Brazil reexamines birth options

When Angela Soares discovered six years ago that she was pregnant, she knew immediately what she wanted: a cesarean.

Like women at the stiflingly hot maternity ward recently at Rio's run-down Gafree and Guinle Hospital, Ms. Soares had heard that cesareans are quicker, less painful, and more comfortable than natural deliveries.

"Everything I heard was an illusion," says Soares, at the hospital to visit her pregnant sister. "But you only find that out afterward. It's only after having a cesarean that you see what it is really like."

A popular view that C-sections are faster, safer, and nearly painless has contributed to making this South American country a world leader in the number of cesareans reported. In many public hospitals, almost 50 percent of births are by cesarean, and in some private clinics the number is close to 100 percent. For some wealthy Brazilian women, a cesarean is a status symbol.

The US national rate rose to 22 percent last year - the third consecutive annual increase - prompting the American College of Obstetricians and Gynecologists to make new recommendations in September on ways to reduce reliance on the procedure.

But proponents say cesareans allow busy professional women to schedule births into their lives and avoid possible complications during vaginal delivery.

Worldwide, debate continues over whether too many cesareans are being performed. A national survey in South Korea, another world leader in cesarean rates, showed that nearly one of every two women delivers by C-section. In Britain, a recent government study found that the number of cesareans has doubled in a generation - a development some medical and women's groups trace to litigation-wary doctors.

Brazil's official rate of cesareans nationwide is 25 percent, but it is almost certainly higher, because some hospitals underreport the procedure, says Dr. Tania Lago, head of women's issues at Brazil's Health Ministry. In government-funded hospitals in at least five of Brazil's 26 states, almost every other birth is a C-section.

According to the World Health Organization, cesarean sections, the process of delivering a baby through incisions in the abdomen and womb, are warranted in between 5 and 15 percent of all births. WHO experts say rates higher than 15 percent indicate the procedure is being used for reasons other than to protect the lives of mother and child.

Until the 1970s, the cesarean rate in Brazil was within those specifications. But a series of factors led to a rapid jump in the number: Public hospitals could earn more by carrying out cesareans rather than allowing natural births. Hospitals also gave women having C-sections a general anesthetic instead of the local anesthetic administered to women giving birth naturally, and so a cesarean was seen as "pain-free."

Although women undergoing a cesarean face a higher risk of post-natal infection or complications brought on by surgery or the anesthetic, the procedure has acquired the cachet of being "modern," says Dr. Lago. Brazilian women, especially the better off, dismissed natural births as "primitive."

"A pro-cesarean culture arose in Brazil, both among doctors who were used to performing cesareans and among women who felt that it was safer and more comfortable," says Lago.

In private clinics, the rise was even more marked. For wealthy Brazilians, good care means higher costs, and cesareans cost more than natural childbirths. Today, the majority of large private hospitals have a cesarean rate of more than 70 percent, according to Brazilian doctors and recent studies.

"The women who form opinions in Brazil - actresses, famous athletes, etc. - the great majority of them have a cesarean because they can choose the date and time their baby is born," Lago says. "It is as if the cesarean is a consumer good. You can program your life, choose the date and time, pick its horoscope."

"The principal factor is comfort, the woman is not surprised by the birth, and neither is the doctor, who arranges everything beforehand so he won't be woken up in the middle of the night or have to interrupt his weekend getaway. For women and doctors, having a cesarean is all about convenience. The women and doctors control the birth, and not the other way around."

Even in the 1990s, with the boom in natural medicine, the myths surrounding childbirth - myths stating that cesareans produced healthier babies - were so strong in Brazil that the demand for C-sections continued.

Public and private health experts are now trying to convince women and doctors that natural births are, in most cases, better for both mother and child. Authorities are working to extend a 1998 effort to limit the number of unnecessary cesareans by financially punishing state-run hospitals that exceed Health Ministry targets. The ministry has told hospitals that 35 percent or fewer births should be cesarean this year, and has set a maximum of 25 percent by 2007. Hospitals exceeding the rate will not be paid for births above that figure.

They have had some success. The rate has started to fall, and almost all the women who sat with Soares at the Gafree and Guinle hospital wanted to give birth vaginally.

Their personal testimony will help change attitudes, but there is still a long way to go, says Marcus Vasconcellos, the gynecologist who heads the hospital's maternity clinic. Doctors taught during an era in which cesareans were the norm are no longer adroit at natural delivery. Additional training is needed for them and to prepare midwives.

In private hospitals, where the Health Ministry has less power, the challenge is greater still. There, doctors contend that cesareans are not only more modern, but also less likely to cause injury to a woman's reproductive organs. Dr. Gilberto Lopes, an outspoken proponent of cesareans, added that women who undergo the operation tend to have fewer children, a useful benefit for a developing nation with a high rate of population growth.

Critics, however, say that doctors, whom insurance companies pay roughly the same amount per birth no matter how it is performed, can earn more by doing as many as a dozen cesareans in the time it takes to supervise one natural birth.

In clinics like Lopes's, the policy is to perform a cesarean unless the pregnant patients request otherwise.

"We have evolved," says Lopes, the owner of a Sao Paulo clinic that boasts a cesarean rate of 98 percent. "I think the cesarean is an improvement, and nobody can halt progress."

(c) Copyright 2000. The Christian Science Publishing Society