Caesarean rates in Brazil: what is involved?

Abstract

Statistical data indicate that rates of caesarean births are increasing worldwide, 1 being particularly high in some countries, including Brazil; 2 however, consensus ends here. This is a controversial subject, particularly with regard to what would be the ideal caesarean rate and what are the determinants of high caesarean rates in some countries. Although factors that seem to contribute to a rise in caesarean rates all over the world are probably common to different countries, the reasons why countries with similar characteristics have distinct caesarean rates whereas high rates are observed in countries with different social and economic status are questions that reinforce this conundrum. 1Rates of caesarean births in Brazil have increased in the last decades. 2 In the early 1970s the rate of caesarean births in Brazil was close to 15%. The rate increased to 30% in the early 1980s, achieving 40% in the early 1990s. The stability observed in the period 1990-2000 was followed by an additional increase, which took the caesarean rates above 50% in 2012;2,3 however, these rates should be viewed in more detail, taking into account geographic and financial variations.Regarding regional differences, caesarean rates are in the range 35-45% in some states of Brazil, especially those in the north and north-east regions, which are more rural and poorer. On the other hand, states in the south, southeast, and central west regions, which are typically urban and wealthier states, have rates in the range 55-65%.3 As shown in Figure 1, the caesarean rate for Brazil as a whole is markedly affected by the high incidence of caesarean sections performed in the richest states of the country, which are also more densely populated, and where the number of deliveries is greater.The most remarkable discrepancies are observed when caesarean delivery rates in the public and private sectors are compared. According to population-based studies, caesarean rates in the private sector are significantly higher (80-90%) 2,4 than in the public system (35-45%). 2,4 As the vast majority of health care in the private sector is provided through health insurance, the percentage rates of caesarean births in Brazilian states are significantly associated with the local coverage of private health insurance (Figure 2). These data indicate that the high rates of caesarean sections in Brazil are related to the characteristics of the private sector of the health system. In this context, it is important to emphasise that the obstetric care provided by health insurance is centred on the doctor, without the participation of other professionals, and in opposition to the guidelines and models of multidisciplinary attendance recommended by Brazilian and international organisations.5 Most private obstetricians, as well as anaesthetists and paediatricians, go to the hospital after a phone call to tell them that their patients have gone into labour, regardless of the day of the week or time of day. 6This feature obviously does not favour intended vaginal deliveries, w...

Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth

“…In 2009, for the first time, the number of CSs exceeded the number of vaginal deliveries, reaching 57 % in 2014 [6]. This difference is significantly associated with the local coverage of private health insurance, because CS rates in private hospitals (80–90 %) are considerably higher than in the public sector (35–45 %) [7–10]. It is likely that many CS performed in Brazil are for non-medical reasons [11–13].…”

Why do women request an elective cesarean delivery for non‐medical reasons? A systematic review of the qualitative literature

“…According to the World Health Organization (WHO), cesarean rates have reached “epidemic proportions.” Cesarean rates have been reported at 36% in Korea and over 50% in China and Brazil . A recent study using survey data collected by the WHO concluded that, at the population level, rates higher than 10% are not associated with reductions in maternal or newborn mortality rates .…”

Provider-initiated delivery, late preterm birth and perinatal mortality: a secondary analysis of the WHO multicountry survey on maternal and newborn health

“…15 The association of higher PLCD rates with reduced rates of stillbirth and perinatal death was stronger in the least-developed countries yet persisted in high HDI-countries where overuse of CD has been reported. 20 21 23 35 We recently reported that the increase in CD rates observed between two WHO surveys (conducted in 2003-2005 and 2011-2012) 28 did not appear to contribute to improved neonatal outcomes observed in these countries. 36 Findings from these and our current study suggest that the increase in PLCD has occurred mostly where it is not needed, but that improved access to that invention among those in need could improve birth outcomes, although at the cost of higher preterm birth rates.…”

“…15 Even in countries such as Brazil 20 and China 21 where excessive CD is of concern, reports continue to show wide socioeconomic disparities in access to such interventions when required. 22 23 Compared with the vast literature on overall rates of CD and their potential maternal and neonatal consequences, we are aware of no previous study from low-income or middle-income countries assessing whether use of LI and/or PLCD are associated with improvement in perinatal survival and increased risk of late preterm birth.…”