Structure and practices in hospitals of the Apice ON Project: a baseline study

ABSTRACT OBJECTIVE To describe some characteristics of the 97 teaching hospitals participating in the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON—Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology). METHODS The semester prior to the beginning of the program was adopted as the baseline to evaluate the subsequent structural and processes changes of this project. Secondary data from the first half of 2017 were extracted from the National Registry of Health Establishments (NRHE), the Hospital Information System and the Sistema de Informações sobre Nascidos Vivos (SINASC—Live Birth Information System). RESULTS Before the implementation of the project, only 66% of the hospitals had a Baby-friendly Hospital Initiative, only 3% offered special accommodations for high-risk pregnant women, mothers and their newborns, and 45.4% hospitals adopted the skin-to-skin contact; 97% hospitals had separate rooms for pre-labor and vaginal delivery (93%), not following the recommendations of the Ministry of Health; nine hospitals (9%) had no rooming-in; there were few obstetrics nurses (less than 1% of professionals enrolled in the NRHE), and in only six hospitals the proportion of births assisted by this professional was above 50% of vaginal deliveries, while in eight this percentage ranged between 15% and 50%; the average cesarean section rate was 42%, ranging between 37.6% (Southeast) and 49.1% (Northeast); ten hospitals did not charge for companions according to inpatient hospital authorization. CONCLUSION The study strengthens the relevance of the Apice ON project as an inducer of change of the care model in teaching hospitals and, therefore, as a strategy for the implementation of the national public policy represented by the Stork Network.


INTRODUCTION
In August 2017, the Brazilian Ministry of Health (MH) implemented the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON-Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology), aiming to promote changes in the model of care training of these specialties, as well as in the management of care processes in teaching hospitals (TH). The purpose of this project is to integrate the affiliate institutions -which define de learning of future professionals -to the Stork Network to incorporate attitudes and practices in harmony with care models. The proposed change encompasses practices based on scientific evidence and humanization of care processes in perinatal care 1 . Thus, it supports changes in the behavior and understanding of professionals who attend deliveries and births, in order to improve future professional practice.

Brief background
Advances in the field of maternal health occurred in the 20th century. Firstly, perinatal care occurred at home, performed by midwives. With the institutionalization of childbirth in hospitals, more interventions were adopted to provide care, forming thus a progressively depersonalized care model, which is characterized by excessive interventions and disregard for the physiological, emotional and cultural aspects of birth. In Brazil, in the late 20th century, more than 90% of the deliveries were performed in hospitals 2 . Annually, three million births occur 3 , being 98.5% of these in hospitals 4 . In the early 1990s, advocates of humanized birth and birth care discussed the inadequacy of the existing care model, system characterized by excessive interventions, most of them without any scientific evidence and disrespectful of women's sexual and reproductive rights 5 .
Davis-Floyd 6 identified three care birth models, which differ regarding body definition and its relationship with the mind. The technocratic model-prevalent in the Western worldemphasizes the institutionalization of births, uncritical adoption of new technologies and interventionist attitude, with a mechanistic view of the birth process, represented by the metaphor "engine-object-path" (the engine being the uterus, the object, the fetus, and the vagina, the path) 2 . In this model, woman and baby are objects of care. The humanistic model-adopted in several European and Eastern countries-respects the physiology of the process, being concerned with the well-being of the newborn and woman all along the childbirth period and recognizing the body as an organism and women as a subject. The holistic model integrates the spiritual issue 6 , generally adopted by individual assistance providers. In Brazil, the technocratic model has been predominant, it is characterized by the use of a set of medical techniques, subjecting women to norms and routines that superimpose their physiological rhythm. One of the effects of this model is the high rate of births by surgical procedures 7 .
The current obstetrics and neonatal care policy represents a convergence of previous initiatives in the search for the care model based on appropriate technologies for humanized practices and attitudes. Initiatives aimed at changes to qualify the care provided to women in the pregnancy-puerperal cycle stand out, such as: the Programa de Humanização do Pré-natal e Nascimento (Prenatal and Birth Humanization Program-2000), which aimed to increase access to prenatal care, to guarantee beds for delivery and to improve the general structure of services 8 ; the Pacto Nacional pela Redução da Taxa de Cesárea (National Pact for the Reduction of the Cesarean Section Rate-2000), delegating to states the control and monitor this rate 9 ; the Política Nacional de Humanização (National Humanization Policy-2003), aiming at changes in health care and management models 10 ; the Pacto Nacional pela Redução da Mortalidade Materna e Neonatal (National Pact for the Reduction of Maternal and Neonatal Mortality-2004); and SN (2011), proposing changes in the obstetrics care model, based on the best scientific evidence, with the aim to rescue the natural birth process 11 .
Considering this study used secondary databases of public domain, there was no need for appreciation by the Research Ethics Committee according to Resolution No. 510/2016 of the National Health Council. Table 1 describes the distribution of total hospitals and the project per regions of the country. Out of the 5,012 hospitals in Brazil, 97 (1.9%) are part of the project. We noted that 32.3% of hospitals in Brazil are located in the Northeast; the percentage is 17.5% among those in the project. The Southeast presents 38.1% of the total number of hospitals participating in the project, whereas the overall percentage in Brazil is 28.7%. The South concentrates 15.7% of the total number of the country's hospitals and 18.6% of the project. The Midwest and the North had the lowest percentage of hospitals in Brazil, with 11.5% and 11.8%, respectively, and a distribution of 12.4% and 13.4% of the project. Table 2 shows some structural characteristics of the hospitals participating in the project. It should be noted that features such as qualifications, physical installation and services can be cumulative. We observed that 18.6% of the hospitals were not classified as TH and 66% of these present the Baby-friendly Hospital Initiative qualification, with the highest proportions in the Northeast, North and South (88.2%, 84.6% and 77.8%, respectively). In relation to the Casa da Gestante, Bebê e Puérpera (a special facility for high-risk pregnant women, mothers and their newborns), only three hospitals are qualified, one in the North and two in the Southeast. Only two hospitals have qualification for in-hospital Birth Center, both in the Northeast. There are 44 (45.4%) qualified hospitals for neonatal care by the kangaroo care, 8 in the North, 8 in the Northeast, 15 in the Southeast, 9 in the South and 4 in the Midwest. A total of 87 (89.7%) hospitals present surgical obstetrics beds and neonatal ICU, 17 (100%) in the Northeast, 17 (94.4%) in the South, 12 (92.3%) in the North, 32 (86.5%) in the Southeast, and 9 (75.0%) in the Midwest, evidencing their characteristic of reference for high-risk situations. Regarding physical installation, 94 (96.9%) hospitals have labor rooms and 90 (92.8%) vaginal birthrooms. A total of 81 (83.5%) hospitals have human breast milk bank service, with the lowest percentage found in the North (76.9%). Among human resources, only 0.9% of the staff is composed of obstetrics nurses, whereas 5.9% is composed of obstetrician-gynecologists. Table 3 shows the obstetrics procedures performed in these hospitals, which presented 46.0% of normal births, 33.2% cesarean section and 6.9% of post-abortion/puerperal curettage, being the highest proportion of this last variable (10.0%) found in the North and the lowest (4.7%) in the Midwest. Ten of these hospitals (10.3%) did not register the payment for companions in the inpatient hospital authorization (IHA), 5 of them in the Southeast. Table 4 presents the characteristics of the deliveries assisted in these hospitals. A total of 75 (77.3%) hospitals have a large quantity of deliveries (above 1,000), especially in the North region, which has 12 of its 13 hospitals in this category. Regarding vaginal deliveries assisted by obstetric nurses, 85.6% of hospitals displayed 0% to 15% of their births, with 94.1% of hospitals in the Northeast in this interval. Only six hospitals (6.2%) showed percentage above 50% assisted by obstetric nurses, four in the North and two in the Southeast. For cesarean section rates, 32 hospitals (33.0%) are between 40% and 50%, 24 hospitals, 50% and 60%, and 15 are above 60%. Notably, 39 TH (40.2%) present percentages above 50%, with emphasis on 8 of the 12 hospitals (66.7%) in the Midwest region. Table 5 shows the rates of cesarean sections in the hospitals of the project compared with those of regular hospitals in Brazil in the first half of 2017. A total of 56.9% of all newborns in Brazil were delivered by cesarean section, with a higher proportion in the South and Midwest (64.0% and 63.9%, respectively) and the lowest in the North (47.3%). In the hospitals within the project, the rate of cesarean section was 42.0%, being higher in the Midwest (49.1%) and lower in the Southeast (37.6%), showing the great difference in surgical practices among the hospitals selected for the project compared with the regular hospitals in the country.

DISCUSSION
This study aimed to describe the structure and some process indicators of the teaching hospitals participating in the Apice ON project, that play a fundamental role in changing the current model of obstetric and neonatal care to a model that has been built since the 2000s, which aims at a humanized care for women and newborns and is based on scientific evidence, and enables women to experience their delivery and the birth of their child as a natural process, as recommended by the World Health Organization (WHO) 14 .
TH are characterized as an extension of health facilities, performing teaching practices, being officially recognized as teaching facilities and providing medical care at tertiary level 15 . In Brazil, the Interministerial Ordinance No. 1006/MEC/MS redefines the role of TH to meet the needs of the population-including the humanization of health care, guided  by the Brazilian National Humanization Policy-, implementing the comprehensive care 16 .
A study conducted in 14 medical schools showed that 86% of the workload of practical internships occur in university hospitals and 14% in other establishments 17 . Therefore, these internships must be modeled, so that learning is in accordance with scientific evidence, as well as with national and international recommendations and regulations for good practice.
According to the SN, continuous assistance to parturient is expected in the humanistic model by using adequate technology, avoiding invasive interventions and techniques without indication; having as place of birth, in addition to hospitals, Birth centers; with the presence of obstetrics nurses responsible for monitoring labor without dystocia; and, in case of any complications, being given the possibility to refer the parturient to other professionals 11 .
Other central aspect of the proposal is the adoption of good care practices, among them, the guarantee of a companion chosen by the woman during labor, birth and recovery (LDR); democratic and participatory management practices in services; adequate ambience in the obstetrics and neonatology sectors, according to the Collegiate Board Resolution (CBR) No. 36/2008 of the Brazilian Health Regulatory Agency (ANVISA), with intra and perihospital Birth centers; ambience in obstetrics centers, with individualized environments for continued LDR care, without transferring the parturient to another environment; offer of general and specialized obstetrics and neonatal beds (ICU, kangaroo care and Casa da Gestante, Bebê e Puérpera); and Baby-friendly Hospital Initiative, strengthening the beginning of breastfeeding and offering rooming-in, among other practices 18,19 .
The results of this baseline study showed that most hospitals attend high-risk pregnancies, because almost 95% of them have neonatal ICU, and more than 80% have important qualifications. However, before the implementation of the project, the proportion of Baby-friendly Hospital Initiative among hospitals was relatively low (66%), although this program exists since 1994 20 ; nine hospitals (9%) still did not offer rooming-in, which is recommended since the 1980s 21  We can assume that these national data are similar to those of TH. Thus, it is noteworthy the strategic role of teaching hospitals of changing the technocratic model of care to the humanistic one, because if teaching occurs in places that adopt the humanistic model, as well as scientifically based practices, professionals will be more likely to reproduce them in their future practices. Rattner 5 (2009) considered paradoxical that, in Brazil, perinatal care practices based on scientific evidence, recommended by WHO and BMS, were not adopted in educational institutions, in contrast, they were one of the focuses of resistance to their adoption, since the academy is expected to be the site privileged for the advancement of knowledge and use of best practices. Hotimsky 28 -in a study on obstetrics training in two renowned medical schools-,identified how technical-scientific competence and care for women in theoretical-practical teaching of birth care are united. Among her various findings, the following are highlighted: doctors do not share some decisions with women; presence of informal agreements between teams for the shifts; predominance of oral transmission of technical-scientific knowledge, devaluing the transmission of humanistic values and disregarding recent scientific evidence to define practices.
Changes in the national curriculum guidelines of health disciplines have been proposed since 2001. Among the proposals for the biomedical model, the teaching of humanization for comprehensive care and improvement in care are included. However, only the insertion of contents and disciplines involving the theme do not guarantee significant changes in training, since these contents are dispersed in disciplines that communicate little with each other. Humanization is more than a content, because it encompasses philosophical aspects of training, teaching practices and professional attitudes in the health and education scenarios, which are configured as a model for future practice, since professors are models of social and professional role during graduation 29 .
The main limitations of this study derive from the use of secondary data, with the possibility of incompleteness, under-registration and inadequate recording of information. Possibly, some indicators do not reflect the reality of ambience, since not all institutions update their data periodically in NRHE. The same occurs to IHA and the live birth certificates, although their bias is probably lower, since HIS/SUS is used for billing and the SINASC variables used here present good completeness. Another limitation derives from the fact that Apice ON Project is new and unprecedent, thus, there is a lack of publications on similar projects to enhance this discussion. On the other hand, studies such as this one are essential because, when performing baseline diagnoses, they produce the necessary support to further evaluate the impact of Apice ON actions on TH, supporting future decisions. Moreover, secondary databases enable us to monitor these same indicators without larger investments.
Finally, the scenario of change is promising, since there is a great distance between what should be adopted and taught in these institutions and what this baseline portrait evidences. Davis-Floyd et al. (p. 452) 30 claim: Health care professionals tend to practice as they were taught, so much so that when new information is presented, many long-time practitioners refuse to integrate or implement it because they are so habituated to doing things the way their teachers did. A primary key to the creation and maintenance of birth models that work is the reform of professional education, so that instead of being educated in the technology-and pathology-oriented biomedical model approach to birth, student doctors, nurses, and midwives are educated in the humanistic and normality-oriented midwifery model of birth.
Hotimsky 28 identified in 2007 that teaching in the institutions studied had not seized scientifically-based content and humanized practices of perinatal care yet. Based on these results, we can assume that the current scenario in TH in 2017 (i.e., more than 20 years after the WHO publication) remains unchanged, proving the relevance of Apice ON as a strategy to implement the public policy represented by SN, whose purpose is to induce change in the care model in TH. A similar future study is expected to identify major changes that might have occurred in these institutions, both in the ambience and other aspects of the structure, and in the care process, causing an impact on its results, but, with greater property, in the professional practice of health professionals.