Cesarean delivery in antepartum fetal death in Brazil: temporal trends and maternal and facility characteristics, 2014-2023

Abstract

Abstract Objectives: to describe cesarean section (CS) rates in antepartum fetal deaths (FD) in Brazil from 2014 to 2023, assess temporal trends, and examine maternal and institutional factors associated with CS. Methods: population-based ecological study using individual-level SIM-DOFET microdata linked to facility registry data from the National Registry of Health Establishments (CNES). Temporal trends were evaluated using linear regression. Adjusted prevalence ratios (aPR) were estimated through Poisson regression with robust variance, restricted to term antepartum FD (≥37 weeks). Results: among 282,327 registered fetal deaths, 95.3% were antepartum. CS rates showed a significant increase across all gestational ages, except for those < 27 weeks; in term FD, rates rose from 43.7% to 51.5%. Higher CS rates were independently associated with maternal age 30-39 years (aPR=1.09), education ≥12 years (aPR=1.17), multiple pregnancy (aPR=1.59), philanthropic (aPR=1.25) and private hospitals (aPR=1.47), and higher municipal HDI (aPR=1.07). Race/skin color could not be evaluated (99.8% missing). Conclusions: CS rates in antepartum FD were persistently high and increasing, driven by factors beyond clinical indication. The FD certificate lacks key obstetric variables, which limits the analysis of care provided to this population. Revising this instrument is necessary to improve both surveillance and obstetric care of people who have experienced a stillbirth.