1. Promoting evidence-informed obstetric care in Brazil: Challenges and Opportunities Dr Maria Helena Bastos, MD MSc Women’s Health Research Kings College London Thames Valley University

2. Overview Brazil is a middle-income country, ranking 69 out of 177 countries on UNDP's Human Development Index (2006) 84 per cent of population lives in urban areas (2004) Total fertility rate is 2.0 births per woman (PNAD 2006) The under-five mortality rate - 56% reduction from 1990 to 33‰ live births in 2005 Continued poverty continues to be a challenge for the government's economic and social policies

3. Why do we need to look beyond reproductive health? Impressive progress in the region in achieving lowered fertility and improved reproductive outcomes Women’s rights perspective implies that women should be viewed in own right, not just in reproductive role Pregnancy and childbirth has different consequences or implications for women or some subgroups of women

4. Policy and practice National Health System (SUS) Women’s health advocates launch national initiative for Women’s Comprehensive Health (PAISM) Some significant advances in the legal, normative and regulatory frameworks, guaranteeing a rights-based approach to the provision of reproductive health care As part of the National Plan for the Reduction of Maternal and Neonatal Mortality, launched in 2004, Mortality Committees are being established at national, regional and municipal levels

5. Vital statistics in Brazil System of Information of Live Births (SINASC) - implemented by the Brazilian Ministry of Health in 1990 Brazilian Death Information System (SIM/MS) - low quality of information provided in death certificates Hospital Information System (SIH/SUS) - incomplete coverage and uncertainties about reliability of data What do we know? MMR is not compatible with the countries’ economic development Neonatal death constitutes the major component of the infant mortality Great number of underreported fetal deaths

6. Hospital births (%) Total: 96.76 90.41 94.43 98.97 99,03 99.22 SINASC/Datasus, 2004

7. Maternity care organization ± 3 million births/year – 70% women deliver in public hospitals Obstetric rather than maternity care dominant Excessive care and over reliance on unnecessary technology is common Obstetric and midwifery care does not follow recognised evidence-based guidelines Unnecessary caesarean section is dominant in the private sector

8. Inequalities in childbirth

9. % ANC coverage by region, 2004 Sinasc/SVS/MS

10. ANC coverage and skin color, 2004 BlackMixed % Sinasc/SVS/MS

11. Distribuition ANC according to skin color in women with 12+ years of education Sinasc/SVS/MS

12. Maternal mortality According to the National Demographic Health Survey (PNDS) –in 1996, MMR was 160 per 100.000 live births (modified sisterhood method) –In 2000, MMR was 260 Official MMR in 1998 was approximately 65 per 100.000 live births

13. Common causes of maternal death in Brazil Pre-eclampsia and eclampsia Complications of unsafe abortion Haemorrhage Puerperal infection

14. Proportion of maternal deaths by maternal skin color, 2004 45.5% 41.4% 12.1% SIM/SVS/MS - 2004

15. Trends in NMR by maternal skin color, 1982-1993-2004, Pelotas Barros, Victora et al, 2005

16. Death of women (10 to 49 years of age) due to maternal causes according with the occurrence period Occurance n% Pregnancy2421.1 Post-partum7263.2 (< 48 hours)(34)(29.8) (48 hours – 42 days)(38)(33.4) Maternal Deaths (WHO’s definition)9684.3 43 days – 1 year (Late maternal death)1614 1 year or more (Sequelae of maternal death)21.7 Ignored1 Total115100 Laurenti et al, WHO Brazilian Collaborating Center - 2003

17. Epidemiological transition and the medicalization of childbirth Operative delivery rates in Brazil are the highest in the world - rates rose from 28% to 42.9% over 20 years, with a staggering 82.4% in the private sector Rise in induction rates from 3% to 45% The amount of pain a woman experiences during childbirth usually reflects issues relating to class based on differences in the quality of care provided. The risks of medicalisation of childbirth should not be ignored because they might offset the gains resulting from improved maternal health and survival of newborn infants.

19. Proportions of Caesareans (2003 - 2005) Private sector Public sector Brazil Total ANS, 2005

20. 2005 WHO global survey on maternal and perinatal health in Latin America High rates of caesarean delivery do not necessarily indicate good quality care Institutions that deliver a lot of babies by caesarean should initiate a detailed and rigorous assessment of the factors related to their obstetric care and the perinatal outcomes achieved vis-à-vis the case mix of the population they serve; at present their services might cause (iatrogenic) harm Villar et al, 2005

21. Risk factors associated with the high caesarean section rates Delivery in the private sector Maternal education and white skin colour More than seven antenatal consultations Antenatal care with the doctor who performed the delivery Being a first time mother (primipara) Previous caesarean section Arriving in the maternity before labour is established Freitas et al, 2005

22. Whose choice is it? In Brazil, many women prefer caesarean sections because they consider it good quality care Mothers accept that caesarean is “just another way of giving birth” Women's power to acquire a medicalised birth continues to have an effect on birth outcome Brazilian doctors frequently use their medical authority to persuade women to "choose" delivery by caesarean section Behague et al, 2002 Potter et al, 2001

23. Government initiatives to reduce caesarean births Galba de Araujo Award for “humanized hospitals” of SUS Sponsors expansion of nurse- midwifery education Incorporation of doula care (labour and birth companions) Creation of Centres for Normal Births (Birth centres) Pact for the Reduction of Caesareans – limits to 25% Reduces payment of caesarean births in relation to normal birth

24. Humanization of care in Brazil Recognition of care in childbirth as a “dehumanizing” event “Humanization” of care often means: –implementation of EBM –respect for womens rights (sexual and reproductive), and universal access to available technology –respectful treatment from providers –availability of pain relief and prevention of iatrogenic pain –multiprofessional care

25. Policy implications Socio-spatial inequalities in the adequacy of Ministry of Health data systems on live births (SINASC) and deaths (SIM) for estimating mortality merits attention Policy makers should give special attention to the needs of black/mixed race women during antenatal and delivery care Priorities to improve programmes on education about sexual and reproductive health, to extend availability of effective family planning and safe abortion care, and to improve the practice of evidence- based obstetric care

26. Challenges and opportunities Unique opportunity to set framework for maternity care Endorse pregnancy & childbirth as normal life events Recommend tailored care packages based on need –Community focussed, nurse/midwife managed care for healthy women –Obstetric care for complex cases Focus on implementation not policy Stakeholder engagement Provide evidence relating to practitioners' performance compared with that of their peers

27. Thank you!