The impact of payment source and hospital type on rising cesarean section rates in Brazil, 1998 to 2008.

BACKGROUND High cesarean section rates in Brazilian public hospitals and higher rates in private hospitals are well established. Less is known about the relationship between payment source and cesarean section rates within public and private hospitals. METHODS We analyzed the 1998, 2003, and 2008 rounds of a nationally representative household survey (PNAD), which includes type of delivery, where it took place, and who paid for it. We construct cesarean section rates for various categories, and perform logistic regression to determine the relative importance of independent variables on cesarean section rates for all births and first births only. RESULTS Brazilian cesarean section rates were 42 percent in 1998 and 53 percent in 2008. Women who delivered publicly funded births in either public or private hospitals had lower cesarean section rates than those who delivered privately financed deliveries in public or private hospitals. Multivariate models suggest that older age, higher education, and living outside the Northeast region all positively affect the odds of delivering by cesarean section; effects are attenuated by the payment source-hospital type variable for all women and even more so among first births. CONCLUSIONS Cesarean section rates have risen substantially in Brazil. It is important to distinguish payment source for the delivery to have a better understanding of those rates.