In recent years, Brazil has earned a reputation as a country with one of the highest rates of cesarean sections in the world.
It’s not exactly a desirable reputation to have: Unnecessary C-sections result in longer recovery times for women and more intensive care for babies than vaginal births. In response, IHI partnered with the Hospital Israelita Albert Einstein and the Brazilian National Regulatory Agency to reduce unnecessary cesarean section procedures in Brazil. The collaborative is called Parto Adequado — Portuguese for appropriate delivery.
We spoke with Dr. Carlos Henrique Silva and Dr. Claudia Soares Laranjeira — both members of the Mater Dei Hospital Obstetric Unit in Belo Horizonte, Brazil — to learn more about how their team achieved some of the highest vaginal birth rates in the project.
Why did your team decide to take part in Parto Adequado?
Dr. Silva: Although we have one of the highest C-section rates in the world, a few years ago we started to see that more women wanted a natural birth. We talked with the doctors on the OB-GYN team about how our attitudes, actions, and daily practice would need to change to meet that need. Above all, we established that we were aiming for a safe birth. We wanted to increase the rates of vaginal birth without having a negative impact on our maternal and newborn safety indicators. When we saw that the project’s objectives aligned with ours, we decided it was essential for us to participate in Parto Adequado.
The team from the Mater Dei Hospital Obstetric Unit in Belo Horizonte, Brazil.
What changes did you make that were the keys to your success?
Dr. Silva: We made four key changes —
- Medical team awareness — we explained to our internal team (32 doctors who attend 50 percent of our hospital’s deliveries) that pregnant women’s expectations about the delivery of their babies are evolving. We described these changes as a great opportunity to improve care and broaden our appeal to more women.
- Setting goals — after we identified our baseline C-section rate, we established clear objectives, including reducing C-section rates for first-time pregnant women and eliminating inductions before 41 weeks of gestation.
- Standardization — we created protocols for assisting during both vaginal and C-section labor and delivery, labor induction, cervical ripening, and other standards of care.
- Training — we provided training for the entire medical team about assisting during labor and how to address complications.
What progress have you made?
Dr. Laranjeira: We started getting close to our goals in under a year. Our surveys also indicated improvements in customer satisfaction. We have no way of knowing for sure, but we suspect that more people were hearing about our focus on vaginal births. We had to triple the size of our team to keep up with the increased demand for our services.
What lessons could you share with others trying to tackle similar challenges?
Dr. Laranjeira: We’ve learned a lot in this process —
- Offer training to the entire obstetrics team — even to those who feel their skills are strong. This is vital to building teamwork.
- Share the C-section/vaginal birth rates of each team member — this creates transparency and fosters the desire for improvement.
- Start by targeting your efforts – At the beginning of the project, we focused our project on avoiding unnecessary C-sections in first-time pregnant mothers. We then applied what we learned from first-time mothers to women with a prior vaginal delivery.
What has surprised you most during your work in Parto Adequado?
Dr. Laranjeira: Our biggest surprise was seeing that recognition of good work seemed to come naturally through the increase in patients seeking our services and care. Before Parto Adequado, we knew we provided high-quality medical care. However, once we started improving our care and patient flow, we made more progress quickly. Each day, more and more patients recognize our work by choosing and trusting us with the beautiful mission of bringing their children into the world.
Also, we thought we could relax once we reached our goal. We thought this meant the culture had changed and the continued improvements would flow naturally. We couldn’t have been more wrong! We realized we needed to keep monitoring and motivating the team every day to maintain the progress we’ve made.
What has been your proudest moment?
Dr. Laranjeira: Our proudest moments happen every month when we analyze the vaginal birth and care indicators. We’ve seen steady improvement, and our maternal and neonatal health indicators continue to be strong. We’ve seen no increase in NICU admissions or worsening of the fifth-minute Apgar score.
Our team was also very proud when we learned that we had the highest vaginal birth rate among the Parto Adequado participants. By bringing together the hospital leaders and market regulators, IHI was the catalyst and motivator of change.
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Changing Culture, Changing Care: Reducing Elective C-Sections in Brazil