{"paper_id":"2087e11b-d7a9-4c5a-9b6e-842107a1559e","body_text":"Cost-Effectiveness Analysis of A Quality Improvement Program to Reduce Cesarean Sections in Brazilian Private Hospitals: A Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Cost-Effectiveness Analysis of A Quality Improvement Program to Reduce Cesarean Sections in Brazilian Private Hospitals: A Case Study Rosa Maria Soares Madeira Domingues, Paula Mendes Luz, Bárbara Vasques da Silva Ayres, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-67630/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: In 2015, a quality improvement project of childbirth care called Adequate Birth Project (“Projeto Parto Adequado”- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce cesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital - the model following the recommendations of the PPA and the standard of care model - in reducing the proportion of cesarean sections. Methods: We conducted a case study in one of the private hospitals included in the PPA project. The main outcome was the proportion of cesarean section. We used total cost of hospitalization for women and newborns, from the perspective of the health care provider, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of cesarean section and of maternal and neonatal complications. Results: 238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the cesarean section probability (88.6% vs 31.7%, p <0.001) and an increase in the total cost of US$ 67,346.25, which an incremental cost-effectiveness ratio of US$ 1,183.59 per avoided cesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal nearmiss. The cost of uncomplicated vaginal births and cesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. Conclusion: The quality improvement project of childbirth care “PPA” was cost-effective in reducing cesarean sections in women assisted in a Brazilian private hospital, without increasing severe negative maternal and neonatal outcomes and reducing the frequency of early term births. Sexual & Reproductive Medicine cesarean delivery healthcare quality improvement hospitals medicine Cost-effectiveness Figures Figure 1 Figure 2 Introduction Caesarean section is a safe intervention to save the lives of women and newborns. However, it is associated with negative short, medium and long-term health consequences for women and children 1 – 5 . Therefore, its harmful effects can outweigh its benefits when used excessively. At the population level, there is no evidence that cesarean rates above 10% are associated with a reduction in the maternal mortality ratio 6 , although population characteristics may affect cesarean rates in each country 7 . In Brazil, considering demographic and obstetric characteristics for Brazilian women, the expected rate of cesarean delivery for the country would be 25 to 30% 8 . For women admitted to private hospitals, this value would be 44.4%. Since 2009, cesarean section is the most frequent type of birth in the country. Cesarean section is associated with demographic, socioeconomic factors and the type of childbirth care services organization. In Brazilian private hospitals, cesarean section rates reach 90% 9, 10 . In 2015, the National Supplementary Health Agency (ANS), responsible for regulating the supplementary health sector in the country, together with the Institute for Health Improvement (IHI) and Hospital Israelita Alberto Einstein, and with the support of the Brazilian Ministry of Health, implemented the Adequate Childbirth Project (“Projeto Parto Adequado-PPA”). This is a quality improvement project of childbirth care in Brazilian hospitals that aims to identify innovative and viable models of care, which value vaginal delivery and reduce the percentage of cesarean sections without clinical indication 11 , 12 . The objective of this study is an economic analysis of two models of care existing in a private Brazilian hospital - the model following the recommendations of the PPA and the standard of care model - in reducing the proportion of cesarean sections. Methods Study design This is an economic analysis of the model of care implemented from the PPA to reduce cesarean sections in a private Brazilian hospital. The PPA is a quality improvement project of childbirth care implemented in Brazilian public and private hospitals, with the goal of increasing the percentage of vaginal deliveries and reducing the rate of hospitalization in a neonatal intensive care unit (NICU) 11 – 13 . It is an ongoing project, started in May 2015 and developed in three phases described in Fig. 1. More information about the PPA is available at the ANS website 11 and at Boren et al 12 . In 2017, an evaluative research called the “Healthy Birth” study was carried out to assess the degree of implementation and the effects of the PPA in a convenience sample of 12 hospitals, among the 23 private hospitals that participated in the first phase of the project 14 . Sample calculation used as parameters a 50% prevalence of cesarean section and a power of 80% to detect a 10% reduction in the cesarean rate with a significance level of 5% resulting in a minimum sample of 400 women in each hospital. Women with live births of any weight or gestational age and stillbirths weighing 500 g or more or with 22 or more gestational weeks were eligible for the “Healthy Birth” study. Exclusions included home births or public deliveries, women who did not speak Portuguese, with hearing loss, and with legal determination to terminate pregnancy. All women admitted for childbirth care and who met the eligibility criteria were invited to participate in the study, until 400 participants were included in each hospital. Face-to-face interviews with puerperal women were conducted at least 6 hours after vaginal delivery and 12 hours after a cesarean section. Hospital records were reviewed and data were extracted after hospital discharge. Data collection was carried out from March 2017 to August 2017, 6 to 8 months after the end of the first phase of the PPA (Fig. 1). More information about the “Healthy Birth” study is available in Torres et al 14 . For this economic analysis, we carried out a case study in one of the hospitals included in the “Healthy Birth” study, the only hospital that made available the hospitalization costs of the 400 women included in the study. This hospital is located in the southeastern region of the country and belongs to a private health insurance provider. Figure 1 summarizes the information from the PPA, the “Healthy Birth” study and this economic analysis. Figure 1: Description of the “Adequate Childbirth Project\", the evaluative research \"Healthy Birth \"and the economic analysis study Comparative models of care: PPA model of care and standard of care model The PPA project aims to support and promote the implementation of actions to reduce the percentage of unnecessary cesarean sections and increase the quality and safety of care during labor and birth. It is a multifaceted intervention, with activities that are structured in four theoretical components: 1) Governance (coalition between leaders aiming at quality and safety in childbirth care); 2) Women and families (empowerment of women and their families aiming at their active participation in the process of pregnancy, childbirth and postpartum); 3) Reorganization of care (reorganization of care in order to favor the physiological evolution of labor and the performance of cesarean sections based on clinical factors); 4) Monitoring (structuring information systems for continuous learning). The activities provided for in the four components are based on scientific evidence 15 and on 2 successful strategies for reducing cesarean sections in Brazilian private hospitals 16 , 17 . The PPA uses the IHI improvement model, where through the cyclical and incremental implementation of changes, the proposed activities are tested and adjusted to the local context, allowing their implementation and refinement 13 . In the first phase of the project, managers and local leaders participated in five face-to-face learning sessions in addition to monthly virtual learning sessions, focusing on training in the improvement model, initial tests of change to reduce the cesarean rate based on the four PPA components and sharing successful experiences and challenges in implementing changes. In addition, the project offered clinical training at realistic simulation centers, with a focus on assisting physiological vaginal delivery and managing obstetric complications 12 . At the hospital level, the project implemented new forms of care organization, with changes in the hospital environment, access to non-pharmacological methods for pain relief and equipment for births in vertical positions. Hospital staff included nurse-midwives in childbirth care and trained professionals implemented clinical guidelines. Activities for women aimed at greater autonomy and involvement of pregnant women in the decision-making process related to childbirth, through access to information, participation in educational groups, encouragement to develop a birth plan and visit to the hospital. In Brazilian private hospitals, women assisted in the standard of care model are usually seen by the same doctor during prenatal and childbirth care 16 . There is low participation of nurse-midwives 18 , a high proportion of antepartum cesarean Sect. 10 , low use of labor induction 10 , low use of best practices and high use of obstetric interventions during labor 19 . Study population In this case study, we restricted the analysis to women in the Robson's groups 1 to 4, the current target population of PPA. Robson's classification classifies women into 10 mutually exclusive groups based on the type of pregnancy, parity, fetal presentation, gestational age and in the presence of a previous cesarean Sect. 20 . Groups 1 to 4 correspond to primiparous and multiparous women, with single, full-term pregnancies, with a fetus in cephalic presentation and without previous cesarean section. Groups 2 and 4 can also be subdivided into groups 2a and 2b and 4a and 4b, with groups “a” represented by women with labor induction and groups “b” by women with antepartum caesarean Sect. 21 . We also excluded women with diagnosis of HIV infection and newborns with congenital malformations or with gestational age equal to or greater than 42 weeks, due to the greater possibility of cesarean sections and negative outcomes. As we used the perspective of the health care provider, we also excluded women with out of pocket payment for childbirth care. In this hospital, all women assisted by the hospital team on duty were followed according to the PPA model of care. Using data obtained during the interview, we classified women as “PPA model of care”, if they reported being assisted by the hospital team on duty, and as “standard of care model”, if they were assisted by an external staff. Effectiveness We used the primary outcome “proportion of cesarean section”, including antepartum and intrapartum cesarean sections, obtained from hospital records, to measure effectiveness. In addition to the crude rate, we used propensity score weighting to obtain a weighted estimate 22 , since some maternal characteristics associated with higher rates of cesarean Sect. 10 showed significant differences between the two models of care. As secondary outcomes we used maternal outcomes (maternal death, Severe Maternal Morbidity, Maternal Near Miss, admission to an adult Intensive Care Unit, satisfaction with the care received) and perinatal outcomes (birth weight, gestational age at birth, asphyxia in the fifth minute of life, any neonatal complication, NICU admission, neonatal Near Miss, neonatal death and fetal death). For the measurement of Severe Maternal Morbidity (SMM), Maternal Near Miss (MNM) and Neonatal Near Miss (NNM), we used data from hospital records and the case definition criteria recommended by the World Health Organization 23 , 24 . To assess satisfaction with hospital care, we used data obtained during the interview and a validated scale for the Brazilian population 25 . Costs We used aggregate costs (total cost of hospitalization for women and newborns), from the perspective of the health care provider, within the adopted time horizon, that is, the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. In Brazilian private hospitals, there are different arrangements for payment of hospitalizations for childbirth care. The hospital included in this case study used the “package model”. In this model, the health plan operator defines a basic package that covers the costs related to hospitalizations of vaginal births and cesarean sections without complications, to which are added the costs resulting from complications that may have occurred during hospitalization. The value of the basic package depends on the type of health plan, with a wide variation in the cost of hospitalization of women with vaginal or cesarean delivery without complications. Complication costs are not broken down into the total amount charged by the hospital to healthcare providers. However, the total cost reported, which we used in this analysis, includes the costs of the vaginal birth or cesarean section and all maternal and neonatal complications that occurred during hospitalization. We assessed the mean cost and the range of the total cost of hospitalization of vaginal births and cesarean sections, with or without maternal and neonatal complications, for women in each type of model of care: the PPA and the standard of care model. The costs related to the implementation of PPA activities were not available. Cost-effectiveness analysis We calculated the incremental cost-effectiveness ratio (ICER) using the difference in the total cost of hospitalization and the difference in the proportion of cesarean sections in the two groups. The cost-effectiveness threshold of 18 to 71% of the Gross Domestic Product (GDP) per capita proposed for middle-high income countries was adopted 26 , corresponding to the values ​​of US $ 1,776.77 to US $ 7,008.37 for the year 2017 (1US $ =R $ 3.2). Scenario analysis We conducted univariate sensitivity analysis with the results being presented on a tornado diagram. We used the minimum and maximum costs observed in hospitalizations with and without maternal and neonatal complications in the two models of care. In the group assisted in the PPA model of care, we used variation in the probabilities of maternal and neonatal complications considering the minimum and maximum values ​​observed, and variation in the probability of cesarean section, considering the theoretical plausibility of greater or lesser effects of the PPA model of care. We also used the hypothetical scenario of equal costs of hospitalizations for uncomplicated vaginal births and cesarean sections in both models of care. We used the statistical package R for analyzes. Results During the study period, 409 women were interviewed. Exclusions included women of Robson´s groups 5 to 10 (164), Robson´s group not classified (2), newborn with congenital malformation (2), gestational age equal to or greater than 42 weeks (2), women with HIV infection (1), or out-of-pocket payment of the hospitalization (2). Of the 238 included in the analysis, 84 were assisted in the PPA model of care and 154 in the standard of care model. Women´s mean age was 29 years old. Most women self-reported as mixed or white, had 11 to 14 years of study, belonged to the higher economic classes 27 , lived with a partner and had paid work. Only a fifth of women had a previous delivery, 55.9% preferred a vaginal delivery and 51.3% belonged to Robson's group 2. A fifth of women had a risk pregnancy and 48.3% were overweight or obese. Women assisted in the standard of care model were older, more educated, belonged more to higher economic classes (A and B), had a higher proportion of risk pregnancy and overweight/obesity, and belonged to a greater proportion to Robson's group 2b. Women assisted in the PPA model of care had a greater preference for vaginal delivery and were mostly from Robson's group 1. There were no statistically significant differences in relation to skin color, parity, marital status and paid work (Table 1 ). Table 1 – Demographic, social and obstetric characteristics of women according to the model of care. Rio de Janeiro, 2017. Characteristic Total (N = 238) Standard of care model (N = 154) PPA model of care (N = 84) p value n % n % n % Age (years) < 20 7 2.9 4 2.6 3 3.6 < 0.001 20–34 186 78.2 109 70.8 77 91.7 35 or more 45 18.9 41 26.6 4 4.8 Skin color White 78 32.8 54 35.1 24 28.6 0.307 Black 45 18.9 25 16.2 20 23.8 Mixed/Asian/Indigenous 115 48.3 75 48.7 40 47.6 Schooling (years) 1 to 10 34 14.3 24 15.6 10 11.9 0.007 11 to 14 136 57.1 76 49.4 60 71.4 15 or more 52 21.8 40 26.0 12 14.3 Postgraduate studies 16 6.7 14 9.1 2 2.4 Economic class D/E 1 0.4 0 0.0 1 1.2 0.003 C 70 29.4 36 23.4 34 40.5 B 156 65.5 107 69.5 49 58.3 A 11 4.6 11 7.1 0 0.0 Lives with partner 205 86.1 136 88.3 69 82.1 0.188 Paid work 183 76.9 118 76.6 65 77.4 0.895 Parity 0 192 80.7 125 81.2 67 79.8 0.957 1 to 2 43 18.1 27 17.5 16 19.0 3 or more 3 1.3 2 1.3 1 1.2 Preference for vaginal birth 133 55.9 66 42.9 67 79.8 < 0.001 Robson Group 1 70 29.4 26 16.9 44 52.4 < 0.001 2a 19 8.0 2 1.3 17 20.2 2b 103 43.3 97 63.0 6 7.1 3 19 8.0 7 4.5 12 14.3 4a 5 2.1 3 1.9 2 2.4 4b 22 9.2 19 12.3 3 3.6 Risk pregnancy 49 20.6 38 24.7 11 13.1 0.035 Pré-gestational BMI Underweight 9 3.8 6 3.9 3 3.6 0.023 Normal 113 47.9 62 40.8 51 60.7 Overweight 68 28.8 48 31.6 20 23.8 Obese 46 19.5 36 23.7 10 11.9 PPA = Adequate Birth Project; BMI = Body Mass Index The proportion of cesarean sections was three times higher in the standard of care model (91.6% vs 32.1%, p < 0.001), with a small difference reduction in the weighted analysis (88.6% vs 31.7%, p < 0.001). There were no maternal deaths. The differences in the proportions of SMM, MNM, admission to an adult ICU and satisfaction with childbirth and newborn care were not significant (Table 2 ). Table 2 – Maternal and neonatal outcomes according to the model of care. Rio de Janeiro, 2017. Maternal and neonatal outcomes TOTAL (N = 238) Standard of care model (N = 154) PPA model of care (N = 84) p value N % n % n % Maternal outcomes Type of labor Spontaneous 89 37.4 33 21.4 56 66.7 < 0.001 Induced 24 10.1 5 3.2 19 22.6 Without labor 125 52.5 116 75.3 9 10.7 Type of birth Vaginal 70 29.4 13 8.4 57 67.9 < 0.001 Cesarean 168 70.6 141 91.6 27 32.1 weighted cesarean* 88.6 31.7 Severe Maternal Morbidity 5 2.1 4 2.6 1 1.2 0.658 Maternal Near Miss 1 0.4 1 0.7 0 0.0 1.000 Maternal death 0 - 0 - 0 - Admission to Intensive Care Unit 5 2.1 5 3.3 0 0.0 0.164 Maternal satisfaction with childbirth care Clarity of information 219 92.0 143 92.9 76 90.5 0.517 Respect 227 95.4 147 95.5 80 95.2 0.939 Preserved intimacy 231 97.1 151 98.1 80 95.2 0.220 Time available for questions 212 89.1 141 91.6 71 84.5 0.096 Participation in the decision making 217 91.2 144 93.5 73 86.9 0.086 Any type of violence 6 2.5 3 1.9 3 3.6 0.668 Global satisfaction with childbirth 228 95.8 148 96.1 80 95.2 0.745 Satisfaction with newborn care 228 95.8 145 94.2 83 98.8 0.103 Neonatal outcomes Birth weight < 2.500 g 7 3.0 5 3.3 2 2.4 0.225 2500 to 3999 g 218 92.8 144 94.1 74 90.2 ≥ 4000 g 10 4.3 4 2.6 6 7.3 Gestational age (weeks) 37 to 38 107 45.0 83 53.9 24 28.6 < 0.001 Spontaneous** 35 21.1 17 19.3 18 23.1 0.553 Induced 72 35.5 66 48.2 6 9.1 < 0.001 39 to 41 131 55.0 71 46.1 60 71.4 < 0.001 Apgar < 7 in the 5th minute of life 2 0.9 1 0.7 1 1.2 1.000 Any neonatal complication 30 12.6 16 10.4 14 16.7 0.163 Admission to NICU 22 9.2 11 7.1 11 13.1 0.130 Neonatal Near Miss 19 8.0 11 7.1 8 9.5 0.517 Stillbirth 0 - 0 - 0 - Neonatal death 0 - 0 - 0 - * weighted proportion of cesarean section using the propensity score. The variables “age”, “years of study”, “initial preference for the type of childbirth” and “risk pregnancy” were used as explanatory variables for the logistic model of the propensity score and the type of model of care as the outcome variable; **Spontaneous labor or rupture of membranes. PPA = Adequate Birth Project; NICU = Neonatal Intensive Care Unit There were no fetal or neonatal deaths. Of the total live births, 3% had low birth weight, 55% had gestational age between 39 and 41 weeks, 0.9% had moderate asphyxia in the 5 minute of life, 12.6% had some neonatal complication, 9.2% were admitted to the NICU and 8% were classified as NNM. A significantly higher proportion of early term births (gestational age 37–38 weeks) was observed in the standard of care model, with 79.5% of these through obstetric intervention (94.1% in antepartum cesarean sections and 5.6% in induced vaginal deliveries, data not shown in the table). The most frequent neonatal complication in both groups was transient tachypnea. Meconium aspiration syndrome was significantly more frequent in the PPA model of care (3.8% in the PPA care model vs 0 in the standard of care model, p = 0.041). There were no significant differences in the other neonatal outcomes (Table 2 ). Women in the PPA model of care were more likely to have maternal complications after a vaginal delivery (0.088) and less likely to have maternal complications after a cesarean Sect. (0.037) than women in the standard of care model (0.077 and 0.050, respectively). The probability of neonatal complications was higher in women in the PPA model of care, both in vaginal delivery (0.105 vs 0.077) and in caesarean section (0.185 vs 0.071). The average cost of hospitalizations without complications was higher in women assisted in the PPA model of care, both for vaginal deliveries (US $ 1,255.06 vs US $ 1,015.74) and for cesarean sections (US $ 1,294.18 vs US $ 918.46). In hospitalizations with complications, the greatest differences were observed in vaginal births with neonatal complications, with the average cost in women assisted in the PPA model of care twice as high (US $ 6,457.21 vs US $ 2,924.62). Considering the primary outcome of the study, the PPA model of care resulted in a 56.9 percentage point reduction in the cesarean section probability and an increase in the total cost of US $ 67,346.25, which implies an incremental cost-effectiveness ratio of US $ 1,183.59 per avoided cesarean section (Table 3 ). Table 3 – Probabilities of type of birth, complications and costs of hospitalization according to model of care. Parameters Standard of care model (n = 154) PPA model of care (n = 84) Effectiveness Proportion of cesarean* 88.6 31.7 Probability of maternal complication after a vaginal birth 0.077 0.088 Probability of maternal complication after a cesarean 0.050 0.037 Probability of neonatal complication after a vaginal birth 0.077 0.105 Probability of neonatal complication after a cesarean 0.071 0.185 Costs Vaginal birth without maternal complication US $ 1,015.74 US $ 1,255.06 Vaginal birth with maternal complication US $ 1,464.53 US $ 1,279.54 Cesarean without maternal complication US $ 918.46 US $ 1,294.18 Cesarean with maternal complication US $ 2,498.99 US $ 1,874.70 Vaginal birth without neonatal complication US $ 0.00 US $ 0.00 Vaginal birth with neonatal complication US $ 2,924.62 US $ 6,457,21 Cesarean without neonatal complication US $ 0.00 US $ 0.00 Cesarean with neonatal complication US $ 4,785.56 US $ 4,527.87 Maternal hospitalization costs US $ 100,350.63 US $ 127,573.84 Neonatal hospitalization costs US $ 32,671.25 US $ 72,794.29 Total cost US $ 133,021.88 US $ 200,368.13 Cost-effectiveness analysis Difference in proportion of cesarean section 56.9 Difference in total cost US $ 67,346.25 Incremental Cost-Effectiveness Ratio (ICER) R $ 1,183.59/avoided cesarean section * weighted proportion of cesarean section using the propensity score. The variables “age”, “years of study”, “initial preference for the type of childbirth” and “risk pregnancy” were used as explanatory variables for the logistic model of the propensity score and the type of model of care as the outcome variable. In the sensitivity analysis, the variation in the cost of cesarean section without maternal complication, applied to both groups, was the parameter with the greatest effect on ICER: when the cost of hospitalization is greater than US $ 1,960.00, women assisted in the PPA model of care have a 56.9 reduction in the proportion of cesarean sections at a lower cost. The increase in the cost of uncomplicated vaginal delivery in both groups and in the proportion of cesarean sections in the PPA group make the PPA model of care less cost-effective, while the reduction in the proportion of neonatal complications in vaginal births in the PPA group and the costs of these hospitalizations in both groups make it more cost-effective. The ICER was less sensitive to variations in the parameters of probability of maternal complications and the cost of these hospitalizations (Fig. 2). The use of the same average cost of hospitalization for vaginal births and cesarean sections without complications in both models of care, with an average cost variation of US $ 625.00 to US $ 2,500,00, resulted in a ICER of US $ 641.20 to US $ 579.38 per cesarean section avoided (data not shown in table). Figure 2: Univariate sensitivity analysis of parameters of cost and complications at the Incremental Cost-Effectiveness Ratio. Discussion The PPA model of care was cost-effective in reducing cesarean sections in a private hospital located in the southeast of Brazil, the most developed region of the country. The Brazilian government does not recommend a threshold value for decisions on the incorporation of new technologies in the National Health System 28 . Therefore, we used a threshold value recommended for the evaluation of interventions in middle-income countries 26 . If we used the threshold of less than 1GDP per effectiveness recommended by the World Health Organization 29 , the PPA model of care would be very cost-effective. The two parameters with the greatest influence on the cost-effectiveness results - the average cost of hospitalizations for vaginal births and cesarean sections without complications - are not related to the model of care. However, they are important parameters in the context of childbirth care in Brazilian private hospitals, since there are different arrangements for paying for hospitalizations in these hospitals. The inpatient package model, used in the hospital included in this case study, is the most common. In this model, the health plan operator defines the cost of hospitalizations for uncomplicated vaginal births and cesarean sections with a wide variation of this value according to the type of health plan. In this study, the average cost of uncomplicated vaginal birth and cesarean sections was higher in women assisted in the PPA model of care. Scenario analysis adopting the same average cost of hospitalization for uncomplicated vaginal and cesarean sections in the two models of care, using a wide range of values, resulted in lower ICER values ​​for avoided cesarean section, making the PPA model of care even more cost- effective. The other parameters found to influence the ICER were the proportion of cesarean sections and the proportion of neonatal complications, especially those related to vaginal deliveries. The greater the reduction in the rate of cesarean section in the PPA model of care, and the lower the occurrence of neonatal complications, the more cost-effective this model of care is. In a scenario of lower reduction in the cesarean section rate, reaching a rate of 50% in the PPA model of care group, the ICER would rise to US $ 1,848.59 per avoided cesarean section. Regarding neonatal complications, the significantly higher proportion of meconium aspiration syndrome in the PPA group indicate that there are possibilities for improving the quality of childbirth care in this model of care. The 2/3 reduction in the cesarean section rate in the PPA model of care, in both crude and weighted analysis, is consistent with two previous studies that evaluated the effects of interventions to reduce cesarean sections in Brazilian private hospitals, which also found significantly lower rates of cesarean Sect. 16 , 17 . All these interventions have as common characteristics the implementation of models of care that promote physiological childbirth through adjustments in the hospital environment, implementation of clinical guidelines based on best clinical practices, promotion of the collaborative model of care between doctor and nurse-midwives during labor and childbirth care, and educational work with women. The group of women assisted by the standard of care model had a much higher proportion of women in the Robson´s groups 2b and 4b, similar to a previous national study carried out in 2011–2012, where group 2b was the most frequent group in Brazilian private hospitals 30 . In the PPA model of care, groups 1 and 2a were the most frequent. Almost 90% of women in the PPA group presented labor, while in the standard of care model this value was lower than 25%. Finally, in the PPA model of care the proportion of induced labor was seven times higher than that observed in the standard of care model, where the induction rate was less than 5%. All these results suggest that the differences found between the two models of care are due to the actions implemented by the PPA. A more global change in the private sector is less likely, as women assisted by external teams showed the same pattern seen in private hospitals in 2011–2012 10, 30 . A 21% increase in the proportion of vaginal deliveries in the period 2014–2016 was also observed when comparing data from 5 hospitals participating in the PPA and 8 hospitals not participating in the city of São Paulo/Brazil 12 . Serious negative outcomes, such as maternal, fetal and neonatal deaths, severe maternal morbidity and maternal and neonatal near miss, presented low frequency and with non-significant differences between the two models of care. However, women in the standard of care model presented almost twice the proportion of early term births, most of them associated with antepartum cesarean sections. It is estimated that, in Brazil, about 35% of live births are early term 31 , corresponding to more than 300 thousand early term births per year, with a higher prevalence in places with cesarean rates above 80% 32 . In a previous nationwide Brazilian study, early term births, especially non-spontaneous births, were associated with several negative outcomes, such as oxygen use, neonatal ICU admission and neonatal death 31 . This study has some limitations. As we used data from only one hospital, we cannot extrapolate the observed results to the set of hospitals participating in the PPA, as the local contextual characteristics may have affected the implementation of the recommended actions and the observed effects 33 . In addition, the study is probably underpowered to detect differences in less frequent results due to the small sample size. Costs related to the implementation of the PPA were not included, as they were not available. Hospital managers, health plan operators and the project coordination should consider these expenses when deciding to implement the PPA in new maternity services. Finally, we used a short time horizon. There is evidence of negative medium and long-term effects associated with cesarean section, both for women and newborns 3 , 4 . There is also evidence of more neonatal complications after hospital discharge in early term births, more frequently observed in the standard of care model. Conclusion The PPA model of care was cost-effective in reducing cesarean sections in women in Robson's group 1 to 4 assisted in a Brazilian private hospital, with a higher occurrence of women in labor, with induction of labor, and a lower proportion of early term births. In this hospital, the cost of uncomplicated vaginal births and cesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. Greater reductions in the rate of cesarean sections and neonatal complications, especially in vaginal births, would also lead to more favorable economic results. New studies in Brazilian hospitals located in other macro-regions, in private hospitals not belonging to health operators, and with the inclusion of women with previous cesarean section, are necessary to expand knowledge on the subject and to base future strategies for reducing cesarean sections in public and private hospitals in the country. Abbreviations ANS - National Supplementary Health Agency BMI - Body Mass Index ICU – Intensive Care Unit IHI - Institute for Health Improvement MNM – Maternal Near Miss NICU – Neonatal Intensive Care Unit NNM – Neonatal Near Miss PPA – Adequate Childbirth Project SMM – Severe Maternal Morbidity WHO – World Health Organization Declarations Ethics approval and consent to participate The “Healthy Birth” study was approved by the research ethics committee of the Escola Nacional de Saúde Pública Sérgio Arouca/Fiocruz (CAAE research protocol: 1.761.027, approved on January 16, 2017). All women received and signed the Free and Informed Consent Form prior to the interview and all precautions were taken to maintain the confidentiality of the information. Consent for publication Not applicable Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This work was supported by fundings from Centro Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Bill & Melinda Gates Foundation, Edital MCTI/CNPq/MS/SCTIE/Decit/Fundação Bill e Melinda Gates N ° 47/2014. The funders had no influence in the identification, design, conduct, and reporting of the analysis. Authors' contributions RMSMD was responsible for the conception and design of the work, data analysis, discussion of results and elaboration of the manuscript; PML contributed to the analysis and interpretation of data, discussion of results and elaboration of manuscript; BVSA contributed to data analysis and approval of the final version of the manuscript; JAT contributed to the review and approval of the final version of the manuscript; MCL was the researcher responsible for the “Healty Birth” study design and contributed to the review and approval of the final version of the manuscript. Acknowledgements Not applicable. References Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean Section Without Medical Indications Is Associated With an Increased Risk of Adverse Short-Term Maternal Outcomes: The 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010;10:8:71. Mascarello KC, Horta BL, Silveira MF. Maternal complications and cesarean section without indication: systematic review and meta-analysis. Rev Saude Publica. 2017;51:105. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018;392(10155):1349–57. Keag OE, Norman J, Stock S. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 2018;15(1):e1002494. Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2019;393(10184):1973–82. Ye J, Betrán AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41:237–44. Souza JP, Betran AP, Dumont A, de Mucio B, Gibbs Pickens CM, Deneux-Tharaux C, et al. A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study. BJOG. 2016;123(3):427–36. Brasil M, Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Comissão Nacional de Incorporação de Tecnologias no SUS. Diretrizes de Atenção à Gestante: a operação cesariana. Brasília, DF: Conitec, 2016. http://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf . Accessed on May 25, 2020. Rebelo F, Rocha CMM, Cortes TR, Dutra CL, Kac G. High cesarean prevalence in a national population-based study in Brazil: the role of private practice. Acta Obstet Gynecol Scand. 2010;89:903–8. Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, D´Orsi E, Pereira APE, et al. Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth. Cad Saude Publica. 2014;30(supl 1):1–16. Agência Nacional de Saúde Suplementar. Parto Adequado. http://www.ans.gov.br/gestao-em-saude/parto-adequado . Accessed on June 27, 2020. Borem P, de Cássia Sanchez R, Torres J, Delgado P, Petenate AJ, Peres D, et al. A Quality Improvement Initiative to Increase the Frequency of Vaginal Delivery in Brazilian Hospitals. Obstet Gynecol. 2020;135(2):415–25. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. http://www.ihi.org/resources/ Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx . Accessed on June 2nd, 2019. Torres JA, Leal MDC, Domingues RMSM, Esteves-Pereira AP, Nakano AR, Gomes ML, et al. Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol. Reprod Health. 2018;15(1):194. Chaillet N, Dumont A. Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth. 2007;34:53–64. Torres JA, Domingues RMSM, Sandall J, Hartz ZMA, Gama SGN, Theme-Filha MM, et al. Caesarean section and neonatal outcomes in private hospitals in Brazil: comparative study of two different perinatal models of care. Cad Saude Publica. 2014;30(supl 1):220–31. 23. Borem P, Ferreira JBB, da Silva UJ, Valério Júnior J, Orlanda CMB. Increasing the percentage of vaginal birth in the private sector in Brazil through the redesign of care model. Rev Bras Ginecol Obstet. 2015;37:446–54. Gama SG, Viellas EF, Torres JA, Bastos MH, Brüggemann OM, Theme Filha MM, et al. Labor and birth care by nurse with midwifery skills in Brazil. Reprod Health. 2016;17(Suppl 3):123. 13(. Leal MC, Pereira APE, Domingues RMSM, Theme-Filha MM, Dias MAB, Nakamura-Pereira M, et al. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica. 2014;30(supl 1):17–32. Robson MS. Can we reduce the caesarean section rate? Best Pract Res Clin Obstet Gynaecol. 2001;15(1):179–94. Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the Robson Classification to Assess Caesarean Section Trends in 21 Countries: A Secondary Analysis of Two WHO Multicountry Surveys. Lancet Glob Health. 2015;3(5):e260-70. Paes AT. Uso de escores de propensão para corrigir diferenças entre grupos. Educ Contin Saúde einstein. 2012;10(3):103–4. Say L, Souza JP, Pattinson RC. Maternal near miss - towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol. 2009;23:287–96. Pileggi-Castro C, Camelo JS Jr, Perdoná GC, Mussi-Pinhata MM, Cecatti JG, Mori R, et al. Development of criteria for identifying neonatal near-miss cases: analysis of two WHO multicountry cross-sectional studies. BJOG. 2014;121(Suppl 1):110–8. Costa DDO, Ribeiro VS, Ribeiro MRC, Esteves-Pereira AP, Sá LGC, Cruz JADS, et al. Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey. Cad Saude Publica. 2019;35(8):e00154918. Woods B, Revill P, Sculpher M, Claxton K. Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value Health. 2016;19(8):929–35. Associação Brasileira de Empresas de Pesquisa. Critério Brasil de classificação econômica. http://www.abep.org/criterio-brasil . Accessed on May 25, 2020. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. Diretrizes metodológicas: Diretriz de Avaliação Econômica. 2. ed. Brasília: Ministério da Saúde, 2014. 132p. http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_metodologicas_diretriz_avaliacao_economica.pdf . Accessed on May 14, 2020. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization; 2001. http://apps.who.int/iris/bitstream/10665/42435/1/924154550X.pdf . Accessed on May 15, 2020. Nakamura-Pereira M, do Carmo Leal M, Esteves-Pereira AP, Domingues RM, Torres JA, Dias MA, et al. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13(Suppl 3):128. Leal MDC, Esteves-Pereira AP, Nakamura-Pereira M, Domingues RMSM, Dias MAB, Moreira ME, et al. Burden of early-term birth on adverse infant outcomes: a population-based cohort study in Brazil. BMJ Open. 2017;7(12):e017789. Barros FC, Rabello Neto DL, Villar J, Kennedy SH, Silveira MF, Diaz-Rossello JL, et al. Caesarean sections and the prevalence of preterm and early-term births in Brazil: secondary analyses of national birth registration. BMJ Open. 2018;8(8):e021538. Domingues RMSM, Torres JA, Leal MC, Hartz Z. Fatores contextuais na análise da implantação de uma intervenção multifacetada em hospitais privados brasileiros: reflexões iniciais da pesquisa avaliativa “Nascer Saudável”. Anais do IHMT 2019;Supl 1:S47-S55. Supplementary Files CHEERSchecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Minor revision 20 Feb, 2021 Reviewer # 3 agreed at journal 30 Jan, 2021 Reviewer # 2 agreed at journal 20 Oct, 2020 Review # 2 received at journal 20 Oct, 2020 Review # 1 received at journal 19 Oct, 2020 Reviewer # 1 agreed at journal 02 Oct, 2020 Editor assigned by journal 04 Sep, 2020 Reviewers invited by journal 04 Sep, 2020 Editor invited by journal 03 Sep, 2020 Submission checks completed at journal 02 Sep, 2020 First submitted to journal 28 Aug, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-67630\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research\",\"associatedPublications\":[],\"authors\":[{\"id\":1945515,\"identity\":\"13d1819f-25a5-4530-a9eb-3e971dfb68c6\",\"order_by\":0,\"name\":\"Rosa Maria Soares Madeira 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17:22:12\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":68604,\"visible\":true,\"origin\":\"\",\"legend\":\"Description of the “Adequate Childbirth Project\\\", the evaluative research \\\"Healthy Birth \\\"and the economic analysis study\",\"description\":\"\",\"filename\":\"Fig1.JPG\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-67630/v1/Fig1.JPG\"},{\"id\":2227935,\"identity\":\"23726398-dc8d-47d0-a5be-dd08d1be5fab\",\"added_by\":\"auto\",\"created_at\":\"2020-09-03 17:22:12\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":33194,\"visible\":true,\"origin\":\"\",\"legend\":\"Univariate sensitivity analysis of parameters of cost and complications at the Incremental Cost-Effectiveness Ratio.\",\"description\":\"\",\"filename\":\"Fig2.JPG\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-67630/v1/Fig2.JPG\"},{\"id\":13587366,\"identity\":\"6991a354-0e10-4e2f-a703-8a251298de83\",\"added_by\":\"auto\",\"created_at\":\"2021-09-17 04:50:46\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":576454,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-67630/v1/ee2d918b-1ad1-4c6b-b768-a25cc0db30c2.pdf\"},{\"id\":2227937,\"identity\":\"d7ec3a5b-552c-4cff-907f-24273d771808\",\"added_by\":\"auto\",\"created_at\":\"2020-09-03 17:22:13\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":17972,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"CHEERSchecklist.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-67630/v1/CHEERSchecklist.docx\"}],\"financialInterests\":\"\",\"formattedTitle\":\"\\u003cp\\u003eCost-Effectiveness Analysis of A Quality Improvement Program to Reduce Cesarean Sections in Brazilian Private Hospitals: A Case Study\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\" \\u003cp\\u003eCaesarean section is a safe intervention to save the lives of women and newborns. However, it is associated with negative short, medium and long-term health consequences for women and children \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR2 CR3 CR4\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e. Therefore, its harmful effects can outweigh its benefits when used excessively. At the population level, there is no evidence that cesarean rates above 10% are associated with a reduction in the maternal mortality ratio \\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e, although population characteristics may affect cesarean rates in each country \\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e. In Brazil, considering demographic and obstetric characteristics for Brazilian women, the expected rate of cesarean delivery for the country would be 25 to 30% \\u003csup\\u003e8\\u003c/sup\\u003e. For women admitted to private hospitals, this value would be 44.4%.\\u003c/p\\u003e \\u003cp\\u003eSince 2009, cesarean section is the most frequent type of birth in the country. Cesarean section is associated with demographic, socioeconomic factors and the type of childbirth care services organization. In Brazilian private hospitals, cesarean section rates reach 90% \\u003csup\\u003e9, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eIn 2015, the National Supplementary Health Agency (ANS), responsible for regulating the supplementary health sector in the country, together with the Institute for Health Improvement (IHI) and Hospital Israelita Alberto Einstein, and with the support of the Brazilian Ministry of Health, implemented the Adequate Childbirth Project (\\u0026ldquo;Projeto Parto Adequado-PPA\\u0026rdquo;). This is a quality improvement project of childbirth care in Brazilian hospitals that aims to identify innovative and viable models of care, which value vaginal delivery and reduce the percentage of cesarean sections without clinical indication \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe objective of this study is an economic analysis of two models of care existing in a private Brazilian hospital - the model following the recommendations of the PPA and the standard of care model - in reducing the proportion of cesarean sections.\\u003c/p\\u003e \"},{\"header\":\"Methods\",\"content\":\" \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy design\\u003c/h2\\u003e \\u003cp\\u003eThis is an economic analysis of the model of care implemented from the PPA to reduce cesarean sections in a private Brazilian hospital.\\u003c/p\\u003e \\u003cp\\u003eThe PPA is a quality improvement project of childbirth care implemented in Brazilian public and private hospitals, with the goal of increasing the percentage of vaginal deliveries and reducing the rate of hospitalization in a neonatal intensive care unit (NICU) \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e. It is an ongoing project, started in May 2015 and developed in three phases described in Fig.\\u0026nbsp;1. More information about the PPA is available at the ANS website \\u003csup\\u003e\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e and at Boren et al \\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eIn 2017, an evaluative research called the \\u0026ldquo;Healthy Birth\\u0026rdquo; study was carried out to assess the degree of implementation and the effects of the PPA in a convenience sample of 12 hospitals, among the 23 private hospitals that participated in the first phase of the project \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e. Sample calculation used as parameters a 50% prevalence of cesarean section and a power of 80% to detect a 10% reduction in the cesarean rate with a significance level of 5% resulting in a minimum sample of 400 women in each hospital.\\u003c/p\\u003e \\u003cp\\u003eWomen with live births of any weight or gestational age and stillbirths weighing 500\\u0026nbsp;g or more or with 22 or more gestational weeks were eligible for the \\u0026ldquo;Healthy Birth\\u0026rdquo; study. Exclusions included home births or public deliveries, women who did not speak Portuguese, with hearing loss, and with legal determination to terminate pregnancy.\\u003c/p\\u003e \\u003cp\\u003eAll women admitted for childbirth care and who met the eligibility criteria were invited to participate in the study, until 400 participants were included in each hospital. Face-to-face interviews with puerperal women were conducted at least 6 hours after vaginal delivery and 12 hours after a cesarean section. Hospital records were reviewed and data were extracted after hospital discharge. Data collection was carried out from March 2017 to August 2017, 6 to 8 months after the end of the first phase of the PPA (Fig.\\u0026nbsp;1). More information about the \\u0026ldquo;Healthy Birth\\u0026rdquo; study is available in Torres et al \\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eFor this economic analysis, we carried out a case study in one of the hospitals included in the \\u0026ldquo;Healthy Birth\\u0026rdquo; study, the only hospital that made available the hospitalization costs of the 400 women included in the study. This hospital is located in the southeastern region of the country and belongs to a private health insurance provider. Figure\\u0026nbsp;1 summarizes the information from the PPA, the \\u0026ldquo;Healthy Birth\\u0026rdquo; study and this economic analysis.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eFigure 1: Description of the \\u0026ldquo;Adequate Childbirth Project\\\", the evaluative research \\\"Healthy Birth \\\"and the economic analysis study\\u003c/b\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eComparative models of care: PPA model of care and standard of care model\\u003c/h2\\u003e \\u003cp\\u003eThe PPA project aims to support and promote the implementation of actions to reduce the percentage of unnecessary cesarean sections and increase the quality and safety of care during labor and birth. It is a multifaceted intervention, with activities that are structured in four theoretical components: 1) Governance (coalition between leaders aiming at quality and safety in childbirth care); 2) Women and families (empowerment of women and their families aiming at their active participation in the process of pregnancy, childbirth and postpartum); 3) Reorganization of care (reorganization of care in order to favor the physiological evolution of labor and the performance of cesarean sections based on clinical factors); 4) Monitoring (structuring information systems for continuous learning). The activities provided for in the four components are based on scientific evidence \\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e and on 2 successful strategies for reducing cesarean sections in Brazilian private hospitals \\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe PPA uses the IHI improvement model, where through the cyclical and incremental implementation of changes, the proposed activities are tested and adjusted to the local context, allowing their implementation and refinement \\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e. In the first phase of the project, managers and local leaders participated in five face-to-face learning sessions in addition to monthly virtual learning sessions, focusing on training in the improvement model, initial tests of change to reduce the cesarean rate based on the four PPA components and sharing successful experiences and challenges in implementing changes. In addition, the project offered clinical training at realistic simulation centers, with a focus on assisting physiological vaginal delivery and managing obstetric complications \\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eAt the hospital level, the project implemented new forms of care organization, with changes in the hospital environment, access to non-pharmacological methods for pain relief and equipment for births in vertical positions. Hospital staff included nurse-midwives in childbirth care and trained professionals implemented clinical guidelines. Activities for women aimed at greater autonomy and involvement of pregnant women in the decision-making process related to childbirth, through access to information, participation in educational groups, encouragement to develop a birth plan and visit to the hospital.\\u003c/p\\u003e \\u003cp\\u003eIn Brazilian private hospitals, women assisted in the standard of care model are usually seen by the same doctor during prenatal and childbirth care \\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e. There is low participation of nurse-midwives \\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e, a high proportion of antepartum cesarean Sect.\\u0026nbsp;\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e, low use of labor induction \\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e, low use of best practices and high use of obstetric interventions during labor \\u003csup\\u003e\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy population\\u003c/h2\\u003e \\u003cp\\u003eIn this case study, we restricted the analysis to women in the Robson's groups 1 to 4, the current target population of PPA. Robson's classification classifies women into 10 mutually exclusive groups based on the type of pregnancy, parity, fetal presentation, gestational age and in the presence of a previous cesarean Sect.\\u0026nbsp;\\u003csup\\u003e\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e. Groups 1 to 4 correspond to primiparous and multiparous women, with single, full-term pregnancies, with a fetus in cephalic presentation and without previous cesarean section. Groups 2 and 4 can also be subdivided into groups 2a and 2b and 4a and 4b, with groups \\u0026ldquo;a\\u0026rdquo; represented by women with labor induction and groups \\u0026ldquo;b\\u0026rdquo; by women with antepartum caesarean Sect.\\u0026nbsp;\\u003csup\\u003e\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eWe also excluded women with diagnosis of HIV infection and newborns with congenital malformations or with gestational age equal to or greater than 42 weeks, due to the greater possibility of cesarean sections and negative outcomes. As we used the perspective of the health care provider, we also excluded women with out of pocket payment for childbirth care.\\u003c/p\\u003e \\u003cp\\u003eIn this hospital, all women assisted by the hospital team on duty were followed according to the PPA model of care. Using data obtained during the interview, we classified women as \\u0026ldquo;PPA model of care\\u0026rdquo;, if they reported being assisted by the hospital team on duty, and as \\u0026ldquo;standard of care model\\u0026rdquo;, if they were assisted by an external staff.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEffectiveness\\u003c/h2\\u003e \\u003cp\\u003eWe used the primary outcome \\u0026ldquo;proportion of cesarean section\\u0026rdquo;, including antepartum and intrapartum cesarean sections, obtained from hospital records, to measure effectiveness. In addition to the crude rate, we used propensity score weighting to obtain a weighted estimate \\u003csup\\u003e\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u003c/sup\\u003e, since some maternal characteristics associated with higher rates of cesarean Sect.\\u0026nbsp;\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e showed significant differences between the two models of care.\\u003c/p\\u003e \\u003cp\\u003eAs secondary outcomes we used maternal outcomes (maternal death, Severe Maternal Morbidity, Maternal Near Miss, admission to an adult Intensive Care Unit, satisfaction with the care received) and perinatal outcomes (birth weight, gestational age at birth, asphyxia in the fifth minute of life, any neonatal complication, NICU admission, neonatal Near Miss, neonatal death and fetal death). For the measurement of Severe Maternal Morbidity (SMM), Maternal Near Miss (MNM) and Neonatal Near Miss (NNM), we used data from hospital records and the case definition criteria recommended by the World Health Organization \\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u003c/sup\\u003e. To assess satisfaction with hospital care, we used data obtained during the interview and a validated scale for the Brazilian population \\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCosts\\u003c/h2\\u003e \\u003cp\\u003eWe used aggregate costs (total cost of hospitalization for women and newborns), from the perspective of the health care provider, within the adopted time horizon, that is, the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon.\\u003c/p\\u003e \\u003cp\\u003eIn Brazilian private hospitals, there are different arrangements for payment of hospitalizations for childbirth care. The hospital included in this case study used the \\u0026ldquo;package model\\u0026rdquo;. In this model, the health plan operator defines a basic package that covers the costs related to hospitalizations of vaginal births and cesarean sections without complications, to which are added the costs resulting from complications that may have occurred during hospitalization. The value of the basic package depends on the type of health plan, with a wide variation in the cost of hospitalization of women with vaginal or cesarean delivery without complications. Complication costs are not broken down into the total amount charged by the hospital to healthcare providers. However, the total cost reported, which we used in this analysis, includes the costs of the vaginal birth or cesarean section and all maternal and neonatal complications that occurred during hospitalization.\\u003c/p\\u003e \\u003cp\\u003eWe assessed the mean cost and the range of the total cost of hospitalization of vaginal births and cesarean sections, with or without maternal and neonatal complications, for women in each type of model of care: the PPA and the standard of care model. The costs related to the implementation of PPA activities were not available.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCost-effectiveness analysis\\u003c/h2\\u003e \\u003cp\\u003eWe calculated the incremental cost-effectiveness ratio (ICER) using the difference in the total cost of hospitalization and the difference in the proportion of cesarean sections in the two groups. The cost-effectiveness threshold of 18 to 71% of the Gross Domestic Product (GDP) per capita proposed for middle-high income countries was adopted \\u003csup\\u003e \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e \\u003c/sup\\u003e, corresponding to the values ​​of US\\u003cspan\\u003e$\\u003c/span\\u003e 1,776.77 to US\\u003cspan\\u003e$\\u003c/span\\u003e7,008.37 for the year 2017 (1US\\u003cspan\\u003e$\\u003c/span\\u003e=R\\u003cspan\\u003e$\\u003c/span\\u003e3.2).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eScenario analysis\\u003c/h2\\u003e \\u003cp\\u003eWe conducted univariate sensitivity analysis with the results being presented on a tornado diagram. We used the minimum and maximum costs observed in hospitalizations with and without maternal and neonatal complications in the two models of care. In the group assisted in the PPA model of care, we used variation in the probabilities of maternal and neonatal complications considering the minimum and maximum values ​​observed, and variation in the probability of cesarean section, considering the theoretical plausibility of greater or lesser effects of the PPA model of care. We also used the hypothetical scenario of equal costs of hospitalizations for uncomplicated vaginal births and cesarean sections in both models of care.\\u003c/p\\u003e \\u003cp\\u003eWe used the statistical package R for analyzes.\\u003c/p\\u003e \\u003c/div\\u003e \"},{\"header\":\"Results\",\"content\":\" \\u003cp\\u003eDuring the study period, 409 women were interviewed. Exclusions included women of Robson\\u0026acute;s groups 5 to 10 (164), Robson\\u0026acute;s group not classified (2), newborn with congenital malformation (2), gestational age equal to or greater than 42 weeks (2), women with HIV infection (1), or out-of-pocket payment of the hospitalization (2). Of the 238 included in the analysis, 84 were assisted in the PPA model of care and 154 in the standard of care model.\\u003c/p\\u003e \\u003cp\\u003eWomen\\u0026acute;s mean age was 29\\u0026nbsp;years old. Most women self-reported as mixed or white, had 11 to 14\\u0026nbsp;years of study, belonged to the higher economic classes \\u003csup\\u003e\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u003c/sup\\u003e, lived with a partner and had paid work. Only a fifth of women had a previous delivery, 55.9% preferred a vaginal delivery and 51.3% belonged to Robson's group 2. A fifth of women had a risk pregnancy and 48.3% were overweight or obese. Women assisted in the standard of care model were older, more educated, belonged more to higher economic classes (A and B), had a higher proportion of risk pregnancy and overweight/obesity, and belonged to a greater proportion to Robson's group 2b. Women assisted in the PPA model of care had a greater preference for vaginal delivery and were mostly from Robson's group 1. There were no statistically significant differences in relation to skin color, parity, marital status and paid work (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; Demographic, social and obstetric characteristics of women according to the model of care. Rio de Janeiro, 2017.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"8\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eTotal\\u003c/p\\u003e \\u003cp\\u003e(N\\u0026thinsp;=\\u0026thinsp;238)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c5\\\" namest=\\\"c4\\\"\\u003e \\u003cp\\u003eStandard\\u003c/p\\u003e \\u003cp\\u003eof care model (N\\u0026thinsp;=\\u0026thinsp;154)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003ePPA\\u003c/p\\u003e \\u003cp\\u003emodel of care\\u003c/p\\u003e \\u003cp\\u003e(N\\u0026thinsp;=\\u0026thinsp;84)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" 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\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWhite\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e78\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e32.8\\u003c/p\\u003e \\u003c/td\\u003e 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\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e75\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e48.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e40\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e47.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSchooling (years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1 to 10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e15.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e11.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.007\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e11 to 14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e136\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e57.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e76\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e49.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e71.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e15 or more\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e52\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e21.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e40\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e26.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e14.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostgraduate studies\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e9.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e2.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEconomic class\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eD/E\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.003\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e70\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e29.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e23.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e40.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eB\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e156\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e65.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e107\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e69.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e58.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLives with partner\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e205\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e86.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e136\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e88.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e69\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e82.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.188\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePaid work\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e183\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e76.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e118\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e76.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e65\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e77.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.895\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e192\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e80.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e125\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e81.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e67\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e79.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.957\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1 to 2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e43\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e18.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e17.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e19.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3 or more\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreference for vaginal birth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e133\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e55.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e66\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e42.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e67\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e79.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRobson Group\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e70\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e29.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e26\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e16.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e44\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e52.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2a\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e20.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2b\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e103\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e43.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e97\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e63.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e7.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e14.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4a\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e2.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4b\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e12.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRisk pregnancy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e24.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e13.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.035\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePr\\u0026eacute;-gestational BMI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnderweight\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.023\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNormal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e113\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e47.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e62\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e40.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e51\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e60.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOverweight\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e28.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e48\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e31.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e23.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eObese\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e46\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e36\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e23.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e11.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"8\\\"\\u003ePPA\\u0026thinsp;=\\u0026thinsp;Adequate Birth Project; BMI\\u0026thinsp;=\\u0026thinsp;Body Mass Index\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe proportion of cesarean sections was three times higher in the standard of care model (91.6% vs 32.1%, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), with a small difference reduction in the weighted analysis (88.6% vs 31.7%, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). There were no maternal deaths. The differences in the proportions of SMM, MNM, admission to an adult ICU and satisfaction with childbirth and newborn care were not significant (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; Maternal and neonatal outcomes according to the model of care. Rio de Janeiro, 2017.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"8\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal and neonatal outcomes\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eTOTAL\\u003c/p\\u003e \\u003cp\\u003e(N\\u0026thinsp;=\\u0026thinsp;238)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c5\\\" namest=\\\"c4\\\"\\u003e \\u003cp\\u003eStandard\\u003c/p\\u003e \\u003cp\\u003eof care model\\u003c/p\\u003e \\u003cp\\u003e(N\\u0026thinsp;=\\u0026thinsp;154)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003ePPA\\u003c/p\\u003e \\u003cp\\u003emodel of care\\u003c/p\\u003e \\u003cp\\u003e(N\\u0026thinsp;=\\u0026thinsp;84)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003ep value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eN\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e%\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003en\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e%\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003en\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e%\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal outcomes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eType of labor\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSpontaneous\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e89\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e37.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e33\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e21.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e56\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e66.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInduced\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e22.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWithout labor\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e125\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e52.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e116\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e75.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eType of birth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVaginal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e70\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e29.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e57\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e67.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCesarean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e168\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e70.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e141\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e91.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e27\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e32.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eweighted cesarean*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e88.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e31.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSevere Maternal Morbidity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.658\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal Near Miss\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal death\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdmission to Intensive Care Unit\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.164\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c3\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal satisfaction with childbirth care\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eClarity of information\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e219\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e92.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e143\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e92.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e76\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e90.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.517\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRespect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e227\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e147\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e95.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e80\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e95.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.939\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePreserved intimacy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e231\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e97.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e151\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e98.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e80\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e95.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.220\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTime available for questions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e212\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e89.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e141\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e91.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e84.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.096\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParticipation in the decision making\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e217\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e91.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e144\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e93.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e73\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e86.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.086\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAny type of violence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e3.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.668\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGlobal satisfaction with childbirth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e228\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e148\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e96.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e80\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e95.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.745\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSatisfaction with newborn care\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e228\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e95.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e145\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e94.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e83\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e98.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.103\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeonatal outcomes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBirth weight\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;2.500\\u0026nbsp;g\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e2.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.225\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2500 to 3999\\u0026nbsp;g\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e218\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e92.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e144\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e94.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e90.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026ge;\\u0026thinsp;4000\\u0026nbsp;g\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e7.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGestational age (weeks)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e37 to 38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e107\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e45.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e83\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e53.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e28.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSpontaneous**\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e21.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e19.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e23.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.553\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInduced\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e72\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e35.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e66\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e48.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e9.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e39 to 41\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e131\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e55.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e46.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e71.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eApgar\\u0026thinsp;\\u0026lt;\\u0026thinsp;7 in the 5th minute of life\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1.000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAny neonatal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e30\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e10.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e16.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.163\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdmission to NICU\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e13.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.130\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeonatal Near Miss\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e7.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e9.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e0.517\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStillbirth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeonatal death\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"8\\\" nameend=\\\"c8\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003e* weighted proportion of cesarean section using the propensity score. The variables \\u0026ldquo;age\\u0026rdquo;, \\u0026ldquo;years of study\\u0026rdquo;, \\u0026ldquo;initial preference for the type of childbirth\\u0026rdquo; and \\u0026ldquo;risk pregnancy\\u0026rdquo; were used as explanatory variables for the logistic model of the propensity score and the type of model of care as the outcome variable; **Spontaneous labor or rupture of membranes.\\u003c/p\\u003e \\u003cp\\u003ePPA\\u0026thinsp;=\\u0026thinsp;Adequate Birth Project; NICU\\u0026thinsp;=\\u0026thinsp;Neonatal Intensive Care Unit\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThere were no fetal or neonatal deaths. Of the total live births, 3% had low birth weight, 55% had gestational age between 39 and 41 weeks, 0.9% had moderate asphyxia in the 5 minute of life, 12.6% had some neonatal complication, 9.2% were admitted to the NICU and 8% were classified as NNM. A significantly higher proportion of early term births (gestational age 37\\u0026ndash;38 weeks) was observed in the standard of care model, with 79.5% of these through obstetric intervention (94.1% in antepartum cesarean sections and 5.6% in induced vaginal deliveries, data not shown in the table). The most frequent neonatal complication in both groups was transient tachypnea. Meconium aspiration syndrome was significantly more frequent in the PPA model of care (3.8% in the PPA care model vs 0 in the standard of care model, p\\u0026thinsp;=\\u0026thinsp;0.041). There were no significant differences in the other neonatal outcomes (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWomen in the PPA model of care were more likely to have maternal complications after a vaginal delivery (0.088) and less likely to have maternal complications after a cesarean Sect.\\u0026nbsp;(0.037) than women in the standard of care model (0.077 and 0.050, respectively). The probability of neonatal complications was higher in women in the PPA model of care, both in vaginal delivery (0.105 vs 0.077) and in caesarean section (0.185 vs 0.071). The average cost of hospitalizations without complications was higher in women assisted in the PPA model of care, both for vaginal deliveries (US\\u003cspan\\u003e$\\u003c/span\\u003e 1,255.06 \\u003cem\\u003evs\\u003c/em\\u003e US\\u003cspan\\u003e$\\u003c/span\\u003e 1,015.74) and for cesarean sections (US\\u003cspan\\u003e$\\u003c/span\\u003e 1,294.18 \\u003cem\\u003evs\\u003c/em\\u003e US\\u003cspan\\u003e$\\u003c/span\\u003e 918.46). In hospitalizations with complications, the greatest differences were observed in vaginal births with neonatal complications, with the average cost in women assisted in the PPA model of care twice as high (US\\u003cspan\\u003e$\\u003c/span\\u003e 6,457.21 \\u003cem\\u003evs\\u003c/em\\u003e US\\u003cspan\\u003e$\\u003c/span\\u003e 2,924.62). Considering the primary outcome of the study, the PPA model of care resulted in a 56.9 percentage point reduction in the cesarean section probability and an increase in the total cost of US\\u003cspan\\u003e$\\u003c/span\\u003e 67,346.25, which implies an incremental cost-effectiveness ratio of US\\u003cspan\\u003e$\\u003c/span\\u003e 1,183.59 per avoided cesarean section (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u0026ndash; Probabilities of type of birth, complications and costs of hospitalization according to model of care.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParameters\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStandard of care model\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;154)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePPA model of care\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;84)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEffectiveness\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProportion of cesarean*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e88.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e31.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProbability of maternal complication after a vaginal birth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.077\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.088\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProbability of maternal complication after a cesarean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.050\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.037\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProbability of neonatal complication after a vaginal birth\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.077\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.105\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProbability of neonatal complication after a cesarean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.071\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.185\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eCosts\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVaginal birth without maternal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 1,015.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 1,255.06\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVaginal birth with maternal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 1,464.53\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 1,279.54\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCesarean without maternal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 918.46\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 1,294.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCesarean with maternal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 2,498.99\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 1,874.70\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVaginal birth without neonatal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 0.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 0.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVaginal birth with neonatal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 2,924.62\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 6,457,21\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCesarean without neonatal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 0.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 0.00\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCesarean with neonatal complication\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 4,785.56\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 4,527.87\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMaternal hospitalization costs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 100,350.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 127,573.84\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeonatal hospitalization costs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 32,671.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 72,794.29\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal cost\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 133,021.88\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e 200,368.13\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eCost-effectiveness analysis\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDifference in proportion of cesarean section\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e56.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDifference in total cost\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUS\\u003cspan\\u003e$\\u003c/span\\u003e67,346.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIncremental Cost-Effectiveness Ratio (ICER)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eR\\u003cspan\\u003e$\\u003c/span\\u003e1,183.59/avoided cesarean section\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"3\\\"\\u003e* weighted proportion of cesarean section using the propensity score. The variables \\u0026ldquo;age\\u0026rdquo;, \\u0026ldquo;years of study\\u0026rdquo;, \\u0026ldquo;initial preference for the type of childbirth\\u0026rdquo; and \\u0026ldquo;risk pregnancy\\u0026rdquo; were used as explanatory variables for the logistic model of the propensity score and the type of model of care as the outcome variable.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e In the sensitivity analysis, the variation in the cost of cesarean section without maternal complication, applied to both groups, was the parameter with the greatest effect on ICER: when the cost of hospitalization is greater than US\\u003cspan\\u003e$\\u003c/span\\u003e 1,960.00, women assisted in the PPA model of care have a 56.9 reduction in the proportion of cesarean sections at a lower cost. The increase in the cost of uncomplicated vaginal delivery in both groups and in the proportion of cesarean sections in the PPA group make the PPA model of care less cost-effective, while the reduction in the proportion of neonatal complications in vaginal births in the PPA group and the costs of these hospitalizations in both groups make it more cost-effective. The ICER was less sensitive to variations in the parameters of probability of maternal complications and the cost of these hospitalizations (Fig.\\u0026nbsp;2). The use of the same average cost of hospitalization for vaginal births and cesarean sections without complications in both models of care, with an average cost variation of US\\u003cspan\\u003e$\\u003c/span\\u003e 625.00 to US\\u003cspan\\u003e$\\u003c/span\\u003e2,500,00, resulted in a ICER of US\\u003cspan\\u003e$\\u003c/span\\u003e 641.20 to US\\u003cspan\\u003e$\\u003c/span\\u003e579.38 per cesarean section avoided (data not shown in table).\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eFigure 2: Univariate sensitivity analysis of parameters of cost and complications at the Incremental Cost-Effectiveness Ratio.\\u003c/b\\u003e \\u003c/p\\u003e \"},{\"header\":\"Discussion\",\"content\":\" \\u003cp\\u003eThe PPA model of care was cost-effective in reducing cesarean sections in a private hospital located in the southeast of Brazil, the most developed region of the country. The Brazilian government does not recommend a threshold value for decisions on the incorporation of new technologies in the National Health System \\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u003c/sup\\u003e. Therefore, we used a threshold value recommended for the evaluation of interventions in middle-income countries \\u003csup\\u003e\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u003c/sup\\u003e. If we used the threshold of less than 1GDP per effectiveness recommended by the World Health Organization \\u003csup\\u003e\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e, the PPA model of care would be very cost-effective.\\u003c/p\\u003e \\u003cp\\u003eThe two parameters with the greatest influence on the cost-effectiveness results - the average cost of hospitalizations for vaginal births and cesarean sections without complications - are not related to the model of care. However, they are important parameters in the context of childbirth care in Brazilian private hospitals, since there are different arrangements for paying for hospitalizations in these hospitals. The inpatient package model, used in the hospital included in this case study, is the most common. In this model, the health plan operator defines the cost of hospitalizations for uncomplicated vaginal births and cesarean sections with a wide variation of this value according to the type of health plan. In this study, the average cost of uncomplicated vaginal birth and cesarean sections was higher in women assisted in the PPA model of care. Scenario analysis adopting the same average cost of hospitalization for uncomplicated vaginal and cesarean sections in the two models of care, using a wide range of values, resulted in lower ICER values ​​for avoided cesarean section, making the PPA model of care even more cost- effective.\\u003c/p\\u003e \\u003cp\\u003eThe other parameters found to influence the ICER were the proportion of cesarean sections and the proportion of neonatal complications, especially those related to vaginal deliveries. The greater the reduction in the rate of cesarean section in the PPA model of care, and the lower the occurrence of neonatal complications, the more cost-effective this model of care is. In a scenario of lower reduction in the cesarean section rate, reaching a rate of 50% in the PPA model of care group, the ICER would rise to US\\u003cspan\\u003e$\\u003c/span\\u003e 1,848.59 per avoided cesarean section. Regarding neonatal complications, the significantly higher proportion of meconium aspiration syndrome in the PPA group indicate that there are possibilities for improving the quality of childbirth care in this model of care.\\u003c/p\\u003e \\u003cp\\u003eThe 2/3 reduction in the cesarean section rate in the PPA model of care, in both crude and weighted analysis, is consistent with two previous studies that evaluated the effects of interventions to reduce cesarean sections in Brazilian private hospitals, which also found significantly lower rates of cesarean Sect.\\u0026nbsp;\\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e. All these interventions have as common characteristics the implementation of models of care that promote physiological childbirth through adjustments in the hospital environment, implementation of clinical guidelines based on best clinical practices, promotion of the collaborative model of care between doctor and nurse-midwives during labor and childbirth care, and educational work with women.\\u003c/p\\u003e \\u003cp\\u003eThe group of women assisted by the standard of care model had a much higher proportion of women in the Robson\\u0026acute;s groups 2b and 4b, similar to a previous national study carried out in 2011\\u0026ndash;2012, where group 2b was the most frequent group in Brazilian private hospitals \\u003csup\\u003e\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e\\u003c/sup\\u003e. In the PPA model of care, groups 1 and 2a were the most frequent. Almost 90% of women in the PPA group presented labor, while in the standard of care model this value was lower than 25%. Finally, in the PPA model of care the proportion of induced labor was seven times higher than that observed in the standard of care model, where the induction rate was less than 5%. All these results suggest that the differences found between the two models of care are due to the actions implemented by the PPA. A more global change in the private sector is less likely, as women assisted by external teams showed the same pattern seen in private hospitals in 2011\\u0026ndash;2012 \\u003csup\\u003e10, 30\\u003c/sup\\u003e. A 21% increase in the proportion of vaginal deliveries in the period 2014\\u0026ndash;2016 was also observed when comparing data from 5 hospitals participating in the PPA and 8 hospitals not participating in the city of S\\u0026atilde;o Paulo/Brazil \\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eSerious negative outcomes, such as maternal, fetal and neonatal deaths, severe maternal morbidity and maternal and neonatal near miss, presented low frequency and with non-significant differences between the two models of care. However, women in the standard of care model presented almost twice the proportion of early term births, most of them associated with antepartum cesarean sections. It is estimated that, in Brazil, about 35% of live births are early term \\u003csup\\u003e\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e\\u003c/sup\\u003e, corresponding to more than 300 thousand early term births per year, with a higher prevalence in places with cesarean rates above 80% \\u003csup\\u003e32\\u003c/sup\\u003e. In a previous nationwide Brazilian study, early term births, especially non-spontaneous births, were associated with several negative outcomes, such as oxygen use, neonatal ICU admission and neonatal death \\u003csup\\u003e\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThis study has some limitations. As we used data from only one hospital, we cannot extrapolate the observed results to the set of hospitals participating in the PPA, as the local contextual characteristics may have affected the implementation of the recommended actions and the observed effects \\u003csup\\u003e\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u003c/sup\\u003e. In addition, the study is probably underpowered to detect differences in less frequent results due to the small sample size.\\u003c/p\\u003e \\u003cp\\u003eCosts related to the implementation of the PPA were not included, as they were not available. Hospital managers, health plan operators and the project coordination should consider these expenses when deciding to implement the PPA in new maternity services.\\u003c/p\\u003e \\u003cp\\u003eFinally, we used a short time horizon. There is evidence of negative medium and long-term effects associated with cesarean section, both for women and newborns \\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e. There is also evidence of more neonatal complications after hospital discharge in early term births, more frequently observed in the standard of care model.\\u003c/p\\u003e \"},{\"header\":\"Conclusion\",\"content\":\" \\u003cp\\u003eThe PPA model of care was cost-effective in reducing cesarean sections in women in Robson's group 1 to 4 assisted in a Brazilian private hospital, with a higher occurrence of women in labor, with induction of labor, and a lower proportion of early term births.\\u003c/p\\u003e \\u003cp\\u003eIn this hospital, the cost of uncomplicated vaginal births and cesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. Greater reductions in the rate of cesarean sections and neonatal complications, especially in vaginal births, would also lead to more favorable economic results.\\u003c/p\\u003e \\u003cp\\u003eNew studies in Brazilian hospitals located in other macro-regions, in private hospitals not belonging to health operators, and with the inclusion of women with previous cesarean section, are necessary to expand knowledge on the subject and to base future strategies for reducing cesarean sections in public and private hospitals in the country.\\u003c/p\\u003e \"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eANS - National Supplementary Health Agency\\u003c/p\\u003e\\n\\u003cp\\u003eBMI - Body Mass Index\\u003c/p\\u003e\\n\\u003cp\\u003eICU \\u0026ndash; Intensive Care Unit\\u003c/p\\u003e\\n\\u003cp\\u003eIHI - Institute for Health Improvement\\u003c/p\\u003e\\n\\u003cp\\u003eMNM \\u0026ndash; Maternal Near Miss\\u003c/p\\u003e\\n\\u003cp\\u003eNICU \\u0026ndash; Neonatal Intensive Care Unit\\u003c/p\\u003e\\n\\u003cp\\u003eNNM \\u0026ndash; Neonatal Near Miss\\u003c/p\\u003e\\n\\u003cp\\u003ePPA \\u0026ndash; Adequate Childbirth Project\\u003c/p\\u003e\\n\\u003cp\\u003eSMM \\u0026ndash; Severe Maternal Morbidity\\u003c/p\\u003e\\n\\u003cp\\u003eWHO \\u0026ndash; World Health Organization\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\" \\u003cp\\u003e \\u003ch2\\u003eEthics approval and consent to participate\\u003c/h2\\u003e \\u003cp\\u003eThe \\u0026ldquo;Healthy Birth\\u0026rdquo; study was approved by the research ethics committee of the Escola Nacional de Sa\\u0026uacute;de P\\u0026uacute;blica S\\u0026eacute;rgio Arouca/Fiocruz (CAAE research protocol: 1.761.027, approved on January 16, 2017). All women received and signed the Free and Informed Consent Form prior to the interview and all precautions were taken to maintain the confidentiality of the information.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e \\u003cp\\u003eNot applicable\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e \\u003cp\\u003eAll data generated or analysed during this study are included in this published article.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e \\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e \\u003c/p\\u003e \\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003eThis work was supported by fundings from Centro Nacional de Desenvolvimento Cient\\u0026iacute;fico e Tecnol\\u0026oacute;gico (CNPq) and Bill \\u0026amp; Melinda Gates Foundation, Edital MCTI/CNPq/MS/SCTIE/Decit/Funda\\u0026ccedil;\\u0026atilde;o Bill e Melinda Gates N \\u0026deg; 47/2014. The funders had no influence in the identification, design, conduct, and reporting of the analysis.\\u003c/p\\u003e \\u003ch2\\u003eAuthors' contributions\\u003c/h2\\u003e \\u003cp\\u003eRMSMD was responsible for the conception and design of the work, data analysis, discussion of results and elaboration of the manuscript; PML contributed to the analysis and interpretation of data, discussion of results and elaboration of manuscript; BVSA contributed to data analysis and approval of the final version of the manuscript; JAT contributed to the review and approval of the final version of the manuscript; MCL was the researcher responsible for the \\u0026ldquo;Healty Birth\\u0026rdquo; study design and contributed to the review and approval of the final version of the manuscript.\\u003c/p\\u003e \\u003ch2\\u003eAcknowledgements\\u003c/h2\\u003e \\u003cp\\u003eNot applicable.\\u003c/p\\u003e \"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e \\u003cspan\\u003eSouza JP, G\\u0026uuml;lmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean Section Without Medical Indications Is Associated With an Increased Risk of Adverse Short-Term Maternal Outcomes: The 2004\\u0026ndash;2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010;10:8:71.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eMascarello KC, Horta BL, Silveira MF. Maternal complications and cesarean section without indication: systematic review and meta-analysis. Rev Saude Publica. 2017;51:105.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018;392(10155):1349\\u0026ndash;57.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eKeag OE, Norman J, Stock S. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 2018;15(1):e1002494.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2019;393(10184):1973\\u0026ndash;82.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eYe J, Betr\\u0026aacute;n AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41:237\\u0026ndash;44.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSouza JP, Betran AP, Dumont A, de Mucio B, Gibbs Pickens CM, Deneux-Tharaux C, et al. A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study. BJOG. 2016;123(3):427\\u0026ndash;36.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBrasil M, Sa\\u0026uacute;de. Secretaria de Ci\\u0026ecirc;ncia, Tecnologia e Insumos Estrat\\u0026eacute;gicos, Comiss\\u0026atilde;o Nacional de Incorpora\\u0026ccedil;\\u0026atilde;o de Tecnologias no SUS. Diretrizes de Aten\\u0026ccedil;\\u0026atilde;o \\u0026agrave; Gestante: a opera\\u0026ccedil;\\u0026atilde;o cesariana. Bras\\u0026iacute;lia, DF: Conitec, 2016. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://conitec.gov.br/images/Relatorios/2016/Relatorio_Diretrizes-Cesariana_final.pdf\\u003c/span\\u003e\\u003c/span\\u003e. Accessed on May 25, 2020.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eRebelo F, Rocha CMM, Cortes TR, Dutra CL, Kac G. High cesarean prevalence in a national population-based study in Brazil: the role of private practice. Acta Obstet Gynecol Scand. 2010;89:903\\u0026ndash;8.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eDomingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, D\\u0026acute;Orsi E, Pereira APE, et al. Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth. Cad Saude Publica. 2014;30(supl 1):1\\u0026ndash;16.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAg\\u0026ecirc;ncia Nacional de Sa\\u0026uacute;de Suplementar. Parto Adequado. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://www.ans.gov.br/gestao-em-saude/parto-adequado\\u003c/span\\u003e\\u003c/span\\u003e. Accessed on June 27, 2020.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBorem P, de C\\u0026aacute;ssia Sanchez R, Torres J, Delgado P, Petenate AJ, Peres D, et al. A Quality Improvement Initiative to Increase the Frequency of Vaginal Delivery in Brazilian Hospitals. Obstet Gynecol. 2020;135(2):415\\u0026ndash;25.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eThe Breakthrough Series: IHI\\u0026rsquo;s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://www.ihi.org/resources/ Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx\\u003c/span\\u003e\\u003c/span\\u003e. Accessed on June 2nd, 2019.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eTorres JA, Leal MDC, Domingues RMSM, Esteves-Pereira AP, Nakano AR, Gomes ML, et al. Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol. Reprod Health. 2018;15(1):194.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eChaillet N, Dumont A. Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth. 2007;34:53\\u0026ndash;64.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eTorres JA, Domingues RMSM, Sandall J, Hartz ZMA, Gama SGN, Theme-Filha MM, et al. Caesarean section and neonatal outcomes in private hospitals in Brazil: comparative study of two different perinatal models of care. Cad Saude Publica. 2014;30(supl 1):220\\u0026ndash;31. 23.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBorem P, Ferreira JBB, da Silva UJ, Val\\u0026eacute;rio J\\u0026uacute;nior J, Orlanda CMB. Increasing the percentage of vaginal birth in the private sector in Brazil through the redesign of care model. Rev Bras Ginecol Obstet. 2015;37:446\\u0026ndash;54.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eGama SG, Viellas EF, Torres JA, Bastos MH, Br\\u0026uuml;ggemann OM, Theme Filha MM, et al. Labor and birth care by nurse with midwifery skills in Brazil. Reprod Health. 2016;17(Suppl 3):123. 13(.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLeal MC, Pereira APE, Domingues RMSM, Theme-Filha MM, Dias MAB, Nakamura-Pereira M, et al. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica. 2014;30(supl 1):17\\u0026ndash;32.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eRobson MS. Can we reduce the caesarean section rate? Best Pract Res Clin Obstet Gynaecol. 2001;15(1):179\\u0026ndash;94.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eVogel JP, Betr\\u0026aacute;n AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the Robson Classification to Assess Caesarean Section Trends in 21 Countries: A Secondary Analysis of Two WHO Multicountry Surveys. Lancet Glob Health. 2015;3(5):e260-70.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003ePaes AT. Uso de escores de propens\\u0026atilde;o para corrigir diferen\\u0026ccedil;as entre grupos. Educ Contin Sa\\u0026uacute;de einstein. 2012;10(3):103\\u0026ndash;4.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSay L, Souza JP, Pattinson RC. Maternal near miss - towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol. 2009;23:287\\u0026ndash;96.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003ePileggi-Castro C, Camelo JS Jr, Perdon\\u0026aacute; GC, Mussi-Pinhata MM, Cecatti JG, Mori R, et al. Development of criteria for identifying neonatal near-miss cases: analysis of two WHO multicountry cross-sectional studies. BJOG. 2014;121(Suppl 1):110\\u0026ndash;8.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eCosta DDO, Ribeiro VS, Ribeiro MRC, Esteves-Pereira AP, S\\u0026aacute; LGC, Cruz JADS, et al. Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey. Cad Saude Publica. 2019;35(8):e00154918.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eWoods B, Revill P, Sculpher M, Claxton K. Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value Health. 2016;19(8):929\\u0026ndash;35.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAssocia\\u0026ccedil;\\u0026atilde;o Brasileira de Empresas de Pesquisa. Crit\\u0026eacute;rio Brasil de classifica\\u0026ccedil;\\u0026atilde;o econ\\u0026ocirc;mica. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://www.abep.org/criterio-brasil\\u003c/span\\u003e\\u003c/span\\u003e. Accessed on May 25, 2020.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBrasil. Minist\\u0026eacute;rio da Sa\\u0026uacute;de. Secretaria de Ci\\u0026ecirc;ncia, Tecnologia e Insumos Estrat\\u0026eacute;gicos. Departamento de Ci\\u0026ecirc;ncia e Tecnologia. Diretrizes metodol\\u0026oacute;gicas: Diretriz de Avalia\\u0026ccedil;\\u0026atilde;o Econ\\u0026ocirc;mica. 2. ed. Bras\\u0026iacute;lia: Minist\\u0026eacute;rio da Sa\\u0026uacute;de, 2014. 132p. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_metodologicas_diretriz_avaliacao_economica.pdf\\u003c/span\\u003e\\u003c/span\\u003e. Accessed on May 14, 2020.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eMacroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization; 2001. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttp://apps.who.int/iris/bitstream/10665/42435/1/924154550X.pdf\\u003c/span\\u003e\\u003c/span\\u003e. Accessed on May 15, 2020.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eNakamura-Pereira M, do Carmo Leal M, Esteves-Pereira AP, Domingues RM, Torres JA, Dias MA, et al. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13(Suppl 3):128.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLeal MDC, Esteves-Pereira AP, Nakamura-Pereira M, Domingues RMSM, Dias MAB, Moreira ME, et al. Burden of early-term birth on adverse infant outcomes: a population-based cohort study in Brazil. BMJ Open. 2017;7(12):e017789.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eBarros FC, Rabello Neto DL, Villar J, Kennedy SH, Silveira MF, Diaz-Rossello JL, et al. Caesarean sections and the prevalence of preterm and early-term births in Brazil: secondary analyses of national birth registration. BMJ Open. 2018;8(8):e021538.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eDomingues RMSM, Torres JA, Leal MC, Hartz Z. Fatores contextuais na an\\u0026aacute;lise da implanta\\u0026ccedil;\\u0026atilde;o de uma interven\\u0026ccedil;\\u0026atilde;o multifacetada em hospitais privados brasileiros: reflex\\u0026otilde;es iniciais da pesquisa avaliativa \\u0026ldquo;Nascer Saud\\u0026aacute;vel\\u0026rdquo;. Anais do IHMT 2019;Supl 1:S47-S55.\\u003c/span\\u003e \\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":true,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"reproductive-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"reph\",\"sideBox\":\"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)\",\"snPcode\":\"12978\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12978/3\",\"title\":\"Reproductive Health\",\"twitterHandle\":\"@Reprod_Health\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"cesarean delivery, healthcare quality improvement, hospitals medicine, Cost-effectiveness\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-67630/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-67630/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eBackground: In 2015, a quality improvement project of childbirth care called Adequate Birth Project (“Projeto Parto Adequado”- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce cesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital - the model following the recommendations of the PPA and the standard of care model - in reducing the proportion of cesarean sections. \\u003c/p\\u003e\\u003cp\\u003eMethods: We conducted a case study in one of the private hospitals included in the PPA project. The main outcome was the proportion of cesarean section. We used total cost of hospitalization for women and newborns, from the perspective of the health care provider, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of cesarean section and of maternal and neonatal complications. \\u003c/p\\u003e\\u003cp\\u003eResults: 238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the cesarean section probability (88.6% vs 31.7%, p \\u0026lt;0.001) and an increase in the total cost of US$ 67,346.25, which an incremental cost-effectiveness ratio of US$ 1,183.59 per avoided cesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal nearmiss. The cost of uncomplicated vaginal births and cesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. \\u003c/p\\u003e\\u003cp\\u003eConclusion: The quality improvement project of childbirth care “PPA” was cost-effective in reducing cesarean sections in women assisted in a Brazilian private hospital, without increasing severe negative maternal and neonatal outcomes and reducing the frequency of early term births.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Cost-Effectiveness Analysis of A Quality Improvement Program to Reduce Cesarean Sections in Brazilian Private Hospitals: A Case Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2020-09-03 17:22:11\",\"doi\":\"10.21203/rs.3.rs-67630/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Minor revision\",\"date\":\"2021-02-21T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2021-01-31T00:00:00+00:00\",\"index\":3,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-10-20T12:00:00+00:00\",\"index\":2,\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-10-20T12:00:00+00:00\",\"index\":2,\"fulltext\":\"Recommendation: Minor Revision\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\n\\nThe study defined as the primary outcome \\\"proportion of cesarean section\\\":\\nPage 9. lines 15,16:\\n\\\"We used the primary outcome \\\"proportion of cesarean section\\\", including antepartum and intrapartum cesarean sections, obtained from hospital records, to measure effectiveness.\\\"\\nThe study restricted the analysis to the Robson's groups 1 to 4:\\nPage 9. Line 1-2\\n\\\"In this case study, we restricted the analysis to women in the Robson's groups 1 to 4, the current target population of PPA\\\".\\nDespite the implementation of health policies to prevent cesarean section as the first form of delivery in nulliparous women, to face the high rates of cesarean section in Brazil is well defined, the reason for not including the other Robson groups (mainly Robson's group 5) in the study could be better clarified in the methods. Robson's group 5 (multiparous women with previous cesarean section delivery) have the highest live births and cesarean section absolute numbers and the highest contribution to global cesarean section rate among all groups in Brazil. In fact, in \\\"hospitals with atypical models of obstetric care\\\", Robson's group 5 is the one that most contributes to the total percentage of cesarean sections. Reports of adverse results have decreased the tendency of doctors to encourage vaginal birth after cesarean (VBAC). The cause of the decline in the total rate of VBAC in recent decades is unclear, although the fear of legal medical disputes plays a role in this scenario (defensive medicine).\\nTherefore, the non-inclusion of the other Robson Classification groups in the study, especially Robson's group 5, has the potential to interfere in the reduction of cesarean sections, and consequently in the primary outcome results of the research.\\n\\n\\nThe study was highly informative when reporting that the costs reported for implementation were not included.\\nPage 20. Line 9-10\\n\\\"Costs related to the implementation of the PPA were not included, as they were not available. \\\"\\nThe three PPA models for organizing medical work include a multi-disciplinary team from the hospital itself. So, it is interesting to mention that the cost of the PPA is not only in the \\\"implementation\\\", but also in the \\\"maintenance\\\" over the time of these professionals. These costs can play an important role in raising the final costs of this assistance model.\\n\\nThe paper was very well prepared and is extremely important to improve obstetric care. The cesarean epidemic in several countries, including Brazil, and the implementation of healthcare policies to avoid cesarean section is important. The article is particularly important and deserves to be published, as it will have relevant scientific importance.\\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\\n* Level of interest: **An exceptional article**\\n* Quality of written English: **Acceptable**\\n* Declaration of competing interests: **1:No\\n2:No\\n3:No\\n4:No\\n5:NO\\n6: I don’t have any non-financial competing interests in relation to this paper. I have other scientific publications with one of the authors of the article.**\\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\\nI agree to the open peer review policy of the journal**\\n\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-10-20T00:00:00+00:00\",\"index\":1,\"fulltext\":\"Recommendation: Major Revision\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nThank you for asking me to review this very important article. This type of work is very important to implementing service improvements. However, a number of very important methodological concerns need to be addressed.\\n\\nThe quality of written English is very good.\\n\\nAbstract conclusion: Suggest breaking this into at least two sentences or that outcomes you are trying to clarify get lost.\\n\\nThe projected CS rates in the introduction are confusing. Why, if there is no evidence of benefit above 10%, should Brazil's projected national rate be 25-30%. That would mean some countries would be lower to counter-balance this. And why would the demographic using private hospitals mean the rate should be 44%? Presumably, healthier women from higher socio-economic backgrounds use private hospitals at higher rates, and therefore this figure should be lower than the national average? Finally, is 90% the national average, the average in private hospitals, or the figure quoted in some private hospitals?\\n\\nWhy were women with hearing loss excluded? Why are the inclusion / exclusion criteria different from the 'Healthy Birth' study? If they are not, why are they not all listed together in the same place? Why did you exclude women who paid out of pocket?\\n\\nP 10. Why would the hospital be charging providers for complications?\\n\\nHow were women assigned to be cared for by PPA staff or standard care? Randomisation or non-randomised assignment is not discussed. This could introduce bias. The two groups had a statistically significant difference in desire for vaginal birth, which undoubtedly affected the difference in CS rate observed between groups.\\n\\nWhy were women interviewed and then excluded? Why were exclusion criteria not applied before interviews? This could introduce bias if the exclusions were applied retrospectively.\\n\\nWhy is the primary outcome the last outcome discussed?\\n\\nI am concerned to see that women were less satisfied with their care and were exposed to more violence in the PPA model. This is not discussed in the findings or discussion. Why? How was satisfaction with care factored into the cost-effectiveness model?\\n\\nWhy is this study called a case study and not a cost effectiveness study?\\n\\nI don't really understand what parameters were used to decide that the intervention was cost effective. I am very interested in this analysis, but from the methodological information provided, I am not sure how it would be reproduced and why an intervention that costs more was considered cost-effective.\\n\\nWhy was no information provided on the costs of training the staff? This seems a major oversight and not particularly difficult to collect.\\n\\nI don't see how it benefits hospitals to adopt this model in a private healthcare system.\\n\\nWhy is a model for calculating cost-effectiveness not included with the paper\\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\\n* Level of interest: **An article of importance in its field**\\n* Quality of written English: **Acceptable**\\n* Declaration of competing interests: **I declare that I have no competing interests.**\\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). 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