High cesarean prevalence in a national population-based study in Brazil: the role of private practice

Background. Excessive use of cesarean sections (CSs) is a serious problem worldwide. Objective. To estimate the frequency and identify factors associated with cesarean deliveries in Brazil. Design. Cross-sectional study conducted in 2006-2007 as part of the third edition of the Children's and Women's National Demographic and Health Survey. Setting. Brazil. Sample. Brazilian women in reproductive age. Methods. Socioeconomic and demographic data were utilized, including maternal age, education level, per capita income, skin color, smoking habit, marital status, age at first delivery, parity, and type of prenatal services. Main outcome measures. Adjusted estimate of the prevalence ratios of the type of delivery performed (cesarean or vaginal). Results. Cesarean prevalence was 43.9% (95% CI: 40.9-46.9), 68.7% for women who had per capita income greater than US$ 125 per month, and 77.2% for those who had attended private or privately insured prenatal services. In the adjusted analysis, the variables that presented significant prevalence ratios (95% confidence interval) were macro-region [southeast = 1.45 (1.21-1.73); south = 1.48 (1.24-1.77), and midwest = 1.43 (1.21-1.71)], maternal age above 25 years [26-30 years = 1.57 (1.25-1.97); >= 31 years = 1.77 (1.39-2.27)], education levels 9 years (PR = 1.86, 95% CI: 1.55-2.23), and having attended private or privately insured prenatal services (PR = 1.87, 95% CI: 1.65-2.12) and parity [primipara = 1.87 (1.47-2.36)]. Conclusions. CS rates are generally very high in Brazil. They are significantly higher than the average among women attending private/insured antenatal care, among the highly educated, and in provinces with higher socioeconomic levels.