Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil

PLoS One. 2016 Apr 13;11(4):e0153396. doi: 10.1371/journal.pone.0153396. eCollection 2016.


Background: Cesarean delivery rates continue to increase worldwide and reached 57% in Brazil in 2014. Although the safety of this surgery has improved in the last decades, this trend is a concern because it carries potential risks to women's health and may be a modifiable risk factor of maternal mortality. This paper aims to investigate the risk of postpartum maternal death directly associated with cesarean delivery in comparison to vaginal delivery in Brazil.

Methods: This was a population-based case-control study performed in eight Brazilian states. To control for indication bias, deaths due to antenatal morbidity were excluded. We included 73 cases of postpartum maternal deaths from 2009-2012. Controls were selected from the Birth in Brazil Study, a 2011 nationwide survey including 9,221 postpartum women. We examined the association of cesarean section and postpartum maternal death by multivariate logistic regression, adjusting for confounders.

Results: After controlling for indication bias and confounders, the risk of postpartum maternal death was almost three-fold higher with cesarean than vaginal delivery (OR 2.87, 95% CI 1.63-5.06), mainly due to deaths from postpartum hemorrhage and complications of anesthesia.

Conclusion: Cesarean delivery is an independent risk factor of postpartum maternal death. Clinicians and patients should consider this fact in balancing the benefits and risks of the procedure.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Brazil
  • Case-Control Studies
  • Cesarean Section / adverse effects
  • Cesarean Section / mortality*
  • Child
  • Female
  • Humans
  • Maternal Mortality
  • Postpartum Hemorrhage / etiology
  • Postpartum Hemorrhage / mortality*
  • Postpartum Period
  • Pregnancy
  • Risk Factors
  • Young Adult

Grants and funding

The Birth in Brazil Study was funded by the National Council for Scientific and Technological Development (CNPq); Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation (INOVA Project); and Foundation for supporting Research in the State of Rio de Janeiro (FAPERJ). The Ministry of Health, Brazil, funded the Maternal Mortality Enquiry Committees. APE received a post-doc scholarship from CNPq. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.