Variations in cesarean and repeated cesarean section rates in Brazil according to gestational age at birth and type of hospital

Dias, Barbara Almeida Soares; Leal, Maria do Carmo; Esteves-Pereira, Ana Paula; Nakamura-Pereira, Marcos

doi:10.1590/0102-311XEN073621

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ARTICLE • Cad. Saúde Pública 38 (6) • 2022 • https://doi.org/10.1590/0102-311XEN073621 copy

Variations in cesarean and repeated cesarean section rates in Brazil according to gestational age at birth and type of hospital

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study aimed to describe cesarean and repeated cesarean section rates in Brazil according to gestational age (GA) at birth and type of hospital. This is an ecologic study using data from the Brazilian Information System on Live Births and the 2017 National Registry of Health Facilities. Overall and repeated cesarean section rates were calculated and analyzed according to GA, region of residence, and type of hospital. Spearman correlations were performed between cesarean and repeated cesarean section rates by GA subgroups at birth (≤ 33, 34-36, 37-38, 39-41, and ≥ 42 weeks) and analyzed according to the type of hospital. Overall and repeated cesarean section rates were 55.1% and 85.3%, respectively. More than 60% of newborns between 37-38 weeks were delivered via cesarean section. Private hospitals in all regions showed the highest cesarean section rates, especially those in the Central-West Region, with more than 80% at all GAs. The overall cesarean section rate was highly correlated with all cesarean section rates of GA subgroups (r > 0.7, p < 0.01). Regarding repeated cesarean sections, the overall rate was strongly correlated with the rates of 37-38 and 39-41 weeks in public/mixed hospitals, differing from private hospitals, which showed moderate correlations. This finding indicates the decision for cesarean section is not based on clinical factors, which can cause unnecessary damage to the health of both the mother and the baby. Then, changes in the delivery care model, strengthening public policies, and encouragement of vaginal delivery after a cesarean section in subsequent pregnancies are important strategies to reduce cesarean section rates in Brazil.

Keywords:
Cesarean Section; Vaginal Birth After Cesarean; Maternal and Child Health; Health Systems

	Geral			Public/Mixed			Private
	Live births (n)	Cesarean section rate (%)	Repeated cesarean section rate (%) *	Live births (n)	Cesarean section rate (%)	Repeated cesarean section rate (%) *	Live births (n)	Cesarean section rate (%)	Repeated cesarean section rate (%) *
Total	2,795,116	55.3	85.3	2,234,136	48.8	82.2	532,962	84.9	96.1
Region
North	292,034	46.3	80.8	250,581	43.6	78.4	30,344	84.5	96.5
Northeast	770,025	50.0	84.8	672,444	45.3	82.4	92,182	86.5	96.8
Southeast	1,113,758	58.1	85.8	818,527	49.5	81.7	287,351	83.5	95.7
South	384,858	60.8	86.0	315,378	55.8	83.7	67,447	85.5	95.8
Central-West	234,441	62.3	88.4	177,206	54.2	85.0	55,638	89.6	96.9
Maternal age (years) **
12-19	461,119	38.2	77.1	434,934	36.8	76.4	20,619	75.9	95.7
20-34	1,933,735	56.6	84.6	1,535,282	50.2	81.7	379,902	84.3	96.0
≥ 35	400,158	69.2	89.8	263,839	60.4	86.0	132,437	88.2	96.3
Skin color **
White	986,872	66.0	88.8	672,361	57.2	85.2	309,057	85.8	95.9
Black	152,188	48.6	81.5	128,118	43.3	78.7	22,314	81.3	95.8
Brown	1,523,505	49.6	83.1	1,328,824	45.4	80.8	180,846	83.7	96.4
Yellow	11,487	56.4	87.1	7,458	44.4	80.9	3,957	79.6	95.0
Indigenous	23,236	20.1	62.2	16,393	26.2	63.2	554	66.2	88.2
Education **
Incomplete elementary school	127,100	37.2	75.0	117,614	38.2	74.8	3,012	75.4	95.1
Complete elementary school	662,152	42.1	78.9	630,430	41.3	78.2	22,617	77.8	95.3
High school or more	1,958,674	61.1	88.1	1,443,817	53.0	84.5	503,647	85.3	96.1
Marital status **
No partner	1,238,749	48.2	81.0	1,078,185	43.9	78.8	147,428	82.7	95.9
With a partner	1,528,226	61.2	88.0	1,131,696	53.6	84.7	382,181	85.8	96.1
Parity
Primiparous	1,107,361	57.0	-	852,399	49.2	-	210,358	84.5	-
Multiparous	1,687,755	54.3	85.4	1,381,737	48.6	82.2	242,308	85.3	96.1
GA (weeks) **
≤ 33	75,243	51.6	78.6	62,457	47.7	76.3	11,314	79.3	90.8
34-36	206,135	54.2	84.3	166,259	48.5	81.4	37,030	83.4	95.2
37-38	808,511	61.2	88.7	591,323	52.2	84.9	210,183	87.9	97.1
39-41	1,627,829	53.0	84.0	1,343,544	47.5	81.2	268,740	83.1	95.5
≥ 42	77,398	49.5	82.7	70,553	47.6	81.4	5,695	82.5	95.9

	Overall cesarean section (%)						Repeated cesarean section (%)
	GA (weeks)						GA (weeks)
	≤ 33	34-36	37-38	39-41	≥ 42	Overall rate	≤ 33	34-36	37-38	39-41	≥ 42	Overall rate
General
Brazil	51.6	54.2	61.2	53.0	49.5	55.3	78.6	84.3	88.7	84.0	82.7	85.4
North	39.5	43.1	49.7	45.9	42.6	46.3	69.9	79.0	83.6	80.4	77.3	80.8
Northeast	43.9	47.9	54.4	48.8	47.4	50.0	74.9	82.8	87.8	84.0	82.9	84.8
Southeast	57.8	58.4	63.7	55.1	54.3	58.1	81.4	85.7	89.1	83.9	84.6	85.8
South	59.9	61.5	67.0	57.5	53.0	60.8	81.2	85.8	89.4	84.2	81.0	86.0
Central-West	54.2	59.5	68.7	59.6	57.7	62.3	80.8	85.7	91.2	87.2	86.3	88.4
Public/Mixed
Brazil	47.7	48.5	52.2	47.5	47.6	48.8	76.3	81.4	84.9	81.2	81.4	82.2
North	39.3	41.9	44.6	43.7	43.2	43.6	68.1	77.2	79.9	78.4	76.6	78.4
Northeast	41.4	43.9	46.7	45.1	46.1	45.3	73.0	80.5	84.5	82.2	82.0	82.4
Southeast	52.4	50.8	52.7	47.6	50.7	49.5	78.9	82.1	84.5	80.2	83.0	81.7
South	57.5	57.3	61.5	52.6	51.3	55.8	80.2	84.0	87.2	81.8	79.9	83.7
Central-West	48.4	51.4	58.3	52.9	53.4	54.2	77.6	81.9	87.3	84.4	84.1	85.0
Private
Brazil	79.3	83.4	87.9	83.1	82.5	84.9	90.8	95.2	97.1	95.5	95.9	96.1
North	76.8	83.1	88.8	82.7	75.6	84.5	91.1	95.6	97.4	96.2	92.4	96.5
Northeast	78.1	84.8	90.1	84.4	82.6	86.5	91.3	95.8	97.7	96.3	96.1	96.8
Southeast	79.1	81.6	86.3	81.7	81.7	83.5	90.2	94.8	96.7	95.1	95.8	95.7
South	78.7	84.1	88.0	84.0	86.5	85.5	90.7	95.0	96.9	95.1	97.2	95.8
Central-West	85.0	89.3	92.3	87.5	88.8	89.6	92.7	96.1	97.8	96.3	97.5	96.9

	Overall rate	Cesareal section					Repeated cesarean section
		GA (weeks)					GA (weeks)
		≤ 33	34-36	37-38	39-41	≥ 42	≤ 33	34-36	37-38	39-41	≥ 42
General
Cesarean section (GA - weeks)
≤ 33	0.75 *	1.00
34-36	0.91 *	0.73 *	1.00
37-38	0.97 *	0.71 *	0.89 *	1.00
39-41	0.99 *	0.70 *	0.88 *	0.94 *	1.00
≥ 42	0.87 *	0.61 *	0.78 *	0.83 *	0.86 *	1.00
Repeated cesarean section (GA - weeks)
≤ 33	0.52 *	0.63 *	0.48 *	0.50 *	0.49 *	0.42 *	1.00
34-36	0.69 *	0.43 *	0.73 *	0.66 *	0.67 *	0.55 *	0.41 *	1.00
37-38	0.82 *	0.51 *	0.72 *	0.84 *	0.80 *	0.67 *	0.46 *	0.60 *	1.00
39-41	0.88 *	0.57 *	0.77 *	0.85 *	0.89 *	0.76 *	0.47 *	0.65 *	0.78 *	1.00
≥ 42	0.61 *	0.36 *	0.52 *	0.58 *	0.60 *	0.66 *	0.31 *	0.43 *	0.54 *	0.59 *	1.00
Public/mixed hospital
Cesarean section (GA - weeks)
≤ 33	0.68 *	1.00
34-36	0.89 *	0.69 *	1.00
37-38	0.97 *	0.64 *	0.87 *	1.00
39-41	0.99 *	0.63 *	0.85 *	0.94 *	1.00
≥ 42	0.86 *	0.55 *	0.74 *	0.81 *	0.84 *	1.00
Repeated cesarean section (GA - weeks)
≤ 33	0.47 *	0.61 *	0.43 *	0.45 *	0.44 *	0.37 *	1.00
34-36	0.65 *	0.34 *	0.72 *	0.62 *	0.62 *	0.50 *	0.35 *	1.00
37-38	0.82 *	0.42 *	0.68 *	0.85 *	0.79 *	0.63 *	0.40 *	0.54 *	1.00
39-41	0.89 *	0.48 *	0.72 *	0.84 *	0.90 *	0.73 *	0.42 *	0.60 *	0.78 *	1.00
≥ 42	0.57 *	0.27 *	0.46 *	0.54 *	0.56 *	0.64 *	0.25 *	0.37 *	0.49 *	0.56 *	1.00
Private hospital
Cesarean section (GA - weeks)
≤ 33	0.57 *	1.00
34-36	0.74 *	0.47 *	1.00
37-38	0.90 *	0.49 *	0.67 *	1.00
39-41	0.94 *	0.48 *	0.65 *	0.77 *	1.00
≥ 42	0.61 *	0.35 *	0.45 *	0.54 *	0.58 *	1.00
Repeated cesarean section (GA - weeks)
≤ 33	0.41 *	0.57 *	0.35 *	0.37 *	0.38 *	0.22 *	1.00
34-36	0.51 *	0.40 *	0.55 *	0.47 *	0.48 *	0.36 *	0.34 *	1.00
37-38	0.62 *	0.39 *	0.50 *	0.66 *	0.59 *	0.43 *	0.36 *	0.47 *	1.00
39-41	0.66 *	0.38 *	0.53 *	0.58 *	0.70 *	0.48 *	0.33 *	0.46 *	0.51 *	1.00
≥ 42	0.31 *	0.17 *	0.24 *	0.29 *	0.31 *	0.41 *	0.18 *	0.27 *	0.29 *	0.31 *	1.00

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[1] Correspondence
B. A. S. Dias Centro de Ciências da Saúde, Universidade Federal de Roraima. Av. Ene Garcez 2413, Boa Vista, RR 69304-000, Brasil. barbaraalmeida4@hotmail.com