Place of birth and impact on maternal and neonatal outcomes: analysis of data from the 'Born in Brazil' Survey

Abstract

Background: The organisation of maternity services has an important role on outcomes of care provided to women giving birth and their infants, with evidence that some outcomes are associated with the model of care provided. Despite an increase in institutionalized care at childbirth in recent decades, from 80% in 1981 to 98% in 2007, the quality of care still is a challenge in Brazil. According to the World Health Organization, Brazil is the fourth slowest country when achieving MDG 5 (reduction in maternal mortality) by 2015, which is partly explained by high caesarean section rates performed with no clinical reasons. The organization and model of care (also the practice culture) received can also influence maternal and perinatal outcomes. However, research to date on models of care and organisation of maternity hospitals in Brazil is limited to studies with a small sample size. The "Born in Brazil" Survey, coordinated by FIOCRUZ, a Brazilian Research Institute, is the first national survey of maternal and perinatal which has investigated the impact of maternity care on a representative sample of Brazilian women for the five macroregions of the country. It included collation of detailed data on organisational aspects and maternity care provided to women and a range of maternal and neonatal outcomes. We decided to investigate the Southeast region of Brazil as it has the highest coverage of health insurance in Brazil, 39%, and includes 40% of the total population of the country.Aim: To assess the extent to which the structure, organization and models of care of maternity hospitals in the Southeast Region of Brazil impact on maternal and neonatal outcomes. Methods: A cross-sectional study will be undertaken with a secondary analysis of data from the National Survey "Born in Brazil," coordinated by the Oswaldo Cruz Foundation (Fiocruz), as part of post-doctoral fellowship in the Florence Nightingale Faculty of Nursing and Midwifery in London, England, under the supervision of Professor Debra Bick. The period planned for these activities is from 1st July 2015 to 30 June 2016 (12 months). Data were collected from February 2011 to October 2012, in 89 hospitals, through interviews and search on maternal records of the 10,126 women who participated in the Southeastern Region of Brazil and interviews with the managers of the hospitals. In the statistical analysis, descriptive analysis will include data consistency checking, corrections and the calculation of means, medians and standard deviations for the numerical variables. The description of the categorical variables involves the description of proportions between categories. In the next step, the variable type of hospital will be built with the use of variables related to location, source of funding, model of care, human resources, equipment and organisational aspects of the hospital facilities. To build this variable, we will use the cluster analysis, with the classification of the hospitals by a similarity criteria (Hair et al., 2005). Univariate and multiple analysis will be used to examine the association between exposure variable (type of hospital) and primary and secondary endpoints. Binary logistic regression will be used in the multivariate analysis to estimate the crude and adjusted odds ratio for maternal and perinatal outcomes, with a 95% confidence interval, considering the type of hospital as an exposure variable. This analysis will include socio-demographic, clinical and obstetric factors as adjustment variables. All statistical analysis will be undertaken using the statistical program IBM SPSS version 22. This research was approved by the Ethics Committee for Research of the ENSP (protocol number 92/10). All directors of the hospitals units and all women signed the informed authorization form.