RESUMO
A cesárea é uma intervenção que salva vidas, mas seu uso sem indicação obstétrica está relacionado a complicações a curto e longo prazo. O Brasil é conhecido internacionalmente por suas altas taxas desse procedimento, ainda mais elevadas no setor privado. Para reverter esse problema, a Agência Nacional de Saúde Suplementar lançou o Programa Parto Adequado, e este estudo tem como objetivo analisar a sua efetividade. Neste estudo retrospectivo, incluímos a totalidade de nascimentos em maternidades privadas ocorridos entre 2014 e 2019 para comparar a evolução das taxas de cesárea de hospitais participantes e não participantes do projeto, a partir das bases de dados públicas do Sistema de Informações sobre Nascidos Vivos (SINASC). Foram analisados 277.747 nascimentos, sendo observada uma redução na taxa de cesárea nos dois grupos, mais acentuada entre os hospitais participantes. Não foi observada redução da chance de cesárea antes do lançamento do programa (2014), mas notou-se uma tendência constante de redução após 2014, até se tornar significativa em 2018. Esse resultado ocorreu de forma independente das variáveis demográficas, maternas e dos grupos de Robson. A taxa de cesárea dos hospitais participantes do programa foi de 83,8% para 72,3% (intervalo de 95% de confiança - IC95%: 71,7-72,9). Apesar da redução, permanece bem acima das taxas esperadas de acordo com a ferramenta c-model, que seria de 45,2% (IC95%: 33,9-56,5) para essa população. Os resultados deste estudo mostraram que uma política pública bem conduzida com o envolvimento de instituições privadas pode mudar o cenário da atenção ao parto e ao nascimento, promovendo a redução das altas taxas de cesárea.
Cesarean section is a life-saving intervention, but its use without obstetric indication leads to short- and long-term complications. Brazil is internationally known for its high cesarean rates, especially in the private sector. To reverse this problem, the Brazilian National Regulatory for Private Health Insurance and Plans launched the Adequate Childbirth Program, and this retrospective study aims to analyze its effectiveness. We included the total of births performed in private maternity hospitals between 2014 and 2019 registered on the Brazilian Information System on Live Births (SINASC) database to compare the evolution of cesarean section rates in hospitals participating and not participating in the project. A total of 277,747 births were analyzed, showing a reduction in the cesarean section rate in both groups but more pronounced among the participant institutions. No reduction in cesarean performance was observed before the program launch (2014), but there was a constant downward trend after 2014, until it became significant in 2018. This result occurred independently of demographic, maternal, and Robson group variables. The cesarean section rate of hospitals participating in the program went from 83.8% to 72.3% (95% confidence interval - 95%CI: 71.7-72.9). Despite the reduction, it remains well above the expected rates according to the c-model tool, which would be 45.2% (95%CI: 33.9-56.5) for this population. Results showed that a well-conducted public policy together with private institutions can change the scenario of labor and birth care, reducing high cesarean section rates.
La cesárea es una intervención que salva vidas, pero su uso sin indicación obstétrica está relacionado con complicaciones a corto y largo plazo. Brasil es conocido internacionalmente por sus elevadas tasas de este procedimiento, que son aún mayores en el sector privado. Para revertir este problema, la Agencia Nacional de Salud Complementaria lanzó el Programa Parto Adecuado, y este estudio tiene como objetivo analizar su efectividad. En este estudio retrospectivo, incluimos todos los nacimientos en maternidades privadas que ocurrieron entre el 2014 y el 2019 para comparar la evolución de las tasas de cesáreas en hospitales participantes y no participantes del proyecto, con base en las bases de datos públicas del Sistema de Informacines de Nacidos Vivos (SINASC). Se analizaron 277.747 nacimientos, y se observó una reducción en la tasa de cesáreas en ambos grupos, más pronunciada entre las participantes. No se observó ninguna reducción en las posibilidades de cesárea antes del lanzamiento del programa (2014), pero se observó una tendencia constante de reducción después del 2014, hasta que se volvió significativa en el 2018. Este resultado se produjo de forma independiente de las variables demográficas, maternas y de los grupos de Robson. La tasa de cesáreas de los hospitales participantes en el programa pasó del 83,8% al 72,3% (intervalo de 95% de confianza - IC95%: 71,7-72,9). A pesar de la reducción, se mantiene muy por encima de las tasas esperadas según la herramienta del c-model, que sería del 45,2% (IC95%: 33,9-56,5) para esta población. Los resultados de este estudio mostraron que una política pública bien conducida con la participación de instituciones privadas puede cambiar el escenario de la atención al parto y al nacimiento, promoviendo la reducción de las elevadas tasas de cesárea.
RESUMO
BACKGROUND: Increasing cesarean section (CS) rates are a global concern because they are related to higher maternal and neonatal complication rates and do not provide positive childbirth experiences. In 2019, Brazil ranked second globally, given its overall CS rate of 57%. According to the World Health Organization (WHO), populational CS rates of 10-15% are associated with decreased maternal, neonatal, and infant mortality rates. This study aimed to investigate whether multidisciplinary care following evidence-based protocols associated with a high motivation of both women and professionals for a vaginal birth leads to less overuse of CS in a Brazilian private practice (PP). METHODS: This cross-sectional study evaluated CS rates by Robson group for women who sought vaginal birth in a private practice in Brazil comparing with Swedish data. Collaborative care of midwives and obstetricians who adopted evidence-based guidelines was offered. CS rates, overall and by Robson group, contribution of each Robson group to the overall CS rate, clinical and nonclinical interventions, vaginal birth, pre-labor CS, and intrapartum CS proportions were estimated. The expected CS rate was calculated using the World Health Organization C-model tool. The analysis used Microsoft Excel and R Studio (version 1.2.1335. 2009-2019). RESULTS: The PP overall CS rate was 15.1% (95%CI, 13.4-17.1%) versus the 19.8% (95%CI, 14.8-24.7%) rate expected by the WHO C-model tool. The population included 43.7% women in Robson Group 1 (nulliparous, single, cephalic, at term, spontaneous labor), 11.4% in Group 2 (nulliparous, single, cephalic, at term, induced labor or CS before labor), and 14.9% in Group 5 (multiparous women with previous CS), the greatest contributors to higher CS rates (75.4% of them). The Swedish overall CS rate was 17.9% (95%CI, 17.6-18.1%) in a population of 27% women in Robson Group 1, 10.7% in Group 2, and 9.2% in Group 5. CONCLUSIONS: Multidisciplinary care following evidence-based protocols, associated with high motivation of both women and professionals for vaginal birth, may lead to a significant and safe reduction of CS rates even in contexts such as Brazil, with high medicalization of obstetric care and excess CS.
Assuntos
Cesárea , Parto , Gravidez , Lactente , Recém-Nascido , Feminino , Humanos , Masculino , Brasil/epidemiologia , Estudos Transversais , Prática PrivadaRESUMO
BACKGROUND: Levator ani avulsion is defined as the interruption of the insertion of this muscle on the pubic bone. It is currently recognized as an important triggering factor for genital prolapse. Although surgical interventions are available, there are no conservative strategies for this muscular injury. DESCRIPTION: A 40-year-old female presented with urinary incontinence and levator ani avulsion, which was confirmed on transperineal three-dimensional ultrasound (3DUS). Upon referral for physiotherapy, she presented with incorrect and weak contractions of the pelvic floor. Her treatment comprised 13 sessions of intravaginal electrotherapy followed by pelvic floor muscle (PFM) exercises in different positions. At the end of the sessions, another transperineal 3DUS was performed, and it revealed rapprochement of the levator ani muscle. The avulsed levator ani muscle can be reinserted using physiotherapeutic interventions, especially a combination of electrotherapy and PFM exercises. CONCLUSION: Transperineal 3DUS is an important approach for the follow-up of conservative treatment until full recovery.