On-demand cesarean section: assessing trends and socioeconomic disparities

ABSTRACT OBJECTIVE: to measure prevalence, evaluate trends and identify socioeconomic differences of on-demand cesarean section in the municipality of Rio Grande (RS), extreme south of Brazil, in 2007, 2010, 2013 and 2016. METHODS: all the puerperae residing in this municipality who had cesarean deliveries in one of the only two local maternity hospitals in the period 01/01-31/12 of the aforementioned years were part of this transversal study. Puerperae were interviewed using a single, standardized questionnaire at the hospital within 48 hours after delivery. The outcome was assessed based on the mothers' report that the cesarean section was performed according to their request. The analysis consisted of the observation of the outcome's frequency in each year and the evaluation of its prevalence throughout this period through the chi-square linear trend test. Socioeconomic inequalities were assessed based on household income and women's schooling using the Slope Index of Inequality and the Relative Index of Inequality. RESULTS: In these four years, 5,721 cesarean deliveries were recorded among mothers living in this municipality (1,309 in 2007, 1,341 in 2010, 1,626 in 2013 and 1,445 in 2016). In this period, the rate of on-demand cesarean sections increased by 107%, from 10.5% (95%CI: 8.9% -12.2%) of the deliveries in 2007 to 21.7% (95%CI: 19.5% -23.8%) in 2016. This increase was more evident among those with lower household income and schooling level. Absolute inequality also increased, especially regarding schooling, while relative inequality sharply declined when assessed by household income. CONCLUSIONS: The increased on-demand cesarean sections in the study location is unsettling, despite the decreasing gap between extreme categories as a consequence of higher levels of this procedure among women of lower income and worse schooling.

Cesarean section on demand: a population-based study in Southern Brazil / Cesariana a pedido: um estudo de base populacional no extremo Sul do Brasil

Abstract Objectives: to measure the prevalence and identify factors associated to the occurrence of cesarean section on demand in the municipality of Rio Grande, RS. Methods: all births that occurred in the two maternities between 01/01 to 12/31/2007, mothers who lived in the municipality were questioned on demographic and maternal reproductive characteristics, family socioeconomic level and health care received during pregnancy and childbirth. The outcome was constituted by cesarean section on demand, in other words, the request was from the parturient. In the analysis, Poisson regression was used with robust adjustment of the variance. The effect measurement used was the prevalence ratios (PR). Results: among the 2,557 parturients included in this study, 51.6% (CI95%:49.6%-53.5%) were submitted to cesarean sections, and 10.7% (CI95%:9.0%-12.4%) were on demand. After the adjustment based on previous hierarchical model, the variables showed significantly the association to the outcomes which were maternal schooling, household income, type of hospitalization (public or private) and being attended by the same physician throughout the prenatal period. Conclusions: the PR obtained show that the probability of occurrence of cesarean section on demand was substantially higher among the mothers who presented the lowest risk of complications during pregnancy and childbirth.

Resumo Objetivos: medir a prevalência e identificar fatores associados a ocorrência de cesarianas a pedido no município de Rio Grande, RS. Métodos: para todos os nascimentos ocorridos nas duas maternidades do município entre 01/01 a 31/12/2007, cujas mães residiam no município, foram investigadas características demográficas e reprodutivas maternas, socioeconômicas da família e assistência recebida durante a gestação e o parto. O desfecho foi constituído pela realização de cesariana a pedido, ou seja, por solicitação da parturiente. Na análise utilizou-se regressão de Poisson com ajuste robusto da variância. A medida de efeito utilizada foi razão de prevalências (RP). Resultados: dentre as 2.557 parturientes incluídas no estudo, 51,6% (IC95%:49,6%-53,5%) foram submetidas à cesariana, sendo 10,7% (IC95%:9,0%-12,4%) a pedido. Após ajuste obedecendo modelo hierárquico prévio, mostraram-se significativamente associadas ao desfecho as variáveis escolaridade materna, renda familiar, tipo de internação (público ou privada) e ter sido atendida pelo mesmo médico durante todo o pré-natal. Conclusões: as RP obtidas mostram que a probabilidade de ocorrência de cesariana a pedido foi substancialmente maior entre mães que apresentam os menores riscos de complicações durante a gravidez e o parto.

Público versus privado: avaliando a assistência à gestação e ao parto no extremo sul do Brasil / Public versus private: assessing maternity care in the far South of Brazil

OBJETIVOS: avaliar a assistência à gestação e ao parto entre o setor público e privado no município de Rio Grande, RS. MÉTODOS: aplicou-se questionário padronizado a todas as gestantes residentes neste município que tiveram filho em 2007. Investigaram-se aspectos relativos a cuidados recebidos desde o início da gestação até o pós-parto imediato. A análise estatística consistiu da comparação de proporções nestes dois grupos através do teste de qui-quadrado. RESULTADOS: dentre os 2584 nascimentos cujas mães residiam no município, foram obtidas informações sobre 2557, o que representa 98,9 por cento do total. Destas mães, 96 por cento realizaram pelo menos uma consulta de pré-natal. Gestantes atendidas no setor privado iniciaram o pré-natal mais cedo, realizaram um maior número de consultas médicas, exame de sangue e ultrassonografia pélvica, exame ginecológico, das mamas e citopatológico de colo uterino. Gestantes do setor público realizaram maior número de exames de urina e sorologia para sífilis e foram mais comumente suplementadas com sulfato ferroso. Todas estas diferenças foram estatisticamente significativas (p<0,05). CONCLUSÕES: gestantes do setor privado receberam de forma sistemática melhor assistência durante o pré-natal em termos de consultas e exames realizados, tiveram seu parto mais comumente realizado por médico, foram mais afetadas por intervenções desnecessárias como cesariana e episiotomia e menos frequentemente suplementadas com ferro.

OBJECTIVES: to compare public and private sector maternity care in the municipality of Rio Grande, in the Brazilian State of Rio Grande do Sul. METHODS: a standardized questionnaire was applied to all pregnant women residing in this municipality who had a child in 2007. All aspects, from the beginning of gestation to immediate post-partum were investigated. Statistical analysis took the form of comparison of proportions for these two groups, using the chi-squared test. RESULTS: of the 2584 children born whose mothers resided in the municipality, information was obtained on 2557, representing 98.9 percent of the total. Of these mothers, 96 percent received at least one prenatal consultation. Pregnant women attended by the private sector began prenatal care earlier, had a larger number of medical consults, blood tests, pelvic ultrasound examinations, and gynecological examinations of the breasts and cytopathological examinations of the cervix. Pregnant women in the public sector had more urine tests and serum tests for syphilis and were often give iron sulfate supplements. All these differences were statistically significant (p<0.05). CONCLUSIONS: pregnant women in the private sector systematically received better prenatal care in terms of consultations and examinations. Their delivery was more often carried out by a physician and they underwent more unnecessary interventions, such as a caesarian section or episiotomy, while they were less likely to receive iron supplements.

Características reprodutivas e utilização de serviços preventivos em saúde por mulheres em idade fértil: resultados de dois estudos transversais de base populacional no extremo Sul do Brasil / Reproductive characteristics and utilization of preventive health services by childbearing-age women: results of two cross-sectional population-based studies in the far South of Brazil

Em 1995 e 2004 foram realizados dois estudos transversais representativos com mulheres de 15 a 49 anos em Rio Grande, Rio Grande do Sul, Brasil, visando avaliar alguns indicadores básicos de saúde. A amostra incluiu 1.339 mulheres em 1995 e 1.311 em 2004. Aplicou-se questionário padronizado no domicílio investigando sobre características demográficas, sócio-econômicas, reprodutivas e utilização de serviços preventivos de saúde. A análise consistiu em comparar estes indicadores nos dois estudos pelo teste do qui-quadrado. Observou-se melhoria nas condições de habitação, saneamento, escolaridade, mas piora da renda familiar. A idade média de início das atividades sexuais diminuiu, a taxa de gravidez na adolescência aumentou em 33 por cento assim como aumentou a realização de exame citopatológico de colo uterino em 48 por cento e mama em 30 por cento. A utilização de métodos contraceptivos diminuiu 3 por cento, enquanto o uso de preservativos masculinos passou de 8 por cento para 21 por cento. Esforços deveriam ser feitos não somente visando incentivar a realização de exames de mama e citopatológico de colo uterino como também de retardar o início das atividades sexuais e de promover o uso de métodos contraceptivos, especialmente de preservativos.

Two surveys were conducted (1995 and 2004) on women 15-49 years of age in Rio Grande, Rio Grande do Sul State, southern Brazil, assess patterns in their use of preventive health services. The sample included 1,339 women in 1995 and 1,311 in 2004. A standardized household questionnaire covered their demographic, socioeconomic, reproductive, and health care-utilization characteristics. The chi-square test was used to compare indicators in the two studies. During the study period, housing conditions, running water, sanitation, and schooling improved, but family income decreased. Mean age at sexual initiation decreased by one year, teenage pregnancy increased 33 percent, and clinical breast examination and Pap smears increased 48 percent and 30 percent, respectively. Overall use of contraceptive methods declined by 3 percent, but condom use increased from 8 percent to 21 percent. Efforts are needed to improve coverage for breast examination and Pap smears, postpone sexual initiation, and promote the use of contraceptive methods, especially condoms.