Childbirth care in Brazil: a critical situation has not yet been overcome. 1999-2013

a time-series ecological study, using data from Ministry of Health, Brazilian Institute of Geography and Statistics, and Interagency Network of Information for Health. 18 indicators were analyzed related to childbirth and mortality.

Results:

there was a reduction in rates of fertility, natality and the total number of births, with increased cesarean surgeries. Growth of prenatal consultation, intensive care beds and reduction of beds in obstetrics sector. The significant growth of caesarean deliveries, prenatal consultation coverage and concentration of births in hospitals occurred simultaneously with the growth: of preventable child deaths by adequate attention, management causes and appropriate delivery, prematurity; low weight; Down's syndrome; and the persistence of maternal deaths due to direct obstetric causes.

Conclusions:

persists hegemonic technocratic model of childbirth care without considering the observed changes in the profile of mothers and births, with slow reduction of perinatal and neonatal deaths and maintenance of high maternal mortality demonstrating that the critical situation of delivery care model in Brazil has not, yet, been overcome.

Key words:
Delivery of health care; Maternal and child health; Health status indicators

Year	Populatio	Women of fertile age
		N	^* * Proportion in relation to total population/year. %	Birth rate	Fecundity rate
1999	163 947 436	53 663 899	32.73	21.86	2.33
2000	169 799 170	55 525 740	32.70	20.32	2.29
2001	172 385 776	56 386 231	32.71	19.49	2.20
2002	174 632 932	57 134 205	32.72	18.73	2.12
2003	176 876 251	57 880 352	32.72	18.23	2.07
2004	179 108 134	58 623 425	32.73	17.88	2.03
2005	184 184 074	60 313 460	32.75	17.47	1.99
2006	186 770 613	61 174 428	32.75	17.00	1.94
2007	189 335 191	61 095 856	32.27	16.60	1.90
2008	189 612 814	60 974 994	32.16	16.26	1.86
2009	191 481 045	61 417 666	32.08	15.98	1.84
2010	190 755 799	62 110 637	32.56	15.78	1.82
2011	192 379 287	62 649 609	32.57	15.63	1.78
2012	193 976 530	63 177 694	32.57	-	-
2013	201 032 714	63 470 428	31.57	-	-
Proportional variation	22.62	18.27	-3.54	-28.50	-23.61
B	-	-	-	-0.47	-0.05
p	-	-	-	<0.001	<0.001

Year	Normal births	^* * Proportion in relation to total births occurring in the SUS network /year; % Caesarian	Pregnant women with 7+ prenatal consults
Year	Normal births		N	^ Proportion in relation to total live births /year. %
1999	1 992 568	24.89	1 510 040	46.37
2000	1 906 320	23.92	1 401 585	43.71
2001	1 801 406	25.06	1 419 062	45.55
2002	1 753 659	25.18	1 463 469	47.84
2003	1 664 680	26.39	1 516 553	49.92
2004	1 626 092	27.53	1 573 185	51.98
2005	1 596 483	28.61	1 601 391	52.76
2006	1 498 323	30.14	1 606 185	54.54
2007	1 496 045	32.23	1 613 980	55.82
2008	1 334 663	33.24	1 672 280	56.98
2009	1 292 222	34.77	1 667 192	57.86
2010	1 237 083	36.74	1 733 492	60.57
2011	1 199 623	38.40	1 785 198	61.28
2012	1 132 041	40.18	1 792 629	61.69
2013	1 063 764	40.74	1 812 681	62.42
Proportional	-46.61	63.68	20.04	34.61
variation
B	-64.369	1.29	28.708	1.38
p	<0.001	<0.001	<0.001	<0.001

Year	Live Births	Age group				First child/Age group
		Adolescents	20 - 39 years	40 - 49 years	50 + years	Up to 15 years		40 + years
		^* * Proportion in relation to total births / year; %	^* * Proportion in relation to total births / year; %	^* * Proportion in relation to total births / year; %	^* * Proportion in relation to total births / year; %	n	^ Proportion in relation to total births in age group / year. %	n	^ Proportion in relation to total births in age group / year. %
1999	3 256 433	23.16	73.65	1.77	0.00	53 109	62.12	4 555	7.88
2000	3 206 761	23.40	74.13	1.88	0.00	55 730	62.91	4 952	8.19
2001	3 115 474	23.27	74.34	1.92	0.00	55 736	63.34	5 549	9.27
2002	3 059 402	22.65	75.15	1.95	0.00	52 647	62.48	5 521	9.25
2003	3 038 251	22.15	75.68	1.98	0.00	53 297	63.26	5 883	9.78
2004	3 026 548	21.85	75.92	2.06	0.00	54 169	66.48	6 704	10.76
2005	3 035 096	21.78	76.01	2.05	0.00	53 740	66.57	6 748	10.84
2006	2 944 928	21.49	76.37	2.12	0.01	57 946	72.03	7 998	12.75
2007	2 891 328	21.11	76.71	2.16	0.01	59 101	73.46	8 129	12.98
2008	2 934 828	20.42	77.40	2.17	0.01	62 791	76.42	9 021	14.10
2009	2 881 581	19.95	77.83	2.21	0.01	63 368	78.37	9 394	14.70
2010	2 861 868	19.31	78.44	2.24	0.01	62 341	79.34	9 707	15.09
2011	2 913 160	19.25	78.46	2.27	0.01	61 754	77.62	10 213	15.33
2012	2 905 789	19.28	78.37	2.34	0.01	61 779	77.50	10 794	15.79
2013	2 904 027	19.28	78.32	2.39	0.01	62 775	78.89	11 068	15.89
Proportional	-10.8	-16.75	-6.34	35.03	175.00	18.20	27.05	142.99	101.27
variation
B	-24.541	-0.34	0.36	0.04	0.0007	806	1.49	490	0.64
p	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

Variables					1999 - 2013
	1999		2013		Proportional	Trend
	n	^* * Proportion in relation to total number of births in age group /year. %	n	^* * Proportion in relation to total number of births in age group /year. %	Variation	B	p
Down syndrome
10 -19 years	27	0.00	66	0.01	144.44	0,7	0,53
20 -39 years	251	0.01	530	0.02	111.16	12	0,06
40 + years	67	0.17	217	0.31	223.88	7	0,01
Low birth weight
10 -19 years	66 201	8.78	53 159	9.49	-19.70	-1.198	<0,001
20 -39 years	170 807	7.12	185 570	8.16	8.64	1.092	<0,001
40 + years	6 318	10.93	8 393	12.05	32.84	127	<0,001
Premature birth
10 -19 years	32 841	4.35	74 396	13.29	126.53	1480	0,03
20 -39 years	84 034	3.50	248 504	10.93	195.72	8184	<0,001
40 + years	2 618	4.53	10 548	15.14	302.90	412	<0,001

Year	^* * Por 100.000 Nascidos Vivos; Maternal Death Rate	^ Por 1.000 Nascidos Vivos; RN= recém-nascido. Neonatal Death Coefficient	^ Por 1.000 Nascidos Vivos; RN= recém-nascido. Perinatal Death Coefficient	Avoidable infant death			Total	Unavoidable infant deaths	Maternal deaths		Total
				Adequate care during gestation and childbirth	Adequate care of fetus or newborn	Health promotion actions			Direct Obstetric Causes	Indirect Obstetric Causes
				%	%	%			%	%
1999	92.26	13.49	22.95	40.42	31.31	13.98	48 541	20 804	70.99	26.02	1 868
2000	73.30	13.60	22.71	41.01	32.11	12.93	46 490	21 709	75.19	21.23	1 677
2001	70.91	12.92	22.31	41.28	32.98	12.57	42 760	19 183	76.60	19.78	1 577
2002	75.87	12.64	21.75	43.29	31.63	12.44	40 959	17 957	73.41	23.75	1 655
2003	72.99	12.27	21.41	44.26	29.75	12.78	39 679	17 861	74.57	21.76	1 553
2004	76.09	11.86	20.80	45.82	29.78	11.67	37 290	16 893	70.93	24.44	1 641
2005	74.68	11.33	19.76	46.22	29.32	11.67	36 193	15 351	73.70	22.72	1 620
2006	77.16	11.07	19.70	50.56	26.64	10.82	34 036	14 296	71.78	25.75	1 623
2007	76.99	10.66	19.02	51.17	27.54	9.73	31 957	13 412	74.03	23.40	1 590
2008	68.73	10.28	18.62	52.08	27.56	9.21	30 755	13 345	71.15	25.34	1 681
2009	72.00	10.14	18.67	51.82	28.28	8.65	29 722	12 920	63.25	34.67	1 872
2010	68.20	9.67	18.06	54.15	27.00	8.30	27 565	12 305	66.72	30.66	1 719
2011	64.75	9.45	17.85	53.46	27.59	7.77	27 469	12 247	66.46	29.88	1 610
2012	-	9.33	17.97	53.20	27.63	8.04	26 899	12 224	65.57	31.27	1 583
2011	-	9.20	17.79	53.76	26.00	8.48	26 930	12 036	68.03	2853	1 686
Proportional variation	-29.82	-31.80	-22.48	33.00	-16.96	-39.34	-44.52	-42.15	-4.17	9.65	-9.74
Β	-1.09	-0.34	-0.41	1.11	-0.43	-0.46	-1593	-712	-0.68	0.70	-1.46
p	0.02	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	0.80

Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br

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[TFN1] ^*
Proportion in relation to total population/year.

[TFN2] Source: Brazilian Institute of Geography and Statistics (IBGE); Interagency Health Information Network (RIPSA).