The program that helps to reduce cesarean sections in private hospitals

Maria do Carmo Leal

National School of Public Health (ENSP) of the Oswaldo Cruz Foundation (Fiocruz)
Project: Healthy birth: a prospective study to assess the introduction and effects of a multifaceted intervention to improve the quality of care during childbirth and birth in hospitals in Brazil

Nine out of ten deliveries performed in private hospitals in Brazil are cesarean sections. The country is among those that most frequently resort to these surgical interventions, which accounted for 55% of all births in the country in 2018. These two rates are much higher than those recommended by the World Health Organization (WHO), which recommends that they should not exceed 10% to 15% of deliveries, as they should only occur for medical reasons.

In order to reduce the high rates of cesarean sections, the National Health Agency (ANS) in partnership with the Albert Einstein Hospital and the Institute for Health Care Improvement, an international organization focused on improving health services around the world, launched the Adequate Childbirth program in 2015.

The national initiative aims to support and facilitate the implementation of actions based on scientific evidence to safely reduce the percentage of unnecessary cesarean sections and improve the quality and safety of care during labor and birth in private hospitals. Between 2015 and 2016, 35 institutions and 19 health plan operators participated in a pilot program, which demonstrated the project’s viability. The current phase of dissemination, which began in 2017 and is still ongoing, involves 108 hospitals and 60 operators. So far, 20,000 unnecessary caesarean sections have been avoided, according to the program. The third and final stage will include the dissemination of strategies and practices pre-tested in several maternity hospitals and operators in the country, at a large scale.

To assess the impact of the program, researcher Maria do Carmo Leal, professor of epidemiology at the National School of Public Health (ENSP) graduate school of the Oswaldo Cruz Foundation (Fiocruz) with experience in epidemiological investigations, analyzed twelve hospitals participating in the Adequate Childbirth program. In each of them, she interviewed approximately 400 women who gave birth at these selected institutions, for a total of 4,800 interviews. Among the questions asked were those that tried to assess the quality of care as a whole, the practices adopted at the time of delivery and the type of delivery: cesarean or normal.

The study found that cesarean sections fell by an average of 10% in all twelve participating hospitals. They also found a 10% reduction in so-called early term newborns — babies born between 37 and 38 weeks, slightly below 39-40 weeks, which is considered ideal. “These births are highly associated with scheduled cesarean sections and, with this program, they have been significantly reduced because hospitals have begun preventing them from being scheduled before 39 weeks of gestation,” says Maria do Carmo Leal. “There was no reduction in prematurity, because births below 37 weeks are caused by other factors.” The program also resulted in an increase in breastfeeding rates in the first hour of life, an extremely important factor in strengthening the bond between mother and baby.

At the beginning of the program, the researchers noted that the medical and nursing teams had difficulty conducting and managing vaginal deliveries because they were no longer used to performing them. But, over time, professionals began to adopt procedures recommended by the scientific literature, based on evidence published internationally. These improvements include an increase in the presence of a companion during births, more assistance by obstetric nurses, an increase in completions of partograms — a graphical record that tracks the evolution of labor – a decrease in maneuvers that are not routinely recommended, including episiotomies (a cut in the perineum to enlarge the birth canal). The medical team also performed fewer invasive procedures, such as a venous catheter (inserted into the woman’s vein) and administered less pain relief drugs and hormones, like oxytocin. As a strategy for pain relief, a bath or shower with warm water and massages were also used. Pregnant women were also able to drink water and eat light meals. In the expulsive period of childbirth, they chose the position that best suited them, reinforcing the woman’s comfort and autonomy.

The study also assessed the satisfaction of mothers and hospitals with the program, a dimension that is still under analysis. When evaluating the detailed costs of childbirth care at a hospital, the team noted that the Adequate Childbirth intervention proved to be cost-effective, bringing more benefits compared to costs. “We found that the program has benefits for pregnant women, participating hospitals and most importantly: for babies, who have been born in a healthier way and at the right time.”