Abstract

Collaborative models (CM) focused on intrapartum care shared between both midwives and obstetricians have been proposed as a strategy to reduce these rates. Our aim was to compare use of evidence-based practices, obstetric interventions and c-section rates in two settings: a maternity hospital that applies a CM of care (MRJ) and data from a pool of maternity hospitals included in the Birth in Brazil Survey (NB) that do not adopt a CM. Data was abstracted from medical and administrative records in MRJ and from medical records and face-to-face interviews in NB. Differences were compared using chi-square test, with significance level set at p<0.05. MRJ showed a higher frequency of labour companionship, labour care provided by nurse midwives, non-pharmacological pain relief methods, food intake during labour, and less use of oxytocin, analgesia and amniotomy. More women also had second stage assisted by a nurse midwife and in a vertical position, as well as lower use of episiotomies and vacuum-extractor/forceps. The c-section rate was lower at MRJ. Shared care between midwives and obstetricians can be an effective strategy to improve quality of intrapartum care.

Key words:
Maternal and child health; Caesarean section; Delivery; Outcome and process assessment (Health Care)

Resumo

Modelos colaborativos (MC) com foco no cuidado intraparto compartilhado entre parteiras e obstetras têm sido propostos como uma estratégia para reduzir essas taxas. Nosso objetivo foi comparar o uso de práticas baseadas em evidências, intervenções obstétricas e taxas de cesarianas em dois ambientes: uma maternidade que aplica um MC de atendimento (MRJ) e dados de um conjunto de maternidades incluídas na pesquisa Nascer no Brasil (NB) que não adotam um MC. Os dados foram extraídos de prontuários médicos e documentos administrativos no MRJ e de prontuários e entrevistas presenciais em NB. As diferenças foram comparadas pelo teste do qui-quadrado, com nível de significância estabelecido em p<0,05. MRJ apresentou maior frequência de acompanhante no parto, assistência ao parto por enfermeiras obstétricas, métodos não farmacológicos de alívio da dor, ingestão de alimentos durante o trabalho de parto e menor uso de ocitocina, analgesia e amniotomia. Mais mulheres também tiveram o parto assistido por enfermeira obstétrica e em posição vertical, bem como menor uso de episiotomias e vácuo-extrator/fórceps. A taxa de cesariana foi menor no MRJ. O cuidado compartilhado entre enfermeiras e obstetras pode ser uma estratégia eficaz para melhorar a qualidade do cuidado intraparto.

Palavras-chave:
Saúde materna e infantil; Cesárea; Parto normal; Avaliação de processos e resultados (Cuidados de Saúde)

Introduction

In Brazil, an intensive use of interventions during labour and birth has been described¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):S17-S47.

2 Moreira MEL, Gama SGN, Pereira APE, Silva AAM, Lansky S, Pinheiro RS, Gonçalves AC, Leal MC. Práticas de atenção hospitalar ao recém-nascido saudável no Brasil. Cad Saude Publica 2014; 30(Supl. 1):S128-S139.^-33 Nakamura-Pereira M, Leal MC, Esteves-Pereira AP, Domingues RMSM, Torres JA, Dias MAB, Moreira ME. Use of Robson Classification to Assess Caesarean Section Rate in Brazil: The Role of Source of Payment for Childbirth. Reprod Health 2016; 13(Supl. 3):128.. According to Birth in Brazil survey (NB), only 5.6% mixed obstetric risk women had a vaginal birth without any intervention in the country¹1 Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica 2014; 30(Supl. 1):S17-S47.. The high caesarean section rate (of 55.9% in 2018) is also another consequence of this highly interventionist model of care⁴4 Brasil. Ministério da Saúde (MS). DATASUS. Sistema de Informações sobre Nascidos Vivos (SINASC) 2010 [Internet]. [acessado 2020 jun 18]. Disponível em: http://www.datasus.gov.br.
http://www.datasus.gov.br... . Even though the full spectrum of clinical consequences of such higher caesarean sections rates are not completely understood, on an individual level it appears to be associated with higher maternal morbidity⁵5 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned caesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176(4):455-460.^,66 Silva JMP, Fonseca SC, Dias MAB, Izzo AS, Teixeira GP, Belfort PP. Conceitos, prevalência e características da morbidade materna grave, near miss, no Brasil: revisão sistemática. Rev Bras Saude Mater Infant 2018; 18(1):37-65. and mortality⁷7 Esteves-Pereira AP, Deneux-Tharaux C, Nakamura-Pereira M, Saucedo M, Bouvier-Colle MH, Leal MC. Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based case Control Study in Brazil. PLoS ONE 2016; 11(4):e0153396., as well as with significant neonatal adverse effects when carried out before full term⁸8 Leal MC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, Victora C. Saúde Reprodutiva, materna, neonatal e infantil nos 30 anos do Sistema Único de Saúde (SUS). Cien Saude Colet 2018; 23(6):1915-1928., while also poses a burden on the healthcare system⁹9 Gibbons L, Belizán JM, Lauer JA, Bétran AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. Working Paper. World Health Report 2010. Geneva: WHO; 2010.^,1010 Entringer AP, Gomes MASM, Costa ACC, Pinto M. Impacto orçamentário do parto vaginal espontâneo e da cesariana eletiva sem indicação clínica no Brasil. Rev Panam Salud Publica 2018; 42:e116..

During the last decades, the Brazilian Ministry of Health issued programs and guidelines focusing on improving obstetric care in the country¹¹11 Brasil. Ministério da Saúde (MS). Portaria/GM nº 569, de 1º de junho de 2000. Implantação do Programa de Humanização do pré-natal e nascimento. Diário Oficial da União 2000; 8 jun.

12 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.^-1313 Agência Nacional de Saúde Suplementar (ANS). Caderno de Informação da Saúde Suplementar: beneficiários, operadoras e planos. Rio de Janeiro: ANS; 2009.. In 2011, the federal government launched a national level program named Stork Network (RC) particularly targeting the public health care system¹²12 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.. RC specifically adopted the collaborative model (CM) of intrapartum care, which consists of involving nurse midwives and midwives in the intrapartum care of low-risk pregnant women, ensuring medical intervention when required¹⁴14 Vogt SE, Silva KS, Dias MAB. Comparação de modelos de assistência ao parto em hospitais públicos. Rev Saude Publica 2014; 48(2):304-313.

15 Shaw-Battista J, Fineberg A, Boehler B, Skubic B, Woolley D, Tilton Z. Obstetrician and Nurse-Midwife Collaboration. Successful Public Health and Private Practice Partnership. Obstet Gynecol 2011;118(3):663-672.

16 Smith DC. Midwife-Physician Collaboration: A Conceptual Framework for Interprofessional Collaborative Practice. J Midwifery Womens Health 2015; 60(2):128-139.^-1717 Avery MD, Montgomery O, Brandl-Salutz E. Essential Components of Successful Collaborative Maternity Care Models. The ACOG-ACNM Project. Obstet Gynecol Clin N Am 2012; 39(3):423-434.. Studies have demonstrated lower rates of caesarean sections and obstetric interventions, as well as increased use of non-pharmacological pain relief methods and greater satisfaction when care is provided by midwives¹⁸18 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led Continuity models versus olther models of care for chilbearing women (Review). Cochrane Database of Systematic Reviews. Cochrane Database Syst Rev 2016; 4(4):CD004667.

19 Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, Silva DRAD, Downe S, Kennedy HP, Malata A, McCormick F, Wick L, Declercq E. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129-1145.^-2020 Nagahama EEI, Santiago SM. Parto humanizado e tipo de parto: avaliação da assistência oferecida pelo Sistema Único de Saúde em uma cidade do Sul do Brasil. Rev Bras Saude Matern Infant 2011; 11(4):415-425..

The present study aims to compare the adoption of evidence-based practices and caesarean section and obstetric interventions rates in a maternity hospital in Rio de Janeiro (MRJ) that adopts the CM of care since its foundation, following RC guidelines, with those in public maternity hospitals located in the Southeast region that were included in NB survey (carried out in 2011-2012, when RC was not yet a national policy).

Methods

This is a comparative analysis of two settings with different models of intrapartum care: a maternity hospital belonging to the local health system of Rio de Janeiro city (MRJ), Brazil, and publicly funded maternity hospitals located in the Southeast region that were enrolled in the NB (MRJ was not part of the NB). The MRJ was chosen due to two key factors: i) the lower c-section rate (18% in 2012 and 24% in 2013)⁴4 Brasil. Ministério da Saúde (MS). DATASUS. Sistema de Informações sobre Nascidos Vivos (SINASC) 2010 [Internet]. [acessado 2020 jun 18]. Disponível em: http://www.datasus.gov.br.
http://www.datasus.gov.br... compared to the national average for publicly funded deliveries (43% between 2011 and 2012)³3 Nakamura-Pereira M, Leal MC, Esteves-Pereira AP, Domingues RMSM, Torres JA, Dias MAB, Moreira ME. Use of Robson Classification to Assess Caesarean Section Rate in Brazil: The Role of Source of Payment for Childbirth. Reprod Health 2016; 13(Supl. 3):128.; ii) the adoption of a CM of intrapartum care since its foundation. In the MRJ CM, low-risk labour and births are primarily assisted by nurse midwives and rely on obstetricians only as a second line of care if complications emerge. Obstetricians are also the primary providers for women with known comorbidities or pre-established obstetric risk criteria.

MRJ Setting

A sample size to identify differences of 0.5% or more in obstetric interventions rates was initially calculated, using a 95% confidence interval and 80% statistical power. A minimum sample of 2,396 women were estimated and then increased by 5%, totalling 2,500 women. We performed a retrospective cohort study collecting data from January 1^st to December 31^st, 2018, when 5,450 women gave birth at a gestational age of ≥22 weeks and/or weight at birth of ≥500 g at MRJ - same eligibility criteria used in NB²¹21 Vasconcellos MT, Silva PL, Pereira AP, Schilithz AO, Souza Junior PR, Szwarcwald CL. Sampling design for the Birth in Brazil: National Survey into Labour and Birth. Cad Saude Publica 2014; 30(Supl. 1):S49-S58.^,2222 Leal MC, Silva AA, Dias MA, Gama SG, Rattner D, Moreira ME, Theme Filha MM, Domingues RMSM, Esteves-Pereira AP, Torres JA, Bittencourt SDA, D'orsi E, Cunha AJ, Leite AJM, Cavalcante RS, Lansky S, Diniz CSG, Szwarcwald CL. Birth in Brazil: national survey into labour and birth. Reproductive Health 2012; 9:15..

We selected the 2,500 women using simple random sampling from a database including all 5,450 women. Data was collected from the maternity ward electronic medical records system and when needed confirmed against information from administrative records kept in the labour and delivery room (L&D) containing summary data from each normal birth and caesarean section. All information was collected from medical records, except for the presence of labour companionship, use of methods for pain relief and the birth position, which we obtained reviewing the L&D administrative records.

Among the 2,500 women in the sample, we were unable to abstract data from hospital records for 265 women (10.6%), once their medical records were numbered according to an older filing system and stored outside the hospital premises. 425 women had their medical records in this situation, from which we were able to recover the medical charts of 160. However, information on maternal age, skin colour, parity, mode of birth, gestational age, birth weight, and Apgar score were available for all women in the L&D administrative records.

Using the available information, we were able to adjust a logistic model and calculate a sample weight so that those 160 women represented the 425 women whose medical records were stored outside the hospital premises. The other women were assigned a weight of “1”. Another 48 women (1.9%) did not have their medical records reviewed for different reasons, therefore were excluded from the sample. The final weighted sample included 2,452 women.

Birth in Brazil Survey

NB was a nationwide hospital-based survey carried out from February 2011 to October 2012, including 266 hospitals and 23,894 women from all regions of the country. The sample was selected in three stages. The criteria for hospitals were having attended ≥500 births in 2007, stratified by the five macro-regions of the country, location (State capital or not) and type of hospital funding (private, public, or mixed). On the second stage, a reverse sample method selected the number of days (minimum of seven) required to interview 90 postpartum women in each hospital. On the third stage, all women who delivered live babies in the hospital, regardless of weight and gestational age, or a stillbirth weighing over 500 g and/or gestational age above 22 weeks were invited to participate. The sample weights were established by the inverse probability of including each postpartum woman in the sample. We applied a calibration process to ensure that the total estimates were equivalent to the number of births in hospitals with 500 or more births/year in 2011. Detailed information about methods were published elsewhere²¹21 Vasconcellos MT, Silva PL, Pereira AP, Schilithz AO, Souza Junior PR, Szwarcwald CL. Sampling design for the Birth in Brazil: National Survey into Labour and Birth. Cad Saude Publica 2014; 30(Supl. 1):S49-S58.^,2222 Leal MC, Silva AA, Dias MA, Gama SG, Rattner D, Moreira ME, Theme Filha MM, Domingues RMSM, Esteves-Pereira AP, Torres JA, Bittencourt SDA, D'orsi E, Cunha AJ, Leite AJM, Cavalcante RS, Lansky S, Diniz CSG, Szwarcwald CL. Birth in Brazil: national survey into labour and birth. Reproductive Health 2012; 9:15..

The present analysis includes a subset of the NB database, comprised by postpartum women from the Southeast region whose births were funded by the public Brazilian Unified Public Health Care System (“SUS”) (n=7,871). All variables in the present analysis were obtained from medical records, except for age, skin colour, education, history of prematurity, labour companionship, use of a non-pharmacological pain relief method, food intake during labour, and birth position, which were obtained during a face-to-face interview.

Exposure variables

Sociodemographic and obstetric variables included in the analysis were: age (10-19 years, 20-34 years, 35-39 years, >40 years); skin colour (white, black, brown, others); years of schooling (<8 years, 8-10 years, 11-14 years, >15 years); number of previous births (0, 1-2, ≥3); number of previous caesarean sections (0, 1, ≥2); type of pregnancy (single, multiple); foetal presentation (cephalic, pelvic, anomalous, non-pelvic); high-risk pregnancy (yes/no); gestational age (<37 or ≥37 weeks); onset of labour (induced, spontaneous, caesarean section before labour); and mode of birth (vaginal, forceps/vacuum and caesarean section).

Risk status

We defined high-risk pregnancies as those in women who presented one or more of the following conditions: gestational hypertension/pre-eclampsia, chronic hypertension, eclampsia, pre-gestational diabetes, gestational diabetes, severe chronic diseases, infection at the time of admission for childbirth (including urinary tract infection and other severe infections, such as chorioamnionitis and pneumonia), placental abruption, placenta previa, restricted intrauterine growth and foetal malformations. Women who did not have any of these conditions were considered low-risk.

Robson Groups

We classified all women into the 10 Robson Classification groups, using the subdivision of groups 2 and 4 to distinguish women who had induced labour (groups 2a and 4a) from those who had elective caesarean sections (groups 2b and 4b). We aggregated groups 6, 7 and 9 (pregnancies with non-cephalic presentation), due to their high rate of caesarean sections. In both samples, we considered that women went into labour if they reached at least 4 cm cervical dilation. We defined elective caesarean sections as those in women who did not go into labour and did not receive any method of labour induction.

Outcomes

The outcomes variables related to intrapartum care were: labour companionship, labour care provided by a nurse midwife or midwife, presence of a partograph in the medical records, use of non-pharmacological methods for pain relief, food intake during labour, venous catheterization during labour, use of synthetic oxytocin, labour analgesia, amniotomy, birth assisted by a nurse midwife or midwife, birth position (vertical/non-vertical), episiotomy, and use of vacuum extractor/forceps.

Statistical analysis

To compare patient-level data from each setting, we used 95% confidence intervals and chi-square test p-values. All analyses considered the design effect weights of the NB survey, as well as the weighting of losses in the MRJ.

Ethical considerations

The survey at MRJ was approved by the institutional ethics committee under the register number CAAE: 00967118.7.3001.5279 on October 11^th, 2018. Since it was a retrospective study and the data collection was restricted to medical charts and administrative records, a waiver of the Informed Consent Form (ICF) was requested and granted by the committee. NB survey ethical approval for all study procedures was obtained from the Public Health National School, Fiocruz Ethical Review Board, under the protocol 92/2010 on May 11^th, 2010. Written informed consent from the postpartum woman was obtained prior to any data collection.

Results

The survey included 10,324 postpartum women, 2,453 from MRJ and 7,871 from the Southeast region subsample of NB. Comparing the sociodemographic and obstetric variables of low-risk women, MRJ had a higher proportion of older women (≥35 years old), with black skin, higher education, nulliparous and without previous caesarean sections than those in the NB subsample (Table 1). These baseline differences were also found among high-risk women, with an emphasis on the doubled percentage of women ≥40 years old and the lower number of white women at MRJ compared to NB. However, in terms of obstetric characteristics, there were no significant differences in parity and number of previous caesarean sections between MRJ and NB high-risk postpartum women.

Table 2 compares the mode of birth and the characteristics of the intrapartum care, stratified by obstetric risk. In low-risk women, the percentage of caesarean sections at MRJ was lower when compared to NB (22.9% vs. 34.8%), with also a significant difference on the percentage of pre-labour c-sections (9.7% vs. 23.4%). The percentage of spontaneous onset of labour within this group was also higher at MRJ (79.3% vs. 28.3%). In terms of evidence-based practices and interventions during labour, there were significant differences for all of them, except for the presence of a complete partograph. MRJ showed a higher frequency of labour companionship, care provided by nurse midwives during labour, use of non-pharmacological pain relief methods, fluids and food intake during labour, and lower use of synthetic oxytocin, analgesia and amniotomy. There was a higher proportion of women who had a vaginal birth assisted by a nurse midwife and on a vertical position, in addition to less use of episiotomy and vacuum-extractor/forceps.

Among high-risk women, there was a lower percentage of c-sections (53.0% vs. 65.6%) and pre-labour c-sections (33.1% vs 49.2%) at MRJ. The difference in terms of spontaneous onset of labour was not that lower at MRJ, but the percentage of labour induction was much higher than observed in NB (31.2% vs. 18.5%). Most of the differences found for low-risk women were also seen in high-risk women, but there was an inversion in the care provided by nurse midwives during labour (first stage), with a lower percentage at MRJ. In the high-risk group, the rate of vaginal births attended by nurse midwives (second stage) was also lower at MRJ (7.6% vs. 25.5%). Even so, the percentage of deliveries in vertical or lateral positions was higher at MRJ, in addition to the much lower percentage of episiotomies (3.8% vs. 51.9%). Comparing low-risk with high-risk women at MRJ, we observed that there is no difference regarding the presence of a labour companionship, use of amniotomy, analgesia, episiotomy, and vacuum-extractor/forceps (Table 3).

Tables 4 and 5 display a comparison of caesarean section rates according to Robson Classification groups among low-risk and high-risk women. By assessing the distribution of the low-risk obstetric population, a higher proportion of women in group 1 and a lower proportion within groups 2, 5 and 10 are observed at MRJ. The rates of caesarean sections at MRJ were different from those found in NB for the group of non-cephalic presentations (79.3% vs. 93.4%) and for groups 5 (49.3% vs. 74.0%) and 10 (1.9% vs. 23.6%). We identified relevant differences in the analysis of relative contributions. In NB, almost 70% of caesarean sections are concentrated in groups 2 and 5, whereas these groups represent just over 50% of caesarean sections at MRJ. The contribution of group 1 is greater at MRJ (21.4% vs. 6.8%), whereas the contribution of group 10 is greater in NB (0.5% vs. 5.0%).

When assessing the distribution of the high-risk obstetric population in the Robson groups, we observed similar proportions at MRJ and NB for most groups. However, when evaluating the subcategories of group 2, we noticed a higher percentage of women in group 2a (induction of labour) at MRJ in relation to NB (14.5% vs. 7.8%). Likewise, group 4a was also more prevalent at MRJ (9.9% vs. 5.8%). The MRJ caesarean rates were significantly lower in groups 1 (20.9% vs. 41.1%), 2 (62.6% vs. 83.5%) and 8 (72.7% vs. 100%). Both at MRJ and NB, the groups that most contributed to the total number of caesarean sections were groups 5, 2 and 10, with the contribution of group 5 being proportionally greater at MRJ and the contribution of group 2 slightly higher in NB.

Discussion

In recent years, we have seen a transition in the obstetric model of care in the country. Although caesarean sections rates are still high, we have seen improvement in the management of labour and childbirth both in public and private sectors²³23 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira, M, Torres JÁ, 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.. Our analysis showed significant differences between the two samples, which may be attributed to either the model of care adopted in each setting or some potential changes between data collection periods (NB in 2011-2012 and MRJ in 2018). The use of evidence-based practices and interventions during labour and childbirth in the MRJ was much higher than on the Southeast NB subsample. A study evaluating maternity hospitals that were part of the RC project in 2017 observed that evidence-based practices were still below the recommended level in the Southeast region. Only 60.7% of patients used non-pharmacological methods for pain relief and only 49.7% could eat during labor²³23 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira, M, Torres JÁ, 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.. Despite these figures surpass those seen in the NB study subsample, the MRJ rates were higher than the ones observed in such study examining the impact of the RC program (71.2% and 91.7%, respectively).

A Brazilian federal law guarantees the presence of a chosen companion during labour and birth since 2005²⁴24 Brasil. Ministério da Saúde (MS). Portaria nº 2.418, de 2 de dezembro de 2005. Regulamenta, em conformidade com o art. 1º da Lei nº 11.108, de 7 de abril de 2005, a presença de acompanhante para mulheres em trabalho de parto, parto e pós-parto imediato nos hospitais públicos e conveniados com o Sistema Único de Saúde - SUS. Diário Oficial da União; 2005.. Nearly all patients in the MRJ had the presence of a labour companionship, regardless of pregnancy risk. This demonstrates the consolidation of this legal right in comparison to what was observed at the time of the NB survey (52.3%) and even in comparison to a more recent period (86.2% of companions during birth in the Southeast region in 2017)²³23 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira, M, Torres JÁ, 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.. Continuous support by a labour companionship is associated to a lower number of interventions during labour and birth, as well as lower caesarean section rates²⁴24 Brasil. Ministério da Saúde (MS). Portaria nº 2.418, de 2 de dezembro de 2005. Regulamenta, em conformidade com o art. 1º da Lei nº 11.108, de 7 de abril de 2005, a presença de acompanhante para mulheres em trabalho de parto, parto e pós-parto imediato nos hospitais públicos e conveniados com o Sistema Único de Saúde - SUS. Diário Oficial da União; 2005.

25 Dodou HD, Rodrigues DP, Guerreiro EM, Guedes MVC, Lago PN, Mesquita NS. A contribuição do acompanhante para a humanização do parto e nascimento: percepção de puérperas. Esc Anna Nery 2014; 18(2):262-269.^-2626 Lunda P. Minnie CS, Benadé P. Women's experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth 2018; 18(1):167., which may at least partially explain the lower percentages of interventions at MRJ. Furthermore, the MRJ infrastructure has individual labour, birth and postpartum rooms, where the woman can stay since active labour till the immediate postpartum period, providing a private environment for women and their labour companions²⁷27 World Health Organization (WHO). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: WHO; 2018..

The study also observed lower rates of synthetic oxytocin use among low-risk patients at MRJ (21.7%) in comparison with NB (55%). This difference persists even among high-risk patients at MRJ (32.2%). We also noticed lower use of amniotomies in low-risk and high-risk women. These differences seem to represent a paradigm shift in childbirth care, reflecting both the prioritization of childbirth as a physiological event according to RC guidelines and the recent changes in recommendations for the diagnosis of intrapartum dystocias²⁸28 The American College of Obstetricians and Gynecologists. Obstetric Care Consensus No. 1: Safe Prevention of the Primary Caesarean Delivery. Obstet Gynecol 2014; 123(3):693-711., after new studies have evidenced that normal labour progress is slower than perceived in the past²⁷27 World Health Organization (WHO). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: WHO; 2018.^,2929 Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, Hatjis CG, Ramirez MM, Bailit JL, Gonzalez-Quintero VH, Hibbard JU, Hoffman MK, Kominiarek M, Learman LA, Van Veldhuisen P, Troendle J, Reddy UM, Consortium on Safe Labor. Contemporary Patterns of Spontaneous Labour with Normal Neonatal Outcomes. Obstet Gynecol 2010; 116(6):1281-1287..

The use of labour analgesia, despite current recommendations of use upon patients’ request²⁷27 World Health Organization (WHO). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: WHO; 2018., was lower at MRJ among average and high-risk patients. The percentage of analgesia for all groups in both MRJ and NB was below 10%. The reduced frequency of labour analgesia in this setting could be attributed to the higher frequency of labour companionship and intrapartum care provided by nurse midwives (both associated with lower rates of epidurals¹⁸18 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led Continuity models versus olther models of care for chilbearing women (Review). Cochrane Database of Systematic Reviews. Cochrane Database Syst Rev 2016; 4(4):CD004667.^,2626 Lunda P. Minnie CS, Benadé P. Women's experiences of continuous support during childbirth: a meta-synthesis. BMC Pregnancy Childbirth 2018; 18(1):167.), as well as increased use of non-pharmacological pain relief methods. However, it is not possible to rule out that barriers to access labour analgesia may also play a role. Previous studies indicated fear of labour pain as one of the contributing factors for the choice of give birth by caesarean sections³⁰30 Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, d'Orsi E, Pereira APE, Schilithz AOC, Leal MC. Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final. Cad Saude Publica 2014; 30(Sup.):S101-S116.^,3131 Wang E. Requests for caesarean deliveries: The politics of labour pain and pain relief in Shanghai, China. Soc Sci Med 2017; 173:1-8.. In this sense, greater publicization of pharmacological analgesia and improved access to this technology when needed could encourage the choice of vaginal birth by pregnant women.

Another relevant difference was noticed on episiotomy rates. Among women who gave birth vaginally at MRJ, 3.3% were subjected to episiotomy, opposed to 50% in NB. Routine episiotomies are associated with more severe complications such as haemorrhage, increased risk of 3^rd and 4^th degree perineal tears, as well as increased postpartum pain³²32 Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009; 1:CD000081.. Even though recommendations to avoid routine episiotomies are prior to the NB survey, at that time more than 50% of women had such intervention. In 2017, there was a decrease to 31% in an analysis of RC maternity hospitals²³23 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira, M, Torres JÁ, 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., but still much higher than the rate seen at MRJ in 2018. It is important to note that there is no difference in episiotomies among high-risk women (whose births are attended by doctors in more than 90% of cases) and low-risk women, showing that there is good adherence by the MRJ clinical staff to the restrictive episiotomy policy regardless of obstetric risk status and birth attendant.

This comparative analysis showed that at MRJ 58% and 55% of low-risk women received care during first and second stage, respectively, by a nurse midwife. These percentages were higher than those found in the NB survey. Previous studies have shown lower rates of interventions during labour when care is provided by non-physician providers¹⁴14 Vogt SE, Silva KS, Dias MAB. Comparação de modelos de assistência ao parto em hospitais públicos. Rev Saude Publica 2014; 48(2):304-313.^,1818 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led Continuity models versus olther models of care for chilbearing women (Review). Cochrane Database of Systematic Reviews. Cochrane Database Syst Rev 2016; 4(4):CD004667.^,1919 Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, Silva DRAD, Downe S, Kennedy HP, Malata A, McCormick F, Wick L, Declercq E. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129-1145.^,3333 Freytsis M, Phillippi JC, Cox KJ, Romano A, Cragin L. The American College of Nurse-Midwives Clarity in Collaboration Project: Describing Midwifery Care in Interprofessional Collaborative Care Models. J Midwifery Women´s Health 2016; 62(1):101-108., which potentially explains the lower use of interventions and more frequent use of evidence-based practices on low-risk women (primarily attended by nurse midwives). However, among high-risk women, only 11% and 7.6% were assisted by nurses during first and second stage of labour at MRJ, numbers even lower than those found in NB, and the differences in the use of evidence-based practices and interventions remained the same. These results indicate that at MRJ the use of evidence-based practices and interventions is not only linked to the provider attending labour or birth, but the model of care implemented in the institution.

The MRJ CM of care is characterized by woman-centred, integrated interdisciplinary work shared between both obstetricians and nurse midwives. This model creates a favourable setting for transformation of the relationships between different birth attendants and clinical practices, resulting in a low number of interventions, lower rates of caesarean sections and higher use of evidence-based practices. The CM builds standards for clinical practice across provider teams by establishing evidence-based protocols¹⁶16 Smith DC. Midwife-Physician Collaboration: A Conceptual Framework for Interprofessional Collaborative Practice. J Midwifery Womens Health 2015; 60(2):128-139.^,1717 Avery MD, Montgomery O, Brandl-Salutz E. Essential Components of Successful Collaborative Maternity Care Models. The ACOG-ACNM Project. Obstet Gynecol Clin N Am 2012; 39(3):423-434..

The analysis of the distribution of low-risk women according to Robson groups reflects the care model implemented at MRJ, and the differences in relation to the NB survey. Nulliparous women with term pregnancies and cephalic presentation (Robson groups 1 and 2) accounted for 39% of the obstetric population in NB and were almost equally divided between groups 1 and 2. At MRJ, this percentage amounts to 46% of women, and group 1 is four times larger than group 2. The higher prevalence of group 1 to the detriment of group 2 reflects the lower use of early elective birth, either by induction of labour or pre-labour caesarean section.

The percentages of caesarean sections in groups 1, 2, 3, 4 and 8 among low-risk women at MRJ are similar to those of NB. However, we shall highlight the difference noticed in group 5, comprised of women with full-term pregnancies, cephalic presentation and at least one previous caesarean section. Over the years, there has been an increase in the contribution of group 5 to the caesarean section rates in Brazil and worldwide³3 Nakamura-Pereira M, Leal MC, Esteves-Pereira AP, Domingues RMSM, Torres JA, Dias MAB, Moreira ME. Use of Robson Classification to Assess Caesarean Section Rate in Brazil: The Role of Source of Payment for Childbirth. Reprod Health 2016; 13(Supl. 3):128.^,3434 Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, Tunçalp Ö, 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 Global Health 2015; 3:e260-e270.. With the increase in caesarean rates globally, the number of women undergoing this surgery becomes more prevalent, increasing the susceptibility to repeating this mode of birth in future pregnancies³⁴34 Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, Tunçalp Ö, 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 Global Health 2015; 3:e260-e270.. Within this group, we can notice a caesarean section rate of less than 50% at MRJ, much lower than the rates found in NB (74%). Even if we added high-risk women, the percentage of caesarean sections within group 5 at MRJ would still be 60.9%, i.e., lower than the rates for low-risk women in NB, and similar to the 61% rate seen in France (where overall caesarean section rate is 20%)³⁵35 Le Ray C, Blondel B, Prunet C, Khireddine I, Deneux-Tharaux C, Goffinet F. Stabilising the caesarean rate: which target population? BJOG 2015; 122(5):690-699.. These results reflect a higher incentive to vaginal birth after caesarean section at MRJ.

Another fact that draws our attention is the difference in the percentage of caesarean sections in low-risk women within group 10, which includes pregnancies of cephalic preterm infants. In NB, the c-section rate for this group was 23%, while 2.9% at MRJ. This difference can be attributed to the higher percentage of spontaneous premature births at MRJ. However, the MRJ population has a higher level of education than that of NB and since spontaneous prematurity is related to social vulnerabilities, the reverse would be expected to occur³⁶36 Leal CM, Esteves-Pereira AP, Nakamura-Pereira M, Torres JA, Theme-Filha M, Domingues RMSM, Dias MAB, Moreira ME, Gama SGN. Prevalence and risk factors related to preterm birth in Brazil. Reproductive Health 2016; 13(Supl. 3):127.

37 Cobo T, Kacerovsky M, Jacobsson B. Risk factors for spontaneous preterm delivery. Int J Gynecol Obstet 2020; 150:17-23.^-3838 Morisaki N, Togoobaatar G, Vogel JP, Souza JP, Hogue CJR, Jayaratne K, Ota E, Mori R, WHO Multicountry Survey on Maternal and Newborn Health Research Network. Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 1221(Supl. 1):101-109.. Therefore, it is possible that this difference reflects different clinical practices towards women with preterm babies presenting at NB hospitals, such as greater use of labour induction for premature rupture of membranes or even pre-labour caesarean sections.

Concerning high-risk women, differences in c-section rates occurred in groups 1 and 2, where the rate of caesarean sections in group 1 at MRJ was half the rate on NB. In addition, in term pregnancies without labour at admission (groups 2 and 4), there was a higher frequency of labour induction in lieu of elective caesarean sections at MRJ. This data may be associated with well-established protocols for terminating pregnancies in patients with comorbidities, but clinically stable to allow labour induction³⁹39 Spong CY, Mercer BM, D'Alton M, Kilpatrick S, Blackwell S, Saade George. Timing of Indicated Late-Preterm and Early-Term Birth. Obstet Gynecol 2011; 118:323-333..

One of the limitations of the study was the time difference (7 years) between data collection periods. Obstetric care in the country has changed over time. In most recent studies, we noticed a reduction of inequities of childbirth care with greater use of evidence-based practices and a reduction in the number of interventions⁴⁰40 Leal MDC, Esteves-Pereira AP, Vilela MEA, Alves MTSSBE, Neri MA, Queiroz RCS, Santos YRP, Silva AAMD. Reduction of inequities of access to appropriate childbirth care in Rede Cegonha. Cien Saude Colet 2021; 26(3):823-835.. However, the large time gap between the samples allowed us to identify a change in the obstetric and sociodemographic profile of women, through the increase in education and higher proportion of primiparous women in 2018. These changes were also seen in cohort studies carried out in the South region of the country, showing an increased number of deliveries in primiparous women and a longer interval between pregnancies. These findings were significant regardless of skin colour and social class, with more robust differences between white women and higher family income⁴¹41 Matijasevich A, Victora CG, Silveira MF, Wehrmeister FC, Horta BL, Barros FC. Maternal reproductive history: trends and inequalities in four population-based birth cohorts in Pelotas, Brazil, 1982-2015. Int J Epidemiol 2019; 48(Supl. 1):i16-i25.. Nevertheless, the caesarean section rates in the country barely changed in the period. In 2011, the year when the data collection for the NB study began, the overall caesarean sections rate in the Southeast region was 59.4%, while 58.4% in 2018⁴4 Brasil. Ministério da Saúde (MS). DATASUS. Sistema de Informações sobre Nascidos Vivos (SINASC) 2010 [Internet]. [acessado 2020 jun 18]. Disponível em: http://www.datasus.gov.br.
http://www.datasus.gov.br... . Leal et al.²³23 Leal MC, Bittencourt SA, Esteves-Pereira AP, Ayres BVS, Silva LBRAA, Thomaz EBAF, Lamy ZC, Nakamura-Pereira, M, Torres JÁ, 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. also did not show any relevant change in the caesarean section rates among publicly funded childbirths in the Southeast region between the NB survey and the Rede Cegonha assessment in 2017 (42.6% and 40.6%, respectively).

Our findings reinforce the feasibility of implementing collaborative models of care between midwives and obstetricians and their potential to improve care provided during labour and childbirth.

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