Unwanted caesarean sections among public and private patients in Brazil: prospective study

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Abstract
Objective: To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. Design: Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. Setting: Four cities in Brazil. Participants: 1612 pregnant women: 1093 public patients and 519 private patients. Main outcome measures: Rates of delivery by caesarean section in public and private institutions; women's preferences for delivery; timing of decision to perform caesarean section. Results: 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. Conclusions: The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery. What is already known on this topic What is already known on this topic In Brazil, one quarter of all women deliver in the private sector The rate of caesarean deliveries in the private sector is extremely high (70%) and more than twice that in the public sector, where rates have recently fallen due to a new policy Previous studies in which women were interviewed after birth showed that a substantial proportion of private patients who have caesarean sections would have preferred normal delivery What this study adds What this study adds In two antenatal interviews, preferences regarding type of delivery were nearly identical among public and private patients and strongly favoured vaginal births Contrary to popular belief, middle and upper class women in Brazil do not want to deliver by caesarean section