Cesarean sections in Brazil: will they ever stop increasing? / Cesáreas en el Brasil: ¿dejarán de aumentar alguna vez?

Objective. To describe trends, geographic distribution, and risk factors for cesarean deliveries in Brazil in 2000–2011, and to determine if efforts to curtail rates have had a measurable impact. Methods. This was an observational study using nationwide information from the Department of Informatics of the Unified Health System (DATASUS). Individual level analyses were based on data regarding maternal education, age, parity, and skin color. Ecological analyses at the level of 431 health districts investigated the relationships with health facility density and poverty level. Results. Cesarean rates increased markedly, from 37.9% in 2000 to 53.9% in 2011. Preliminary results from 2012 showed a rate of 55.8%, with the richest geographic areas showing the highest rates. Rates at the municipal level varied from 9%–96%. Cesareans were more common in women with higher education, white skin color, older age, and in primiparas. In the ecological analyses, the number of health facilities per 1 000 population was strongly and positively correlated with cesarean rates, with an increase of 16.1 percentage points (95% Confidence Interval [95%CI] = 4.3–17.8) for each facility. An increase of 1 percentage point in the poverty rate was associated with a decline of 0.5 percentage point in cesarean rates (95%CI = 0.5–0.6). Conclusions. The strong associations with maternal education and health facility density suggest that the vast majority of cesareans are not medically indicated. A number of policies and programs have been launched to counteract this trend, but have had virtually no impact.

Objetivo. Describir las tendencias, la distribución geográfica, y los factores de riesgo de parto por cesárea en el Brasil durante el período del 2000 al 2011, y determinar si las iniciativas dirigidas a reducir las tasas de cesáreas han tenido una repercusión cuantificable. Métodos. Se trata de un estudio de observación que utilizó información a escala nacional del Departamento de Informática del Sistema Unificado de Salud (DATASUS). Los análisis a nivel individual se basaron en datos sobre el nivel de formación materna, la edad, la paridad y el color de la piel. Se investigaron las relaciones con la densidad de establecimientos de salud y el nivel de pobreza mediante análisis ecológicos a nivel de 431 distritos de salud. Resultados. Las tasas de cesáreas aumentaron notablemente, de 37,9% en el 2000 a 53,9% en el 2011. Los resultados preliminares del 2012 mostraron una tasa de 55,8%, con tasas más elevadas en las zonas geográficas más ricas. Las tasas a escala municipal variaron de 9 a 96%. Los partos por cesárea fueron más frecuentes en las mujeres blancas, en las que tenían un mayor nivel de formación, en las de mayor edad y en las primíparas. En los análisis ecológicos, el número de establecimientos de salud por 1 000 habitantes se correlacionó intensa y positivamente con la tasa de cesáreas, con un incremento de 16,1 puntos porcentuales (intervalo de confianza (IC) de 95% = 4,3–17,8) para cada establecimiento. Un aumento de un punto porcentual en la tasa de pobreza se asociaba con una disminución de medio punto porcentual en la tasa de cesáreas (IC de 95% = 0,5–0,6). Conclusiones. Las intensas asociaciones con el nivel de formación materna y la densidad de establecimientos de salud indican que la mayor parte de las cesáreas no están indicadas médicamente. Se han puesto en marcha diversos programas y políticas dirigidos a contrarrestar esta tendencia, pero prácticamente no han tenido ninguna repercusión.

Cesarean sections in Brazil: will they ever stop increasing? / Cesáreas en el Brasil: ¿dejarán de aumentar alguna vez?

OBJECTIVE: To describe trends, geographic distribution, and risk factors for cesarean deliveries in Brazil in 2000-2011, and to determine if efforts to curtail rates have had a measurable impact. METHODS: This was an observational study using nationwide information from the Department of Informatics of the Unified Health System (DATASUS). Individual level analyses were based on data regarding maternal education, age, parity, and skin color. Ecological analyses at the level of 431 health districts investigated the relationships with health facility density and poverty level. RESULTS: Cesarean rates increased markedly, from 37.9% in 2000 to 53.9% in 2011. Preliminary results from 2012 showed a rate of 55.8%, with the richest geographic areas showing the highest rates. Rates at the municipal level varied from 9%-96%. Cesareans were more common in women with higher education, white skin color, older age, and in primi- paras. In the ecological analyses, the number of health facilities per 1 000 population was strongly and positively correlated with cesarean rates, with an increase of 16.1 percentage points (95% Confidence Interval [95%CI] = 4.3-17.8) for each facility. An increase of 1 percentage point in the poverty rate was associated with a decline of 0.5 percentage point in cesarean rates (95%CI = 0.5-0.6). CONCLUSIONS: The strong associations with maternal education and health facility density suggest that the vast majority of cesareans are not medically indicated. A number of policies and programs have been launched to counteract this trend, but have had virtually no impact.

OBJETIVO: Describir las tendencias, la distribución geográfica, y los factores de riesgo de parto por cesárea en el Brasil durante el período del 2000 al 2011, y determinar si las iniciativas dirigidas a reducir las tasas de cesáreas han tenido una repercusión cuantificable. MÉTODOS: Se trata de un estudio de observación que utilizó información a escala nacional del Departamento de Informática del Sistema Unificado de Salud (DATASUS). Los análisis a nivel individual se basaron en datos sobre el nivel de formación materna, la edad, la paridad y el color de la piel. Se investigaron las relaciones con la densidad de establecimientos de salud y el nivel de pobreza mediante análisis ecológicos a nivel de 431 distritos de salud. RESULTADOS: Las tasas de cesáreas aumentaron notablemente, de 37,9% en el 2000 a 53,9% en el 2011. Los resultados preliminares del 2012 mostraron una tasa de 55,8%, con tasas más elevadas en las zonas geográficas más ricas. Las tasas a escala municipal variaron de 9 a 96%. Los partos por cesárea fueron más frecuentes en las mujeres blancas, en las que tenían un mayor nivel de formación, en las de mayor edad y en las primíparas. En los análisis ecológicos, el número de establecimientos de salud por 1 000 habitantes se correlacionó intensa y positivamente con la tasa de cesáreas, con un incremento de 16,1 puntos porcentuales (intervalo de confianza (IC) de 95% = 4,3-17,8) para cada establecimiento. Un aumento de un punto porcentual en la tasa de pobreza se asociaba con una disminución de medio punto porcentual en la tasa de cesáreas (IC de 95% = 0,5-0,6). CONCLUSIONES: Las intensas asociaciones con el nivel de formación materna y la densidad de establecimientos de salud indican que la mayor parte de las cesáreas no están indicadas médicamente. Se han puesto en marcha diversos programas y políticas dirigidos a contrarrestar esta tendencia, pero prácticamente no han tenido ninguna repercusión.

Cesarean sections in Brazil: will they ever stop increasing?

OBJECTIVE: To describe trends, geographic distribution, and risk factors for cesarean deliveries in Brazil in 2000-2011, and to determine if efforts to curtail rates have had a measurable impact. METHODS: This was an observational study using nationwide information from the Department of Informatics of the Unified Health System (DATASUS). Individual level analyses were based on data regarding maternal education, age, parity, and skin color. Ecological analyses at the level of 431 health districts investigated the relationships with health facility density and poverty level. RESULTS: Cesarean rates increased markedly, from 37.9% in 2000 to 53.9% in 2011. Preliminary results from 2012 showed a rate of 55.8%, with the richest geographic areas showing the highest rates. Rates at the municipal level varied from 9%-96%. Cesareans were more common in women with higher education, white skin color, older age, and in primi- paras. In the ecological analyses, the number of health facilities per 1 000 population was strongly and positively correlated with cesarean rates, with an increase of 16.1 percentage points (95% Confidence Interval [95%CI] = 4.3-17.8) for each facility. An increase of 1 percentage point in the poverty rate was associated with a decline of 0.5 percentage point in cesarean rates (95%CI = 0.5-0.6). CONCLUSIONS: The strong associations with maternal education and health facility density suggest that the vast majority of cesareans are not medically indicated. A number of policies and programs have been launched to counteract this trend, but have had virtually no impact.

Estimativas corrigidas da prevalência de nascimentos pré-termo no Brasil, 2000 a 2011* / Improved estimates of preterm birth prevalence in Brazil, 2000-2011

Objetivo: estimar a prevalência corrigida de nascimentos pré-termo no Brasil, macrorregiões e unidades da federação para o período de 2000 a 2011. Métodos: utilizou-se a distribuição de peso ao nascer informada pelo Sistema de Informações sobre Nascidos Vivos (Sinasc) e aplicou-se essa distribuição às prevalências de nascimentos pré-termos obtidas em estudos com dados primários brasileiros, para construção de curvas de correção; as prevalências de prematuridade foram calculadas separadamente, para cada sexo e para cada grupo de 100g de peso ao nascer, logo acumuladas para as diferentes unidades geográficas. Resultados: a prevalência oficial de nascimentos pré-termo no Brasil oscilou entre 6 e 7 por cento, de 2000 a 2010, conforme o Sinasc, enquanto as estimativas corrigidas mostraram valores entre 11 e 12 por cento; no ano de 2011, a prevalência de prematuridade foi apenas 15 por cento inferior àquela estimada. Conclusão: no período estudado, foi confirmada a subestimação dos nascimentos pré-termo na base de dados do Sinasc.

Objective: to estimate corrected preterm birth prevalence nationally, as well as in the country’s macro-regions and states in 2000-2011. Methods: we used the distribution of birth weight reported by the Live Births Information System (SINASC) and, in order to build correction curves, applied this distribution to preterm birth prevalence obtained in primary studies conducted in different regions of Brazil. Preterm birth prevalence was calculated separately for both sexes and for each 100g birth weight group, and then accumulated for the different geographical units. Results: official prevalence of preterm births in Brazil was between 6 per cent and 7 per cent for the 2000-2011 period according to the SINASC system, while the corrected estimates showed values between 11 per cent and 12 per cent. In 2011, preterm birth prevalence was only 15 per cent below the estimated. Conclusion: our study confirmed underestimated preterm birth on the SINASC system for the 2000-2011 period.

Were equatorial regions less affected by the 2009 influenza pandemic? The Brazilian experience.

Although it is in the Tropics where nearly half of the world population lives and infectious disease burden is highest, little is known about the impact of influenza pandemics in this area. We investigated the mortality impact of the 2009 influenza pandemic relative to mortality rates from various outcomes in pre-pandemic years throughout a wide range of latitudes encompassing the entire tropical, and part of the subtropical, zone of the Southern Hemisphere (+5(°)N to -35(°)S) by focusing on a country with relatively uniform health care, disease surveillance, immunization and mitigation policies: Brazil. To this end, we analyzed laboratory-confirmed deaths and vital statistics mortality beyond pre-pandemic levels for each Brazilian state. Pneumonia, influenza and respiratory mortality were significantly higher during the pandemic, affecting predominantly adults aged 25 to 65 years. Overall, there were 2,273 and 2,787 additional P&I- and respiratory deaths during the pandemic, corresponding to a 5.2% and 2.7% increase, respectively, over average pre-pandemic annual mortality. However, there was a marked spatial structure in mortality that was independent of socio-demographic indicators and inversely related with income: mortality was progressively lower towards equatorial regions, where low or no difference from pre-pandemic mortality levels was identified. Additionally, the onset of pandemic-associated mortality was progressively delayed in equatorial states. Unexpectedly, there was no additional mortality from circulatory causes. Comparing disease burden reliably across regions is critical in those areas marked by competing health priorities and limited resources. Our results suggest, however, that tropical regions of the Southern Hemisphere may have been disproportionally less affected by the pandemic, and that climate may have played a key role in this regard. These findings have a direct bearing on global estimates of pandemic burden and the assessment of the role of immunological, socioeconomic and environmental drivers of the transmissibility and severity of this pandemic.