The Birth in Brazil study published its first results four years ago in a special thematic issue of Cadernos de Saúde Pública/Reports in Public Health, revealing for the first time an overview of the obstetric and birth care in the country, which is characterized by excessive interventions and even iatrogenic complications for mothers and their infants ¹1. Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saúde Pública 2014; 30 Suppl 1:S17-47. . The study’s findings raised concerns and debates in the academic community, health professionals’ associations, social organizations, and in the society at large.

A review of the changes that have occurred is necessary, although challenging, knowing that research results alone are unable to produce immediate changes in practices and public policies in obstetric and birth care. Still, to the results are added other ongoing initiatives in the quest to respond to the desires of women, families, policymakers, and health professionals.

In 2011, the program known as Stork Network was launched in the Brazilian Unified National Health System SUS , involving hospitals that serve users of public health services, with the aim of guaranteeing access, solidarity, and quality of obstetric and birth care ²2. Ministério da Saúde. 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; 27 jun. . A recent independent evaluation of the Stork Network was conducted by academic institutions and showed promising results, with higher rates of good practices and a reduction in unnecessary interventions.

Among the educational initiatives, we highlight the the development of a distance education program called Training in Surveillance of Maternal, Infant, and Fetal Deaths for Action by Mortality Committees, developed by our research group in collaboration with the Brazilian Ministry of Health. The course aimed to enhance data recording and information systems in order to improve the care provided to mothers and infants. From 2013 to 2015, 99 tutors and 2,586 students were trained in 891 municipalities of Brazil.

In 2015, a program called Adequate Birth was launched aiming primarly at reducing cesarean sections in private services in Brazil. Although initial participation was limited, the program included highly prestigious hospitals in the early stage, which later helped consolidate and expand the initiative, now boasting voluntary participation by nearly 150 hospitals. The program’s initial results are also being assessed and have shown improvement in various indicators in these hospitals, such as reductions in cesarean sections and in births at 37-38 weeks’ gestational age, referred to as early-term neonates ³3. Torres JA, Leal MC, Domingues RMSM, Esteves-Pereira AP, Nakano AR, Gomes ML, et al. Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol. Reprod Health; in press. .

Another major stride in this area was the study on motherhood behind bars called Birth in Prison. All pregnant women and women with children under one year of age were visited in the women’s prison facilities in Brazilian state capitals and metropolitan areas. For the first time, the study revealed the cruel and inhumane reality experienced by these women and their children and families, including substandard prenatal care, vertical transmission of syphilis, high HIV rates, and the use of handcuffs during childbirth and hospitalization ⁴4. Leal MC, Ayres BV, Esteves-Pereira AP, Sanchez AR, Larouze B. Birth in prison: pregnancy and birth behind bars in Brazil. Ciênc Saúde Coletiva 2016; 21:2061-70.^,55. Domingues RMSM, Leal MC, Pereira APE, Ayres B, Sánchez AR, Larouze B. Prevalence of syphilis and HIV infection during pregnancy in incarcerated women and the incidence of congenital syphilis in births in prison in Brazil. Cad Saúde Pública 2017; 33:e00183616. . Two legal measures in the wake of this study benefited mothers in prison: a ban on the use of handcuffs during childbirth Law n. 13,434/2017 and the right to house arrest for female detainees who are awaiting sentencing in the case of pregnant women and mothers of children under 12 years of age or with disabilities Collective Habeas Corpus granted by the Brazilian Supreme Court in February 2018 .

Another key finding from Birth in Brazil study was the high early-term birth rate, accounting for 31% of all singleton live births in the public healthcare sector and 47% in the private. The finding was highly relevant, since these children were shown to be at increased risk of negative outcomes such as oxygen use, neonatal ICU admissions, hypoglycemia, respiratory problems, jaundice, and delays in breastfeeding, especially in neonates born by prelabour cesarean sections ⁶6. Leal MC, Esteves-Pereira AP, Nakamura-Pereira M, Domingues RMSM, Dias MAB, Moreira ME, et al. Burden of early-term birth on adverse infant outcomes: a population-based cohort study in Brazil. BMJ Open 2017; 7:e017789. . The Federal Board of Medicine issued a crucial resolution Resolution CFM n. 2,144/2016 according to which cesareans in normal-risk pregnancies can only be performed at 39 weeks’ gestational age or greater ⁷7. Conselho Federal de Medicina. Resolução nº 2.144, de 17 de março de 2016. Art. 2º - para garantir a segurança do feto, a cesariana a pedido da gestante, nas situações de risco habitual, somente poderá ser realizada a partir da 39ª semana de gestação, devendo haver o registro em prontuário. Diário Oficial da União 2016; 22 jun. , in line with the decision made by the American College of Obstetrics and Gynecology ACOG in 2013 ⁸8. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 559: cesarean delivery on maternal request. Obstet Gynecol 2013; 121:904-7. .

More recently, the Brazilian Ministry of Health launched a project for improvement and innovation in obstetric and neonatal care, called Apice-On, the aim of which is to improve clinical training and management of care in childbirth, birth, and miscarriage/abortion, using a model based on scientific evidence, humanization, safety, and patients’rights ⁹9. Portal da Saúde. Ministério da Saúde lança Projeto Apice on - Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia. http://u.saude.gov.br/index.php/o-ministerio/principal/secretarias/sas/sas-noticias/29278-ministerio-da-saude-lanca-projeto-apice-on-aprimoramento-e-inovacao-no-cuidado-e-ensino-em-obstetricia-e-neonatologia acessado em 16/Mar/2018 .
http://u.saude.gov.br/index.php/o-minist... .

The data from these studies clearly demonstrate the benefits of investments in science and technology for the analysis and monitoring of public policies. It is thus essential for the measures currently under way to continue and expand in order to ensure ongoing improvement in obstetric and birth care. Nevertheless, consolidation of the steps taken thus far requires expanding the government funding for the health sector, safeguarding democracy, and valuing women’s rights, as well as reducing poverty and social inequalities in health. One of the main Sustainable Development Goals is to reduce maternal mortality, and health professionals, policymakers, and society thus need to join forces to strengthen the changes in obstetric care, improving the quality of prenatal and childbirth care and reducing adverse outcomes for mothers and infants.

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