Reducing Cesarean Section Rates in Brazil: An Evidence Brief for Policy

Introduction: Although the World Health Organization has established since 1985 that the ideal rate for cesarean sections should range between 10% and 15%, in the last 15 years rates have doubled worldwide, representing 21% of the total births, with an estimated annual growth rate of 4%. Brazil is the second country in the world in numbers of cesarean sections performed, with rates that increased from 15% in 1970 to 56% in 2016. Even though several strategies have been implemented since the 1980s, aiming to improve maternal and child care in the country, the reduction of elective cesarean sections is still an important challenge for health policies.

Objective: To produce an Evidence Brief for Policy with strategies for reducing cesarean section rates in Brazil, in order to inform discussions and decisions made by policy makers and health managers.

Method: We followed the methodological guidelines proposed by the SUPPORT collaboration group (Supporting Policy Relevant Reviews). The search for evidence was carried out between March and July of 2018 in 10 different databases. Search filters were used for identifying systematic reviews published in English, Spanish and Portuguese, and no limits were placed on the publication date. Inclusion criteria were: non-clinical interventions to reduce cesarean rates, women with low-risk pregnancy, singleton and cephalic term pregnancies. In total, 6,491 articles were identified and two more were included following specialists recommendation. At least two independent researchers performed the article selection and extraction, and disagreements were discussed until consensus was reached. 2,630 articles were excluded from duplicates and after reading titles and abstracts, 2,888 were discarded because did not meet the inclusion criteria. 43 articles were selected for full-text appraisal, of which 26 were removed. The remaining 17 systematic reviews were used to elaborate five options to deal with the problem. Their order was listed according to the opinion of experts who participated in the Deliberative Dialogue.

Results: The five options were: 1) Encouraging the use of combined interventions to reduce cesarean section rates, focusing on health professionals and in the management of health services and systems (reduction of 1.6 to 57%); 2) Preparing women for birth during the antenatal care (4.5% to 88%); 3) Providing continuous support for women during labor and delivery (25-51%); 4) Structuring and facilitating the access to different birth places (13.9 to 65%) and 5) Implementing strategies to support vaginal birth after previous cesarean delivery (9.1 to 25%).

Conclusions: The options listed were effective in reducing cesarean rates and could be implemented in both public and private health care settings. They are not mutually exclusive, allowing them to be implemented simultaneously, or even that single elements from each option are rearranged, creating a new intervention. Based on the scientific evidence and discussions performed with experts at the Deliberative Dialogue, important information regarding equity and implementation for each one of the options were included in this Evidence Brief Policy, producing consistent elements to inform decision making.