Abstract

Using a judgment framework, this article analyzes the degree of implementation of the best practices in labor and childbirth care contained in the guidelines of the Rede Cegonha (RC) across Brazil. The study eligibility criteria were public and mixed hospitals located in a health region with a RC action plan in place in 2015, resulting in a total of 606 facilities distributed across the country. Three different data collection methods were used: face-to-face interviews with managers, health professionals and puerperal women; document analysis; and on-site observation. The framework was built around the five guidelines of the Labor and Childbirth component of the RC. Degree of implantation was rated as follows: adequate; partially adequate and inadequate. The performance of maternity facilities was rated as partially adequate for all guidelines except for hospital environment, which was rated as inadequate. A huge variation in degree of implementation was observed across regions, with the South and Southeast being the best-performing regions in most items. The results reinforce the need for an ongoing evaluation of the actions developed by the RC to inform policy-making and the regulation of labor and childbirth care.

Key words
Maternity facilities; Unified Health System; Health evaluation; Best practices; Stork Network

Introduction

Antenatal care coverage is high in Brazil (97.6%)¹1 Datasus. Arquivos de declarações de nascido vivos. Reduzida para tabulação do Sistema de Informação de Nascidos Vivos. DF: Datasus; 2019. [acessado 2019 Jan 6]. Disponível em: ://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def
://tabnet.datasus.gov.br/cgi/tabcgi.exe?... , and almost all births (91.5%)¹1 Datasus. Arquivos de declarações de nascido vivos. Reduzida para tabulação do Sistema de Informação de Nascidos Vivos. DF: Datasus; 2019. [acessado 2019 Jan 6]. Disponível em: ://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def
://tabnet.datasus.gov.br/cgi/tabcgi.exe?... occur in hospitals and are assisted by qualified staff (99.1%)²2 Gapminder. Download the data. [acessado 2019 Abr 13]. Disponível em: s://www.gapminder.org/data/
s://www.gapminder.org/data/... . However, the large proportion of maternal deaths due to direct obstetric complications, high concentration of neonatal deaths in the first hours of life, frequency of fetal deaths towards the end of a pregnancy or during labor – predominantly preventable causes of death – high frequency of unnecessary interventions such as cesarean sections in low risk women, and occurrence of neonatal deaths in hospitals without neonatal care support reveal deficiencies in maternal and newborn care services, particularly in hospitals, where a significant proportion of these adverse outcomes occur³3 Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML, Frias PG, Cavalcante RS, Cunha AJLA. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saude Publica Rio de Janeiro, 2014; 30(Supl. 1):S192-S207.^,44 Silva ALA, Mendes ACG, Miranda GMD, Sá DA, Souza WV, Lyra TM. Avaliação da assistência hospitalar materna e neonatal: índice de completude da qualidade. Rev Saude Publica 2014; 48(4):682-691..

With the aim of transforming this situation and guaranteeing women’s and children’s rights to health, in 2011, the Ministry of Health launched the Rede Cegonha (RC), implementing an integrated network of maternal and infant care services. The Labor and Childbirth component of this program adopts a women-centered model of care that views childbirth as a normal physiologic processes, thus ensuring a safe birth⁵5 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 jun.^,66 Giovanni MRC. Da concepção à implantação. Brasília: Escola Nacional de Administração Pública; 2013..

To determine the extent to which the country’s maternity facilities are implementing this care model and identify advances and gaps to inform the planning and organization of health services and discussions between clinicians and management, a new cycle of the survey “Evaluation of Good practice in childbirth care in maternity facilities covered by the Rede Cegonha” was conducted.

This article analyzes the degree of implementation of Good practice in childbirth care in accordance with the standards set by the RC by region and across the country as a whole.

Methods

We conducted a normative evaluation using a qualitative and quantitative design and participatory rapid assessment⁷7 Di Villarosa FNA. Estimativa Rápida e a divisão do território no Distrito Sanitário: Manual de Instruções. Brasília: OPS-Representação do Brasil; 1993. (Série Desenvolvimento de Serviços de Saúde, no 11).. The study eligibility criteria were public and mixed hospitals located in a health region with a RC action plan in place in 2015, resulting in a total of 606 facilities distributed across the country. The data were collected between 2016 and 2017.

Three different data collection methods were used. The first was face-to-face interviews with managers, health professionals and puerperal women to capture their perceptions of the management model and labor and childbirth care. The managers and health professionals were selected using purposive sampling. One group interview was conducted with the maternity facility managers and coordinators/heads (doctor and nurse) of obstetrics and neonatology in each hospital, resulting in 2,765 interviews. The health professionals (doctors, nurses and nursing technicians) were interviewed individually. The number of interviews per maternity facility varied in proportion to the size of the facility in 2015¹1 Datasus. Arquivos de declarações de nascido vivos. Reduzida para tabulação do Sistema de Informação de Nascidos Vivos. DF: Datasus; 2019. [acessado 2019 Jan 6]. Disponível em: ://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def
://tabnet.datasus.gov.br/cgi/tabcgi.exe?... , resulting in a total of 5,033 interviews. The puerperal women were selected using sequential sampling, resulting in 10,665 interviews. The sample design is described in Vilela et al.⁸8 Vilela MEA, Leal MC, Thomaz EBAF, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBRAA, Lamy ZC. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

The second method was document analysis to verify the standards, protocols, and process indicators and labor and childbirth care outcomes. Data on hospital care were extracted from the women’s and newborn’s medical records.

The third data collection method was on-site observation to inspect the facilities and floor plan. This assessment encompassed all areas of the maternity facility, including the entrance, rooming-in facility, and neonatal unit.

The instruments were divided into blocks of questions related to each of the RC guidelines. The visits to the maternity facilities in each state were made by a team of trained health professionals with experience of working in maternity facilities. Further information can be found in Vilela et al., 2020⁸8 Vilela MEA, Leal MC, Thomaz EBAF, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBRAA, Lamy ZC. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800..

To evaluate the degree of implementation of good practices, we constructed a judgment framework based on the regulatory documents and legislation that guide the actions of the RC⁵5 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 jun.. The framework was divided into the five guidelines of the RC’s Labor and Childbirth component subdivided into 17 devices with 60 verification items (Chart 1). Compliance with the established criteria was based on a combination of the answers from the puerperal women, health professionals and managers and the information obtained from the document analysis and on-site observations. The degree of implementation in each maternity facility was estimated based on the proportion of affirmative answers to each question. The calculation was based upon the sum of the scores of the verification items weighted by their relevance to the quality of labor and childbirth care according to the standards set by Vilela et al.⁸8 Vilela MEA, Leal MC, Thomaz EBAF, Gomes MASM, Bittencourt SDA, Gama SGN, Silva LBRAA, Lamy ZC. Avaliação da atenção ao parto e nascimento nas maternidades da Rede Cegonha: os caminhos metodológicos. Cien Saude Colet 2021; 26(3):789-800.. Each guideline had the following weighting: Welcoming in Obstetric Care (18.5%), Good practice in childbirth care (41.5%), Monitoring childbirth care and related outcomes (10.0%), Shared management (10.0%), and Hospital environment (20.0%). The scores were also weighted according to the information source, as follows: puerperal women – 24.7%; on-site observation – 23.9%; health professionals – 21.0%; managers – 15.4%; puerperal women’s/newborn’s medical records – 9.8%; document analysis – 5.2%. The following parameters were used to rate the degree of the implementation of RC’s guidelines and devices⁹9 Alves CA, Natal S, Felisberto E, Samico, I Interpretação e Análise das Informações: O uso de Matrizes, Critérios, Indicadores e Padrões. In: Avaliação em Saúde- Base Conceituais e Operacionais. Samico I, Eronildo F, Figueiró AC, Frias PG, organizadores. Rio de Janeiro: MedBook; 2010. p. 89-107.: adequate (75.01 to 100%); partially adequate (50.1 to 75%), and inadequate (0 to 50%).

The judgment framework was validated by a group of specialists from the following organizations: the Ministry of Health (four from the Office for the General Coordination of Women’s Health, two from the Office for the General Coordination Children’s Health and Breastfeeding, and one from the Department of Science and Technology); Maranhão Federal University (four professors from the Department of Public Health); and the Oswaldo Cruz Foundation (four researchers from the Sergio Arouca National School of Public Health’s Department of Epidemiology and Quantitative Methods in Health and one researcher from the National Institute of Women, Children and Adolescents Fernandes Figueira). The team of specialists discussed the appropriateness of the verification items, either excluding items and including new items or maintaining/altering existing items. The weightings of the revised verification items were then recalculated to substantiate the final version of the judgment framework. Chart 1 shows the distribution of the framework weighting by guideline, device and verification item according to the source of data.

For each maternity facility, we estimated the adequacy of each item and device of the five RC guidelines. The results are presented by region and for the country as a whole. The analyses were conducted using Stata 14 and SPSS® Statistics 21.

The study was carried out in accordance with the requirements of the National Health Council Resolution Nº. 196/96 and was approved by the Maranhão Federal University’s and Sergio Arouca National School of Public Health’s human research ethics committees. All necessary precautions were taken to safeguard the confidentiality of the information.

Results

The implementation of the RC’s Good practice in childbirth care component was rated as partially adequate in all regions except the North, where it was rated as inadequate. One-quarter of the maternity facilities in Brazil were rated as inadequate. The region with the highest percentage of inadequate facilities was the North, followed by the Center-West, Northeast, Southeast and South.

With respect to the performance of the maternity facilities in each of the five guidelines, up to 30% of the maternity facilities were rated as inadequate in Welcoming in Obstetric Care, Good practice in childbirth care, Monitoring childbirth care and related outcomes, and Shared management, rising to 61.6% in Hospital environment. Degree of implementation across the five guidelines was lowest in the North, with 54.7%, 62.8% and 82.6% of facilities showing inadequate implementation for Monitoring childbirth care and related outcomes, Shared management, and Hospital environment, respectively. The degree of implementation of the devices and items in each of the five guidelines is outlined below.

Table 1 shows that the implementation of Welcoming in Obstetric Care was rated as inadequate in 7.9% of the country’s maternity facilities, with rates varying between slightly over 2% in the South and Southeast and 23.3% in the North. With regard to the three devices that make up this guideline, 3.0% of the country’s maternity facilities were rated as inadequate for “Welcoming” and “Network obstetric care”. The result for “Welcoming” was due mainly to the low percentage of facilities rated as inadequate for the items “Addressing patients by name” (4.0%), “Active listening to patients’ complaints, fears and expectations” (2.5%), and “Effective health professional/patient communication” (2.5%). In contrast, implementation for “Health professionals introduce themselves to patients” was inadequate in almost one-quarter of hospitals.

The device with the highest number of maternity facilities rated as inadequate was “Risk assessment”. The findings show that 34.0% (206) of the maternity facilities had not implemented this device (data not shown). Implementation was inadequate (no informative risk rating signs showing colors and waiting times and/or non-provision of information to pregnant women about their health status) in 37.8% of the maternity facilities whose managers confirmed that this device was in place. The percentage of facilities rated as inadequate in this device was highest in the Southeast and North.

Weaknesses in the device “Network obstetric care” were observed in the items “Registration of pregnant women with the referral maternity facility” (20.5%) and “Counter-referral from the maternity facility to primary care” (24.3%). On the other hand, the implementation of the item “Hospital bed always available” was inadequate in only 2.3% of the maternity facilities.

The implementation of Guideline 2 – Good practice in childbirth care was inadequate in almost 30% of the maternity facilities, with the Center-West and Northeast showing the highest percentage of inadequate facilities. The implementation of the item “Inclusion of a companion of choice” was inadequate in 8.4% of the country’s maternity facilities, rising to 19.8% in the North, while “Availability of chairs for companions during labor and birth” was inadequate in 43.1% facilities, reaching 52.6% in Center-West. The implementation of the item “Meals provided to companions” was inadequate in 24.4% of the maternity facilities. The worst-performing regions in this item were the South and Southeast. The item “Newborn’s mother and father have free 24-hr access to and can stay in the neonatal unit” was rated as inadequate in a little over one-third of the maternity facilities in Brazil, with only small variations across regions.

With regard to the device “Good Practices in Labor, Childbirth and Postpartum Care”, the implementation of the item “Partogram filled in” was inadequate in 60% of the maternity facilities in Brasil, with the Center-West, North and Northeast showing the highest percentage of inadequate facilities. The implementation of the item “Obstetric nurses/midwives participate in low-risk vaginal deliveries” was inadequate in 38.4% of the maternity facilities, with the South, Center-West and Southeast having the highest percentage of inadequate facilities. The overall percentage of facilities rated as inadequate for the implementation of the item “Encouragement of walking around during labor and childbirth” was 37.6%, rising to 40.0% in the Center-West and Northeast and 61.6% in the North. The implementation of the items “Non-pharmacological pain relief methods offered during labor” and “Encouragement of non-supine birth positions” was inadequate in over 80% of the facilities, with percentages showing little variation across regions, while the item “Drinks and food offered to normal-risk pregnant women during labor” was inadequate in 56.8% of the facilities.

The findings show that the percentage of maternity facilities with an inadequate rating for the items in the device “Unnecessary Maternal Care Interventions” was high: “Amniotomy” (87.1%), “Use of a venous catheter during labor” (63.5%), “Episiotomy” (55.6%), “Kristeller maneuver” (18.5%), and “Administration of uterotonic drugs during labor” (4.3%).

With regard to “Good Newborn Care Practices”, the implementation of the item “Optimal umbilical cord clamping” was inadequate in 55.9% of the maternity facilities in Brazil, with the North and Northeast showing lower percentages. The implementation of the items “Immediate and not interrupted skin to skin contact between women and baby to stimulate breastfeeding in the first hour after birth” and “Encouraging breastfeeding in the first hour of life” was inadequate in 24.8% and 22.6% of facilities, respectively, with the Center-West, South and Southeast showing lower percentages. Only 0.5% of the maternity facilities in Brazil were rated as inadequate for the item “Encouraging breastfeeding in the rooming-in facility”, with almost all women stating that they breastfed their baby in the first 24 hours of life.

With regard to the device “Good Newborn Care Practices”, 49.3% and 50.3% of the maternity facilities were rated as inadequate in the items “Use of kangaroo care protocols” and “Reducing light and sound levels”, respectively.

With regard to the device Unnecessary Newborn Care Interventions, one-quarter of the maternity facilities were rated as inadequate for the item “Neonatal airway suctioning”, rising to one-third of the facilities in the South. Mother-baby separation was a common practice in maternity facilities, with 54.3% of facilities being rated as inadequate in this item, rising to 71.6% in the South.

Table 2 shows that the implementation of the guideline Monitoring childbirth care and related outcomes was inadequate in almost one-third of the country’s facilities. This result was influenced mainly by the level of implementation of the device “Availability of Labor and Childbirth Care Indicators”, which was rated as inadequate in 50% of the maternity facilities, with percentages rising to 57.1%, 61.0% and 66.3% in the Northeast, Center-West and North, respectively. The items “Risk assessment”, “Presence of companion during hospital stay”, “Bed occupancy”, “Average length of stay in rooming-in and neonatal unit”, and “Percentage of episiotomies in normal births” were rated as inadequate in 84.5%, 67.5%, 46%, 48% and 38% of facilities, respectively.

The device “Availability of Maternal, Neonatal and Fetal Mortality Indicators” was rated as inadequate in 13% of the country’s maternity facilities, with the Northeast, Center-West and North obtaining the worst results. One-quarter of the maternity facilities did not have a maternal and neonatal death committee in place, while the implementation of the items “Maternity facility develops strategies to reduce the number of cesarean sections” and “Publication of mortality and morbidity indicators” indicators was inadequate in over 40% of the facilities.

Table 2 also shows large variations across the verification items that make up the guideline “Shared management”. The implementation of the item “Existence of a management committee or other management body” was inadequate in 40% of the maternity facilities. The worst-performing item was “Participation of professionals performing different roles in collegial management bodies”, with 100% of the maternity facilities rated as inadequate. A little over 60% of the maternity facilities did not hold regular meetings with staff to ensure the functioning of collegial management mechanisms facilities. The worst-performing items in this device were “Promotion of debates on Good labor and childbirth care practices with professional staff” and “Staff participation in decision making about work processes”, with 35.6% and 33.7% of facilities rated as inadequate, respectively. The implementation of the items “Patient access to the NHS Ombudsman” and “Changes in work processes and decision making from listening to patients” was inadequate in 55% and 30% of facilities, respectively.

Also in Table 2, among the different areas of the maternity facility, welcoming in obstetric are, risk assessment, clinical examination and admission of parturient women showed the lowest percentage of maternity facilities rated as inadequate (around 40%), with more than 50% of maternity facilities in Northeast obtaining an inadequate rating.

The implementation of the item “Adequate level of comfort in rooming-in” (access to private bathroom, chairs for companions and bathing area for the newborn) was inadequate in 43.1% of the maternity facilities.

The degree of implementation of the item “Adequacy of the provision of LDP (Birthing rooms) rooms” varied across regions, with the South having the highest percentage of inadequate facilities (97.5%). The best-performing state in this item was the Center-West, where 74.4% of the facilities were rated as inadequate. The findings also show that the implementation of the item “Adequacy of LDP room facilities” (private bathroom with shower with hot and cold water) was inadequate in 16.1% of the facilities.

With respect to neonatal units, the implementation of the item “Noise, brightness and temperature control in the NICU and Conventional Intermediate Care Unit (CICU)” was inadequate in around one-third of the maternity facilities, except in the Center-West, where only 16.7% of the facilities were inadequate. The implementation of the items “Accommodation provided for the mother of babies admitted to the neonatal unit” and “Chairs and easy chairs in the NICU and CICU” was inadequate in around 50% of facilities.

With regard to the device “Accessible Environment”, the implementation of the item “Access for disabled pregnant women/companions” (ramp, wheelchair accessible door width and grab bars) was inadequate in 87.0% of the country’s maternity facilities. The worst-performing regions for this item were the North, Northeast and South.

Discussion

This study evaluated the degree of implementation of the Labor and Childbirth component of the RC guidelines, permitting the identification of areas of progress and deficiencies in labor and childbirth care in SUS health facilities.

The evaluation of strategies like the RC is a complex task, especially considering the specificities of different contexts and multifaceted characteristics of labor and childbirth care. To capture the complexity of the implementation of the RC, the evaluation model incorporated a participatory approach¹⁰10 Brasil. Ministério da Saúde (MS). Política Nacional de Humanização (PNH). Rede HumanizaSUS. Folheto. Brasília: MS; 2013..

It is important to highlight the possibility of bias in the responses given by managers and staff, in so far as they may have repeated what is in the technical guidelines and not actually what happens in practice. This was partially overcome by assigning greater weight to the answers of the puerperal women and on-site observations. The triangulation of the results across multiple verification items enabled a more accurate interpretation of the issues related to the organization of health service work processes.

The results of the judgment framework show that the degree of implementation of labor and childbirth care processes and procedures varies across regions. The South and Southeast, which have a higher level of social and economic development, are the best performing regions in the majority of the verification items.

Of the five guidelines evaluated by this study, Welcoming in Obstetric Care achieved the highest degree of implementation, signaling the importance of this practice in promoting a shift in the approach to service delivery, as laid out in the National Humanization Policy (NHP)¹¹11 Cardoso GC, Oliveira EA, Casanova AO, Toledo PPS, Santos EM. Participação dos atores na avaliação do Projeto QualiSUS-Rede: reflexões sobre uma experiência de abordagem colaborativa. Saúde Debate 2019; 43:54-68..

Humanizing practices such as the simple gesture of health professionals addressing patients by name and listening to their complaints, concerns and anxieties stood out among the verification items¹²12 Silva MZN, Andrade AB, Bosi MLM Acesso e acolhimento no cuidado pré-natal à luz de experiências de gestantes na Atenção Básica. Saúde Debate 2014; 38(103):805-816.. However, several challenges remain in relation to the operation and improvement of Welcoming in Obstetric Care. These include gaps in communication mechanisms and in the integration of primary and maternity care services, factors that contribute to the continuum of care, which is critical for ensuring the adequacy of care¹³13 Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003; 327(7425):1219-1221.. One of the consequences of poor communication between services in registering pregnant women with facilities that are able to respond to the both the mother’s and newborn’s specific need is the high percentage of women moving between services in search of childbirth care, as observed among the women interviewed in this study (21.9%)¹⁴14 Leal MDC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JA, Gama SGN, Domingues RMSM, Vilela MEA. Progress in childbirth care in Brazil: preliminary results of two evaluation studies. Cad Saude Publica 2019; 35(7):e00223018.. This situation is alarming, particularly in the case of obstetric emergencies, which require timely treatment to prevent maternal health complications¹⁵15 Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, Souza JP, Pattinson RC; Brazilian Network for the Surveillance of Severe Maternal Morbidity study group. Delays in receiving obstetric care and poor maternal outcomes: Results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth 2014; 14:159.. Another obstacle identified by this study is the significant percentage of hospitals that had not implemented the item “Risk assessment”. This can lead to delays in identifying pregnant women in a critical or serious state and result in adverse maternal outcomes¹⁶16 Brasil. Ministério da Saúde (MS). Manual de Acolhimento e Classificação de Risco em Obstetrícia. Brasília: MS; 2015..

The findings show that the right to have a companion of choice during labor and childbirth, guaranteed by federal law 11.108¹⁷17 Brasil. Lei nº 11.108, de 7 de abril de 2005. Altera a Lei no 8.080, de 19 de setembro de 1990, para garantir às parturientes o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2005; 8 abr., is a reality, although with restrictions observed in 30% of the facilities. Evidence shows that, apart from providing emotional support, the presence of a companion is a marker of safety and quality of care, protecting against violence and inappropriate practices during labor and childbirth¹⁸18 Diniz CSG, D'orsi E, Domingues RMSM, Torres JA, Dias MAB, Schneck CA, Lansky S, Teixeira NZF, Rance S, Sandall J. Implementação da presença de acompanhantes durante a internação para o parto: dados da pesquisa Nascer no Brasil. Cad. Saúde Pública 2014; 30(Supl. 1):S140-S141.. The adoption of welcoming strategies such as the provision of easy chairs and meals and inclusion of companions needs to be expanded to advance the humanization of care and improve the companion-health team relationship¹¹11 Cardoso GC, Oliveira EA, Casanova AO, Toledo PPS, Santos EM. Participação dos atores na avaliação do Projeto QualiSUS-Rede: reflexões sobre uma experiência de abordagem colaborativa. Saúde Debate 2019; 43:54-68..

The prevailing model of care in Brazil is based on interventions that should be stopped or reduced and the timid presence of appropriate practices. The majority of Brazilian women still give birth lying down and are subjected to intravenous medications, amniotomy and episiotomy¹⁴14 Leal MDC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira M, Torres JA, Gama SGN, Domingues RMSM, Vilela MEA. Progress in childbirth care in Brazil: preliminary results of two evaluation studies. Cad Saude Publica 2019; 35(7):e00223018.. This situation reflects the maintenance of non-participatory work processes marked by the increased medicalization of hospital services, subjecting low-risk pregnant women to unnecessary interventions, in addition to incurring unnecessary costs and wasting resources¹⁹19 Coulm B, Ray CL, Lelong N, Drewniak N, Zeitlin J, Blondel B. Obstetric Interventions for Low-Risk Pregnant Women in France: Do Maternity Unit Characteristics Make a Difference? Birth 2012; 39(3):183-191.. The partogram is rarely used in labor monitoring and non-pharmacological pain relief methods and food are not offered during labor. The best-performing item was “Encouragement of walking around during labor and childbirth”.

Although it is acknowledged that protocols are important tools for improving the quality of care, and at the same time training tools, the low level of implementation of kangaroo care protocols in neonatal units points to the need for a better understanding of the obstacles to reversing the situation.

Despite the fact that the promotion of skin-to-skin contact between the mother and newborn immediately after birth promotes the early initiation of breastfeeding²⁰20 Sociedade Brasileira de Pediatria (SBP). Programa de Reanimação Neonatal. Reanimação do recém-nascido = 34 semanas em sala de parto. 2016. [acessado 2019 Mar 30]. Disponível em: www.sbp.com.br/reanimacao
www.sbp.com.br/reanimacao... , the adoption of this practice with healthy newborns remains a challenge in around one-quarter of the maternity facilities evaluated.

With regard to newborn care, optimal timing of umbilical cord clamping has yet to be widely adopted, with a significant number of newborns not receiving the benefits of the blood flow allowed by this practice²⁰20 Sociedade Brasileira de Pediatria (SBP). Programa de Reanimação Neonatal. Reanimação do recém-nascido = 34 semanas em sala de parto. 2016. [acessado 2019 Mar 30]. Disponível em: www.sbp.com.br/reanimacao
www.sbp.com.br/reanimacao... . Despite national regulations, the results highlight that access to appropriate labor and childbirth technology⁵5 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 jun. remains a challenge. The findings also reveal the low level of participation of obstetric nurses in low-risk normal births, going against evidence of the potential benefits of their involvement in birth care²¹21 Gama SGNG, Viellas EF, Torres JA, Bastos MH, Brüggemann OM, Theme Filha MM, Schilithz AOC, Leal MC. Labor and birth care by nurse with midwifery skills in Brazil. Reprod Health 2016; 13(Supl. 3):123 and demonstrating the need for advances in multidisciplinary team working to improve the quality of obstetric and neonatal care.

Despite the large volume of hospital procedures, significant rate of maternal, neonatal and fetal deaths in hospitals, and substantial spending, significant challenges remain in monitoring of process indicators and outcomes to inform initiatives to improve care quality, such as continuing training and protocol development²²22 Barbosa Junior A, Pascom ARP, Szwarcwald CL, Dhalia CBC, Monteiro L, Simão MBG. Indicadores propostos pela UNGASS e o monitoramento da epidemia de Aids no Brasil. Rev Saude Publica 2006; 40(Supl.):94-100.

23 Escosteguy CC, Pereira AGL, Medronho RA. Três décadas de epidemiologia hospitalar e o desafio da integração da Vigilância em Saúde: reflexões a partir de um caso. Cien Saude Colet 2017; 22(10):3365-3379.^-2424 Vos MD, Graafmans W, Kooistra M, Bert Meijboom, Voort PVD, Westert G. Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care 2009; 21(2):119-129..

The findings show that the monitoring of the quality of care is incipient in the hospitals evaluated, varying considerably across regions. A significant number of health facilities do not regularly collect the data necessary to calculate quality indicators. While other have incorporated this activity into the hospital routine, there are still few initiatives that are capable of promoting changes in the everyday practice of health professionals, such as the disclosure results to the health professionals working in the facilities²⁵25 Melo CM, Aquino TIS, Soares MQ e Bevilacqua PD. Vigilância do óbito como indicador da qualidade da atenção à saúde da mulher e da criança. Cien Saude Colet 2017; 22(10):3457-3465.^,2626 Dejong J, Akik C, El Kak F, Osman H, El-Jardali F. The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon. Midwifery 2010; 26(5):549-557..

The results for Guideline 4 reveal a number of weaknesses in the promotion of quality management mechanisms such as increasing staff participation and promoting shared responsibility and listening to patients. This situation reduces the possibility of developing a critical process committed to health practices and specific patient needs. In this regard there is an urgent need to increase the level of shared responsibility across the range of staff that make up the maternity facility. The means changing management processes to create possibilities to strengthen health workers’ capacity to create new actions and be co-managers of their work process and increasing the participation of patients and their families in the shared care process, as laid out in the NHP¹¹11 Cardoso GC, Oliveira EA, Casanova AO, Toledo PPS, Santos EM. Participação dos atores na avaliação do Projeto QualiSUS-Rede: reflexões sobre uma experiência de abordagem colaborativa. Saúde Debate 2019; 43:54-68..

The worst-performing guideline was Hospital environment. The results highlight that a number of problems remain in the promotion of better working conditions and services that emphasize healthy work environments, privacy, and creating a welcoming and comfortable hospital environment.

The implementation of this guideline is a huge challenge, especially considering that it is now over 10 years since the publication of Resolution RDC36 by Brazil’s health protection agency, Anvisa²⁷27 Brasil. Agência Nacional de Vigilância Sanitária (Anvisa). Resolução RDC n° 36, de 3 de junho de 2008. Dispõe sobre Regulamento Técnico para Funcionamento dos Serviços de Atenção Obstétrica e Neonatal. Diário Oficial da União 2008; 4 jun., which restructured the organization of obstetric units, and almost 10 years since creation of the RC⁵5 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 jun.. An on-site observation of the environment of labor and childbirth services reported that the traditional model still predominates. Studies show that the separation of labor, childbirth and postpartum areas fragments the work process, strengthening the Taylorist²⁸28 Campos GWS. O anti-Taylor: sobre a invenção de um método para co-governar instituições de saúde produzindo liberdade e compromisso. Cad Saude Publica 1998; 14(4):863-870. view of health work processes and comprising the physiological progression of labor and childbirth.

The findings also show that privacy, a fundamental factor for labor and childbirth, is not assured in the majority of maternity units. In most maternity facilities, labor areas tend to be either shared, in cubicles or separated by curtains.

Although the public spending ceiling and cuts²⁹29 Brasil. Emenda constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 16 dez. make the refurbishment of the physical spaces of maternity facilities unviable, particularly in the North and Northeast, regions which have a lower level of social and economic development³⁰30 Projeto de Avaliação do Desempenho do Sistema de Saúde (PROADESS). Avaliação do Desempenho do Sistema de Saúde. Boletim Informativo nº 3, agosto/2018. Indicadores para o monitoramento do setor Saúde na Agenda 2030 para o Desenvolvimento Sustentável. [acessado 2019 Jun 14]. Disponível em: s://www.proadess.icict.fiocruz.br/index.php?pag=boletins
s://www.proadess.icict.fiocruz.br/index.... , this situation should not be understood as an obstacle to the transformation and creation of new spaces of interaction and work as envisioned by the RC³¹31 Pessati PM. A Intercessão Arquitetura e Saúde: quando o problema é a falta de espaço na unidade de saúde, qual é o espaço que falta? [dissertação]. Campinas: Universidade de Campinas; 2008..

Although the reduction of light and noise levels in NICUs is recommended in current legislation³²32 Brasil. Ministério da Saúde (MS). Portaria nº 930, de 10 de maio de 2012. Define as diretrizes e objetivos para a organização da atenção integral e humanizada ao recém-nascido grave ou potencialmente grave e os critérios de classificação e habilitação de leitos de Unidade Neonatal no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2012; 10 maio., this item, together with the provision of accommodation for the mothers of babies admitted to the neonatal unit, was not guaranteed in all facilities. The on-site observations revealed barriers to access for disabled pregnant women/companions, indicating a lack of actions to meet the special needs of this group³³33 Thomaz EBAF, Costa EM, Andrade YNL, Rocha TAH, Rocha NCS, Marques MCO, Queiroz RCS. Acessibilidade às gestantes e puérperas com deficiência motora, visual e auditiva: uma análise da estrutura de estabelecimentos do SUS vinculados à Rede Cegonha. Cien Saude Colet 2020; 26(3):897-908..

Articles comparing the evolution of good practices and reduction of unnecessary maternal and newborn care interventions between a study conducted in the same facilities in 2011 and the present evaluation (2016/2017)³⁴34 Leal MC, Pereira APE, Vilela MEA, Alves MTSSB, Neri MA, Queiroz RCS, Santos YRP, Silva AAM. Redução das iniquidades sociais no acesso às tecnologias apropriadas ao parto na Rede Cegonha: comparação entre o Nascer no Brasil (2011) e a Avaliação da Rede Cegonha (2017). Cien Saude Colet 2021; 26(3):825-835.^,3535 Gomes MAM, Esteves-Pereira AP, Bittencourt DAS, Augusto, LCR, Lamy-Filho F, Lamy Z, Magluta C, Moreira MELM. Atenção Hospitalar ao recém-nascido saudável no Brasil: Estamos avançando na garantia das boas práticas? Cien Saude Colet 2020; 26(3):859-874. clearly show that Brazil has made significant advances in promoting the care model centered on mothers’ and newborns’ needs embodied by the RC⁵5 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 jun.^,. Challenges remain however and major efforts are needed to improve labor and childbirth care in the maternity facilities evaluated. Key initiatives should include training in Good practice in childbirth care and knowledge dissemination.

Over the last two decades, the evaluation of health services has received growing attention due to persistently unacceptable levels of maternal and perinatal morbidity and mortality indicators³3 Lansky S, Friche AAL, Silva AAM, Campos D, Bittencourt SDA, Carvalho ML, Frias PG, Cavalcante RS, Cunha AJLA. Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido. Cad Saude Publica Rio de Janeiro, 2014; 30(Supl. 1):S192-S207.^,44 Silva ALA, Mendes ACG, Miranda GMD, Sá DA, Souza WV, Lyra TM. Avaliação da assistência hospitalar materna e neonatal: índice de completude da qualidade. Rev Saude Publica 2014; 48(4):682-691.^,3636 Bittencourt SDA, Reis LGC, Ramos MM, Rattner D, Rodrigues PL, Neves DCO, Arantes SL, Leal MC. Structure in Brazilian maternity hospitals: key characteristics for quality of obstetric and neonatal care. Cad Saude Publica 2014; 30(Supl. 1):S208-S219.. The regular evaluation of the actions developed by the RC should form the basis of the information employed to direct policy making and the regulation of hospital labor and childbirth care, incorporating the discussion of care practices and quality into health planning. To this end, in line with the aims of evaluation of the RC, feedback workshops were held in all states and the Federal District, attended by managers and professionals from health departments, specialists form the Ministry of Health and researchers from the Sergio Arouca National School of Public Health and UFMA. The workshops confirmed the pertinence of the judgment framework in promoting improvements to the labor and childbirth care model and guided the confirmation of the commitments outlined in the RC’s regional action plans³⁷37 Silva LBRAA, Angulo-Tuesta A, Massari, MTR , Augusto LCR, Gonçalves LLM, Silva CKRT, Minoia N. Avaliação da Rede Cegonha: devolutiva dos resultados para as maternidades no Brasil. Cien Saude Colet 2021; 26(3):931-940., thus forging an instrument that can be used to enhance management and the delivery of care in maternity facilities. The role of this evaluation is accordant with the responsibility to promote equal access of effective comprehensive health services, constituting an important element of the implementation of evidence-based labor and childbirth care practices observing care, management and training models, inseparable dimensions of health care.

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