Restricting the timing of Elective CS: evidence from Brazil

Melo, Lucas

doi:10.1590/0101-41615122lbm

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Brasil

Estudos Econômicos (São Paulo)

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Artigo de Pesquisa • Estud. Econ. 51 (02) • Apr-Jun 2021 • https://doi.org/10.1590/0101-41615122lbm copy

Restricting the timing of Elective CS: evidence from Brazil^* * I’d like to thank Cecilia Machado, Rudi Rocha, Andre Trindade, Guilherme Hirata, participants of Stata Conference Sao Paulo 2019 and two anonymous referees for helpful comments on this research. All errors remain mine. This study was also financed and supported by IDados, this study was financed in part by the CAPES - Finance Code 001.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Brazil has one of the highest Cesarean Section (CS) rates in the world. It is a share of 58.3% reported by the Living Births Information System (SINASC) 2015-2017. It is well above the maximum rate of 15% recommended by the World Health Organization (WHO). In this paper, we estimate impacts and unintended consequences of the Resolution 2,144 from the Federal council of Medicine (CFM) on outcomes of Low Risk First Born births (LRFB). The Resolution introduces a minimum of 39th weeks of gestation for Elective CS. Elective CS before the 39th week rate dropped 2.78 percentage points, which is statistically significant and equivalent to a 24% decrease in this outcome’s mean. We also find increases in birth’s time length: the percentage of births happening before the 39th week decreased 2.34 percentage points, which is a decrease of 6% in its average. Our results suggest that Elective CS’s were postponed from the 37-38th week to after the begin of the 39th week. We show that the policy had an unintended consequence once it seems to have changed the way potential spontaneous Natural Deliveries are anticipated from weekends to weekdays through Scheduled CS.

Keywords:
Scheduled Cesarean Section; Dif-in-Dif; Policy

Variable	Description	Variable	Description
birth_id	Child’s identification	mother_city_cd	Mother’s city
weight	Child’s weight	date	Procedure date
apgar1	APGAR Score 1’	hospital_cd	Hospital code.
apgar5	APGAR Score 5’	mothers_age	Mother’s age
n_prev_preg	Nº of previous pregnancies	city_cd	City of procedure realization
weeks	Gestational length in weeks	month_prenat	Month prenatal care started.
cs	Type of delivery : 0: Natural; 1: CS.	marital_status	1: Single; 2: Married; 3: Widow; 4: Separeted;
i_sex	0: female; 1: male.	position	Fetus position: 1:Cephalic; 2: Breech; 3:Transverse
induced_labor	0: No; 1:Yes;	type_preg	1: Unique; 2: Double; 3: Triple and more;
i_anomal	Congenital anomaly : 1: Yes; 0 : No	cslabor	1:Caesarean section before labor began; 0: CS after labor or Natural delivery:
mothers_school	Mother’s educational attainament: 1: None; 2: 1 to 3 years; 3: 4 to 7 years; 4: 8 to 11 years; 5: 12 or more;	mothers_race	1: White; 2: Black; 3: Yellow; 4: Non-white; 5: Idigenous people.
birthplace	1: Hospital; 2: Other Health est.; 3: Home; 4: Others.	visits	Nº of prenatal consultations: 1: None; 2: 1 to 3; 3: 4 to 6; 4: 7 or more.

	CS	Sched CS	Private	Weeks	Before 39	Induced	Apgar 1
Policy 0
Mean	0.59	0.30	0.21	39.06	0.33	0.23	8.44
Std. Error	0.49	0.46	0.40	1.25	0.47	0.42	1.04
Sum	566194	286536	196635		317813	211925
Policy 1
Mean	0.59	0.29	0.19	39.11	0.31	0.22	8.45
Std. Error	0.49	0.45	0.39	1.23	0.46	0.41	1.02
Sum	556208	271817	180576		290526	200521
Total
Mean	0.59	0.29	0.20	39.09	0.32	0.22	8.44
Std. Error	0.49	0.46	0.40	1.24	0.47	0.42	1.03
Sum	1122402	558353	377211		608339	412446
	Apgar 5	Weight	Age	Visits	Month Prena	Sex
Policy 0
Mean	9.43	3229	24.35	3.74	2.37	0.51
Std. Error	0.68	413	4.85	0.56	1.33	0.50
Policy 1
Mean	9.43	3236	24.41	3.76	2.32	0.51
Std. Error	0.67	414	4.86	0.54	1.27	0.50
Total
Mean	9.43	3233	24.38	3.75	2.34	0.51
Std. Error	0.67	413	4.86	0.55	1.30	0.50

Mothers race				Education attainment
	Policy 0	Policy 1	Total		Policy 0	Policy 1	Total
White	424,597	409,371	833,968	None	979	822	1,801
	50.91	49.09	100		54.36	45.64	100
Black	44,906	47,896	92,802	1 to 3	6,572	5,097	11,669
	48.39	51.61	100		56.32	43.68	100
Asian	3,835	4,114	7,949	4 to 7	68,146	57,208	125,354
	48.25	51.75	100		54.36	45.64	100
Brown	453,812	459,816	913,628	8 to 11	615,367	609,950	1,225,317
	49.67	50.33	100		50.22	49.78	100
Indigene	2,769	3,234	6,003	12 or more	254,174	265,147	519,321
	46.13	53.87	100		48.94	51.06	100
Total	929,919	924,431	1,854,350	Total	945,238	938,224	1,883,462
	50.15	49.85	100		50.19	49.81	100
Marital Status
	Policy 0	Policy 1	Total
Single	402,272	415,445	817,717
	49.19	50.81	100
Married	355,044	341,790	696,834
	50.95	49.05	100
Widow	862	777	1,639
	52.59	47.41	100
Divorced	5,706	6,118	11,824
	48.26	51.74	100
Stable Union	184,071	176,377	360,448
	51.07	48.93	100
Total	947,955	940,507	1,888,462
	50.2	49.8	100

	CS	Sched. CS	Policy	Weeks	Before 39	Induced	Apgar 1
Public
Mean	0.53	0.23	0.60	39.17	0.30	0.24	8.40
Std. Error	0.50	0.42	0.49	1.27	0.46	0.43	1.05
Sum	804931	343350	910153		450797	362875
Private
Mean	0.84	0.57	0.57	38.74	0.42	0.14	8.59
Std. Error	0.37	0.50	0.50	1.06	0.49	0.34	0.93
Sum	317471	215003	216180		157542	49571

	Apgar 5	Weight	Age	Visits	Month Prena.	Sex
Public
Mean	9.41	3233.71	23.62	3.72	2.45	0.51
Std. Error	0.68	417.70	4.61	0.57	1.32	0.50
Private
Mean	9.52	3228.76	27.45	3.87	1.94	0.51
Std. Error	0.62	395.16	4.62	0.42	1.12	0.50

Mothers Race				Educational Attainment
	Public	Private	Total		Public
White	594,646	239,322	833,968	None	1,753
	40.08	64.58	44.97		0.12
Black	78,149	14,653	92,802	1 to 3	11,340
	5.27	3.95	5		0.75
Asian	5,145	2,804	7,949	4 to 7	121,189
	0.35	0.76	0.43		8.04
Brown	800,124	113,504	913,628	8 to 11	1,071,056
	53.92	30.63	49.27		71.05
Indigene	5,727	276	6,003	12 or more	302,236
	0.39	0.07	0.32		20.05
Total	1,483,791	370,559	1,854,350	Total	1,507,574
	100	100	100		100
Marital Status
	Public	Private	Total
Single	706,843	110,874	817,717
	46.72	29.51	43.3
Married	466,514	230,320	696,834
	30.84	61.31	36.9
Widow	1,313	326	1,639
	0.09	0.09	0.09
Divorced	8,391	3,433	11,824
	0.55	0.91	0.63
Stable Union	329,713	30,735	360,448
	21.8	8.18	19.09
Total	1,512,774	375,688	1,888,462
	100	100	100

	I	II	III
$p o l_{t} * p r i v_{h}$	-0.0137	-0.0163	-0.0174
	0.0106	0.00924	0.0093
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
Std. Cluster Level	Hospital	City	City
N	1902430	1902430	1830813
adj.R2	0.101	0.324	0.332

	I	II	III
$p o l_{t} * p r i v_{h}$	-0.0278***	-0.0269***	-0.0278***
	0.00552	0.00493	0.00496
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
Std. Cluster Level	Hospital	City	City
adj.R2	0.05	0.162	0.167

	I	II	III
$p o l_{t} * p r i v_{h}$	-0.0034	-0.00463	-0.00521
	0.00409	0.00336	0.00355
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
Std. Cluster Level	Hospital	City	City
N	1901845	1901845	1830312
adj. R2	0.074	0.236	0.256

	I	II	III
$p o l_{t} * p r i v_{h}$	-0.0231***	-0.0217***	-0.0234***
	0.00429	0.00347	0.00364
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
Std. Cluster Level	Hospital	City	City
N	1902430	1902430	1830813
adj. R2	0.05	0.162	0.167

	A-SCS (1)	B-SCS (2)	A-Births (3)	B-Births (4)
$p o l_{t} * p r i v_{h}$	-0.0254***	-0.0255***	-0.0237***	-0.0234***
	0.00643	0.00627	0.0061	0.00593
$h s_{i} * p o l_{t} * p r i v_{h}$	0.0133*	0.0137*	0.00762	0.0075
	0.00621	0.00629	0.00597	0.00596
Time related F.E.	YES	YES	YES	YES
Covariates	NO	YES	NO	YES
Std. Cluster Level	Hospital	Hospital	Hospital	Hospital
N	1918624	1862453	1918624	1862453
adj. R2	0.062	0.073	0.021	0.026

	A-SCS (1)	B-SCS (2)	A-Births (3)	B-Births (4)
$p o l_{t} * p r i v_{h}$	-0.0240**	-0.0263***	-0.0245**	-0.0264**
	0.00797	0.00766	0.00897	0.00869
$v i s_{i} * p o l_{t} * p r i v_{h}$	-0.00186	-0.00132	-0.00199	-0.00139
	0.00706	0.00695	0.00785	0.00776
Time related F.E.	YES	YES	YES	YES
Covariates	NO	YES	NO	YES
Std. Cluster Level	Hospital	Hospital	Hospital	Hospital
N	1918624	1847636	1918624	1847636
adj. R2	0.051	0.072	0.017	0.026

	I	II	III
$p o l_{t} * p r i v_{h}$	-0.0105	-0.0111*	-0.0101
	0.0065	0.00562	0.00575
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
N	1918624	1918624	1847636
adj. R2	0.049	0.162	0.166

	I	II	II
$p o l_{t} * p r i v_{h}$	-0.0172***	-0.0173***	-0.0166***
	0.00512	0.00439	0.00433
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
N	1918624	1918624	1847636
adj. R2	0.016	0.051	0.057

	I	II	III
$p o l_{t} * p r i v_{h}$	-0.00623	-0.00808	-0.00744
	0.00781	0.00654	0.00638
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
N	1819195	1819195	1749795
adj. R2	0.074	0.199	0.205

	I	II	II
$p o l_{t} * p r i v_{h}$	0.00104	-0.00089	-0.00006
	0.006	0.00513	0.00508
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
N	1819195	1819195	1749795
adj. R2	0.029	0.073	0.08

	I	II	III
$p o l_{t} * p r i v_{h}$	0.00346	0.0177	-0.00441
	0.0254	0.027	0.0209
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
N	7516	7516	6569
adj. R2	0.01	0.237	0.226

	I	II	II
$p o l_{t} * p r i v_{h}$	-0.0251	-0.0299	-0.0588
	0.0419	0.0445	0.0425
F.E.related to time	YES	YES	YES
F.E. of Hospital	NO	YES	YES
Covariates	NO	NO	YES
N	7516	7516	6569
adj. R2	0.036	0.205	0.21

	Sched. CS (1)	Spont.ND (2)
$p o l_{t} * w k d_{t} * I_{38}$	-0.0446***	0.0348***
	0.00513	0.00688
$p o l_{t} * w k d_{t} * I_{39}$	-0.0125**	0.0132*
	0.00475	0.00644
$p o l_{t} * w k d_{t} * I_{40}$	0.0370***	-0.024***
	0.0048	0.00656
$p o l_{t} * w k d_{t} * I_{41}$	0.0519***	-0.037***
	0.00567	0.00758
$p o l_{t} * w k d_{t} * I_{42}$	0.0275***	-0.0101
	0.00835	0.0124
$p o l_{t} * w k d_{t} * I_{43}$	0.0327*	-0.0279
	0.0143	0.0225
$p o l_{t} * w k d_{t} * I_{44}$	0.0167	-0.00848
	0.0184	0.0325
$p o l_{t} * w k d_{t} * I_{45}$	0.00488	0.109*
N	1527806	1527806
adj. R2	0.016	0.006

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