Initially, I should say of my satisfaction and sense of responsibility for commenting on an article drawn from the national survey Birth in Brazil. This survey is a milestone in the production of knowledge about birthcare models in the country, given its relevance, comprehensiveness and uniqueness.
Except for c-section, episiotomy and pain-relief in normal vaginal delivery, the other data presented on the article are unique. I had not known of information about the other obstetric practices and interventions during childbirth – nutrition, mobility, use of a partogram, use of peripheral intravenous line, oxytocin infusion, amniotomy, lithotomy position in labor, Kristeller maneuver (uterine fundal pressure during expulsion of fetus), and normal vaginal delivery without interventions –, other than in partial or limited studies. In addition, as commentator, I have the freedom-of-interpretation privilege without having to stick to the “immanence” of the results.
It is probable that the “idea of safety” regarding birthcare, with timely interventions to prevent morbid outcomes is mixed up with the goals of swiftness and opportunism, in detriment of the “idea of physiology” of the birth. The c-section is a way to swiftly resolve delivery to low-risk (45.5%) and other pregnant women (60.3%).
For women considered as being of low risk, another way to shorten delivery is to perform interventions that prompt, expedite, hasten, or quicken the care-provision process. The interventions that, successfully or not, accelerate the vaginal delivery include: amniotomy and oxytocin infusion for cervical dilation; Kristeller and episiotomy for fetus expulsion.
For the women of the investigation, the mainstay of health-care delivery is centered in the clinic and the practitioner, rather than on the woman and the childbirth process. Thus, some of the results observed in the study include a higher exposure of nulliparous women to oxytocin infusion, Kristeller maneuver and episiotomy; higher chance of poorly educated women undergo amniotomy and receive oxytocin when giving birth in public health facilities; also for those who give birth in the Central region of the country, in addition to Kristeller maneuver and episiotomy.
Even in birth centers where only low-risk women are attended, some unnecessary interventions are highly performed. Amniotomy and oxytocin infusion rates reach 75.1% and 46.3%, respectively, which evidence an indiscrimina- te use1.
Concerning episiotomy, even though their rates in birth centers are high (ranging from 16.2% and 35%) 1, this intervention is prone to be reduced, as there was a significant decrease of this rate in all macro-regions of Brazil in the Birth in Brazil study compared to the 2006 Brazilian National Survey of Demography and Health (PNDS) 2, in which the national rate was of 76.1%.
There seems to be a hierarchy in regards to discontinuation of inadequate practices in obstetric care. It is likely that interventions in which the current process of care strongly supports its means of production are the last obstacles that will have to be overcome towards the promotion of physiologic childbirth. I imagine that such interventions are the c-section and the use of oxytocin.
Data indicate the need for swift changes in birthcare in Brazil, or else, in the long term, irreversible patterns of maternal and neonatal morbidity may be established, due to unnecessary interventions.
Finally, I reinforce that the information of the analyzed article is a major contribution to current and future interpretations on the adoption of obstetric practices and the trends of birthcare and delivery models in low-risk pregnancies.
- 1Riesco MLG, Oliveira SMJV, Bonadio IC, Schneck CA, Silva FMB, Diniz CSG, Lobo SF, Saito E. Birth centers in Brazil: scientific production review. Rev Esc Enferm USP 2009; 43:1291-6.
- 2Lago TDG, Lima LP. Assistência à gestação, ao parto e ao puerpério: diferenciais regionais e desigualdades socioeconômicas. In: Ministério da Saúde, organizador Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006. p. 150-68.
- Publication in this collection