title: The Brazilian preference: cesarean delivery among immigrants in Portugal.
abstract: OBJECTIVE
  To evaluate how the country of origin affects the probability of being delivered by cesarean section when giving birth at public Portuguese hospitals.
  
  
  METHODS
  Women delivered of a singleton birth (n = 8228), recruited from five public level III maternities (April 2005-August 2006) during the procedure of assembling a birth cohort, were classified according to the country of origin and her migration status as Portuguese (n = 7908), non-Portuguese European (n = 84), African (n = 77) and Brazilian (n = 159). A Poisson model was used to evaluate the association between country of birth and cesarean section that was measured by adjusted prevalence ratio (PR) and respective 95% confidence intervals (95%CI).
  
  
  RESULTS
  The cesarean section rate varied from 32.1% in non-Portuguese European to 48.4% in Brazilian women (p = 0.008). After adjustment for potential confounders and compared to Portuguese women as a reference, Brazilian women presented significantly higher prevalence of cesarean section (PR = 1.26; 95%CI: 1.08-1.47). The effect was more evident among multiparous women (PR = 1.39; 95%CI: 1.12-1.73) and it was observed when cesarean section was performed either before labor (PR = 1.43; 95%CI: 0.99-2.06) or during labor (PR = 1.30; 95%CI: 1.07-1.58).
  
  
  CONCLUSIONS
  The rate of cesarean section was significantly higher among Brazilian women and it was independent of the presence of any known risk factors or usual clinical indications, suggesting that cultural background influences the mode of delivery overcoming the expected standard of care and outcomes in public health services.
authors.affiliation: Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal. cristina.teixeira@ipb.pt
authors.forename: Cristina
authors.initials: C
authors.lastname: Teixeira
authors.forename: Sofia
authors.initials: S
authors.lastname: Correia
authors.forename: César G
authors.initials: CG
authors.lastname: Victora
authors.forename: Henrique
authors.initials: H
authors.lastname: Barros
mesh_terms: D000328:Adult; D001938:Brazil; D002585:Cesarean Section / Q000706:statistics & numerical data*; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D011174:Portugal; D011247:Pregnancy
references.citation: BMC Public Health. 2009 Mar 20;9:84
references.pmid: 19298682
references.citation: Acta Obstet Gynecol Scand. 2010 Nov;89(11):1460-5
references.pmid: 20955100
references.citation: BJOG. 2006 Jun;113(6):647-56
references.pmid: 16709207
references.citation: Soc Sci Med. 2009 Sep;69(6):934-46
references.pmid: 19664869
references.citation: Paediatr Perinat Epidemiol. 2009 Sep;23(5):454-62
references.pmid: 19689496
references.citation: Pediatrics. 2001 Aug;108(2):E35
references.pmid: 11483845
references.citation: Int J Gynaecol Obstet. 2009 Dec;107(3):198-201
references.pmid: 19782979
references.citation: Acta Obstet Gynecol Scand. 2007;86(4):389-94
references.pmid: 17486457
references.citation: Eur J Obstet Gynecol Reprod Biol. 2004 Oct 15;116(2):170-2
references.pmid: 15358458
references.citation: Acta Obstet Gynecol Scand. 2005 Sep;84(9):825-32
references.pmid: 16097970
references.citation: BJOG. 2008 Dec;115(13):1630-40
references.pmid: 19035939
references.citation: BMJ. 2002 Apr 20;324(7343):942-5
references.pmid: 11964338
references.citation: Sociol Health Illn. 2005 Mar;27(2):215-42
references.pmid: 15787776
references.citation: Eur J Public Health. 2010 Oct;20(5):524-9
references.pmid: 20522515
references.citation: Int J Public Health. 2007;52(4):210-22
references.pmid: 18030953
references.citation: BJOG. 2010 Mar;117(4):399-406
references.pmid: 19943828
references.citation: Am J Obstet Gynecol. 2010 Mar;202(3):245.e1-245.e12
references.pmid: 20207242
references.citation: BJOG. 2004 Aug;111(8):849-55
references.pmid: 15270935
references.citation: Matern Child Health J. 2005 Mar;9(1):11-20
references.pmid: 15880970
references.citation: CMAJ. 2007 Feb 13;176(4):455-60
references.pmid: 17296957
references.citation: BMJ. 2000 Jul 15;321(7254):137-41
references.pmid: 10894690
references.citation: Bull World Health Organ. 2005 Jun;83(6):449-55
references.pmid: 15976896
references.citation: Soc Sci Med. 1996 Dec;43(12):1765-84
references.pmid: 8961420
references.citation: Acta Obstet Gynecol Scand. 2000 Jul;79(7):553-8
references.pmid: 10929954
references.citation: Birth. 2011 Sep;38(3):191-9
references.pmid: 21884227
references.citation: Eur J Public Health. 2011 Apr;21(2):229-34
references.pmid: 20522516
references.citation: Arch Gynecol Obstet. 2006 Aug;274(5):271-8
references.pmid: 16847635
references.citation: BJOG. 2002 Jun;109(6):677-82
references.pmid: 12118647
references.citation: Soc Sci Med. 2009 Feb;68(3):452-61
references.pmid: 19042065
references.citation: BMJ. 1999 Nov 27;319(7222):1397-400
references.pmid: 10574855
references.citation: Birth. 2009 Mar;36(1):26-33
references.pmid: 19278380
references.citation: Lancet. 2003 Aug 23;362(9384):628
references.pmid: 12947949
references.citation: Paediatr Perinat Epidemiol. 2011 Nov;25(6):575-92
references.pmid: 21980947
references.citation: Acta Obstet Gynecol Scand. 2008;87(6):662-8
references.pmid: 18568466
references.citation: Eur J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):214-9
references.pmid: 21733613
references.citation: BJOG. 2001 Feb;108(2):149-57
references.pmid: 11236114
references.citation: BMC Med Res Methodol. 2003 Oct 20;3:21
references.pmid: 14567763
references.citation: Lancet. 1991 Jul 20;338(8760):167-9
references.pmid: 1677075
references.citation: BMJ. 2001 Nov 17;323(7322):1155-8
references.pmid: 11711406
references.citation: Lancet. 2011 May 28;377(9780):1863-76
references.pmid: 21561656