Measuring harm-free care in childbirth: a pilot application of the maternity safety thermometer in Brazil


  • Bruna Dias Alonso aRM, BSc, MSc, PhD. Department of Health, Life Cycles, and Society; School of Public Health, University of São Paulo, Brazil. Midwifery course; School of Arts, Sciences and Humanities, University of São Paulo, Brazil.
  • Denise Yoshie Niy bMSc, PhD. Department of Health, Life Cycles, and Society; School of Public Health, University of São Paulo, Brazil.
  • Eder Lucio da Fonseca dMSc, PhD. John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, USA.
  • Cláudia de Azevedo Aguiar cBSc, MSc, PhD. Department of Public Health, Federal University of Triângulo Mineiro, Brazil.
  • Jane Sandall eBSc, MSc, PhD. Department of Women and Children’s Health, Faculty of Life Sciences and Medicine, King’s College London, UK.
  • Carmen Simone Grilo Diniz fMD, MSc, PhD. Department of Health, Life Cycles, and Society; Public Health School of University of São Paulo, Brasil.



Hospitals, Maternity, Patient Safety, Outcome Assessment, Health Care


Introduction: In Brazil, interventions during labor and childbirth are harmful and, for the most part, unnecessary. In addition, there is a high prevalence of abuse and disrespect for women and babies during this period.

Objective: To describe the prevalence of maternal and neonatal harm and harm-free care in a Brazilian maternity setting.

Methods: Pilot application of the Portuguese version of Maternal Safety Thermometer (MST) by a cross-sectional study in a public setting. Data collection was made at two timepoints.

Results: 140 women were included. Over 84% of women had a postpartum sutured wound, resulting from a caesarean section, an episiotomy, or a perineal trauma. Puerperal infection, especially on a caesarean wound, was the most frequent physical harm. Women’s perception of safety, including being left alone in labour, and feeling their safety concerns were not taken seriously, decreased from 80.6% to 43.3% in the second timepoint. Using the MST helped to improve the quality of medical records since critical information about a patient’s health status was not properly recorded, or even absent.

Conclusion: MST is a concise tool and includes indicators related to harm-free care in a short time range. However, this study suggests that the MST can underestimate harm if it is used alone to assess harm-free care in maternities with excessive levels of intervention, and poor reporting of harms (i.e., blood loss), as in most Brazilian settings.


Download data is not yet available.


Brasil, Ministério da Saúde. DATASUS/SINASC-Sistema de Informações sobre Nascidos Vivos. Accessed October 21, 2019.

Leal MC, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, Gama SGN. Intervenções obstétricas durante o trabalho de parto e parto em mulheres Brasileiras de risco habitual. Cad Saude Publica 2014; 30. DOI:10.1590/0102-311X00151513

WHO. The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: WHO, 2014.

Hotimsky SN, de Aguiar JM, Venturi GA. Violência institucional no parto em maternidades brasileiras. In: Venturi G, Godinho T (Org.). Mulheres brasileiras e gênero nos espaços público e privado: uma década de mudanças na opinião pública. São Paulo: Perseu Abramo; Sesc, 2013.

Pacagnella RC, Nakamura-Pereira M, Gomes-Sponholz F, Aguiar RALP, Guerra GVQL, Diniz CSG, Campos BBNS, Amaral EM, Moraes Filho OB. Maternal mortality in Brazil: Proposals and strategies for its reduction. Rev. Bras. Ginecol. e Obstet. 2018; 40: 501–6. DOI: 10.1055/s-0038-1672181

Power M, Stewart K, Brotherton A. What is the NHS safety thermometer? Clin Risk. 2012;18:163–9. DOI: 10.1258/cr.2012.012038

Davis-Floyd RE, Sargent CF. Childbirth and authoritative knowledge. London: University of California Press, 1997.

Miller S et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet, 2016; vol. 388, 2176-2192. DOI: 10.1016/S0140-6736(16)31472-6

Viacava F, De Oliveira RAD, Carvalho C de C, Laguardia J, Bellido JG. SUS: Supply, access to and use of health services over the last 30 years. Cienc e Saude Coletiva 2018; 23: 1751–62. DOI: 10.1590/1413-81232018236.06022018

Diniz SG, d’Oliveira AFP L, Lansky S. Equity and women’s health services for contraception, abortion and childbirth in Brazil. Reproductive Health Matters, 2012, 20(4): 84-101. DOI: 10.1016/S0968-8080(12)40657-7

Anvisa. Resolução RDC nº 36, de 25 de julho de 2013. Institui ações para a segurança do paciente em serviços de saúde e dá outras providências. Brasília, DF: Anvisa, 2013.

Anvisa. Serviços de atenção materna e neonatal: segurança e qualidade. Brasília, DF: Anvisa, 2014.

WHO. Standards for improving quality of maternal and newborn care in health facilities. Geneva: WHO, 2016.

NHS. Maternity Safety Thermometer. 2015. Accessed October 21, 2019.

Melo, CR de. Crosscultural adaptation of the Maternity Safety Thermometer to the Brazilian Portuguese language. 2015. 291p. Thesis (Ph.D.). Post-Graduate Program in Nursing, Federal University of Santa Catarina, Florianópolis, 2015.

Salgado HO, Queiroz MR, dos Santos HG, Andreucci CB, Diniz CSG. Using the Maternity Safety Thermometer to estimate harm-free care in Southeast Brazil: A hospital-based cohort. Birth Published Online First: 3 October 2019. DOI: 10.1111/birt.12454

Diniz CSG, Bussadori JCC, Lemes LB, Moisés ECD, Prado CAC, McCourt C. A change laboratory for maternity care in Brazil: Pilot implementation of Mother Baby Friendly Birthing Initiative, Medical Teacher, 2020. DOI: 10.1080/0142159X.2020.1791319

International Federation of Gynecol. Mother−baby friendly birthing facilities. Int J Gynecol Obstet 2015;128:95–9. DOI: 10.1016/j.ijgo.2014.10.013

Engeström Y, Sannino A, Virkkunen J. On the methodological demands of formative interventions. Mind, Cult. Act. 2014; 21: 118–28. DOI: 10.1080/10749039.2014.891868.

Serruya SJ, Cecatti JG, Lago T di G. The Brazilian Ministry of Health’s Program for Humanization of Prenatal and Childbirth Care: preliminary results. Cad. Saúde Pública, 2004; 5: 1281-1289. DOI: 10.1590/S0102-311X2004000500022

GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1775–812. DOI: 10.1016/S0140-6736(16)31470-2

Diaz V, Abalos E, Carroli G. Methods for blood loss estimation after vaginal birth. Cochrane Database Syst. Rev. 2018; 2018. DOI: 10.1002/14651858.CD010980.pub2

Betran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-Tharaux C, Oladapo OT, Souza JP, Özge T, Vogel JP, Gülmezoglu AM. What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reprod. Health 2015; 12. DOI: 10.1186/s12978-015-0043-6

WHO. Care in normal birth: a practical guide. Geneva: WHO, 1996.

WHO. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: WHO, 2018.

Amorim M M, Coutinho I C, Melo I, Katz L. Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial. Reprocutive Health, 14 (55), 2017. DOI: 10.1186/s12978-017-0315-4

Axelsson D, Brynhildsen J, Blomberg M. Postpartum infection in relation to maternal characteristics, obstetric interventions and complications. J Perinat Med 2018; 46: 271–8. DOI: 10.1515/jpm-2016-0389

Chang SR, Chen KH, Lin HH, Chao YMY, Lai YH. Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study. Int J Nurs Stud 2011; 48: 409–18. DOI: 10.1016/j.ijnurstu.2010.07.017

Diniz CSG, Rattner D, d’Oliveira AFPL, Aguiar JM, Niy DY. Disrespect and abuse in childbirth in Brazil: social activism, public policies and providers’ training. Reprod. Health Matters 2018; 26: 19–35. DOI: 10.1080/09688080.2018.1502019

Dias MAB, Domingues RMSM, Schilithz AOC, Nakamura-Pereira M, Diniz CSG, Brum IR, Martins AL, Theme Filha MM, Gama SGN, Leal M do C. Incidence of maternal near miss in hospital childbirth and postpartum: data from the Birth in Brazil study. Cad Saude Publica 2014; 30: S169–81. DOI: 10.1590/0102-311x00154213

Gundersen TD, Krebs L, Loekkegaard ECL, Rasmussen SC, Glavind J, Clausen TD. Postpartum urinary tract infection by mode of delivery: A Danish nationwide cohort study. BMJ Open 2018; 8. DOI: 10.1136/bmjopen-2017-018479

Mascarello KC, Matijasevich A, Santos IDS dos, Silveira MF. Early and late puerperal complications associated with the mode of delivery in a cohort in Brazil. Rev Bras Epidemiol 2018; 21. DOI: 10.1590/1980-549720180010

Sandall J, Tribe RM, Avery L, Mola G, Visser GHA, Homer CSE, Gibbons D, Kelly NM, Kennedy HP, Kidanto H, Taylor P, Temmerman M. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018; 392: 1349–57. DOI: 10.1016/S0140-6736(18)31930-5

Saccone G, Della Corte L, Maruotti GM, Quist-Nelson J, Raffone A, De Vivo V, Esposito G, Zullo F , Berghella V. Induction of labor at full-term in pregnant women with uncomplicated singleton pregnancy: A systematic review and meta-analysis of randomized trials. Acta Obstet. Gynecol. Scand. 2019. DOI: 10.1111/aogs.13561

Lansky S, Friche A de AL, da Silva AAM, Campos D, Bittencourt DAS, Carvalho ML, Frias PG, Cavalcante RS, Cunha AJLA. Birth in Brazil survey: Neonatal mortality profle, and maternal and child care. Cad Saude Publica 2014; 30. DOI: 10.1590/0102-311X00133213

Moreira MEL, Gama SGN da, Pereira APE, Silva AAM, Lansky S, Pinheiro RS, Gonçalves AC, Leal MC. Clinical practices in the hospital care of healthy newborn infant in Brazil. Cad Saude Publica 2014; 30: S128–39. DOI: 10.1590/0102-311x00145213

Rance S, Mccourt C, Rayment J, Mackintosh N, Carter W, Watson K, Sandall J. Women’s safety alerts in maternity care: is speaking up enough? BMJ Qual Saf 2013; 22: 348–355. DOI: 10.1136/bmjqs-2012-001295

Niy DY, Oliveira VC de, Oliveira LR de, Alonso BD, Diniz CSG. Overcoming the culture of physical immobilization of birthing women in Brazilian healthcare system? Findings of an intervention study in São Paulo, Brazil. Interface - Comun Saúde, Educ 2019; 23. DOI: 10.1590/interface.180074

Salgado HDO, Niy DY, Diniz CSG. Groggy and with Tied Hands: The First Contact with the Newborn According to Women that Had an Unwanted C-Section. J Hum Growth Dev 2013; 23: 190. DOI: 10.7322/jhgd.61298

Venturi G, Godinho T. Mulheres Brasileiras e Genero nos Espacos Publico e Privado – Uma decada de mudancas da opiniao publica. São Paulo: Editora Fundacao Perseu Abramo/Servico Social do Comercio; 2013.

Santos NET, Leal MC, Oliveira AE, Zandonade E, Gama SGN. Concordância entre informações do Cartão da Gestante e da memória materna sobre assistência pré-natal. Cad. Saúde Pública. 2012. Feb; 28 (2): 256-266. DOI: 10.1590/S0102-311X2013000500019