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Caesarean sections and the prevalence of preterm and early-term births in Brazil: secondary analyses of national birth registration
  1. Fernando C Barros1,
  2. Dacio de Lyra Rabello Neto2,
  3. Jose Villar3,4,
  4. Stephen H Kennedy3,4,
  5. Mariangela F Silveira5,
  6. Jose Luis Diaz-Rossello6,
  7. Cesar G Victora5
  1. 1 Post-Graduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil
  2. 2 Ministry of Health, Brasilia, Brazil
  3. 3 Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
  4. 4 John Radcliffe Hospital, Oxford, UK
  5. 5 Post Graduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil
  6. 6 Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR-PAHO/WHO), Montevideo, Uruguay
  1. Correspondence to Dr Fernando C Barros; fcbarros.epi{at}


Objectives To investigate whether the high rates of caesarean sections (CSs) in Brazil have impacted on the prevalence of preterm and early-term births.

Design Individual-level, cross-sectional analyses of a national database.

Setting All hospital births occurring in the country in 2015.

Participants 2 903 716 hospital-delivered singletons in 3157 municipalities, representing >96% of the country’s births.

Primary and secondary outcome measures CS rates and gestational age distribution (<37, 37–38, 39–41 and 42 or more weeks’ gestation). Outcomes were analysed according to maternal education, measured in years of schooling and municipal CS rates. Analyses were also adjusted for maternal age, marital status and parity.

Results Prevalence of CS was 55.5%, preterm prevalence (<37 weeks’ gestation) was 10.1% and early-term births (37–38 weeks of gestation) represented 29.8% of all births, ranging from 24.9% among women with <4 years of schooling to 39.8% among those with >12 years of education. The adjusted prevalence ratios of preterm and early-term birth were, respectively, 1.215 (1.174–1.257) and 1.643 (1.616–1.671) higher in municipalities with≥80% CS compared with those <30%.

Conclusions Brazil faces three inter-related epidemics: a CS epidemic; an epidemic of early-term births, associated with the high CS rates; and an epidemic of preterm birth, also associated with CS but mostly linked to poverty-related risk factors. The high rates of preterm and early-term births produce an excess of newborns at higher risk of short-term morbidity and mortality, as well as long-term developmental problems. Compared with high-income countries, there is an annual excess of 354 000 preterm and early-term births in Brazil.

  • perinatology
  • preterm births
  • early term births
  • caesarean sections

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  • Contributors FCB conceived the idea of the present article and together with CGV, formulated the original hypotheses and conducted the analyses of the databases and writing up of the paper. DdLRN, JV, SHK, MFS and JLD-R contributed with original ideas and worked in the drafting of the manuscript, revised and approved the final version. All authors had full access to all of the data (including statistical reports and figures) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. Also, all authors agreed to be accountable for all aspects of the work and ensured the manuscript accuracy and integrity.

  • Funding Brazilian Ministry of Health.

  • Disclaimer The funding organisation did not influence the design and conduct of the study; collection, management, analysis or interpretation of the data; and preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.