Factors associated with cesarean sections in a public hospital in Rio de Janeiro, Brazil Fatores associados à realização de cesáreas em uma maternidade pública do Município do Rio de Janeiro, Brasil

Brazil has one of the world’s highest cesarean section rates. Contributing factors include the organization of obstetric practice, physicians’ attitudes, and women’s preferences and decisions. This study aimed to identify factors associated with cesarean sections in a public maternity hospital in Rio de Janeiro. A case-control study was conducted with 231 cesarean sections (cases) and 230 vaginal deliveries (controls). Hierarchical logistic regression analysis was performed, based on a conceptual model. Factors associated with increased odds of cesarean section were: primiparity; mother’s age 20-34; last birth by cesarean; cervical dilatation < 3cm at admission; patient request; daytime birth; male attending obstetrician; obstetrician on duty for more than 24 hours a week; obstetrician with private practice; gestational hypertension; noncephalic presentation; and gestational age > 41 weeks. Factors associated with lower odds of cesarean were: gestational age < 37 weeks; leaving home with signs of labor, use of oxytocin; and amniotomy. In this hospital, interventions aimed to modify the above-mentioned factors can help lower the cesarean rate. Cesarean Section; Parturition; Maternity Introduction Brazil has one of the world’s highest cesarean section rates in the world (38% of live births in 2000) 1, surpassed only by Chile, with 42% in 1999 2. Recently, a slight downward trend in the cesarean rate has been observed in the Brazilian public sector, from 32% in 1994-1997 to 25% in 2001 3. In Brazil, higher socioeconomic status is associated with increased probability of a cesarean section. Thus, the cesarean rate is higher in more developed regions like the Southeast (45%), South (40%), and Central-West (43%) than in the less developed North (27%) and Northeast (25%) 4. The rate is also higher in private hospitals (70%) as compared to public (32%) 5 and in women with more schooling and higher income 6. Another aspect of inadequate use of cesareans in Brazil is the difficult access to hospital care (particularly in poorer regions of the country) 7, but even in developed metropolitan areas like Rio de Janeiro the excessive use of cesarean sections coexists with its absence when clearly indicated 8. Studies suggest several factors related to the high cesarean rate, including obstetrician’s convenience with this programmed intervention 9, physicians’ lack of training for unexpected situations during delivery 10, lack of integration between prenatal and childbirth services, D’Orsi E et al. 2068 Cad. Saúde Pública, Rio de Janeiro, 22(10):2067-2078, out, 2006 and the hospital shift system, which does not allow women to remain in labor from one shift to the next 11. Contrary to allegations by some obstetricians, recent studies, including the Latin American Study on Cesarean Sections (ELAC) 14, show a declared preference for vaginal birth among Brazilian women (about 70%) 5,12,13. This study shows faster recovery and a less painful postpartum as the principal reasons for this preference, and the absence of contractions as the principal advantage of a cesarean. Most women feel that a cesarean should be performed only when there is no alternative (due to serious illness of the woman or risk to the fetus) 14. This study focuses on the association between cesarean sections and factors related to the patient, physicians, and organization of obstetric practice. Brazilian epidemiological studies on these three dimensions are scarce 11,15. We thus aim to contribute to a more detailed knowledge of the mechanisms leading to cesarean sections in the selected maternity hospital.