Norwegian Institute of Public Health, Postboks 4404 Nydalen, N-0403 Oslo, Norway. E-mail: siri.vangen{at}fhi.no
Birthweight is closely associated with morbidity and mortality of the newborn. Extensive research during the past 15 years has provided increasing evidence that birthweight is also important for health later in life.1 Such information underscores the importance of birthweight monitoring. In this issue of the International Journal of Epidemiology Silva et al. publish a paper about birthweight fluctuations in Ribeirão Preto, Sao Paulo, Brazil.2 During a 15-year period from 1978/79 to 1994 there was considerable economic development and a general improvement in education and income level accompanied by a population growth of 45% in the region. Even though the social indicators improved, a birthweight reduction of 122 g was observed. The downward trend may partly be explained by an increasing number of preterm births and factors related to marital status.
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A lesson from history |
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Socio-economic factors and birthweight |
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The Caesarean epidemic |
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The WHO has recommended a maximum desirable rate of Caesarean section of 15%. Substantially higher rates have been reported from parts of Europe, USA, Asia, and South America. The world's highest rates, exceeding 70% in the private health sector, were reported from Brazil.9 The reason for the excess is a complex interplay between medical, psychosocial, and economic factors that may vary from country to country. There is a general trend of increasing use of medical technology, a broader range of indications, and a greater involvement of the woman herself in the decision-making process. In countries with very high Caesarean section rates such as Brazil, non-medical issues such as private care and high educational level play an important role.6 The essential question is: why do a large proportion of Brazilian women deliver for non-medical reasons by a procedure that is known to be more dangerous, more expensive, and requires a longer recovery than vaginal birth? Both women's choice of a high-status mode of delivery that may appear easy, less painful and more convenient in the short term, and the doctor's possibility of accommodating their working and leisure time by scheduling Caesarean sections have been discussed as possible contributing factors. However, recent evidence has shown that more than 70% of Brazilian women prefer a vaginal birth.9 Furthermore, anecdotal reports say that Brazilian doctors feel pressured to perform Caesarean sections. Both women and doctors could be trapped in a reimbursing and financing system of health services that encourages a quick cut rather than the long hours of waiting associated with vaginal births, thus counteracting the best outcomes for mother and child.10
Further studies addressing the role of Caesarean section in preterm birth are warranted. It would be desirable to extend such studies to include other populations with extraordinarily high rates. Premature rupture of membranes was the indication for 24% of the preterm Caesarean sections in Northeast Brazil, a condition traditionally handled by the induction of labour. This could be an example of how a biological justification may cover up a non-medical indication.7 The question of how the health services financing systems encourage Caesarean sections for non-medical reasons should be further explored. It is necessary to identify factors contributing to a reduction of population birthweight in order to inform public health interventions designed to increase birthweight in groups at risk. The paper by Silva et al. makes it clear that information concerning Caesarean section is important in the study of risk factors associated with birthweight reduction.
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References |
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2 Silva AA, Barbieri MA, Bettiol H, Goldani MZ, Rona RJ. Can we explain why Brazilian babies are becoming lighter? Int J Epidemiol 2004;33:82128.
3 Ward WP. Birth weight and standards of living in Vienna 18651930. J Interdiscip Hist 1988;19:20329.[ISI][Medline]
4 Ward WP, Ward PC. Infant birth weight and nutrition in industrializing Montreal. Am Hist Rev 1984;89:32445.[ISI][Medline]
5 Gomes UA, Silva AA, Bettiol H, Barbieri MA. Risk factors for the increasing Caesarean section rate in Southeast Brazil: a comparison of two birth cohorts, 19781979 and 1994. Int J Epidemiol 1999;28:68794.[Abstract]
6 Kramer MS, Goulet L, Lydon J et al. Socio-economic disparities in preterm birth: causal pathways and mechanisms. Pediatr Perinat Epidemiol 2001;15:10423.[CrossRef][ISI][Medline]
7 Silva AA, Lamy-Filho F, Alves MT, Coimbra LC, Bettiol H, Barbieri MA. Risk factors for low birthweight in north-east Brazil: the role of Caesarean section. Pediatr Perinat Epidemiol 2001;15:25764.[CrossRef][ISI][Medline]
8 Schuitemaker N, van Roosmalen J, Dekker G, van Dongen P, van Geijn H, Bennebroek Gravenhorst J. Maternal mortality after cesarean section in The Netherlands. Acta Obstet Gynecol Scand 1997;76:33234.[ISI][Medline]
9 Potter JE, Berquó E, Perpétuo IHO et al. Unwanted Caesarean sections among public and private patients in Brazil: prospective study. BMJ 2001;323:115558.
10 Groom K, Paterson Brown S, Quadros LG et al. Letters: Caesarean section controversy. BMJ 2000;320:1072a.
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