Significant differences in cesarean section rates between a private and a public hospital in Brazil

Rate and direct medical costs of cesarean sections among supplementary health plan holders living in the state of São Paulo, Brazil: 2015-2021

Brazil has the second largest cesarean section rate in the world. Differences in rates exist between the public and private health sectors. This study used data on admissions of supplementary health plan holders aged between 10 and 49 years living in the state of São Paulo admitted between 2015 and 2021 to determine cesarean section rates and costs in the private health sector. We conducted a partial economic analysis in health from a supplementary health perspective focusing on the direct medical costs of admissions. A total of 757,307 admissions were analyzed with total costs amounting to R$7.701 billion. The cesarean section rate over the period was 80%. Rates were lowest in young women (69%) and highest in the oldest age group (86%), exceeding 67% across all groups. The rate was 71% higher than in public services. The proportion of admissions with use of the intensive care unit was higher among cesarian deliveries. The median cost of a cesarean was 15% higher than that of a normal delivery and twice as high in insurance companies than healthcare cooperatives. There is an opportunity to apply policies that are widely used in public services to the private sector with the aim of reducing cesarean rates in private services, direct costs of admission, and the cost of supplementary health plans.

Variation of caesarean section rates in Palestinian governmental hospitals

BACKGROUND

Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines.

METHODS

A qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section.

RESULTS

The results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations.

CONCLUSION

Several institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data

BACKGROUND

Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia.

METHOD

Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure.

RESULTS

Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia.

CONCLUSION

Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

Prevalence and factors associated with catastrophic health expenditure among slum and non-slum dwellers undergoing emergency surgery in a metropolitan area of South Western Nigeria

BACKGROUND

Out of Pocket (OOP) payment continues to persist as the major mode of payment for healthcare in Nigeria despite the introduction of the National Health Insurance Scheme (NHIS). Although the burden of health expenditure has been examined in some populations, the impact of OOP among slum dwellers in Nigeria when undergoing emergencies, is under-researched. This study sought to examine the prevalence, factors and predictors of catastrophic health expenditure amongst selected slum and non-slum communities undergoing emergency surgery in Southwestern Nigeria.

METHODS

The study utilised a descriptive cross-sectional survey design to recruit 450 households through a multistage sampling technique. Data were collected using pre-tested semi-structured questionnaires in 2017. Factors considered for analysis relating to the payer were age, sex, relationship of payer to patient, educational status, marital status, ethnicity, occupation, income and health insurance coverage. Variables factored into analysis for the patient were indication for surgery, grade of hospital, and type of hospital. Households were classified as incurring catastrophic health expenditure (CHE), if their OOP expenditure exceeded 5% of payers' household budget. Analysis of the data took into account the multistage sampling design.

RESULTS

Overall, 65.6% (95% CI: 55.6-74.5) of the total population that were admitted for emergency surgery, experienced catastrophic expenditure. The prevalence of catastrophic expenditure at 5% threshold, among the population scheduled for emergency surgeries, was significantly higher for slum dwellers (74.1%) than for non-slum dwellers (47.7%) (F = 8.59; p = 0.019). Multiple logistic regression models revealed the significant independent factors of catastrophic expenditure at the 5% CHE threshold to include setting of the payer (whether slum or non-slum dweller) (p = 0.019), and health insurance coverage of the payer (p = 0.012). Other variables were nonetheless significant in the bivariate analysis were age of the payer (p = 0.017), income (p<0.001) and marital status of the payer (p = 0.022).

CONCLUSION

Although catastrophic health expenditure was higher among the slum dwellers, substantial proportions of respondents incurred catastrophic health expenditure irrespective of whether they were slum or non-slum dwellers. Concerted efforts are required to implement protective measures against catastrophic health expenditure in Nigeria that also cater to slum dwellers.

Rising cesarean deliveries in India: medical compulsions or convenience of the affluent?

From 2005-06 to 2015-16, proportion of cesarean deliveries in total deliveries has almost doubled in India. In this paper, we study changes in prevalence of cesarean deliveries across different social-economic groups and study factors affecting odds of undergoing cesarean delivery. The present paper was based on National Family Health Surveys and employs logistic regression. We find that rise in cesarean deliveries has been across social groups, religions, urban/rural India, wealth groups, though increase has not been uniform. Further, many economically affluent states have high proportion of cesarean deliveries. We find that women delivering at private hospitals had significantly higher odds of opting for cesarean delivery. Further, women belonging to rich households were more likely to go through surgery for birth. In case of earlier terminated pregnancies, odds were higher too. The higher odds of cesarean sections in the relatively affluent geographic regions, richer households and private institutions indicate that these procedures may be driven by non-medical reasons in many cases, pointing toward the use of surgical procedures for the convenience.

Prevalence, indications, and outcomes of caesarean section deliveries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Caesarean section rates have increased worldwide in recent decades. Caesarean section is an essential maternal healthcare service. However, it has both maternal and neonatal adverse outcomes. Therefore this systematic review and meta-analysis aimed to estimate the prevalence, indication, and outcomes of caesarean section in Ethiopia.

METHODS

Twenty three cross-sectional studies with a total population of 36,705 were included. Online databases (PubMed/Medline, Hinari, Web of Science, and Google Scholar) and online university repository was used. All the included papers were extracted and appraised using the standard extraction sheet format and Joanna Briggs Institute respectively. The pooled prevalence of the caesarean section, indications, and outcomes was calculated using the random-effect model.

RESULT

The overall pooled prevalence of Caesarean section was 29.55% (95% CI: 25.46-33.65). Caesarean section is associated with both maternal and neonatal complications. Cephalopelvic disproportion [18.13%(95%CI: 12.72-23.53] was the most common indication of Caesarean section followed by non-reassuring fetal heart rate pattern [19.57% (95%CI: 16.06-23.08]. The common neonatal complications following Caesarean section included low APGAR score, perinatal asphyxia, neonatal sepsis, meconium aspiration syndrome, early neonatal death, stillbirth, and prematurity whereas febrile morbidity, surgical site infection, maternal mortality, severe anemia, and postpartum hemorrhage were the most common maternal complications following Caesarean section.

CONCLUSION

In this systematic review and meta-analysis, the rate of Cesarean section was high. Cephalopelvic disproportion, low Apgar score, and febrile morbidity were the most common indication of Caesarean section, neonatal outcome and maternal morbidity following Caesarean section respectively. Increasing unjustified Caesarean section deliveries as a way to increase different neonatal and maternal complications, then several interventions needed to target both the education of professionals and the public.

Factors associated with the route of birth delivery in a city in the Northeast region in the State of Rio Grande do Sul, Brazil

Abstract Objectives: to investigate factors associated with the route of birth delivery in a hospital extending public and private healthcare services, in the Northeast region in the State of Rio Grande do Sul. Methods: a cross-sectional study with 676 postpartum women, conducted from January to May 2017. The data were collected from the hospital records and women were interviewed shortly after childbirth in the maternity. Data analysis was performed by associating the Pearson’s chi-square and the Poisson regression tests with robust variance. Results: the prevalence of cesarean sections was 58.7%, that is, 41.7% in public health-care and 83.9% in private healthcare. The main reason for having a cesarean section was having had a previous one (PR=5.69; CI95%=3.64 - 8.90; p<0.001), followed by having source of childbirth financing (PR=1.54; CI95%=1.27 - 1.87; p<0.001), having source of prenatal care financing (PR=1.48; CI95%=1.22 - 1.79; p<0.001), the childbirth and prenatal care professional (PR=1.46; CI95%=1.28 - 1.66; p<0.001) and the prenatal care professional (PR=1.43; CI95%=1.07 - 1.90; p=0.016). Conclusions: the high cesarean section rates identified in this study were mainly associated with previous cesarean section. The findings suggest a change in the current childbirth care model in the city, characterized as highly medicalized, focused on the physician and on hospital care.

Prevalence and associated factors of caesarean section in Addis Ababa hospitals, Ethiopia

Introduction

Caesarean section refers to the operation of delivering a baby through incisions made in the mother's abdominal wall and uterus. A caesarean section is medically indicated when a significant risk of adverse outcome for mother or baby is present. The objective of this study was to assess the prevalence and associated factors of caesarean section in Addis Ababa Hospitals, Ethiopia.

Methods

Institutional based cross-sectional study design was employed on 298 women from between April and May 2017. Study subjects were selected using systematic random sampling by considering the number of delivery. A structured questionnaire was used to collect the data. The data were coded and entered into Epi data version 3.1 and the analysis was carried out in a statistical package for social science versions 22. Descriptive statistics for each variable and binary logistic regression analysis with 95% CI was carried out.

Results

A total of 298 mothers were participated in the study with a response rate of 100%. The overall prevalence of caesarean section in this study was 38.3%. The multivariable analysis indicated that mother who had collage and above [AOR = 3.46 (95%CI; 1.2, 10.76)], giving birth in private health facility [AOR = 1.48 (95%CI; 1.84, 2.59)], and having risk factors [AOR = 2.86 (95%CI; 1.96, 3.42)], were some of the factors associated with caesarean section.

Conclusion

The finding of this study showed that the prevalence of caesarean section was higher in women who gave birth in private health facility, mothers having risk factors, and mothers having educational status of diploma and above. Therefore, identifying risky group during antenatal care follow-up and restraining numbers of caesarean section in private health facilities is essential steps to reduce high prevalence of caesarean section.

Cesarean delivery among women who gave birth in Dessie town hospitals, Northeast Ethiopia

BACKGROUND

One of the key strategies for reducing maternal and perinatal morbidities and mortalities is the provision of skilled intrapartum care. While cesarean section is an important emergency obstetric intervention for saving the lives of mothers and newborns, a study comparing the prevalence of cesarean delivery is not sufficiently available in Ethiopia. This study aimed at assessing the prevalence and associated factors of cesarean delivery among women who gave birth at hospitals in Dessie town, Northeast Ethiopia.

METHODS

A facility based cross-sectional study was conducted between July and October 2013. A total of 520 women who gave birth in four hospitals (public = 1, private = 3) were interviewed. Face-to-face interviews using a pre-tested and structured questionnaire were conducted for primary data collection. Additionally, patients' charts were reviewed to collect mothers' clinical data. Bivariate and multiple logistic regressions analyses were conducted. Odds ratios and 95% confidence intervals were computed and a P-value of less than 0.05 was taken to declare the level of significance.

RESULTS

A total of 512 mothers were included in the final analysis (response rate = 98.4%), the prevalence of cesarean delivery was found to be 47.6% (95% CI: 44.3, 51.1), While 46 (18.2%) of the procedure conducted in public and 198 (76.1%) were in private hospitals. Partograph monitoring [AOR = 3.84 95%CI: 2.24, 6.59], oxytocin administration [AOR = 4. 80 95%CI: 2.87-8.02], previous cesarean delivery [AOR = 2. 86 95%CI: 1.64-5.01] and place of delivery being a private hospital [AOR = 6. 79 95%CI: 4.18-11.01)] were associated with cesarean delivery.

CONCLUSION

The prevalence of cesarean delivery was found to be high, and was significantly higher in private hospitals than a public facility. There is a need to conduct cesarean delivery audits to appropriately utilize scarce resources. Further an in-depth exploration of the experiences of women with cesarean delivery is necessary.

Monitoring and interventions are needed to reduce the very high Caesarean section rates in Vietnam

AIM

The aim of this study was to estimate the prevalence of Caesarean sections in the third largest city in Vietnam and identify the associated risk factors.

METHODS

This descriptive study was conducted in Da Nang from April 2015 to March 2016 and the hospital-based sample comprised 20 535 women who delivered during this period. Caesarean section cases were categorised into private and public hospitals and groups of primiparous and multiparous women.

RESULTS

We recruited 10 of the 12 hospitals in the City and they covered 90% of births during the study period. The overall Caesarean section rate was 58.6%: 57.9% in public hospitals and 70.6% in private hospitals. The three main indications for Caesarean sections were previous Caesarean sections, cephalopelvic disproportion and foetal distress. The factors that increased the likelihood of Caesarean sections were the mother being over 30, having an office job, a history of abortions, having a male infant and a higher neonatal birth weight.

CONCLUSION

Our study demonstrated an extremely high rate of Caesarean section and associated factors in public and private hospitals in one of the biggest cities in Vietnam. The findings highlight the need for monitoring and interventions to reduce the Caesarean section rates.

High prevalence of cesarean section births in private sector health facilities- analysis of district level household survey-4 (DLHS-4) of India

Background

Worldwide rising cesarean section (CS) births is an issue of concern. In India, with increase in institutional deliveries there has also been an increase in cesarean section births. Aim of the study is to quantify the prevalence of cesarean section births in public and private health facility, and also to determine the factors associated with cesarean section births.

Methods

We analyzed data from district level household survey data 4 (DLHS-4) combined individual level dataset for 19 states/UTs of India comprising 24,398 deliveries resulting in 22,111 live births for year 2011. The percentages and Chi-square has been computed for the select variables viz. Socio demographic, maternal, antenatal care and delivery related based on type of births (CS Vs normal births). The multiple logistic regression model has been used to identify the potential risk factors associated with CS births.

Results

Of 22,111 live birth analyzed 49.2% were delivered at public sector, 31.9% at private sector and 18.9% were home deliveries. Prevalence of CS births were 13.7% (95% CI; 13.0- 14.3%) and 37.9% (95% CI; 36.7- 39.0%) in the public and private sectors, respectively. Higher odds of CS births were observed with- delivery at private health facility (OR 3.79; 95% C.I 3.06-4.72), urban residence (OR 1.15; 95% C.I 1.00- 1.35), first delivery after 35 years of maternal age (OR 5.5; 95% C.I 1.85- 16.4), hypertension in pregnancy (OR 1.32; 95% C.I 1.06- 1.65) and breach presentation (OR 2.37; 95% C.I. 1.63- 3.43).

Conclusions

Our findings shows that CS births are nearly three times more in private as compared to public sector health facilities.The higher rates of CS births, especially in private sector, not only increase the cost of care but may pose unnecessary risks to women (when there is no indications for CS). The government of India need to take measures to strengthen existing public health facilities as well as ensure that cesarean sections are performed based upon medical indications in both public and private sector health facilities.

Equity of access to maternal health interventions in Brazil and Colombia: a retrospective study

Background

Reducing maternal mortality is a top priority in Latin American countries. Despite the progress in maternal mortality reduction, Brazil and Colombia still lag behind countries at similar levels of development.

Methods

Using data from the Demographic Health Survey, this study quantified and compared, by means of concentration indices, the socioeconomic-related inequity in access to four key maternal health interventions in Brazil and Colombia. Decomposition analysis of the concentration index was used for two indicators – skilled attendance at birth and postnatal care in Brazil.

Results

Coverage levels of the four key maternal health interventions were similar in the two countries. More specifically, we found that coverage of some of the interventions (e.g. ante-natal care and skilled birth assistance) was higher than 90% in both countries. Nevertheless, the concentration index analysis pointed to significant pro-rich inequities in access in all four key interventions in both countries. Interestingly, the analysis showed that Colombia fared slightly better than Brazil in terms of equity in access of the interventions studied. Finally, the decomposition analysis for the presence of a skilled attendant at birth and postnatal care in Brazil underlined the significance of regional disparities, wealth inequalities, inequalities in access to private hospitals, and inequalities in access to private health insurance.

Conclusions

There are persistent pro-rich inequities in access to four maternal health interventions in both Brazil and Colombia. The decomposition analysis conducted on Brazilian data suggests the existence of disparities in system capacity and quality of care between the private and the public health services, resulting in inequities of access to maternal health services.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0752-x) contains supplementary material, which is available to authorized users.

Cesarean section in Ethiopia: prevalence and sociodemographic characteristics

OBJECTIVE

The objective of this study was to assess the prevalence and sociodemographic characteristics of cesarean section in Ethiopia.

METHODS

We used data collected for Ethiopia Demographic and Health Surveys (DHS) conducted in 2000, 2005, 2011, and 2016. A two-stage, stratified, clustered random sampling design was used to gather information from women who gave birth within the 5-year period before each of the surveys. We analyzed the data to identify sociodemographic characteristics associated with cesarean section using log-Poisson regression models.

RESULTS

The national cesarean section rate increased from 0.7% in 2000 to 1.9% in 2016, with increases across seven of the eleven administrative regions of Ethiopia. Addis Ababa had the highest cesarean section rate (21.4%) in 2016 and the greatest increase since 2000. In the adjusted analysis, women who gave birth in private health facility had a 78.0% higher risk of cesarean section (adjusted prevalence ratio (aPR) (95% CI) 1.78 (1.22, 2.58)) compared with women who gave birth in public health facility. Having four or more births was associated with a lower risk of cesarean section compared with first births (aPR (95% CI) 0.36 (0.16, 0.79)).

CONCLUSIONS

The Ethiopian national cesarean section rate is about 2%, but the rate varies widely among administrative regions, suggesting unequal access. Cesarean sections were highest among urban mothers, first births, births to women with higher education, and births to women from the richest quintile of household wealth.

Vaginal birth after caesarean section: why is uptake so low? Insights from a meta-ethnographic synthesis of women's accounts of their birth choices

OBJECTIVE

To identify what women report influences their preferred mode of birth after caesarean section.

DESIGN

Systematic review of qualitative literature using meta-ethnography.

DATA SOURCES

Medline, EMBASE, ASSIA, CINAHL and PsycINFO (1996 until April 2013; updated September 2015). Hand-searched journals, reference lists and abstract authors.

STUDY SELECTION

Primary qualitative studies reporting women's accounts of what influenced their preferred mode of birth after caesarean section.

DATA EXTRACTION AND SYNTHESIS

Primary data (quotations from study participants) and authors' interpretations of these were extracted, compared and contrasted between studies, and grouped into themes to support the development of a 'line of argument' synthesis.

RESULTS

20 papers reporting the views of 507 women from four countries were included. Distinctive clusters of influences were identified for each of three groups of women. Women who confidently sought vaginal birth after a caesarean section were typically driven by a long-standing anticipation of vaginal birth. Women who sought a repeat caesarean section were strongly influenced by distressing previous birth experiences, and at times, by encouragement from social contacts. Women who were more open to information and professional guidance had fewer strong preconceptions and concerns, and viewed a range of considerations as potentially important.

CONCLUSIONS

Women's attitudes towards birth after caesarean section appear to be shaped by distinct clusters of influences, suggesting that opportunities exist for clinicians to stratify and personalise decision support by addressing relevant ideas, concerns and experiences from the first caesarean section birth onwards.

Factors associated with cesarean delivery in public and private hospitals in a city of northeastern Brazil: a cross-sectional study

Background

To evaluate the prevalence and factors associated with cesarean delivery according to whether care was provided in public or private hospitals in Brazil.

Methods

This was a cross-sectional study based on a cohort of live births between April 2004 and March 2005. A total of 1,344 mother-child pairs were followed up during the first month of life. The variables analyzed were the socioeconomic and demographic characteristics of the mother and newborn, as well as the healthcare provided during pregnancy and childbirth. Hierarchical analysis was carried out for both prediction models, i.e. healthcare provision either within the Brazilian National Health System (public service) or within the private network. Prevalence and association measurement calculations were carried out. Values were considered significant when pless than or equal to 5.0 %.

Results

A total of 1,019 (75,8 %) gave birth in public hospital. The prevalences of cesarean delivery were 29.9 % and 86.2 % in the public and private sectors, respectively. Through hierarchical logistic regression, the risk factors for cesarean delivery presented in the public hospital were maternal age greater than or equal to 20 years (p = 0.003), primiparity (p = 0.004), twinning (p = 0.039), prenatal care provided in the private network (p = 0.004), delivery in hospitals providing high complexity medical care (p = 0.000) and prenatal care with greater than or equal to 6 consultations (p = 0.035). In the private sector, no association was observed between the variables studied and cesarean delivery.

Conclusions

The cesarean delivery rates were high in both sectors, although in the private network the rate was almost triple that of the public service. The absence of determinant factors of birth in the private sector drew attention. In planning measures against the growing cesarean rates, it is necessary to take into consideration the environmental determinants as primiparity, twinning and greater maternal age, frequent indications of primary cesarean delivery, as well as to implement actions that might improve the quality of prenatal and delivery care.

Caesarean section and neonatal outcomes in private hospitals in Brazil: comparative study of two different perinatal models of care

This study aims at comparing caesarean section rates and neonatal outcomes of two perinatal models of care provided in private hospitals in Brazil. Birth in Brazil data, a national hospital-based cohort conducted in the years 2011/2012 was used. We analysed 1,664 postpartum women and their offspring attended at 13 hospitals located in the South-east region of Brazil, divided into a "typical"--standard care model and "atypical"--Baby-Friendly hospital with collaborative practices between nurse-midwives and obstetricians on duty to attend deliveries in an alternative labour ward. The Robson's classification system was used to compare caesarean sections, which was lower in the atypical hospital (47.8% vs. 90.8%, p<0.001). Full term birth, early skin-to-skin contact, breastfeeding in the first hour, rooming-in care, and discharge in exclusive breastfeeding were more frequent in the atypical hospital. Neonatal adverse outcome did not differ significantly between hospitals. The atypical hospital's intervention should be further evaluated since it might reduce caesarean section prevalence and increase good practices in neonatal care.

Sexual and reproductive health: progress and outstanding needs

We examine progress towards the 1994 International Conference on Population and Development (ICPD) commitment to provide universal access to sexual and reproductive health (SRH) services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor.

Spatial distribution of C-sections within the state of São Paulo

Objective: to identify spacial patterns for cesarean deliveries per microregion in the state of São Paulo. Methods: this is an ecological and exploratory study with data on live births occurred between 2003 and 2007 in 63 microregions in the state of São Paulo. Variables analyzed included cesarean delivery rates, teenage mothers, mothers with high levels of education and who had at least seven prenatal consultations. Moran's index (I), a measure of spatial autocorrelation of rates related to the variables described above and which identifies the presence of spatial clusters, was calculated. The distributions of the variables' rates in this study were visualized using thematic maps. The Moran map was used to identify microregions with high priority need for attention. Pearson correlation coefficients among the variables were also obtained. Results: there were 3,045,293 births, being 1,636,009 (53.7 %) cesarean deliveries. It was possible to identify spatial clusters of C-sections (I = 0.58 and p < 0.01) in the microregions located on the north and northwest of the state of São Paulo, as well as in Guaratinguetá; the values found for Moran index were, I = 0.32, I = 0.30 and I = 0.24, for the rates of teenage mothers, schooling and number of consultations, respectively, being all significant results (p <0.01). Micro-regions with high-priority need for attention were identified. Cesarean rates were significantly correlated with high rates of maternal education and number of prenatal consultations. Conclusion: the identification of these microregion clusters with high rates of cesarean delivery allows health managers to implement policies in order to minimize these rates.

Factors associated with high rates of caesarean section in Brazil between 1991 and 2006

AIM

To assess trends in caesarean sections in Brazil, identify associated factors and evaluate changes in these factors over time.

METHODS

Nationally representative data from the 1996 Demographic and Health Survey (n = 4918) and the 2006 Brazilian National Survey (n = 6125) were analysed using binomial logistic regression to assess variations in caesarean sections. Univariate logistic regression and multivariate analysis were used to select variables for predicting caesarean sections and assess potential factors associated with them.

RESULTS

Caesarean sections increased from 33% in 1991 to 40% in 2006 and were significantly more common among older, highly educated, wealthy women living in the South, who had received antenatal care and been delivered by private caregivers. Wealthy, educated women were significantly less likely to have a caesarean section in 2006 than in 1991. Women living in urban areas and in the South had higher odds of caesarean sections in 1991, but not in 2006.

CONCLUSION

Caesarean section rates in Brazil increased by seven percentage points from 1991 to 2006, but factors associated with high rates changed over time. The odds of caesarean sections decreased for wealthy, educated women over time. By 2006, region and urban versus rural residence were no longer significantly associated with caesarean sections.

Epidemiological profile of Trypanosoma cruzi-infected mothers and live birth conditions in the state of Minas Gerais, Brazil

INTRODUCTION

The aim of this study was to assess the epidemiological characteristics of Trypanosoma cruzi-infected mothers and the live birth conditions of neonates.

METHODS

A serological survey with IgG-specific tests was conducted using dried blood samples from newborn infants in the State of Minas Gerais. T. cruzi infection was confirmed in mothers through positive serology in two different tests, and infected mothers were required to have their infants serologically tested after the age of 6 months. The birth conditions of the neonates were obtained from the System of Information on Live Births database.

RESULTS

The study included 407 children born to T. cruzi-infected mothers and 407 children born to uninfected mothers. The average age of seropositive mothers was 32 years (CI95% 31.3-32.6), which was greater than the average age of seronegative mothers - 25 years (CI95% 24.8-25.2). The mothers' level of education was higher among uninfected mothers (41% had 8 or more years of education, versus 22% between the infected mothers). Vaginal delivery was more frequent among infected mothers. There was no evidence of inter-group differences with respect to the child's sex, gestational age, birth weight or Appearance, pulse, grimace, activity and respiration (APGAR) scores at 1 and 5 minutes.

CONCLUSIONS

The level of education and the greater number of previous pregnancies and cases of vaginal delivery reflect the lower socioeconomical conditions of the infected mothers. In the absence of vertical transmission, neonates had similar health status irrespective of the infection status of their mothers.

Partos cesáreos e a escolha da data de nascimento no Município de São Paulo

O Brasil tem uma das maiores taxas de partos cesáreos do mundo, e esse valor tem aumentado anualmente. O presente estudo teve como objetivo analisar possíveis mudanças na data de nascimento decorrentes desse aumento. Foram obtidos os dados dos 1.933.137 nascidos vivos ocorridos no Município de São Paulo entre 2001 e 2010, divididos segundo tipo de parto e data exata de nascimento. Em 2001, a taxa de cesarianas foi de 48,9%, passando a 56,8% em 2010. O dia da semana com menor número de nascimentos (domingo) aumentou a diferença em relação aos outros dias de 111,4 (IC95%: 101,7 - 121,0) em 2001 para 143,1 (IC95%: 135,0 - 151,3) em 2010. Os dois dias com menos nascimentos (Natal e Dia de Finados), apresentaram diferença estatisticamente significativa em relação aos outros dias do ano (p < 0.05) durante praticamente todo o período (a exceção foi o Dia de Finados em 2009). A data com o maior número de nascimentos (Dia Internacional da Mulher) apresentou diferença significativa em 2005 e 2010. O aumento no número de partos cesáreos tem tido efeito significativo na data de nascimento, o que pode trazer consequências no planejamento administrativo de instituições de saúde.

Factors on the Gap between Predicted Cesarean Section Rate and Real Cesarean Section Rate in Tertiary Hospitals

PURPOSE

This study was aimed to examine the gap between predicted cesarean section rate and real cesarean section rate and it's determining factors of 44 tertiary hospitals.

METHOD

This study is a cross-sectional analysis using the data of 25,623 deliveries in 2009 drawn from homepage of Health Insurance Review and Assessment Service. Data were analyzed with t-test, F-test, Scheffe? test, and logistic regression.

RESULT

There were statistically significant differences in the gap of cesarean section rate (more gap indicates higher quality of delivery) by grade of nurse staffing and delivery cases. Hospitals with nurse staffing grade 1 to 2 had more possibility to be classified into higher grade in quality of delivery (OR 5.67, 95% CI 1.07~30.08). Also hospitals with over 500 delivery cases had more possibility be classified into higher grade in quality of delivery (OR 4.92, 95% CI 1.14~21.23, respectively).

CONCLUSION

The finding suggests that grade of nurse staffing may influence the real cesarean section rate because nurses do a vital role to prevent unnecessary cesarean section. Further study is required to provide evidence that nurse staffing influence on patient outcome and cost-effectiveness in order to obtain adequate number of nursing staffs.

Birth in Brazil: national survey into labour and birth

BACKGROUND

Caesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction.

METHODS

Nationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients' medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson's groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design.

DISCUSSION

This study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it's consequences on postnatal health.

Desigualdades sociais nas complicações da cesariana: uma análise hierarquizada

Com objetivo de investigar associações entre fatores socioeconômicos e complicações da cesariana, uma amostra de 604 puérperas cujos partos ocorreram em duas maternidades no Sul do Brasil foi entrevistada 24 horas pós-parto e na segunda semana do puerpério, por meio de entrevistas hospitalares e domicilio. Regressão de Cox foi aplicada ao modelo hierárquico dos fatores associados ao tipo de parto e às complicações no pós-parto. Complicações foram duas vezes mais frequentes após cesariana, independentemente das condições socioeconômicas. Contudo, a maneira como o parto cesáreo se associou ao risco de complicações mostrou-se mediada pelas circunstâncias socioeconômicas representadas pela categoria do pré-natal e parto, ter ou não o mesmo profissional no pré-natal e parto e ter sua cesariana decidida intraparto. Resultados do estudo evidenciam que complicações pós-cirúrgicas da cesariana têm impacto adverso, principalmente, entre aquelas mulheres vivendo em condições sociais e de saúde menos privilegiadas, as quais, após o parto, retornam para um ambiente de menor suporte, com uma cicatriz abdominal.

Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off

OBJECTIVE

To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries.

METHODS

All children born to mothers from the urban area of Pelotas, Brazil, in 2004, were recruited for a birth cohort study. Mothers were contacted and interviewed during their hospital stay when extensive information on the gestation, the birth and the newborn, along with maternal health history and family characteristics was collected. Maternal characteristics and childbirth care financing - either private or public healthcare (SUS) patients - were the main factors investigated along with a description of C-sections distribution according to day of the week and delivery time. Standard descriptive techniques, Χ² tests for comparing proportions and Poisson regression to explore the independent effect of C-section predictors were the methods used.

RESULTS

The overall C-section rate was 45%, 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were more frequent on Tuesdays and Wednesdays, reducing by about a third on Sundays, while normal deliveries had a uniform distribution along the week. Delivery time for C-sections was markedly different among public and private patients. Maternal schooling was positively associated with C-section among SUS patients, but not among private patients.

CONCLUSIONS

C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor's schedule. Drastic action is called for to change the current situation.

Analyzing the impact of private service on the cesarean section rate in public hospital Thailand

OBJECTIVE

To assess the cesarean section rate and compare the risk profiles of cesarean delivery in nulliparous women between private and non-private service.

MATERIALS AND METHODS

The computerized delivery records, collected from June 2006 to May 2009 at Rajavithi Hospital were retrospectively reviewed. Of these, 11,049 term singleton nulliparous pregnant women without maternal chronic medical disease were divided into two groups; private and non-private group. Demographic data, cesarean section rate, indication for cesarean section, time of delivery, maternal and neonatal outcomes were assessed and analyzed.

RESULTS

The cesarean section rate was markedly different between both groups. The cesarean rates of all pregnant women, women in private group and non-private group were 25.7% (2,841 out of 11,049), 67.3% (1,187 out of 1,765), and 17.8% (1,654 out of 9,284), respectively. The private group's odds of having a cesarean delivery was 9.44 times [95% confidence interval (95% CI) 8.372-10.655] higher than the non-private group's after adjusting for background differences (maternal age, race, gestational age and birth weight). The most common indications for cesarean delivery in private group were elderly gravida, unfavorable cervix and cephalopelvic disproportion. The private group had significantly higher operation rate in the office hours than that of non-private group (70.1 vs. 41.8%; p < 0.0001). After adjusted for background differences, postpartum hemorrhage was significant higher in private group. Conversely, there was fewer admission to neonatal intensive care unit in private group. Low Apgar score at 5 min and perinatal death were not statistically significant in both groups. No cesarean hysterectomy and maternal death in both groups were noted.

CONCLUSIONS

Private patients had a significantly higher rate of cesarean section than non-private patients. NICU admission was significantly lower in the private group, but postpartum hemorrhage was significantly higher. There were no significant differences in maternal mortality, low Apgar score at 5 min, perinatal death in both group. This study suggests that a significant number of cesarean sections among private services may be unnecessary. To safely reduce a cesarean section rate, an appropriate policy and guideline for auditing cesarean section among private service should be developed.

Time, space and touch at work: body work and labour process (re)organisation

With 'efficiency savings' the watchword for health and social care services, reorganisation and labour rationalisation are the order of the day. This article examines the difficulties involved in (re)organising work which takes bodies as its object, or material of production. It shows that working on bodies ('body work') systematically delimits possibilities for labour process rationalisation which, in turn, constrains reorganisation of the health and social care sector. It does this in three main ways. First: rigidity in the ratio of workers to bodies-worked-upon limits the potential to increase capital-labour ratios or cut labour. Secondly: the requirement for co-presence and temporal unpredictability in demand for body work diminish the spatial and temporal malleability of the labour process. Thirdly: the nature of bodies as a material of production--complex, unitary and responsive--makes it difficult to standardise, reorganise or rationalise work. A wide-ranging analysis of body work in health and social care, as well as other sectors, fleshes out these three constraints and shows that attempts to overcome them and reorganise the sector in pursuit of cost savings or 'efficiency', generate problems for workers and the patients, whose bodies they work upon.

Is generalized maternal optimism or pessimism during pregnancy associated with unplanned cesarean section deliveries in China?

This research examines whether maternal optimism/pessimism is associated with unplanned Cesarean section deliveries in China. If so, does the association remain after controlling for clinical factors associated with C-sections? A sample of 227 mostly primiparous women in the third trimester of pregnancy was surveyed in a large tertiary care hospital in Beijing, China. Post-delivery data were collected from medical records. In bivariate analysis, both optimism and pessimism were related to unplanned c-section. However, when optimism and pessimism were entered into a regression model together, optimism was no longer statistically significant. Pessimism remained significant, even when adjusting for clinical factors such as previous abortion, previous miscarriage, pregnancy complications, infant gestational age, infant birthweight, labor duration, birth complications, and self-rated difficulty of the pregnancy. This research suggests that maternal mindset during pregnancy has a role in mode of delivery. However, more research is needed to elucidate potential causal pathways and test potential interventions.

Factors associated with breastfeeding in the first hour of life

OBJECTIVE

To identify factors associated with breastfeeding in the first hour of life (Step 4 of the Baby-Friendly Hospital Initiative).

METHODS

A cross-sectional study was conducted with a representative sample of mothers who gave birth in maternity wards in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2001. Newborns or mothers with restriction to breastfeeding were excluded, resulting in a sample of 8,397 pairs. A random effect--at maternity hospital level--Poisson model was employed in a hierarchical approach with three levels: distal, intermediate and proximal for characteristics of the mother, of the newborn, and of prenatal and hospital assistance.

RESULTS

Only 16% of the mothers breastfed in the first hour of life. Breastfeeding in this period was less prevalent among neonates with immediate intercurrences after birth (PR = 0.47; CI99% 0.15;0.80); among mothers who did not have contact with their newborns in the delivery room (PR = 0.62; CI99% 0.29;0.95); among mothers submitted to cesarean section delivery (PR = 0.48; CI99% 0.24;0.72); and among mothers who gave birth at private maternity hospitals (PR = 0.06; CI99% 0.01;0.19) or at maternity hospitals contracted out to National Health System (SUS) (PR = 0.16; CI99% 0.01;0.30). The context effect of maternity wards was statistically significant.

CONCLUSIONS

At an individual level, breastfeeding within one hour after birth was constrained by inappropriate practices in private or SUS-contracted maternity hospitals. The group effect of maternity hospitals and the absence of individual maternal-related factors that explain the outcome suggest that mothers have little or no autonomy to breastfeed their babies within the first hour of life, and depend on the institutional practices that prevail at the maternity hospitals.

Metformin compared with glyburide for the management of gestational diabetes

OBJECTIVE

To assess blood glucose control and neonatal outcomes when women with gestational diabetes mellitus (GDM) were treated with metformin or glyburide.

METHODS

When an appropriate diet was insufficient to control their blood glucose levels, women with GDM were randomized to a glyburide or a metformin treatment group. If the maximum dose was reached, the assessed drug was replaced by insulin. The primary outcome measures analyzed were maternal glucose levels during pregnancy, birth weight, and neonatal glucose levels.

RESULTS

The only significant difference in outcome between the 2 treatment drugs was that maternal weight gain during pregnancy was less in the metformin (n=40) than in the glyburide group (n=32) (10.3 kg vs 7.6 kg; P=0.02). No differences were found in treatment failure, mean level of fasting or postprandial plasma glucose, rate of participants with glycated hemoglobin, birth weight, rate of large-for-gestational-age newborns, or newborns with hypoglycemia.

CONCLUSION

The treatment of GDM with metformin or glyburide was found to be equivalent for both women and newborns.