title: Cesarean sections in Brazil: will they ever stop increasing?
abstract: 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.
authors.affiliation: Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas, Rio Grande do Sul, Brazil.
authors.forename: Fernando C
authors.initials: FC
authors.lastname: Barros
authors.affiliation: Department of Preventive Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
authors.forename: Alicia
authors.initials: A
authors.lastname: Matijasevich
authors.affiliation: Ministry of Health, Brasilia, Brazil.
authors.forename: Ana Goretti K
authors.initials: AG
authors.lastname: Maranhão
authors.affiliation: Ministry of Health, Brasilia, Brazil.
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Escalante
authors.affiliation: Ministry of Health, Brasilia, Brazil.
authors.forename: Dacio L
authors.initials: DL
authors.lastname: Rabello Neto
authors.affiliation: Ministry of Health, Brasilia, Brazil.
authors.forename: Roberto M
authors.initials: RM
authors.lastname: Fernandes
authors.affiliation: Ministry of Health, Brasilia, Brazil.
authors.forename: Maria Esther A
authors.initials: ME
authors.lastname: Vilella
authors.affiliation: United Nations Children's Fund, Brasilia, Brazil.
authors.forename: Ana Cristina
authors.initials: AC
authors.lastname: Matos
authors.affiliation: United Nations Children's Fund, Brasilia, Brazil.
authors.forename: Cristina
authors.initials: C
authors.lastname: Albuquerque
authors.affiliation: Latin American Center for Perinatology, Women and Reproductive Health, Pan American Health Organization, World Health Organization, Montevideo, Uruguay.
authors.forename: Ricardo Gómez Ponce de
authors.initials: RG
authors.lastname: Léon
authors.affiliation: Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, Rio Grande do Sul, Brazil.
authors.forename: Cesar G
authors.initials: CG
authors.lastname: Victora
mesh_terms: D001938:Brazil / Q000453:epidemiology; D002585:Cesarean Section; D005260:Female; D006801:Humans; D011203:Poverty; D011247:Pregnancy; D012307:Risk Factors; D044465:White People