Objective: The current study aimed to describe risk factors for adverse perinatal outcomes (APOs) among pregnant women nonvaccinated for COVID-19 who had respiratory symptoms. Methods: A nested case-control study was performed within the REBRACO (in Portuguese, the Brazilian Network of COVID-19 During Pregnancy) initiative. Women were recruited during pregnancy in 15 maternity hospitals in Brazil from February 1, 2020, to February 28, 2021, while seeking medical care for respiratory symptoms, and were followed up until childbirth regardless of confirmation of COVID-19. For this analysis, women were divided into two groups: (1) those with APOs, defined as the occurrence of fetal or neonatal death, preterm delivery, 5-min Apgar score <7, neonatal respiratory distress, neonatal mechanical ventilation, admission to the neonatal intensive care unit, small-for-gestational-age newborn, or any neonatal morbidity; and (2) those without APOs. Results: The total number of women included in this analysis was 481, with 210 having APOs (43.7%). The characteristics independently associated with APOs were a composite outcome of severe acute respiratory syndrome, maternal admission at the intensive care unit, or maternal death (relative risk [RR], 3.30 [95% confidence interval (CI), 1.38-7.89]), living in the North and Northeastern regions of Brazil (RR, 3.09 [95% CI, 1.13-8.41]), and pre-eclampsia (RR, 2.77 [95% CI, 1.19-6.43]). Conclusion: Severe maternal illness was strongly associated with APO regardless of COVID-19 confirmation. It is essential to provide sufficient and timely health care for women who have respiratory symptoms compatible with COVID-19.

OBJECTIVE:The current study aimed to describe risk factors for adverse perinatal outcomes (APOs) among pregnant women nonvaccinated for COVID-19 who had respiratory symptoms. METHODS:A nested case-control study was performed within the REBRACO (in Portuguese, the Brazilian Network of COVID-19 During Pregnancy) initiative. Women were recruited during pregnancy in 15 maternity hospitals in Brazil from February 1, 2020, to February 28, 2021, while seeking medical care for respiratory symptoms, and were followed up until childbirth regardless of confirmation of COVID-19. For this analysis, women were divided into two groups: (1) those with APOs, defined as the occurrence of fetal or neonatal death, preterm delivery, 5-min Apgar score <7, neonatal respiratory distress, neonatal mechanical ventilation, admission to the neonatal intensive care unit, small-for-gestational-age newborn, or any neonatal morbidity; and (2) those without APOs. RESULTS:The total number of women included in this analysis was 481, with 210 having APOs (43.7%). The characteristics independently associated with APOs were a composite outcome of severe acute respiratory syndrome, maternal admission at the intensive care unit, or maternal death (relative risk [RR], 3.30 [95% confidence interval (CI), 1.38-7.89]), living in the North and Northeastern regions of Brazil (RR, 3.09 [95% CI, 1.13-8.41]), and pre-eclampsia (RR, 2.77 [95% CI, 1.19-6.43]). CONCLUSION:Severe maternal illness was strongly associated with APO regardless of COVID-19 confirmation. It is essential to provide sufficient and timely health care for women who have respiratory symptoms compatible with COVID-19.

Objective: To compare access and suitability of antenatal care between years 2020 and 2022 among postpartum individuals at a Hospital in Florianopolis, and evaluate factors associated with antenatal suitability. Methods: Observational, cross-sectional, and quantitative study carried out in 2022. Collected data were compared with the database of a previous similar study carried out in the same setting in 2020. Data were extracted from medical records and prenatal booklets, in addition to a face-to-face questionnaire. Adequacy was measured using the Carvalho and Novaes index and health access was qualitatively evaluated. Socio-demographic and antenatal variables were analyzed. A statistical significance level of 0.05 was considered. Open-ended questions were categorized for analysis. Results: 395 postpartum individuals were included. Antenatal care was adequate for 48.6% in 2020 and 69.1% in 2022. Among the barriers to access, 56% reported difficulty in scheduling appointments and/or exams and 23% complained of reduced healthcare staff due to strikes, COVID-19, among others. Adequate antenatal care was associated with being pregnant in 2022, being referred to highrisk units [PNAR], and not reporting difficulties in access. Also, it was associated with twice the chance of investigation for gestational diabetes [GDM] and syphilis. Conclusion: The 2022 post-vaccination period showed higher antenatal adequacy. The main difficulty for postpartum individuals was scheduling appointments and/or exams. Having antenatal care in 2022, no reports of difficulty in access, and follow-up at a high-risk unit were associated with antenatal adequacy.

Key points• It is essential to resume teaching external cephalic version and obstetric maneuvers in vaginal breech birth, both in lithotomy and in the vertical position.• The adoption of strict protocols for planned vaginal breech birth correlates with a success rate of approximately 70% and adverse outcome rates of less than 7%.Fetal and neonatal morbidity and mortality are similar to those of a planned cesarean section.• Pregnant women eligible for vaginal breech birth must agree to the mode of delivery, be at low risk of complications and have assistance of professionals with experience in vaginal birth of abnormal presentations and in obstetric maneuvers.• Previous cesarean section and prematurity between 32 and 36 weeks are not absolute contraindications to vaginal breech birth and must be individually evaluated when deciding on the route of delivery.• Neonatologists must be present at the birth of breech fetuses, and a complete neonatal examination must be performed.• Posterior rotation of the fetal back, prolapse of the umbilical cord, deflection of the arms and/or cephalic pole and retention of the after-coming head are the main dystocias related to vaginal breech birth assistance.Every professional assisting vaginal breech births must be trained to adequately resolve these events.• In vaginal breech birth in lithotomy, the main maneuvers to help in the delivery of the fetal pelvis are bidigital inferior traction on the inguinal region and the Pinard maneuver; for the release of the fetal trunk, those of Rojas, Deventer-Miler and Pajot; and for the release of the after-coming head, those of Mauriceau, Bracht, Champetier de Ribes and Prague and operative vaginal delivery with Piper's forceps.• Non-lithotomic positions in vaginal breech birth are associated with reduced dilation and expulsion periods, need for maneuvers for fetal extraction, as well as reduced rates of cesarean sections and neonatal injuries.• In vaginal breech birth assisted in the all fours position, the aspects to be observed during delivery of the fetal body include the fetal muscle tone of lower limbs, the correct rotation of the fetal trunk (fetal abdomen facing the maternal back), vascular engorgement of the umbilical cord, the presence of elbows and folds of the fetal chest and maternal anal dilatation.• In vaginal breech births assisted in the all fours position, more than half of fetuses are delivered without the need for any maneuver.Usually, only two maneuvers may be necessary: one to help release the shoulders (180°-90° rotation) and another to release the fetal head (Frank's nudge). Recommendatios• In order to prevent cesarean sections and dystocia associated with vaginal breech birth, the external cephalic version, when available, should be offered to pregnant women who reach term with their fetuses in breech presentation.• The mode of delivery in breech presentation must be an informed choice, defined according to the values and preferences of the parturient woman, the experience, values and preferences of the care team, adequacy of obstetric and neonatal care conditions, and assessment of benefits and risks of approaches.• Pregnant women without pelvic abnormalities or defects, fetuses in incomplete breech (Frank breech) or complete breech presentation, weighing between 2,000 and 4,000 g, excluding intrauterine growth re-

BackgroundPregnant and postpartum women infected by COVID-19 are at increased risk of adverse outcomes, including negative effects on their mental health. Brazilian maternal mortality rate due to COVID-19 is 2.5 times higher than overall mortality rates. This study aimed to understand how pregnant/postpartum women experienced the COVID-19 suspicion/investigation or confirmed infection in different Brazilian cities, the pandemic's consequences to women and their families, and their needs to improve maternal health services during public health emergencies.MethodsWe conducted a qualitative study with 27 women with COVID-19 and 6 of their family members, as part of a multicenter study among 15 maternity hospitals in Brazil. We applied in-depth interviews through telephone calls when women received the diagnostic or had a suspect infection and after 60 days. Another semi-structured interview was applied to their close family members. The interviews were considered through thematic analysis.ResultsFrom the thematic content analysis three major themes emerged from the first and second interviews: (Cucinotta and Vanelli, 2020) assistance received by the woman and newborn in the medical services; (World Health Organization (WHO) 2021) stigma/fear of contamination from health workers and from family and friends reported by the women; (Allotey et al., 2020) the COVID-19 pandemic impact.ConclusionBefore the availability of the COVID-19 vaccine, pregnant women experienced fear of death, hospitalization, quarantine, loss of family members, and financial repercussions, resulting in physical, psychological, and socioeconomic impacts on these women's lives.

Objective To evaluate the impact of the race (Black versus non-Black) on maternal and perinatal outcomes of pregnant women with COVID-19 in Brazil.Methods This is a subanalysis of REBRACO, a Brazilian multicenter cohort study designed to evaluate the impact of COVID-19 on pregnant women. From February 2020 until February 2021, 15 maternity hospitals in Brazil collected data on women with respiratory symptoms. We selected all women with a positive test for COVID-19; then, we divided them into two groups: Black and non-Black women. Finally, we compared, between groups, sociodemographic, maternal, and perinatal outcomes. We obtained the frequency of events in each group and compared them using X2 test; p-values < 0.05 were considered significant. We also estimated the odds ratio (OR) and confidence intervals (CI).Results 729 symptomatic women were included in the study; of those, 285 were positive for COVID-19, 120 (42.1%) were Black, and 165 (57.9%) were non-Black. Black women had worse education (p = 0.037). The timing of access to the health system was similar between both groups, with 26.3% being included with seven or more days of symptoms. Severe acute respiratory syndrome (OR 2.22 CI 1.17-4.21), intensive care unit admission (OR 2.00 CI 1.07-3.74), and desaturation at admission (OR 3.72 CI 1.41-9.84) were more likely to occur among Black women. Maternal death was higher among Black women (7.8% vs. 2.6%, p = 0.048). Perinatal outcomes were similar between both groups.Conclusion Brazilian Black women were more likely to die due to the consequences of COVID-19.

Dear Editor, We have read with interest the article by Silva et al.1 The study concluded that in a real-life setting there was no difference in the intensity of labor pain between patients who used nonpharmacologicalmethods during the active phase of labor and those who did not. We appreciate the efforts of the research team, as their study undoubtedly contributes to enhance knowledge about labor and childbirth care. We find it crucial to highlight the widespread use of non-pharmacologicalmethods for pain control in the institution inwhich the study was conducted, a highly recommended practice2 that is not frequently available in Brazilian settings.3 Whilewe acknowledge the importance of their results, we would like to raise some concerns we believe are relevant for a more accurate understanding of their findings. Measuring pain is challenging because pain is a personal, subjective, andmultifaceted experience. Labor pain presents additional difficulties because of all the emotions and concerns involved in the process, the duration of the painful sensations (which can last several hours), and the increasing intensity of the pain during the progression of dilation and fetus descent through the maternal pelvis.4,5 We have considered that one single evaluation using the Visual Analog Scale (VAS) after the deliverywould not suffice to measure all multifaceted, variable, and usually longlasting aspects of labor pain. In most of the studies using VAS included in the Cochrane Systematic Reviews, the tool was applied several times throughout the course of labor and/or before and after the intervention.6,7 Additionally, although the VAS is widely used, more comprehensive instruments that enable multidimensional assessments of pain and the experience of the parturient are necessary.5 Furthermore, regarding the interpretation of results, it would be important to consider not only pain, but also satisfaction, the perception of a safe environment, personal achievement, and situation control.8,9 Moreover, there is a comparative issue that needs to be taken into consideration. The study compares groups that are not analogous in terms of the time of exposure to nonpharmacological methods. It is important to note that one group had little to no time to become familiar with the resources, and even use them, while the other group had a more extensive opportunity to become familiar with the pain control methods, and a longer active phase period. Moreover, the abstract and conclusions of the aforementioned study may lead readers to believe that non-pharmacological methods are ineffective, when the measurement of painwas imprecise, and the groupswere not comparable.We

Brazil presented a very high number of maternal deaths and evident delays in healthcare. We aimed at evaluating the characteristics of SARS-CoV-2 infection and associated outcomes in the obstetric population. We conducted a prospective cohort study in 15 Brazilian centers including symptomatic pregnant or postpartum women with suspected COVID-19 from Feb/2020 to Feb/2021. Women were followed from suspected infection until the end of pregnancy. We analyzed maternal characteristics and pregnancy outcomes associated with confirmed COVID-19 infection and SARS, determining unadjusted risk ratios. In total, 729 symptomatic women with suspected COVID-19 were initially included. Among those investigated for COVID-19, 51.3% (n = 289) were confirmed COVID-19 and 48% (n = 270) were negative. Initially (before May 15th), only 52.9% of the suspected cases were tested and it was the period with the highest proportion of ICU admission and maternal deaths. Non-white ethnicity (RR 1.78 [1.04–3.04]), primary schooling or less (RR 2.16 [1.21–3.87]), being overweight (RR 4.34 [1.04–19.01]) or obese (RR 6.55 [1.57–27.37]), having public prenatal care (RR 2.16 [1.01–4.68]), planned pregnancies (RR 2.09 [1.15–3.78]), onset of infection in postpartum period (RR 6.00 [1.37–26.26]), chronic hypertension (RR 2.15 [1.37–4.10]), pre-existing diabetes (RR 3.20 [1.37–7.46]), asthma (RR 2.22 [1.14–4.34]), and anaemia (RR 3.15 [1.14–8.71]) were associated with higher risk for SARS. The availability of tests and maternal outcomes varied throughout the pandemic period of the study; the beginning was the most challenging period, with worse outcomes. Socially vulnerable, postpartum and previously ill women were more likely to present SARS related to COVID-19.

"Letter to the editor regarding the article: COVID-19 and maternal, fetal and neonatal mortality: a systematic review." The Journal of Maternal-Fetal & Neonatal Medicine, 35(19), pp. 3831–3832 Disclosure statementThe authors report no conflicts of interest

The progressive incidence of obesity and diabetes has determined the contemporary increase in shoulder dystocia incidence.

Objective: To evaluate the prevalence of preeclampsia among cases of COVID-19 infection during pregnancy and the association between both conditions, in a multicenter cohort of Brazilian women with respiratory symptoms. Study design: Ancillary analysis of the Brazilian Network of COVID-19 in Obstetrics (REBRACO) study. We performed a nested case-control analysis selecting all women with COVID-19 and compared outcomes between women with and without PE. Main outcomes: Maternal, gestational, and clinical characteristics and perinatal outcomes. Measures: Prevalence ratio (PR) and its 95%CI for each of the predictors and outcomes. Results: A total of 203 women were included: 21 (10.3%) in PE group and 182 (89.7%) in non-PE group. Preeclampsia was not different among women with and without COVID-19 (10.3% vs 13.1%, p-value = 0.41), neither complication such as eclampsia and HELLP syndrome. Chronic hypertension (33.4%) (p < 0.01) and obesity (60.0%) (p = 0.03) were the most frequent comorbidities in PE group, and they were significantly more frequent in this group. Women with PE had more cesarean section (RR 5.54 [1.33 - 23.14]) and their neonates were more frequently admitted to neonatal intensive care unit (PR 2.46[1.06 - 5.69]), most likely due to preterm-birth-related complications. Conclusion: The prevalence of PE among women with COVID-19 infection during pregnancy was around 10%; women with COVID-19 and a history of chronic hypertension or obesity are more likely to have preeclampsia. Cesarean section is increased among women with PE and COVID-19, with increased rates of neonatal admission to intensive care units, mostly due to prematurity.

Abstract Introduction Brazil is a country of continental dimensions with a great challenge to ascertain adequate healthcare throughout regions. The country registered increased numbers of maternal deaths and adverse perinatal outcomes in pregnant and postpartum women with COVID-19 infection, rising great concern. There is scarce data on findings among public versus private settings. Objective to compare maternal and perinatal outcomes in pregnant and postpartum women with SARS-CoV-2 infection, among admissions in public and private maternity hospitals during a period before vaccination. Study Design Secondary analysis of the REBRACO initiative, a national multicenter cohort study in Brazil, considering pregnant and postpartum women with suspected or confirmed COVID-19 infections (from February 2020 to February 2021) in 15 maternity centers (2 private and 13 public facilities). Sociodemographic and obstetric characteristics were compared according to the type of hospital care. In addition, clinical, laboratory findings and maternal and perinatal outcomes were compared in both groups. The prevalence ratio (PR) and its 95%CI for each predictor and outcome were calculated. Results Of 559 symptomatic cases tested, 289 confirmed COVID-19 cases were included, with 213 (72.7%) women in public hospitals and 76 (27.3%) women in private hospitals. SARS-CoV-2 infection frequency was not significantly different among groups. Women treated at public hospitals had lower schooling (p < 0.001), and half of them declared that their pregnancy was not planned. There were 13 maternal deaths among women treated at public services and no maternal deaths among pregnant women treated at private hospitals (p-value – 0,024). Pregnant women in public hospitals had higher rates of fever (p-value – 0,041), tachypnea (p-value – 0,003), abnormal laboratory findings in liver enzymes (p-value – 0,005), severe acute respiratory syndrome SARS (p-value 0.014) and their neonates presented more neonatal respiratory distress (p-value – 0,020). Conclusion Adverse maternal and perinatal outcomes were worse in the public hospital group with increased rates of severe acute respiratory syndrome and neonatal respiratory distress. The alarming difference between the number of deaths in patients treated in the public and private sector calls attention to the need to better understand the differences in access to health and other delays experienced by patients of different social levels.

INTRODUCTION:The aim of this study was to evaluate the clinical, epidemiological and laboratory aspects of SARS-CoV-2 infection during pregnancy and postpartum in 16 maternity hospitals.METHODS AND ANALYSIS:A prospective multicentre study, with five axes. First, the prevalence of SARS-CoV-2 infection among women admitted for childbirth will be described in a cross-sectional study. Second, maternal and perinatal outcomes will be assessed in a prospective cohort study including pregnant or postpartum women with suspected COVID-19. Third, a cohort of positive COVID-19 cases with sampling of a variety of biological material. Histopathological and viral analysis of biological maternal and neonatal samples will be performed, and the assessment of nutritional variables to evaluate the association between vitamin D and severity of infection. Fourth, a monitoring and evaluation committee to collect relevant healthcare information and plan actions in centres facing the pandemic. Furthermore, qualitative studies will be performed to study pregnant women, their families and health professionals. Fifth, an ecological study will monitor the number of live births, stillbirths and other outcomes to explore any trend among the periods before, during and after the pandemic. Data will systematically be collected in an electronic platform following standardised operational procedures. For quantitative study components, an appropriate statistical approach will be used for each analysis. For qualitative data, in-depth interviews recorded in audio will be transcribed, checking the text obtained with the recording. Subsequently, thematic analysis with the aid of the NVivo programme will be performed.ETHICS AND DISSEMINATION:Ethical approval was obtained (letters of approval numbers 4.047.168, 4.179.679 and 4.083.988). All women will be fully informed to sign the consent form before enrolment in the study. Findings will be disseminated through peer-reviewed journals and scientific conferences.

Introduction The 2016 WHO antenatal guidelines propose evidence-based recommendations to improve maternal outcomes. We aim to complement these recommendations by describing and estimating the effects of the interventions recommended by WHO on maternal well-being or functioning. Methods and analysis We will conduct a systematic review of experimental and quasi-experimental studies evaluating women’s well-being or functioning following the implementation of evidence-based antenatal interventions, published in peer-reviewed journals through a 15-year interval (2005–2020). The lead reviewer will screen all records identified at MEDLINE, EMBASE, CINAHL Plus, LILACS and SciELO. Two other reviewers will control screening strategy quality. Quality and risk of bias will be assessed using a specially designed instrument. Data synthesis will consider the instruments applied, how often they were used, conditions/interventions for positive or negative effects documented, statistical measures used to document effectiveness and how results were presented. A random-effects meta-analysis comparing frequently used instruments may be conducted. Ethics and dissemination The study will be a systematic review with no human beings’ involvement, therefore not requiring ethical approval. Findings will be disseminated through peer-reviewed publication and scientific events. PROSPERO registration number CRD42019143436.

OBJECTIVE:To understand the childbirth experience of women assisted in a maternity hospital signatory of the Adequate Childbirth Project.METHODOLOGY:Mixed study, carried out in 2018. Applied the Free Word Association Test in 62 pregnant women and then conducted an open interview with 18 of them, then puerperal women, and, for analysis, the Central Nucleus Theory, Word Cloud, and thematic Categories, respectively.RESULTS:The predominant words revealed in the quantitative stage were: pain, wonderful, recovery, anxiety, and desires. The qualitative analysis is presented by thematic categories "Women's insecurities in the PPA model" and "New perspectives from experience in the PPA model".CONCLUSIONS:The women's experiences demonstrated that the model favored the remodeling of childbirth care. However, they still experience pain, dissatisfaction, and lack of autonomy. The impossibility of choosing a trusted professional was a source of insecurity, and nurses had no voice in decisions and actions in care.

Objective To compare risk of death due to COVID-19 among pregnant, postpartum, and non-pregnant women of reproductive age in Brazil, using the severe acute respiratory syndrome surveillance system (SARS-SS). Methods A secondary analysis was performed of the Brazilian official SARS-SS, with data retrieved up to August 17, 2020. Cases were stratified by pregnancy status, risk factors or co-morbidities, and outcome (death or recovery). Multiple logistic regression was employed to examine associations between independent variables and risk of death. Results A total of 24 805 cases were included, with 3129 deaths (12.6%), including 271 maternal deaths. Postpartum was associated with increased risk of death, admission to the intensive care unit (ICU), and mechanical ventilation. Co-morbidities with higher impact on case fatality rate among non-obstetric cases were cancer and neurological and kidney diseases. Among pregnant women, cancer, diabetes mellitus, obesity, and rheumatology diseases were associated with risk of death. In the postpartum subgroup, age over 35 years and diabetes mellitus were independently associated with higher chance of death. Conclusion Postpartum was associated with worse outcomes among the obstetric population, despite lower risk of dying without accessing ICU care. Non-pregnant women with cancer, neurological diseases, and kidney diseases have a higher risk of death due to COVID-19.

BackgroundFor most parents, getting pregnant means having a child. Generally, the couple outlines plans and has expectations regarding the baby. When these plans are interrupted because of a perinatal loss, it turns out to be a traumatic experience for the family. Validating the grief of these losses has been a challenge to Brazilian society, which is evident considering the childbirth care offered to bereaved families in maternity wards. Positively assessed care that brings physical and emotional memories about the baby has a positive impact on the bereavement process that family undergoes. Therefore, this study aims to assess the effects supportive guidelines have on mental health. They were designed to assist grieving parents and their families while undergoing perinatal loss in public maternities in Ribeirão Preto, São Paulo state, Brazil. MethodA mixed-methods (qualitative/quantitative), quasi-experimental (before/after) study. The intervention is the implementation of bereavement supportive guidelines for women who experienced a stillbirth or a neonatal death. A total of forty women will be included. Twenty participants will be assessed before and twenty will be assessed after the implementation of the guidelines. A semi-structured questionnaire and three scales will be used to assess the effects of the guidelines. Health care professionals and managers of all childbirth facilities will be invited to participate in focus group interviews. Data will be analyzed using statistical tests, as well as thematic analysis approach. DiscussionThe Brazilian Perinatal Bereavement guidelines are a local adaptation of the Canadian and British corresponding guidelines. These guidelines have been developed based on the families’ needs of baby memories during the bereavement process and include the following aspects: (1) Organization of care into periods, considering their respective needs along the process; (2) Creation of the Bereavement Professional figure in maternity wards; (3) Adequacy of the institutional environment; (4) Communication of the guidance; (5) Creation of baby memories. We expect that the current project generates additional evidence for improving the mental health of women and families that experience a perinatal loss. Trial registrationClinical trial registry (waiting approval)

Em diversos países, a atenção primária às gestantes é conduzida por enfermeiras obstetras e/ou obstetrizes. No Sistema Suplementar de Saúde no Brasil, a cobertura da assistência pré-natal é obrigatória e realizada por médicos obstetras. O objetivo deste estudo é conduzir análise de custo-efetividade, comparando desfechos clínicos e custos associados à incorporação do pré-natal por enfermeiras obstetras e obstetrizes no âmbito do Sistema de Saúde Suplementar, sob a perspectiva da operadora de planos de saúde como fonte pagadora. Foi construída uma árvore de decisão, baseada nos dados de metanálise da Colaboração Cochrane que mostrou redução do risco de parto prematuro no grupo de gestantes de risco habitual acompanhado por enfermeiras obstetras e obstetrizes. Foram considerados apenas os custos médicos diretos cobertos pelas operadoras de planos de saúde para a realização de consultas e exames essenciais, conforme protocolo do Ministério da Saúde vigente. Assumiu-se custo unitário de consulta com cada profissional como iguais e aplicou-se um aumento do custo global com exames pré-natais associado ao acompanhamento médico, conforme dado obtido na literatura. Estimou-se a razão de custo-efetividade incremental de -R$ 10.038,43 (economia de R$ 10.038,43) por parto prematuro evitado. Esse resultado mostrou-se consistente nas análises de sensibilidade, com economias associadas à substituição variando de -R$ 2.544,60 até -R$ 31.807,46 por parto prematuro evitado. Como conclusão, observou-se que o cuidado pré-natal por enfermeiras obstetras e obstetrizes é superior ao prestado por médicos obstetras para o desfecho prevenção de parto prematuro, resultando ainda em economia de recursos.