Cesarean section rates in Ecuador: a 13-year comparative analysis between public and private health systems

OBJECTIVE. To demonstrate the prevalence of cesearean sections (C-sections) in Ecuador and their distribution between private and public health centers. METHODS. An observational population-based study was conducted of patients discharged from public and private hospitals in Ecuador after a C-section or vaginal delivery. Data were collected by the Ecuadorian National Institute of Statistics and Census (INEC) between 2001 and 2013. RESULTS. The overall national C-section rate in the private health care system is double the rate in the public health care system. Over the 13 years of the study, C-sections accounted for 57.5% of births in the private sector, while the public sector proportion did not exceed 22.3%. Countrywide, less than 36% of C-sections were found to be clinically justified by parallel analysis of absolute or relative indications. Acute fetal distress (AFD) was more frequently reported in private centers compared to public ones (446 per 10 000 live births versus 274 per 10 000). Since 2001, the number of births by cesarean section increased by more than 50% (R(2) = 0.7306, P < 0.05), with an annual growth rate of 4.03%. In Guayaquil, the largest city in Ecuador, up to 74% of live births occurred by C-section. CONCLUSION. National data show that C-sections are performed more frequently in Ecuador than the rate recommended by the World Health Organization, especially in the private health care system. Private centers also report higher rates of AFD, which implies that this diagnosis is either overused in private centers or underrecognized in public centers. Although several factors might be influencing these trends, no data are available to determine the relative importance of economics, practicality, and medical or personal concerns of mothers and physicians in deciding which method of delivery should be used.