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Conteúdo (article):

Estrutura e práticas dos hospitais de ensino brasileiros: uma avaliação antes e depois do Projeto Apice ON
Structure and practices of Brazilian teaching hospitals: an assessment before and after the Apice ON Project
Estructura y prácticas de los hospitales de enseñanza brasileños: una evaluación antes y después del Proyecto Apice ON

Yluska Myrna Meneses Brandão e Mendes1; Daphne Rattner2
1.Universidade de Brasília.
E-mail: yluskamyrna@yahoo.com.br
ORCID: https://orcid.org/0000-0002-6165-6930
2 Programa de Pós-graduação em Saúde Coletiva da Faculdade de Ciências da Saúde da Universidade de Brasília.
E-mail: daphne.rattner@gmail.com
ORCID: https://orcid.org/0000-0003-1354-9521

RESUMO
Este estudo busca identificar alterações estruturais, de práticas e evolução das cesáreas nos hospitais de ensino do Projeto Aprimoramento e Inovação no Cuidado e Ensino de Obstetrícia e Neonatologia, focado em transformar a assistência obstétrica e neonatal, alinhando práticas de ensino e cuidado com evidências científicas e humanização. Foi realizado estudo exploratório descritivo, com dados secundários do Cadastro Nacional de Estabelecimentos de Saúde, Sistema de Informações Hospitalares e Sistema de Informações sobre Nascidos Vivos referentes ao primeiro semestre de 2017 e segundo semestre de 2019, próximo ao término. Houve evolução em habilitações como Casa da Gestante, Bebê e Puérpera e Centro de Parto Intra-hospitalar; expansão no quadro de enfermeiros obstetras; acréscimo de pontos percentuais em nascimentos assistidos por esses profissionais; aumento em nascimentos nos grupos de baixo risco de cesárea (G1 a G4); redução dos nascimentos antes não classificados; as taxas de cesáreas permaneceram elevadas, principalmente nos grupos destaque para sua redução (G1, G3 e G5). Ressalta-se que transformações culturais e a transição para um cuidado obstétrico humanizado é lenta, reforçando o papel estratégico na política pública formada pela Rede Cegonha.
Palavras-chave: Maternidades; Estrutura dos Serviços; Qualidade da Assistência; Hospitais de ensino; Brasil.

ABSTRACT
This study identifies structural changes, changes in the delivery of care, and trends in the use of cesarean sections in teaching hospitals participating in the Apice ON project, which focuses on transforming the teaching and delivery of obstetric and neonatal care towards a humanized, evidence-based approach. A descriptive and exploratory study was conducted using secondary data from the National Registry of Health Establishments, the Hospital Information System, and the Live Birth Information System from before the project (first half of 2017) and near its completion (second half of 2019). The study found progress in the provision of specialized facilities such as-high-risk maternity homes and in-hospital birth centers; an increase in the number of obstetric nurses; a three-percentage-point increase in births assisted by these professionals; an increase in births in low-risk cesarean groups (Robson groups 1 to 4); and a decrease in unclassified births. Overall, however, cesarean section rates remained high, even in the groups where they should be reduced (Robson groups 1, 3, and 5). It is important to note that cultural transformations and the transition from technocratic to humanized obstetric care takes time, which reinforces the strategic importance of the Stork Network for implementing public policies for more humanized childbirth.
Keywords: Maternity; Service structure; Quality of care; Teaching hospital; Brazil.

INTRODUCTION
Perinatal care in Brazil is based on an obsolete institutionalized model that allows for excessive interventions in the delivery of care and the persistence of inadequate practices. Although this model has undergone considerable changes over the years1, progress still needs to be made in the consolidation of humanized, evidence-based care during pregnancy and childbirth.
Despite this scenario, a few initiatives stand out. Rede Cegonha (the “Stork Network”) was created in 2011 by the Brazilian Ministry of Health and partners to ensure the availability of a care network to cover everything from family planning to infant care until two years of age. The care model associated with this network is centered on the needs of the woman, the infant, and the family2. In 2015, ANS, the agency that regulates and oversees private healthcare in the country, introduced its Parto Adequado (“Adequate Childbirth”) project with the aim of reducing the number of cesarean sections (CSs) being carried out without obstetric or clinical indication in private healthcare facilities3. Finally, there is the Apice ON project (full name: Improvement and Innovation in the Care and Teaching of Obstetrics and Neonatology), introduced in August 2017 by the Ministry of Health in partnership with the Brazilian Company of Hospital Services, the Brazilian Association of University Teaching Hospitals, the Ministry of Education, Fernandes Figueira Institute, and other civil society associations4. The objective of this initiative is to improve the training, management, and delivery of care for childbirth in teaching hospitals, where the training given often reproduces interventionist approaches, rarely addressing resolution approaches, and where technology tends to supersede physiology, the use of appropriate technologies is limited, and CS rates are high.
These three projects aim to improve the delivery and teaching of obstetric care, which should then be reflected in enhanced quality of care and a reduction in the number of CSs with no clinical or obstetric indication, together with new ways of delivering care in line with the recommended guidelines.
Apice ON has some characteristics that have the power to produce positive transformations vis-à-vis the traditional training, care, and management models4. It encompasses several strategic dimensions, which are assessed using specific indicators to monitor their impacts. In the structural dimension, the aim is to adapt hospitals’ resources and infrastructure, creating high-risk maternity homes (the Casa da Gestante, Bebê e Puérpera) and in-hospital birth centers. The care dimension focuses on the delivery of safe obstetric and neonatal care, encouraging vaginal birth, reducing CS without clinical or obstetric indication, and respecting the physiology of childbirth, aligned with the rights of women and infants. The management and monitoring dimensions make use of quality indicators, such as the CS rate per risk group (categorized by the Robson classification) and the number of vaginal births assisted by obstetric nurses4. Other aspects assessed include access to postpartum and post-miscarriage family planning, and specific care regimes for women at risk of violence.
The World Health Organization (WHO) regards the CS rate as an important indicator of the model of care for childbirth, stipulating that it should not exceed 15% in any given territory5. Brazil has traditionally had high CS rates, reaching 55.3% in 2017, 56.3% in 2019, and 58.1% in 20226. When adequate use is made of this surgical procedure, it preserves the lives of the mother and infant7; however, like all surgical procedures, it has associated risks and should only be performed when indicated conscientiously,
To address this issue, the WHO recommends the Robson classification8, which can be used to identify groups at lower and higher risk for surgical procedures and to analyze care services in a bid to promote safe obstetric care9. The organization’s concern is justified by the short- and long-term impacts that the high CS rates have on the health of women and infants in many parts of the world, not least Brazil10.
Teaching hospitals are important for the training of health workers. As well as serving for the practice of curricular activities, they also provide healthcare services, high-complexity care, and teaching and research activities. This means they are fundamental in training professionals to work in both primary care and hospital settings11. In such hospitals, obstetric nursing and midwifery have earned increased recognition for their importance in the delivery of humanized care during vaginal childbirth, contributing with good practices that help ensure women are at the center of the childbirth experience and that fewer interventionist practices are conducted without indication12.
A baseline study with the teaching hospitals participating in the Apice ON project identified significant procedural and environmental problems in the care provided for women during childbirth13. The baseline findings on the organization of services provided a basis for follow-up studies of changes over time, both in structural standards and in the organization of the care delivered. Furthermore, a similar study14 found that in these teaching hospitals the average CS rates were higher than those recommended by the WHO for all risk groups (based on the Robson classification), especially in the lowest-risk groups (1–4).
Considering that Apice ON was concluded in June 2020, it is important for knowledge about its effects to be acquired, especially since it was introduced with the aim of inducing significant changes in training for health workers in line with broader public policies for care during childbirth. For this purpose, the trends in key childbirth indicators before and after its implementation should be observed so they can inform subsequent public policymaking processes15.
Accordingly, this article aims to describe the structural changes, changes in the delivery of care, and trends in the use of CSs in hospitals participating in Apice ON to identify how this project affected these areas throughout its implementation.

METHODS
This is an exploratory, descriptive study on the characteristics of the hospitals from the Apice ON project. Secondary data were gathered from the National Registry of Health Establishments (CNES), the Hospital Information System (SIH/SUS), and the Live Birth Information System (Sinasc) from the first half of 2017 (H1 2017), prior to the project’s implementation, and the second half of 2019 (H2 2019), near its completion. Although the project ended in June 2020, data from this year were not used due to possible confounding factors associated with the Covid-19 pandemic, such as changes in care.
Ninety-seven hospitals from the Stork Network that were classified as teaching hospitals were admitted to the project. To be eligible to join, these hospitals had to be teaching hospitals and had to have been responsible for more than 1,000 deliveries in 2015, according to data from SIH/SUS. In 2018, there were 96 teaching hospitals in the project, after the exit of one4.
Monthly data for each hospital, including admission dates, were obtained from SIH/SUS. Data on the hospitals’ infrastructure and resources were acquired from CNES. Finally, monthly data on births were extracted from Sinasc. The data were analyzed using spreadsheets (Microsoft Excel 2016). The results are presented in absolute numbers, means, and proportions.
The hospitals were analyzed individually and in groups by geopolitical macro-region and state (plus the federal district). The variables of interest from each system were as follows:
CNES: human resources (obstetric nurses and midwives), infrastructure (labor, delivery & recovery (LDR) rooms, rooming-in beds), and specialized facilities (child-friendly facilities, high-risk maternity homes [providing humanized pre- and post-partum care in a residential setting for high-risk women and/or their high-risk infants], and in-hospital birth centers).
SIH: allowances for companions staying overnight with the women;
Sinasc: number of live births and the professional who attended the birth.
For the Robson classification, the following variables were acquired: gestational history (i.e., number of previous pregnancies; number of vaginal births; number of CSs; number of live births; number of fetal losses/miscarriages; date of last menstrual period or number of weeks of gestation; number of fetuses; fetal presentation; whether labor was induced; and type of delivery (including, in the case of CS, whether it was performed before labor began)16.
The ten Robson groups were then grouped together by obstetric characteristics and compared with the WHO parameters17. Robson groups 1 and 2 represent full-term pregnancies in nulliparous women; groups 3 and 4 represent full-term pregnancies in multiparous women without a previous CS scar; and groups 6, 7, and 9 represent non-cephalic fetal presentations.
Births not classified into any group were also analyzed, as this is an indicator of the quality of the completion of data.
As set forth in the Brazilian National Health Council resolution #510/2016, ethics approval was not required for this study as it used publicly available secondary data.

RESULTS
Table 1 shows some structural characteristics and procedures of the teaching hospitals included in the project. Overall, the number of registered child-friendly facilities remained the same across the two periods studied, with two new facilities registered in the Central West, and one lost each in the South and the Southeast. Regarding the number of high-risk maternity homes, there was an increase from three to ten in the teaching hospitals, with three in the Northeast and five in the Southeast. As for the birth centers, the total increased from two to 10 between H1 2017 and H2 2019, with five being installed in teaching hospitals in the North region. There was no significant change in the numbers of LDR, and postpartum rooms. Regarding human resources, there were 259 new obstetric nurses and midwives in H2 2019 vis-à-vis H1 2017, especially in the Northeast and the North, with 95 and 79 more professionals, respectively. However, in the Southeast there was a reduction in these professionals. As for the daily allowance for companions, the data indicate that two of the hospitals in the Northeast and two in the South were not observing this legal requirement at the end of the project.
Table 2 shows the number of births attended by an obstetric nurse or midwife. Overall, there was an increase of approximately 3.5 percentage points between H1 2017 (13.7%) and H2 2019 (17.2%). The Central-West had the largest increase (12.6 percentage points), led by the state of Mato Grosso do Sul (20.7 percentage point increase), and the Northeast had the second largest increase (7.1 percentage points). However, there was a reduction of 3 percentage points in the Southeast, led by Minas Gerais, where the proportion dropped by 6.8 percentage points. Meanwhile, the proportion of births attended by an obstetric nurse or midwife more than doubled in the South, from 2.1% to 5.7%.
Table 3 shows the distribution of births in the teaching hospitals grouped into their corresponding Robson groups, comparing the two periods. There was an increase in the proportion of births in the low-risk cesarean groups (G1 to G4), with negligible differences between the periods studied. Nationally, there was an increase of 2.2 percentage points of births classified as group 5, characterized by multiparous women with previous CS scars, led by the North, where the figure increased by 4.2 percentage points. There was a significant reduction in unclassified births, from 0.47% in H1 2017 to 0.09% in H2 2019, evidencing an improvement in the completion of the live birth registration forms.
Table 4 shows the CS rates at the teaching hospitals broken down by Robson groups. The rates for all the groups are higher than the WHO reference values. Furthermore, in the North region, the CS rates in G1 rose by 6.0 percentage points and in G3 by 3.9 percentage points, suggesting that there were more CSs performed without indication. In Robson group 5, which is for multiparous women with CS scars, the CS rates were 73% or higher at the end of the project – well above the 50%–60% recommended by the WHO – indicating that the HEs had not seized the opportunity to teach how to assist vaginal birth after cesarean section (VBAC). For Robson group 10 (preterm births), the CS rates were around 50%, although the reference for this group is approximately 30%. Overall, the region where the CS rate was highest was the Northeast, where it actually rose from 64.5% in H1 2017 to 68.8% in H2 2019. The Central-West showed a slight drop, of 1.6 percentage points, while the rate in the North remained at 59%.

DISCUSSION
This study investigated the infrastructure, resources, and practices of teaching hospitals included in the Apice ON project, using data from before the project began and near its completion (in H1 2017 and H2 2019, respectively) to identify changes.
Teaching hospitals are strategically important for driving the transition from a technocratic to a human-centered care model, since they guide professionals to adopt this model and a science-based approach, making them more likely to reproduce them in their subsequent activities13. Their services are expected to follow evidence-based guidelines rigorously, resulting in higher-quality care and a reduced likelihood of CSs being conducted without due obstetric or clinical indication, avoiding the associated risks of morbidity and mortality14,18.
The findings indicate some progress in the provision of specialized facilities like high-risk maternity homes and in-hospital birth centers, which were rare at the beginning of the project but are still few in number. As for rooming-in beds, although the recommendation for this provision dates back to the 1980s, ten teaching hospitals still did not offer it in 2019. Nonetheless, the number of obstetric nurses grew in the period, with a 3-percentage-point increase in births assisted by these professionals between H1 2017 and H2 2019; and there was a significant decrease in unclassified births. However, some good practices in the management of labor were not being followed in three hospitals, such as facilitating the presence of a companion, even though this has been a legal requirement for almost 20 years. The lack of oversight and of penalties for failure to observe this women’s right is instrumental in the low implementation rates of this policy19-20. Finally, overall CS rates remained high, which is especially concerning for the groups that should be recording a reduction (namely G1, G3 and G5).
Adequate physical resources and infrastructure, combined with qualified human resources and scientifically based care processes available in protocols, are essential for a good childbirth experience, contributing to a favorable environment where women can have a safe, positive, engaging experience of childbirth21.
When it comes to structural changes, one key issue is how to organize human resources in the care model in such a way that the obstetric nurse/midwife is in charge of the delivery of care of low-risk pregnancies during labor and birth22. The Apice ON project seems to have yielded some, albeit modest, progress in this indicator. Notably, the Stork Network recommends that obstetric nursing and midwifery should have responsibility for care during childbirth with a view to migrating away from the overly interventionist model2.
Although the responsibilities of obstetric nurses and midwives during childbirth are enshrined in law and ethical guidelines, their presence can spark conflicts in health teams, especially at the interface between their attributes and those of an attending physician. Truly collaborative teamwork must be the goal, enabling physicians, obstetric nurses, and other team members to engage in delivering care during childbirth, each with clarity as to their own responsibilities so that care can be provided safely and efficiently23. Nonetheless, it should be stressed that there are as yet multiple challenges in the training of obstetric nurses and midwives in the human-centered care model, which means there are not enough trained professionals to bring about the changes envisioned in their work and the associated outcomes.
Despite the WHO recommendation that CS rates should be reduced, with CSs only being performed when imperative for maternal and infant health, they continue to increase in Brazil. Some factors that could be behind this trend include: the preferences of women themselves; a culture of “once a cesarean, always a cesarean”; previous unpleasant childbirth experiences; and, possibly, doctors’ lack of experience in attending vaginal births22, insofar as their training exposes them more to surgical procedures and fails to provide training in how to attend a VBAC, as our data show.
Furthermore, the number of CSs being conducted in the Brazilian public health system is also on the rise, compounded by the enactment of state laws that allow them to be performed on request, without obstetric or clinical indication24. This suggests that in the long term, public policies to encourage vaginal birth may yield limited results.
VBAC has been recommended as a way to avoid repeat CSs25. Recourse to CS after a woman has had one before contributes significantly to the overall increase in CS rates, accounting for more than one third of all CSs performed in the United States26. Our data support this interpretation, insofar as there were high CS rates even among the low-risk groups (Robson groups 1 to 4). As for group 5, which is for multiparous women with previous CS scars, it would seem that teaching hospitals are failing to take advantage of the opportunity to teach VBAC. It is worth noting that high CS rates in nulliparous women and the philosophy of “once a cesarean, always a cesarean” indicate the difficulty in reducing the proportion of women in this group.
During obstetrics training in Brazil, students are required to perform a certain number of procedures in order to be evaluated. However, these are often without a precise indication, as identified in one study, which described the use of women\'s bodies to perform procedures such as multiple episiotomies27, constituting a form of obstetric violence. There may be several factors behind this phenomenon, such as the belief that medical training supersedes women’s needs, even though the indiscriminate use of procedures causes physical and psychological suffering28. Such practices often disregard women’s autonomy, dignity, and rights during the care process in teaching hospitals, resulting in traumatic and dehumanizing experiences.
Although the Apice ON project yielded some progress in the provision of care, such as the adoption of evidence-based procedures, there are still challenges to be overcome. Resistance to change may hinder the adoption of novel approaches and best practices. Furthermore, some studies have found that professional training and culture, the broader social culture, and political and management issues also play a part in how care is delivered for childbirth in Brazil29-30. Overcoming these difficulties requires continuous endeavors to improve professional training, invest in healthcare infrastructure, and take actions to encourage the adoption of evidence-based practices.
Notwithstanding the potential of the Apice ON project, there are some barriers to its future development. These include the limited numbers of LDR, and postpartum rooms and rooming-in beds, as well as shortages of trained professionals and adequate infrastructure. These barriers compromise women’s privacy during care, which jeopardizes the humanization of their experience28. However, one publication on Apice ON reported that it focused mainly on changing the culture of services and pointed out some major changes in the delivery of care, teaching, and management31. From a cultural perspective, changes have indeed been seen in the acceptance of the importance of obstetric nurses for labor and childbirth by other health workers and managers32. These specialized professionals are pivotal for the vaginal delivery process, empowering women during this life-changing moment and helping reduce the occurrence of CSs without obstetric or clinical indication33.
The dismantling of and gaps in policies addressing maternal and infant health are worrying, as they could undermine the progress made by the Stork Network. It is crucial for governments and society to commit to policy continuity, maintaining and strengthening this care network and other projects that have the potential to induce transformation, such as Apice ON. When there is discontinuity or underinvestment in programs of this kind, the consequences can be drastic, reversing progress made and ultimately leading to an increase in maternal and infant mortality.
Sustaining the changes rendered by Apice ON requires continuous efforts on several fronts, such as continuing education, participatory management, political will, and cultural transformation. The improvements observed in this study were driven by technical support provided by local strategic groups, effective management, and political goodwill. However, their continued survival depends on structural, cultural, and political factors. The continuity of such changes requires the institutionalization of continuing professional development and the integration of teaching and services34. In addition, consistent political support is needed, since changes in government priorities can compromise the progress of ongoing actions.
Although challenges exist, Apice ON proves that significant changes are possible and can have a positive impact on maternal and infant care, provided they are sustained by an ongoing commitment to quality and equity. Nonetheless, the biggest challenge is the achievement of cultural transformation. The transition from a technocratic to a person-centered model of care takes time and the engagement of whole teams. Also, to overcome any resistance to change and the diversity of realities experienced by hospitals, it is imperative for strategies to be adapted to local realities.
This study had some limitations. One is the potential for the incorrect completion of the live birth registration forms, which would have a direct impact on the accuracy of the data collected. A survey in one teaching hospital found that the number of births assisted by an obstetric nurse or midwife during the period studied was underreported – something that could also have occurred in other hospitals, leading to an underestimation of the overall number of infants delivered with the assistance of these professionals. Additionally, it was not possible to verify the reliability of the data, especially from smaller hospitals. Furthermore, several changes rendered by the project were qualitative and were therefore not picked up in the data. Currently, information systems do not monitor changes in practices. Indeed, there is no central record of the administration of oxytocin, the performance of episiotomies, the presence of a companion, and other factors, and there are no indicators designed to identify whether the childbirth experience was positive, as recommended by the WHO8.
In conclusion, this evaluation of the Apice ON project identified a small number of quantitative and structural changes over a period of five semesters. It is important to emphasize that cultural transformation and the transition from a technocratic model to humanized obstetric and neonatal care require time and investment. The process of organizational change must be continued, encouraging the joint teaching of nursing and medicine, integrating students from different health professions, and ensuring there is cross-professional collaboration in both teaching and healthcare. Apice ON should also be continued, since it is pivotal in driving the implementation of the public policy established by the Stork Network, driving change in the model of care at teaching hospitals by bolstering the training of professionals, promoting humanized practices, and contributing to an approach that focuses more on the health and well-being of women and newborns.

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