Leal M Brazil Research Paper

Main Findings

In Brazil, one in nine births is preterm (S2 Table) [21]. In this study, late prematurity accounted for 75% of all preterm births, and around 40% of these were provider-initiated births. Labour induction practice was low in public health services, and almost nil in private health services. Provider-initiated late prematurity was associated with previous preterm birth(s) and maternal pathologies in both health services, and with maternal age ≥35 years in public health services only. The higher rate of provider-initiated late preterm birth in women receiving private healthcare compared with the ones receiving public care was independent of obstetric risk.

Strengths and Limitations

The strength of this study is that we have used a representative nationwide survey, with primary data collected from medical records. This allowed, for the first time, a description of the national late prematurity rate and its determinants, as well as a more accurate gestational age estimate calculated by an algorithm that primarily relied upon early ultrasound estimates [18]. Furthermore, we stratified the analysis by source of healthcare provision (public or private) and according to obstetric risk (low or high). The obstetric risk was independently performed and validated by two obstetricians who also classified the prematurity determining factor (as spontaneous, Pprom or provider-initiated). Nonetheless, we failed to analyse whether C-section indication was appropriate on a case-by-case basis.

Interpretation

Maternal age, previous C-section, and non-cephalic presentation were not associated with provider-initiated late prematurity in private health services, as in the public services. This could be attributed to the indiscriminate use of interventions in private health services, independent of a patient’s characteristics, as well as the high prevalence of the interventions in the full-term comparison group. Nakamura-Pereira et al. (2016) have previously observed that in private health services C-section rate in cephalic presentation preterms was 77%, even among women at low obstetric risk (S1 Table) [10].

Women receiving public healthcare live in poorer socioeconomic conditions and face barriers of access to prenatal care more frequently [24, 25]. However, the prevalence of maternal morbidities was comparable to women receiving private healthcare. On the other hand, we observed a stronger association between these morbidities and provider-initiated late prematurity in private health services. This may indicate greater anticipation of birth even under the same health conditions. Possible explanations would be the easier access to neonatal ICU in private hospitals, as well as unawareness or minimization of the risks of late preterm infants, who are generally still immature [22].

In the short term, late preterm infants are vulnerable to thermal instability, breastfeeding difficulties, hypoglicemia, hyperbilirubinemia, infections, and respiratory morbidities. This leads to a greater need for neonatal ICU and readmission after birth [26, 27]. In the long term, they have a higher risk of respiratory diseases, infant hospitalisation, neurodevelopmental problems, and poorer school performance [26–28]. Probably many infants in Brazil are unnecessarily being placed at risk for these outcomes.

Our data reaffirm that the prevalence of provider-initiated births in Brazil is one of the highest worldwide. This is especially true in private health services, which shows an inverted pattern of two thirds of births determined by an obstetric intervention. In contrast, two thirds of preterm births from high-income countries occur spontaneously [6, 15]. The major intervention characterising Brazilian obstetric care is C-section. We observed that 53% of late preterm births were by C-section, among which 86% were pre-labour C-section. Unsurprisingly, labour induction practice corresponded to less than 10% of births; around 20% in public health services and only 4% in the private.

Brazilian private health services schedule birth care to optimise physician’s time and usually the same physician provides both prenatal and birth care. As such, several deliveries are set for the same date, in agreement with the pregnant women [8, 29, 30]. Thus, receiving prenatal and birth care from the same practitioner turned out to be the highest risk factor for having a C-section [22]. This is probably the main reason rates of pre-labour C-section are particularly high in Brazilian private health services. [7, 10, 22, 29].

C-section can impact negatively woman's obstetric life. There is substantial evidence that C-section increases the risk of placenta previa and accreta in subsequent pregnancies [31], severe acute maternal morbidity [32], and mortality [33]. In addition, newborns endure losses in breastfeeding [12] and have smaller diversification of the intestinal microbiota [34], which has been related to chronic diseases in adult life [35–38].

We found higher odds of provider-initiated late preterm birth in women receiving private care compared with the ones receiving public healthcare. This was regardless of the obstetric risk classification of the women (low or high) and adjustment for confounding variables. However, when adjusted for previous C-section, there was a reduction in the OR for low-risk women. This implies that, for low-risk women, the association was partially explained by a higher prevalence of previous C-section in private health services. This was not evident in the adjusted model of Table 3 owing to the extremely high frequency of mothers with previous C-section in the full-term comparison group from private health services.

According to recommendations from the American Congress of Obstetricians and Gynecologists [39], most women with one previous C-section with a low-transverse incision are candidates for and should be counselled about vaginal birth after cesarean (VBAC) and offered a trial of labour after C-section [40]. Studies have referred to a 70% VBAC success rate [41], which should be incorporated into Brazilian obstetric practice, as repetitive C-section further increases the risk of haemorrhage, abnormal placenta [31], and uterine rupture [42] in subsequent pregnancies.

In the USA, it has been quantified that one in five late preterm births were not registered as indicated for an intervention in the medical records [6]. Therefore, it was suggested that other non-clinical factors might have influenced the decision at the moment of intervention. The authors of the study strongly recommended the reduction of iatrogenic interventions, and suggested the use of guidelines to optimise and plan the timing and route of delivery. The Institute of Medicine (IOM) estimated a burden of prematurity in the USA of about $26 billion or $51,600 per child [43]. It is worth noting that provider-initiated prematurity has been reduced recently in the USA [44].

Excessive perinatal interventions (in mothers and newborns), independent of obstetric/fetal risks, have previously been reported in private health services of Brazil [9, 12] and Australia [45]. Our study estimated the effect on rates of prematurity if, among low-risk women, rates of provider-initiated late preterm births were the same in private services as in public services. We found that the prematurity rate would decrease to 11% (from 9.5% to 8.4%) in private health services. This would indicate an annual reduction of approximately 6,600 preterm births nationally. It is essential to highlight that there would be a higher impact on preterm birth rates if provider-initiated late preterm births were prevented in women of high obstetric risk as well. Although this group corresponded to 24% of women, provider-initiated late preterm birth rate was more than five times higher when compared to women of low obstetric risk; with additional differences between public and private services. Moreover, the potential for reduction of preterm birth rates in Brazil can be of greater magnitude if the comparison group is external (from high-income European countries) rather than Brazilian public health services, which is yet quite interventionist.

Corporate Governance and Value in Brazil (and in Chile)

77 PagesPosted: 21 May 2005  

Ricardo P. C. Leal

Universidade Federal do Rio de Janeiro (UFRJ) - The COPPEAD Graduate School of Business

Andre Carvalhal

Universidade Federal do Rio de Janeiro (UFRJ) - The COPPEAD Graduate School of Business

Date Written: May 2005

Abstract

We construct a corporate governance practices index (CGI) from a set of 24 questions that can be objectively answered from publicly available information. Our goal was to measure the overall quality of corporate governance practices of the largest possible number of firms without the biases and low response ratios typical of qualitative surveys. CGI levels have improved over time in Brazil. CGI components demonstrate that Brazilian firms perform much better in disclosure than in other aspects of corporate governance. We find very high concentration levels of voting rights leveraged by the widespread use of indirect control structures and non-voting shares. Control has concentrated between 1998 and 2002. We do not find evidence for either entrenchment or incentives in Brazil using ownership percentages but find that the separation of control from cash flow rights destroys value. The CGI maintains a positive, significant, and robust relationship with corporate value. A worst-to-best improvement in the CGI in 2002 would lead to a .38 increase in Tobin's q. This represents a 95% rise in the stock value of a company with the average leverage and Tobin's q ratios. Considering our lowest CGI coefficient, a one point increase in the CGI score would lead to a 6.8% rise in the stock price of the average firm in 2002. We found no significant relationship between governance and the dividend payout but there are indications that dividend payments are greater when control and cash flow rights concentration are greater. We place our results in context by offering a comparative analysis with Chile. We would offer a sound "yes" if asked whether good corporate governance practices increase corporate value in Brazil.

Keywords: Corporate Governance, Latin American Equity Markets, Shareholder Rights, Ownership, Value

JEL Classification: G32, G34

Suggested Citation:Suggested Citation

Leal, Ricardo P. C. and Carvalhal, Andre, Corporate Governance and Value in Brazil (and in Chile) (May 2005). Available at SSRN: https://ssrn.com/abstract=726261 or http://dx.doi.org/10.2139/ssrn.726261

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