In Brazil, during 2011 and 2012, only 7.7 % of all births were nurse or nurse-midwife led. When considering only vaginal births, this proportion rises to 16.2 %. There was no difference in the obstetric risk profile between vaginal births cared for by physicians and those cared for by a nurse/nurse-midwife. The implementation of good practices in labor and birth care, recommended by the World Health Organization [18], was significantly more frequent in those births assisted by a nurse/nurse-midwife than in those assisted by physicians. Obstetric interventions were very common in births cared for by both types of health care providers. The presence of a nurse/nurse-midwife in the maternity care team had a positive impact, including a reduction in the rate of cesarean section.
The North and Southeast Regions saw the greatest frequency of childbirth care led by a nurse/nurse-midwife, but for different reasons. In the North, it was for a lack of physicians, whereas in the Southeast it was due to the purposeful inclusion of nurse-midwives in the childbirth care model.
The North Region is the poorest area of the country. It is a vast territory that includes the Amazon rainforest; many cities are isolated and accessible only by boat or airplane [19]. It has the lowest number of doctors per 1,000 inhabitants (1.01) [20] and the highest occurrence of home births in the country (3.96 %) [21], which tend to be cared for by traditional birth attendants.
The Southeast Region, the richest region in the country, contains the highest number of physicians per 1,000 inhabitants (2.67) [20] and the lowest rate of home births (0.22 %) [21]. Since the end of the 1990s, this region has seen the adoption of “humanizing” policies in labor and birth care, especially in the state capital cities. These policies have led to the participation of a nurse-midwife in routine practice, carrying for women with low-risk births in some public and private facilities [22–26].
We found nursing and medical care of vaginal birth to be virtually identical in terms of the demographic and socioeconomic characteristics of women, probably because of the strong correlation between social class and type of birth. In Brazil, nearly 90 % of births in the private sector, where the majority of women of a higher socioeconomic class are cared for, occur via cesarean section. Although the private sector represents approximately 20 % of births in Brazil, from the 11,499 vaginal births analyzed, only 578 (5.0 %) happened in this sector (data not shown).
As such, women included in this study were mostly cared for in the public sector, and thus are similar in terms of socioeconomic factors, such as years of education, social class and marital status. The only observed differences were maternal age and parity, with the majority of primiparous women and adolescents cared for by physicians. Other national studies have also found that a lower proportion of primiparous births are managed by a nurse/nurse-midwife [27].
Nurses/nurse-midwives, as well as physicians, exposed women to excessive interventions. Despite strict guidelines for oxytocin administration in the induction or augmentation of labour, nearly half of all women received the drug, suggesting a tendency to routinely use the substance in isolation or in combination with other procedures. Such routine use should be avoided, as it increases the difficulty for women’s mobility in labour and because of the related side effects, such as uterine tachysystole, hypertonic uterine dysfunction, uterine rupture and acute fetal distress [28–30]. Similarly, episiotomy and placement of a venous catheter for hydration as routine support have not been proved beneficial for women [31–33]. Even though a woman’s birthing position should be her choice and respected by the care team [34], the majority of women gave birth in lithotomy position, most times with someone performing Kristeller maneuver; such practices can cause discomfort, pain, and pose risks for women, their newborn and have subsequently been banned in many countries [35].
Overall, nurses/nurse-midwives facilitate greater use of good practices in labor and birth. In a study carried out in Minas Gerais, Brazil, in two facilities participating in the National Health System (known as SUS), it was found that inclusion of a nurse-midwife in a collaborative care team was linked with less frequent use of oxytocin for augmentation of labor, lower rates of artificial rupture of membranes and episiotomy, and greater use of non-pharmacological pain relief during labor [36]. Even in Birth Centers (health facilities linked to a hospital for low-risk birth care, physiological puerperium and care of healthy newborn) where nurse-midwives have autonomy over care practices, the use of oxytocin was still high, varying between 24 % [37] and 31 % [38].
In Rio de Janeiro, studies examining the public sector’s uptake of “humanizing” policies found that nurses/nurse-midwives do incorporate the corresponding practices and appropriate communication in labor and birth care. However, in order to assert themselves in a field traditionally dominated by physicians, they comply with the prevailing technical model, not directly resisting the use of interventions but gradually reducing their use and integrating practices for “humanizing” care [25, 39].
One finding that stood out in this study was the presence of a nurse or a nurse-midwife in labor and birth care helped to reduce cesarean section rates for a given facility. This study has found similar results to another study of an innovative private hospital, which had 76 % of its births assisted by nurse-midwives and a cesarean section rate of 47 % - nearly half of what has been estimated for the Brazilian private sector, where physicians control obstetric care [26].
The strength of this study is that we have used a representative nationwide survey, with primary data collected from medical records. This allowed, for the first time, a description of the participation of nurses/nurse-midwives assisting vaginal births and their positive influence in implementing good practices and appropriate interventions during labor and birth in Brazil.
One limitation of this study is that only hospitals with more than 500 births per year were eligible for the Birth in Brazil study, leading to the exclusion of those with fewer births that apparently are more frequent in cities far from the large urban centers. As such, we were not able to evaluate the involvement of the nurse/nurse-midwife during labor and birth care in those areas, which account for 20 % of all national births.
Another limitation is that the inclusion of a nursing professional in labor and birth care is materializing slowly in Brazil, and for this reason we chose to examine the participation of all nurses, regardless of specific training in midwifery. However, although the vast majority of nurses providing labour and birth care in Brazil have been trained with some midwifery skills, it was not possible to distinguish the proportion of births attended by professionals with this training in accordance with ICM competency standards.