A broad survey has been completed evaluating maternal and perinatal health indicators and their association with socioeconomic factors in 19 municipalities in the Metropolitan Region of Campinas (RMC), as well as childbirth care routines in 16 public maternity hospitals. The general conclusion is that, despite the region's good level of development, socioeconomic inequalities remain that impact the health indicators of mothers and babies, with worse results in adolescents and women with lower education and income; in relation to health practices, that some routines are excessive and others need to be improved; and, furthermore, that economic power increases the rate of cesarean sections in the region's municipalities.

“Being born in the Metropolitan Region of Campinas: advances and challenges” is the title of the doctoral thesis by nurse Fátima Filomena Mafra Christóforo, supervised by professor Eliana Martorano Amaral and defended at the Faculty of Medical Sciences (FCM). Before its execution, the research project was approved by the Unicamp Research Ethics Committee and presented to the Regional Health Directorate VII of Campinas, the RMC Health Thematic Chamber (consultative body composed of the Health secretaries) and all public and mixed maternity hospitals where it was carried out; It also obtained support from the Public Policy Studies Center (NEPP). Now, the results will be discussed in a seminar with representatives of DRS-VII and the municipalities and hospitals involved in the research, seeking ways to minimize the problems detected.

“The focus of the thesis is the evaluation of the quality of the services offered to, from there, propose some intervention with the health service, in an integrated manner with the State Secretariat and the Regional Directorate”, says professor Eliana Amaral. “The other aspect was to associate the results with different segments of the population. Despite being in a region with high purchasing power and great access to health services, there are still pockets of need, which we seek to identify and verify how they are distributed across the municipalities. The main interest of the thesis is not in the purely academic discussion, but in supporting changes in practices and management of the region’s health system.”

Fátima Christóforo explains that two studies made up the thesis: the first, ecological, based on indicators available in Datasus (Informatics Department of the Unified Health System), Fundação Seade (State Data Analysis System) and IBGE 2010 Census; and the second describing birth care practices in 16 maternity hospitals, interviewing managers of obstetric services, doctors and nurses. RMC has 30 services, 13 of which are private, 10 mixed (private with an agreement with the SUS) and seven public. Seven public services and nine mixed services participated in the study, offering 54,8% of the 649 obstetric beds available. 

ATTENTION PRACTICES 

Among the excessive practices used during labor are the use of oxytocin (hormone) in most parturient women, in 10 maternity hospitals, and episiotomy (incision made in the perineum region), also in almost all parturient women, in nine institutions. “Oxytocin is a hormone that women have in their body and that causes contractions”, explains Eliana Amaral. “It is unlikely that most of them will need the synthetic medicine; This is a practice that has been maintained since procedures to speed up labor were seen as natural. The same in relation to episiotomy, which was previously a recommended practice for 100% of cases – today, it is recommended that its indication be selective. Unicamp has not used routine episiotomy for almost 20 years, but we see that scientific information has not yet reached the practice of such services. Hence, the need for studies like this, which encourage the assessment of the quality of care.”

Fátima Christóforo found that qualified practices in childbirth care occur in most aspects and in a large number of maternity hospitals, such as screening for HIV and syphilis (in all 16); availability of protocols for care in cases of severe hypertension during pregnancy and prophylaxis of group B Streptococcus infection in newborns (in 15 hospitals); active management of the 3rd period of labor to prevent postpartum hemorrhage (in 14); routine use of the partogram to record the frequency of contractions, dilation and fetal heartbeats (13); reception with risk classification (10); and the presence of a companion during labor (9) and delivery (14). “On the other hand, given the high incidence of cesarean sections, it was surprising to find five maternity hospitals that did not confirm the use of antibiotics to prevent infections after surgery.”

In Eliana Amaral's opinion, three problems found in the research are very worrying: the unavailability of blood and blood products in four hospitals (two of them exclusive public hospitals), the lack of conditions to care for pregnant women in critical condition (observed in eight) and the difficulty transport to take patients to other hospitals (two). “The lack of blood products in a quarter of hospitals is very serious, as bleeding after birth, due to some complication, can put the mother's life at risk in less than 30 minutes. The lack of conditions for assistance in emergency situations is unacceptable. In this metropolitan region, with all the available access to resources, we have a management problem on the part of institutions and the health system, which requires a minimum quality of care.”

The thesis advisor also defends physical adaptations in hospitals to facilitate access for companions during labor. “The presence of a companion helps to improve the progress of labor and increase the natural birth rate. But we see that there are more people accompanying the birth than the labor – the partner is not participating in the entire process. Maternity hospitals claim that they only have one common room and that it is necessary to respect the privacy of other patients. At Caism da Unicamp, we have separate rooms for couples, but before the physical renovations, we tried to guarantee their presence by separating the beds with curtains. One of the relevant conclusions of this study is the need for public policies to promote adaptations in the physical structure as well.”

HEALTH INDICATORS

According to the author of the research, the worst maternal and perinatal health indicators are in municipalities with the worst socioeconomic indicators, located to the north, northeast and some to the southwest of the RMC. “In 12 cities, more than 50% of the women who took part in the study did not have the support of a partner to meet their child's needs and education; in 11 municipalities, more than 20% of the population had a female leader. Teenagers make up more than 15% of mothers in seven cities; teenage pregnancy is notable in regions with greater health and education needs, being an indicator of perinatal risk, and often associated with the absence of a partner.”

The data show that income less than or equal to the minimum wage, the Municipal Human Development Index (IDHM), the average per capita household income, the greater presence of teenage mothers, illiteracy and study time of less than eight years are correlated with a lower number of prenatal consultations and perinatal mortality rates. “One aspect to highlight from the study is the existence of these pockets of social need and teenage pregnancy, which will bring worse results to the lives of mothers and children”, says Eliana Amaral. “There is a need to identify and focus on these pockets to improve the care offered during pregnancy and childbirth, going beyond generic policies such as guiding teenagers about the impact of early pregnancy.”

Fátima Christóforo confirmed in the research the increase in cesarean sections in the Metropolitan Region of Campinas: the average is more than 60% in 14 municipalities, reaching 70% in areas with greater purchasing power, sometimes associated with higher rates of perinatal mortality and prematurity. “The lower rate of cesarean births in needy regions is due not only to financial issues (not being able to pay for the procedure), but also to the fact that these women generally seek out public institutions, where the delivery follows more strictly the technical recommendations.”

Eliana Amaral observes that prematurity represents a problem, because even if the cesarean section is elective, with the gestational age properly calculated, sometimes the child has breathing difficulties. “It’s different from vaginal birth. Today we know that the ideal date for a cesarean section is 39 weeks, not 37 which is 'already at term', as people say. There is a certain anguish to anticipate the procedure and, with it, comes the risk of prematurity. Cesarean section is part of obstetric practice in the private system and is sought by the patient herself with the agreement of doctors. We are moving to change this culture.”

In the opinion of the Unicamp professor, there is a clear “inequity” in childbirth care even in a region where it is possible to offer all the resources for qualified health practices. “Some resources are missing where they would be needed and others are being used inappropriately. Financial power ends up leading to excessive procedures. Taking into account young people from the middle and upper middle class under the age of 30, very few were born by natural birth. Having a cesarean section has become almost a status symbol, with vaginal birth not being understood as the natural process that allows the baby to grow and mature. This is a worldwide phenomenon, based on the perception of cesarean sections as more comfortable and also safer.”

Publication

Tese: “Being born in the Metropolitan Region of Campinas: advances and challenges”

Author: Fátima Filomena Mafra Christóforo

counselor: Eliana Martorano Amaral

Each: Faculty of Medical Sciences (FCM)