Unwanted caesarean sections among public and private patients in Brazil: prospective study.

OBJECTIVE To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. DESIGN Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. SETTING Four cities in Brazil. PARTICIPANTS 1612 pregnant women: 1093 public patients and 519 private patients. MAIN OUTCOME MEASURES Rates of delivery by caesarean section in public and private institutions; women's preferences for delivery; timing of decision to perform caesarean section. RESULTS 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. CONCLUSIONS The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery.