The questions would be whether IUD was offered in the immediate postpartum or post-abortion period and the IUD insertion percentage among eligible women.

7. Continuing education of obstetricians in the leading causes of maternal death

Implementing good practices to reduce cesarean sections and the leading causes of maternal mortality involves refreshing professional knowledge in the maternity hospitals. Thus, I suggest that the evidence-based professional refresher courses be monitored³³33 Maluf-Filho Fauze. A contribuição da medicina baseada em evidências para a introdução de novo conhecimento na prática clínica. Arq. Gastroenterol. [Internet]. 2009 June [cited 2020 Sep 20] ; 46(2):87-89. Available from: ://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-28032009000200002&lng=en
://www.scielo.br/scielo.php?script=sci_a... .

An example of implementation in the reduction of mortality due to hemorrhage is the “Zero Maternal Death by Hemorrhage” strategy of the Pan American Health Organization (PAHO), in which theoretical and practical training is carried out through realistic simulation stations, providing updating and systematization of practical approaches in postpartum hemorrhage scenarios, which aims to qualify doctors and nurses who technically support the implementation of the strategy in Brazilian states.

Scientific entities such as the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO) can regularly conduct refresher courses in obstetric emergencies, in conjunction with state and municipal secretariats for maternity hospital professionals. Maternity managers can also monitor professionals’ regular participation in courses to qualify services, reducing near-death and maternal death cases (Table 2).

Conclusion

The regular cycles of monitoring and evaluating the actions recommended by Rede Cegonha are fundamental to improving the quality of care offered to Brazilian pregnant women³⁴34 Carvalho ALB, Souza MF, Shimizu HE, Senra IMVB, Oliveira KC. SUS management and monitoring and evaluation practices: Possibilities and challenges for building a strategic agenda. Cien Saude Colet [Internet]. 2012 [cited 2020 Sep 18];17(4):901-911. Available from: ://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232012000400012&lng=en&nrm=iso& tlng=pt
://www.scielo.br/scielo.php?script=sci_a... ^-3535 Campos FCC, Faria HP, Santos MX. Planejamento e avaliação das ações em saúde. 2010. [cited 2020 Sep 18]. Available from: s://www.nescon.medicina.ufmg.br/biblioteca/imagem/modulo-planejamento-avaliacao-saude.pdf
s://www.nescon.medicina.ufmg.br/bibliote... . We propose the addition of seven new indicators to be included in the next evaluation cycle. These indicators are based on robust scientific evidence and can reduce unnecessary cesarean sections and prevent maternal deaths and future unplanned pregnancies.

Acknowledgments

I am grateful to Prof. Dr. Maria Regina Torloni for her comments, review, and suggestions.

References

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