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

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

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Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Paris, France.
Department of Epidemiology and Quantitative Methods in Health, Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil.
National Institute of Women, Children and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil.



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.


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.


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.


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.

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