Factors associated to Caesarean delivery in public and private health care systems

Oliveira, Rosana Rosseto de; Melo, Emiliana Cristina; Novaes, Elisiane Soares; Ferracioli, Patrícia Louise Rodrigues Varela; Mathias, Thais Aidar de Freitas

doi:10.1590/S0080-623420160000600004

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Sumário

Artigo Original • Rev. esc. enferm. USP 50 (05) • Sep-Oct 2016 • https://doi.org/10.1590/S0080-623420160000600004 copy

Factors associated to Caesarean delivery in public and private health care systems

Factores asociados con el parto Cesárea en el sistema público y privado de atención sanitaria

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

OBJECTIVE

Identifying factors associated to Caesarean sections among the residents of Maringá-PR, according to the financing source for delivery.

METHODS

A cross-sectional study with data from 920 postpartum women interviewed between October 2013 and February 2014. Association analysis was performed by logistic regression.

RESULTS

Caesarean section rates were 55.5% in the Unified Healthcare System (SUS) and 93.8% in the private system. Factors associated with Caesarean section in the SUS were: previous Caesarean section (OR=8.9; CI=4.6-16.9), desire for Caesarean section early in pregnancy (OR=2.0; CI=1.1-3.6), pregestational overweight/obesity (OR=1.8; CI=1.1-2.8), and per capita family income higher than one minimum wage (OR=2.1; CI=1.3-3.4). In the private system, desire for Caesarean section early in pregnancy (OR=25.3) and a previous Caesarean section (OR=11.3) were strongly associated to its performance.

CONCLUSION

It is necessary to properly orientate all pregnant women who desire a Caesarean delivery, from both the SUS and the private system, about the inherent risks of the surgical procedure without indication. In the public health sector, guidelines should be focused on pregnant women with previous Caesarean delivery, with a per capita income higher than one minimum wage and those who are overweight or obese, as these women are more likely to have a Caesarean section.

Descriptors
Cesarean Section; Risk Factors; Maternal and Child Health; Maternal-Child Nursing; Healthcare Financing

	SUS					Private system
	n (485)					n (435)
	C-section	Vaginal				C-section	Vaginal
Variables	55.5 %	44.5%	OR	CI	p	93.8%	6.2%	OR	CI	p
Age
≤ 19	44.2	55.8	0.62	0.37-1.01	0.057	87.5	12.5	0.45	0.05-3.18	0.463
20-34	56.2	43.8	-	1		94.0	6.0	-	1
≥ 35	66.1	33.9	1.52	0.85-2.72	0.155	93.6	6.4	0.93	0.34-2.56	0.896
Education level
< 8 years	54.8	45.2	-	1		77.8	22.2	-	1
≥ 8 years	55.6	44.4	1.03	0.60-1.76	0.916	94.1	5.9	4.58	0.90-23.22	0.066
Family income *per capita^ * Current minimum wage in October 2013 (R$ 678.00).
< 1 minimal wage	52.5	47.6	-	1		96.6	3.4	-	1
≥ 1 minimal wage	59.1	40.9	1.31	0.91-1.87	0.143	93.4	6.7	0.50	0.11-2.14	0.344
GA at start of prenatal care^ GA: gestational age in complete weeks.
< 16	53.2	46.8	-	1		94.1	5.9	-	1
≥ 16	65.4	34.6	1.66	1.00-2.75	0.050	77.8	22.2	0.22	0.04-1.11	0.067
Number of prenatal consultations
< 7	54.2	45.8	0.93	0.62-1.41	0.742	79.0	21.1	0.22	0.07-0.71	0.012
≥ 7	55.9	44.1	-	1		94.5	5.5	-	1
History of obstetrical risk^* ***** Having had at least one abortion and/or a previous stillbirth and/or a previous LBW child and/or a previous premature child and/or a child who died in the first year of life.
Yes	62.6	37.4	1.47	0.96-2.26	0.078	93.3	6.7	0.89	0.36-2.17	0.800
No	53.2	46.8	-	1		94.0	6.0	-	1
BMI before pregnancy (kg/m² )
< 18.5	40.8	59.2	0.72	0.39-1.35	0.312	80.0	20.0	0.30	0.09-0.99	0.048
18.5 to 24.9	48.8	51.3	-	1		93.0	7.0	-	1
≥ 25.0	68.1	31.9	2.24	1.51-3.33	<0.001	97.7	2.3	3.19	0.93-10.95	0.065
Previous c-section^** ****** Only multiparous women were considered for this variable.
None	41.4	58.6	-	1		91.2	8.8	-	1
≥ 1	87.3	12.8	16.99	2.23-129.40	0.006	98.7	1.3	21.43	4.70-97.61	<0.001
Labor in standing position
Yes	55.7	44.3	-	1		91.1	8.9	-	1
No	55.4	44.6	0.99	0.58-1.67	0.969	96.9	3.1	3.00	1.07-8.40	0.036
Practice of physical activity
Yes	42.9	57.1	-	1		92.5	7.6	-	1
No	56.2	43.8	1.71	0.79-3.70	0.171	94.2	5.8	1.33	0.56-3.14	0.512
Desired type of delivery in early pregnancy
C-section	80.9	19.1	5.48	3.40-8.86	<0.001	99.3	0.7	30.06	7.01-129.00	<0.001
Vaginal	43.5	56.5	-	1		82.3	17.7		-	1

	SUS					Private system
	n (485)					n (435)
Variables	C-section	Vaginal				C-section	Vaginal
	%	%	OR	CI	p	%	%	OR	CI	p
Hypertension
Yes	69.4	30.6	2.10	1.31-3.37	0.002	95.4	4.6	1.43	0.42-4.91	0.566
No	51.9	48.1	-	1		93.5	6.5	-	1
Diabetes
Yes	83.3	16.7	4.32	1.63-11.50	0.003	97.7	2.3	2.98	0.39-22.55	0.289
No	53.6	46.4	-	1		93.4	6.6	-	1
Hospitalization
Yes	59.5	40.5	1.29	0.88-1.88	0.191	91.4	8.6	0.58	0.26-1.30	0.187
No	53.3	46.7	-	1		94.8	5.2	-	1
Depression
Yes	82.6	17.4	4.03	1.35-12.02	0.013	92.9	7.1	0.85	0.11-6.80	0.883
No	54.1	45.9	-	1		93.8	6.2	-	1

	SUS^a a Statistical adjustment for BMI <18.5 kg/m2 (underweight); hypertension during pregnancy. n (485)			Private system^b b Statistical adjustment for: labor in orthostatic position (standing); BMI <18.5 kg/m2 (underweight); BMI ≥ 25 kg/m2 (overweight/obese). n (435)
Variables	ORaj	CI	P	ORaj	CI	P
Socioeconomic and demographic characteristics of mothers
Income per capita ≥ 1 SM	2.03	1.10-3.77	0.024	-	-	-
Pregestational, gestational and maternal reproductive history characteristics
Previous C-section	11.11	1.29-95.63	0.028	11.27	1.18-107.63	0.035
BMI ≥ 25 (overweight/obesity)	2.30	1.16-4.56	0.018	-	-	-
Mother's condition during pregnancy
Preference for Caesarean section early in pregnancy	3.38	1.24-9.17	0.017	18.29	1.93-173.25	0.011

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Elisiane Soares Novaes. Universidade Estadual de Maringá Av. Colombo, 5.790 - Bloco 002, sala 001- Campus Universitário. CEP 87020-900 - Maringá, PR, Brazil. elisianenovaes@hotmail.com