8
Freitas M, Segre CAM, Siqueira AAF
ORIGINAL ARTICLE
Obstetric care in Brazil: An analysis of the situation Assistência obstétrica no Brasil: Uma análise de situação Marcia de Freitas1, Conceição Aparecida de Mattos Segre2, Arnaldo Augusto Franco de Siqueira3
ABSTRACT Objective: To evaluate the situation of obstetric care in Brazil. Methods: Analysis of data from the Ministry of Health: Information System on Mortality; Information System on Live Births; Information System on Ambulatory Care of the Brazilian Unified Health System; Information System on Hospital Care of the Brazilian Unified Health System. Others source of data: the Brazilian Institute of Geography and Statistics. Results: Maternal mortality rate was 50.83/100000 live births in Brazil. Prenatal care in the Northern and Northeastern regions of the country presented the lowest number of prenatal care appointments (27% of pregnant women with less than 3 appointments). Premature labor was the main diagnosis for hospital admission before delivery. The number of obstetric beds exceeds the population demand throughout the country. The main causes of maternal deaths were direct causes. Conclusions: Maternal mortality rate in Brazil is high and the main causes of deaths are preventable and related to medical and non-medical factors. Keywords: Maternal health services; High risk pregnancy; Pregnancy complications; Maternal mortality
RESUMO Objetivo: Elaborar um diagnóstico de situação da assistência obstétrica no Brasil. Métodos: Consultas aos sistemas de informação de abrangência nacional operados pelo Ministério da Saúde: Sistema de Informação sobre Mortalidade; Sistema de Informações sobre Nascidos Vivos; Sistema de Informações Ambulatoriais do Sistema Único de Saúde; Sistema de Informações Hospitalares do Sistema Único de Saúde. Outras fontes consultadas: Instituto Brasileiro de Geografia e Estatística. Resultados: A razão de mortalidade materna encontrada foi de 50,83/100.000 nascidos vivos no Brasil. As regiões Norte e Nordeste apresentaram os menores números de consulta pré-natal (27% das gestantes com menos de 3 consultas). O procedimento “trabalho de parto prematuro” do Grupo de Obstetrícia, como causa de internação antes do parto, liderou a lista de procedimentos em todas as regiões brasileiras, tanto nas capitais como no interior. Ao compararmos a necessidade de leitos de obstetrícia na população com a capacidade instalada, pode-se verificar que essa última é superior em todas as regiões do Brasil, tanto nas capitais como no interior. As principais causas de morte materna
foram diretas. Conclusões: A taxa de mortalidade materna no Brasil é alta e as principais causas de mortes maternas são evitáveis, relacionadas a fatores médicos e não-médicos. Descritores: Serviços de saúde materna; Gravidez de alto risco; Complicações na gravidez; Mortalidade materna
INTRODUCTION The Federal Constitution of 1988, in Title II, Chapter II on Social Rights(1), defines health as a right of all citizens and an obligation of the State, with the guarantee of economical and social policies aimed to reduce the risks of diseases and other health conditions, as well as to provide universal and equitable access to actions and services for promotion, protection and recovery of health in a Unified Health System (SUS, Brazilian acronym), of public, federative, decentralized and participatory nature and offering full care. Brazil has signed several international agreements that are directly or indirectly related to maternity issues and establish legal obligations to the country. Acknowledging woman’s rights and reproduction rights is basically the idea of human reproduction as a social function that should be protected by the society(2-3). The World Health Organization (WHO), in the 10th Review of the International Classification of Diseases (ICD-10), defines maternal death as the “death of women during pregnancy or within a period of 42 days after the end of pregnancy due to any cause related to or impaired by pregnancy or by measures taken related to it, but not due to accidental or incidental causes”(4). In Latin America, approximately 40 thousand women die every year due to the complications of pregnancy, delivery and puerperium. If all these women could receive care similar to that provided in developed countries, 98% of deaths could be prevented, as per the report of the Congressional Investigation Committee about Maternal Mortality(5).
Study carried out for the Curso de Especialização em Perinatologia of the Instituto Israelita de Ensino e Pesquisa – IIEP, São Paulo (SP), Brazil. Sources: Ministério da Saúde e Instituto Brasileiro de Geografia e Estatística – IBGE. 1
Ph.D. Student at the Faculdade de Saúde Pública da Universidade de São Paulo - USP; Neonatologist, Instituto Israelita de Ensino e Pesquisa Albert Einstein - IIEP, São Paulo (SP), Brazil.
2
Post doctorate degree in Neonatal Pediatrics from the Universidade Federal de São Paulo - UNIFESP; Lecturer of the Specialization course in Perinatology of the Instituto Israelita de Ensino e Pesquisa Albert Einstein - IIEP, São Paulo (SP), Brazil.
3
Lecturer at the Department of Maternal-Infant Health, Faculdade de Saúde Pública da Universidade de São Paulo - USP, São Paulo (SP), Brazil. Corresponding author: Marcia de Freitas – Av. Albert Einstein, 627 - Morumbi - CEP 05651-901 - São Paulo (SP), Brazil - e-mail:
[email protected] Received on December 1, 2005 - Accepted on March 1, 2006
einstein. 2006; 4(1):8-15
Obstetric care in Brazil: An analysis of the situation
As late as 1998, the Resolution number 256/97 of the Brazilian Ministry of Health, homologated on February 12, 1998, defined maternal death as an event of Mandatory Notification for Epidemiological Surveillance(6). A high number of maternal deaths represents a major challenge both to health services and to the society. Poor maternal health and nutritional status, adolescent pregnancy, lack of information and access to prenatal care, delivery and post-delivery period of poor quality, all change a special moment in a woman’s life to hours of suffering and despair. Analyzing such deaths, a high percentage could have been prevented with efficient medical care during pregnancy and delivery, when morbid conditions could be earlier detected or treated or managed before or during delivery. The Brazilian legislation recognizes the basic rights to maternity and to the newborn(7). However, the problem arises when the implementation of effective measures that could guarantee the social rights stated in these legal texts be assessed; these rights range from appropriate nutrition to efficient medical and hospital care. In face of higher vulnerability of pregnant women to become sick and die, and because health in this population group is a clear reflection of the socioeconomic and care conditions they are subject to, it is necessary to consider such data in order to raise discussions that may eventually lead to better obstetric care in the country.
OBJECTIVE To elaborate a diagnosis of the obstetric care in Brazil according to some selected variables: maternal mortality rate, prenatal care, adolescent pregnancy, types of delivery, availability of obstetric beds and causes of maternal mortality.
METHODS Analysis of national data from the Ministry of Health was performed, as described in chart 1. The Brazilian Institute of Geography and Statistics was another source consulted.
9
The data presented are related to maternal mortality rates, prenatal care, adolescent pregnancy, types of delivery, causes of maternal death (data obtained in Brazil), diagnosis at admission before delivery and distribution of hospital beds (data from SUS only).
RESULTS Maternal mortality rate Table 1 shows the data of maternal mortality rates in Brazil and its distribution in the different regions of the country; the numbers reported for the Northern and Northeastern regions are above the national values, and the lowest rates are reported in the South region(8). Prenatal care Table 2 shows the number of prenatal appointments performed during pregnancy in all Brazilian regions(9). This table shows that the Northern and Northeastern regions present the lowest numbers of prenatal appointments with approximately 20.2% of pregnant women presenting fewer than 3 appointments; this percentage decreases to approximately 8% in the Southeastern and Southern regions. Adolescent pregnancy Table 3 shows the percentage of adolescent pregnancy in Brazil and the distribution in Brazilian regions; the Northern and Northeastern regions present the highest percentage of live births at the age range 10-19 years. The lowest percentage was seen in the Southeastern and Southern regions(9). Type of delivery Table 4 shows the percentage number of cesarean sections in the total number of deliveries in SUS and the ratio between deliveries at SUS Hospitals and the total number of deliveries in Brazil(10).
Chart 1. Information systems from Ministério da Saúde, Brazil Systems Information System on Mortality
Abbreviation SIM
Information system on Live Births
SINASC
Information System on Ambulatory Care of the SUS
SIA/SUS
Information System on Hospital Care of the SUS
Agency
Type of information
CENEPI
Related to the epidemiological profile
DATASUS
Related to care and administration
SIH/SUS
einstein. 2006; 4(1):8-15
10
Freitas M, Segre CAM, Siqueira AAF
Bed availability Table 5 shows the number of existing obstetric beds compared with the bed demand by the population(11). When comparing the necessity of obstetric beds for the population with the number of existing beds we noticed that the latter is higher in all regions in Brazil (both in capital cities and countryside).
As regards to the number of deliveries reported by the Birth Information System (SINASC) reporting data of the whole country, it is reported that approximately 74.4% of deliveries in the Northeastern and Northern regions occurred at SUS Hospitals (2261513/3038251).
Causes of hospital admission before delivery The main causes of hospital admission of pregnant women at SUS Hospitals in the different Brazilian regions point to a high number due to premature labor – 75.3% (42373/56277), observed both in the countryside and capital cities. Hemorrhages during pregnancy account for 12.1% (6794/56277) and premature rupture of membranes for 6.2% (3510/56277)(10).
Causes of maternal mortality Figure 1 shows the main causes of maternal mortality in the world (WHO, 1997) that show no differences in Brazil, demonstrating the role of direct causes of mortality(12).
Table 1. Distribution of maternal mortality rate/100,000 live births in Brazil and Brazilian regions - 1998 Brazil and regions
Material death
North Northeast Southeast South Central-western Brazil
Live Births
Maternal mortality rate
152 491 915 350 131
266332 847686 1305587 459039 238903
63.67 57.47 44.94 35.11 39.56
2039
3144547
50.83
Source: SIM/SINAC/CENEPI/FNS. Manual de Comitê de Mortalidade Materna do Ministério da Saúde(8).
Table 2. Distribution of number of prenatal care visits by Brazilian regions, 2003 Regions
None
1 to 3 visits
North Northeast Southeast South Central-western
20140 45964 19173 6018 4019
55379 129161 71914 26130 17798
Brazil
95314
300382
4 to 6 visits
7 ou more visits
Unknown
Total
143874 401588 327136 111927 72155
87177 327259 730658 243515 127944
4765 26173 32250 2085 4049
311335 930145 1181131 389675 225965
1056680
1516553
69322
3038251
(9)
Source: MS/SVS/DASIS. Manual System on Live Births – SINASC .
Table 3. Distribution of live births by Brazilian region, according to percentage of adolescent mothers (10 to 19 years) in 2003 Regions
Number of live births of Mothers aged 10-19 yaers
Total number of live births in the regions
Percentage (%) of live births of adolescent mpothers
North Northeast Southeast South Central-western
90706 236359 16178 77197 52605
311335 930145 1181131 389675 225965
29.1 25.4 19.3 19.8 23.3
TOTAL
673045
3038251
22.2
(10)
Source: MS/SVS/DASIS. Information System on Live Births – SINASC .
einstein. 2006; 4(1):8-15
Obstetric care in Brazil: An analysis of the situation
11
Table 4. Distribution of number of deliveries at SUS hospitals, by type of procedure performed in 2003 Regions
Vaginal deliveries Cesarean sections
Total deliveries SUS
Cesarean section delivery rate SUS
Total deliveries Brazil
% SUS / Brazil
North
189073
57476
246549
23.3
311335
79.2
Northeast
620828
172439
793267
21.7
930145
58.3
Southeast
543976
240870
784486
30.7
1181131
66.4
South
193093
79316
272409
29.1
389675
69.9
Central-western 117710
46732
164442
28.4
225965
72.8
596833
2261513
26.4
3038251
74.4
Brazil
1664680
Source: Minstry of Heath. Information System on Hospital Care of the SUS (SIH/SUS)(10).
Table 5. Distribution of obstetric beds by Ministry parameters and beds paid Brazil and regions
Location
North
Capital cities
Population
Obstetric beds(1)
Beds paid by the SUS
3895400
1109
1237
12900704
3673
4789
Capital cities
10162346
2893
3695
Countryside
37579365
10699
17040
47741711
13592
20735
Capital cities
18822986
5359
4708
Countryside
53589425
15257
16147
72412411
20616
20855
Capital cities
3290220
937
1161
Countryside
21817396
6211
7544
25107616
7148
8705
Capital cities
4291120
1222
1427
Countryside
7345608
2091
4299
11636728
3313
5726
Countryside Total North Northeast
Total Northeast Southeast
Total Southeast South
Total South Central-western
Total Central-western Total regions
Capital cities
40462072
11520
12228
Total regions
Countryside
129337098
36822
48582
169799170
48342
60810
Total Brazil
Source: DATASUS/MS(11). (1) Ideal necessity of obstetricc beds = 9.49% of total beds (PT GM/MS 1101 of June 12, 2002).
einstein. 2006; 4(1):8-15
12
Freitas M, Segre CAM, Siqueira AAF
Source: WHO (12).
Figure 1. Main causes of maternal death
DISCUSSION Maternal morbidity should not be a cause of death among women at childbearing age; however, it is one of the leading positions. According to a study performed by Laurenti et al., the direct causes of maternal mortality are prevalent in the whole country and the main cause is related to the hypertensive disorders(13). Similar data are reported in the current study. In Brazil, however, maternal mortality rates do not show the real dimension of the problem. This is mainly due to the still low report of maternal death in the certificate of death. An idea of the underreported cases can be formed based on the estimates of the IBGE, in which 16.55% of deaths were not notified in the system(14). Nevertheless, it is necessary to point out that the researches based solely on certificates of death substantially underestimate the number of maternal deaths even in developed countries(15). Official data for Brazilian capital cities - admittedly underestimated – are alarming even if they were considered as absolutely true. In 2001, maternal mortality rates in Brazilian capital cities were classified as high according to the WHO criteria(11), whereas in developed countries this rate is low, i.e., it ranges from 6 to 20 deaths per 100000 live births – at least 2.5 to 8.0 times lower than the average in Brazil(16). Therefore, the current analysis provides the details of some variables considered important to determine maternal mortality. Prenatal care of good quality and a minimum number of five obstetric appointments are factors associated with good perinatal results (17) . A randomized, multicenter trial involving two groups of pregnant women who attended prenatal care clinics in several countries – one group with 5 appointments and the other group with 8 appointments – analyzed the minimum number of appointments in comparison with einstein. 2006; 4(1):8-15
the perinatal outcomes. The authors verified that the rates were similar in both groups in terms of low birth weight, post-partum maternal anemia and urinary tract infection. The rates of eclampsia and preeclampsia were slightly higher in the group with 5 obstetric appointments but the difference was not statistically significant and the adjustment for various confounding factors did not change the results(17). A study performed at the Latin American Center of Perinatology and Human Development(18) analyzed 837232 single births with the purpose of verifying the risk factors associated with fetal death; this study identified the absence of prenatal care as the main risk factor. Nevertheless, the evaluation of the association between the number of prenatal appointments and prematurity deserves special attention since the number of obstetric appointments may be low because the child may have been born prematurely; therefore, this low number would be a consequence rather than a cause of premature birth or fetal death(19). The Humanization Program for Prenatal Care and Birth (20) , requires a guarantee of 6 (six) prenatal appointments and 1 (one) appointment during the puerperium. In 2002, the Program showed that out of 3283589 pregnant women in the country, 2734052 were covered by it, accounting for 83.2%. This percentage is close to the ideally recommended percentage (100.0%); therefore, the coefficients of maternal mortality and perinatal mortality should also be close to those in developed countries, but that is not the finding in the analysis of maternal mortality in Brazil. To explain this apparent discrepancy between a satisfactory prenatal network (in quantitative terms) and the high rates of maternal and perinatal mortality it is important to question the quality of medical care rendered. Although there is no recent evaluation of such quality, since 1974 attention has been drawn to this problem, showing that the policies adopted are not always aligned with technical recommendations(21). The current analysis demonstrated that a great number pregnant women in the Northern and Northeastern regions had fewer than three prenatal appointments according to data of the Ministry of Health (9) . Therefore, this is an issue to be addressed by the healthcare authorities in order to reduce maternal mortality. The WHO defines adolescence as the life period between 10 and 19 years(22). The number of pregnant adolescents represents 20 to 25% of the world population, mainly in urban areas of developing countries and thus concentrated in youngsters from
Obstetric care in Brazil: An analysis of the situation
lower socioeconomic classes who have no access to good health, education and work conditions(22). The occurrence of pregnancy in adolescents is seen as a social problem not only in Brazil but in several countries in the world. Pregnant adolescents receive less prenatal care, bear children with poorer health conditions, have very bad health conditions and poor educational and financial results throughout their lives. The risk factors for pregnancy in adolescence include poverty, residence in an urban area, poor parental supervision, low educational expectations and no access to healthcare services(23). According to reports published by the WHO, due to the repercussions on the mother and fetus, pregnancy in adolescents should always be considered a high risk pregnancy(22). The National Survey on Demographics and Health of 1996(24) showed fertility decreased about 30% in all age groups with the exception of adolescence. At this stage of life, at the moment of the survey, 18% of Brazilian adolescents had a child or were pregnant. Data from the Ministry of Health reveal that, in the same year, 40% of abortions were performed in adolescent patients (25). Out of the total number of hospitalizations among adolescents in Brazil, 80.3% were related to pregnancy, delivery and puerperium. According to the 2001 Statistics Directory, (26) from the 3.2 million births recorded in 1999, the highest concentration in terms of maternal age corresponded to the age group 20-24 years (31%); yet, the percentage of mothers aged 10 to 19 years (25.7%) is still very high; there was a slight decrease of this percentage in 2000, as shown in the current study. It is imperative to indicate the main causes of hospitalizations of pregnant women at SUS Hospitals in different Brazilian regions. Emphasis should be given to the increased number of admissions due to premature labor, both in the countryside and capital cities. This cause is followed by hemorrhages during pregnancy and premature rupture of the membranes. These conditions certainly have an important influence on the neonatal morbidity and mortality, such as lowweight births and/or premature births. Although it is well known that the maternal health has a direct repercussion on the fetal development and neonate health, the current work does not intend to analyze these effects; however, since several maternal disorders can cause premature births (main cause of hospital admissions of pregnant women at SUS hospitals), it is worthwhile to analyze, even superficially, some of these effects. Pregnancy increases sensitivity to infections caused by some microorganisms, as well as virulence of some agents. Hormone changes
13
associated with pregnancy can also be predisposing factors to infections because of alterations in the local mucosal barriers. Practically all infections affecting a pregnant woman have some influence on pregnancy and the sexually transmitted diseases can cause ectopic pregnancy and miscarriage, among other complications(27). Premature rupture of membranes occurs in 3 to 18.5% of pregnancies and it may be a cause of maternal infection, premature labor and increased rate of cesarean sections(28). Hypertensive conditions (preeclampsia/eclampsia, transient hypertension, chronic hypertension and eclampsia in addition to chronic hypertension) still represent major risks for maternal mortality(29). The frequency of hypertensive episodes during pregnancy is very high in Brazil and it is related to socioeconomic levels. A study performed in Sao Paulo involving 8277 pregnant women at a hospital serving low income population, the prevalence was 37.1%(29). In the USA, preeclampsia affects 5 to 7% of pregnant women, but it reaches 15% among patients of a low socioeconomic status(29). In the current analysis, the hypertensive disorders were the first cause of maternal mortality. This fact is essentially serious since these deaths could be avoided if the pregnant women were appropriately and timely treated. Nowadays it is estimated that 2 to 3% of pregnant women are diabetic(30). This disorder has numerous influences on pregnancy including a higher rate of hypertensive syndrome, asymptomatic bacteriuria, miscarriages, prematurity, polyhydramnios, increased number of dystocias and intrauterine death (30). All conditions could be diagnosed and treated, or even prevented, during prenatal care. In Brazil, the vast majority of births occurs at SUS Hospitals, and this percentage is above the Brazilian mean in the Northern and Northeastern regions; these hospitals are the main responsible for the high rates of cesarean sections in Brazil. The frequency of cesarean sections in our setting is considered high and persistent. Comparing the Brazilian rate with that of other countries we can conclude that our country probably presents the highest rate in the world, above the rate found in the USA (20.8%), England (19%), Scotland (18%) and Ireland (9%)(31). Data from the Ministry of Health show that the cesarean rates may vary considerably among the different regions in the country, states, cities and type of the healthcare providers. The states of Amapá and Sergipe presented the lowest national rates of cesarean sections as a consequence, among others, of lack of professionals skilled to perform cesarean sections as well as of support service (anesthesia,
einstein. 2006; 4(1):8-15
14
Freitas M, Segre CAM, Siqueira AAF
blood bank, neonatal ICU)(9) and not due to technically recommended aspects. Finally, when we compared the necessity of obstetric beds in the population with the number of existing beds, the latter demonstrated to be higher than the former in all Brazilian regions, both in capital cities and countryside. There are no direct data available to qualitatively analyze obstetric care in our setting. However, the availability of obstetric and neonatal beds is not enough; there must be safe conditions for delivery and for newborns – this purpose could be achieved if the emphasis on risk were adopted by the health system. Therefore, the perinatal assistance should be regionalized and hierarchized within the three levels of care, in which the existence of tertiary care would include an appropriate number of specialists in obstetrics, anesthesiology, pediatrics, and nurses according to the number of patients to be assisted, 24 hours a day, in addition to laboratory, imaging and blood transfusion services as well as medications and equipment. Such centers should offer easy access to the population and should be an element of an integrated and regionalized health system with an emphasis on risk. The investigations of the causes of death among pregnant women revealed a predominance of direct obstetric causes, mainly those associated with hypertensive disorders, miscarriages and complications of labor and delivery. It is evident that all these causes could be preventable. As to abortion, the Brazilian legislation authorizes the legal abortion in very specific situations, such as a pregnancy resulting from a rape or a situation that poses a threat to the mother (32); since the abortion is an illegal and illicit procedure, it is possible to anticipate how unsafe it is and the numerous complications it can lead to; one of the most important complications is infection, which is a frequent cause of maternal death. Safe pregnancy and delivery are constitutional guarantees. In 1907, Rossi-Doria stated “Di parto non si deve morire” (one should not die from delivery)(33). The data presented in the current study should motivate a great effort towards avoiding preventable deaths and trying to establish a synergistic effect of combined actions at all levels of care with no need for high investments.
CONCLUSIONS The rate of maternal mortality in Brazil is high and the main causes are preventable and associated with medical and non-medical factors; this suggests that the low quality of obstetric care is responsible for such einstein. 2006; 4(1):8-15
findings since there is no lack of obstetric beds. Adolescent pregnancy, improvement of prenatal care, and early identification of maternal diseases are aspects that require immediate intervention by healthcare authorities.
REFERENCES 1. Brasil. Constituição 1988. Constituição da República Federativa do Brasil. Título II. Dos Direitos e Garantias Fundamentais. Capítulo II. Dos Direitos sociais; art 6 a art 11. São Paulo: IMESP; 1988. 2. Organização das Nações Unidas. Convenção sobre a eliminação de todas as formas de discriminação contra as mulheres. 1979 [texto na Internet]; [citado 2005,Jul 20]. Disponível em: http://www.direitoshumanos.usp.br/counter/Onu/ mulher/texto/texto_3.html. 3. Organização das Nações Unidas. IV Conferência Mundial sobre a Mulher. Apresentado em Conferência Mundial da Mulher, Beijing, 1995. Rio de Janeiro; Fundação Oswaldo Cruz; 1996. 352p. (Série Conferências Mundiais das Nações Unidas). 4. Organização Mundial de Saúde. CID-10 - Manual de classificação estatística internacional de doenças e problemas relacionados à saúde. 10ª revisão. São Paulo: Edusp; 1997. 5. Brasil. Comissão Parlamentar de Inquérito. Requerimento n. 22 de 1996 da Deputada Fátima Pelaes e outros. Requer a criação de CPI com a finalidade de investigar a incidência da mortalidade materna no Brasil [texto na Internet]; [citado 2004 Set 20]. Disponível em: www.senado.gov.br/web/senador patriciasaboyagomes/publicacoes CPMI_Exploracao_Sexual_Redacao_Final.doc. http: www.portalmedico.org.br/biblioteca_virtual/cpi/CPIMortalidade_ Matern.htm 6. Brasil. Ministério da Saúde. Resolução n. 256/97 homologada em 12/02/ 1998. Resolve definir o Óbito Materno nos estados e municípios como evento de Notificação Compulsória para a Vigilância Epidemiológica. Diário Oficial da República Federativa do Brasil, Brasília (DF); 1997: out 01. 7. Brasil Constituição 1988. Constituição da República Federativa do Brasil. Título VIII. Da Ordem Social. Capítulo II. Da Seguridade Social; art 194 a art 204. São Paulo: IMESP; 1988. 8. Brasil. Ministério da Saúde. Manual dos Comitês de Mortalidade Materna. 2ª ed. Secretaria de Políticas de Saúde. Departamento de Ações Programáticas Estratégicas. Área temática de saúde da Mulher;2001. ISBN Manual dos Comitês de Mortalidade Materna. N. 85-3340065-9. 9. Brasil. Ministério da Saúde. Sistema de Informações sobre Nascidos Vivos (SINASC). 2003.[texto na Internet]; [citado 2005 Set 20]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def 10. Brasil. Ministério da Saúde. Sistema de Informações sobre Nascidos Vivos (SINASC). 2003.[texto na Internet]; [citado 2005 Set 20]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/piuf.def 11. Brasil. Ministério da Saúde. Cadastro Nacional de Estabelecimentos de Saúde. Secretaria de Atenção à Saúde. DATASUS [texto na Internet]; [citado 2005 Set 20]. Disponível em: http://cnes.datasus.gov.br/Mod_Ind_Tipo_Leito.asp 12. Brasil. Ministério da Saúde. Principais causas de mortalidade materna no Brasil.[texto na Internet]; [citado 2005 Mar 12]. Disponível em: http:// tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obtuf.def 13. Laurenti R, Mello Jorge MHP, Gotlieb SLD. A mortalidade materna nas capitais brasileiras: algumas características e estimativas de um fator de ajuste. Rev Bras Epidemiol. 2004;7(4):449-60. 14. Instituto Brasileiro de Geografia e Estatística [sítio na Internet]. São Paulo; IBGE. [citado 2005M 12]. Disponível em: http://www.ibge.gov.br 15. Horon IL. Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. Am J Public Health. 2005;95(3):478-82. 16. Maranhão AGK, Joaquim MMC, Siu C. A mortalidade perinatal e neonatal no Brasil. Tema Radis. 1999;2(1):6-17.
Obstetric care in Brazil: An analysis of the situation
17. Villar J, Baaqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, Farnot U et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001;357(9268):1551-64.
15
25. Brasil. Ministério da Saúde. Fundação Nacional de Saúde. Informe epidemiológico do SUS. 1996;2(supl. 3):13-41.
18. Conde-Agudelo A, Belizan JM, Diaz-Rossello JL. Epidemiology of fetal death in Latin America. Acta Obstet Gynecol Scand. 2000;79(5):371-8.
26. Brasil. Ministério da Saúde . Anuário Estatístico de Saúde no Brasil. [texto na Internet]; [citado 2003, Nov 11]. Disponível em: http://portal.saude.gov.br/ saude/aplicacoes/anuario2002/mort/notas.cfm
19. Rouquayrol MZ, Correia LL, Barbosa LM, Xavier LG, Oliveira JW, Fonseca W. Fatores de risco de natimortalidade em Fortaleza - Brasil: um estudo casocontrole. J Pediatr (Rio J). 1996;72(6):374-8.
27. Porto AGM. Infecções sexualmente transmissíveis.Tendências atuais. In: Segre CAM, editor. Perinatologia. Fundamentos e prática. São Paulo: Sarvier; 2002. p.109-15.
20. Brasil. Ministério da Saúde. Secretaria Executiva. Programa de humanização do parto: humanização no pré-natal e nascimento. Brasília (DF): Ministério da Saúde; 2000.
28. Segre CAM, Lippi UG. Rotura prematura das membranas. In: Segre CAM, editor. Perinatologia. Fundamentos e prática. São Paulo: Sarvier; 2002. p.184-8.
21. Ciari C Jr, Arnoni A, Siqueira AAF, Almeida PA, Giron SG. Avaliação qualitativa dos serviços de assistência pré-natal. Auditoria de prontuários. Rev Saúde Pública. 1974;8(2):203-12. 22. World Health Organization. Young people’s health – a challenge for society. Geneva: WHO;1986. [Technical Report Series, 731]. 23. Viner R, Booy R. Epidemiology of health and illness. BMJ. 2005;330(7488):411-4. 24. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico de 2000 [texto na Internet]; [citado 2003 Dez 10]. Disponivel em http://www.ibge.gov.br
29. Lippi UG. Hipertensão e gravidez. In: Segre CAM, editor. Perinatologia. Fundamentos e prática. São Paulo: Sarvier; 2002. p.262-65. 30. Lippi UG. Diabetes.Aspectos obstétricos. In: Segre CAM, editor. Perinatologia. Fundamentos e prática. São Paulo: Sarvier; 2002. p.70-2. 31. World Health Organization. Care in normal birth: a practical guide, maternal and newborn health/safe motherhood unit. Family and reproductive health. Geneva: World Health Organization. 1996. 32. Código Penal. CP-DL-002.848-1940. Artigos 124 a 128. 33. Rossi-Doria AR. Quali diritti per la donna [texto na Internet]; [citado 2004 Dec 10]. Disponível em: http://www.uniurb.it/scipol/drs.htm
einstein. 2006; 4(1):8-15
