Cesareans and unnecessary medical procedures are the daily reality of labor in Brazil. Here, 52% of all babies are born by cesarean, a rate three times bigger than the accepted as normal by the World Health Organization (WHO). When it comes only to the private health system the number is even higher: 88% of births are from cesareans. Brazil has a free and public health care system, but a quarter of the population (which has a wealthier condition) use a private insurance.
According to the WHO, cesarean must be the exception and not the rule. This procedure can indeed save lives, but must only be used when there are health risks for the baby or for the mother. Babies born from cesarean don’t have the chance to get the good microbes provided by the contact with their mother’s vagina during the labor. This exposure is vital for the maturation of the immune system. The lack of this contact is associated with increased risk of developing a series of diseases, such as diabetes and asthma.
Besides all the risks normaly involved in a surgery, the cesarean also leaves profound marks in the mother which can be harmful for future pregnancies. The uterine scar left by the C-section can affect the egg fixation and also increases the risk of uterine rupture and some placenta problems during another pregnancy.
According to the doctor Maria do Carmo Leal, who coordenated the bigger research ever done on pregnancies in Brazil, by the Oswaldo Cruz Foundation, what is happening is an ‘epidemic’ of unnecessary cesareans. “There is no clinical justification for a so high number of cesareans”, she says. “We are talking about health pregnancies. Women are being exposed to risks and the health system is having unnecessary costs to support a medical culture that prioritizes C-sections.”
In the private health system, the high number of cesareans can be explained by monetary reasons. For a normal delivery a physician may receive about R$440 (195 dollars) while for a cesarean the price can reach R$800 (355 dollars).
Another reason pointed out by doctor Silvana Granado, wich applies both to the private health system and the public one, is simply a matter of convenience for the doctor. “Physicians tend to choose cesareans because with this procedure they can finish more deliveries in less time”, she says. “Instead of losing 12 to 30 hours doing a normal delivery, they can schedule more than one cesarean delivery at the same time. I have visited public hospitals in small cities where there is the ‘C-section day’, when the doctor perform cesareans in all pregnant women.”
Despite being prevalent, cesareans aren’t the first choice between pregnant women in Brazil. The Oswaldo Cruz Foundation research, which interviewed 23 thousand pregnant women before and after delivery, shows that only 28% of them wanted a C-section – most of them fearing the labor pain.
The same research shows that the number of woman planning a cesarean increases significantly during the pregnancy progress. During the prenatal care, 36% of them change to cesarean. When arriving to the hospital, 67% reported wanting a cesarean. This change of mind may be influenced by doctor pressure.
“Lots of woman change their mind due to an inadequate prenatal care”, says Leal. “Unfortunately, many physicians don’t inform the woman about the real risks of a cesarean.”
The reality is that it is becoming more and more difficult for women who desires a normal labor to deliver. Often the hospital has so many cesarean scheduled that there aren’t room for a woman who is waiting for a normal delivery and didn’t scheduled her delivery.
C., a 30 year old mother of a 3 year old child, pregnant for the second time, tells she always planned a normal birth, but she was persuaded by the doctor at the last minute. “I didn’t know at that time of the risks of a cesarean, so when the doctor told it would be better to do a cesarean I believed him”, she says. “I fell like I am not in control of my choices and I don’t want this to happen again.”
An extreme example of the tension between personal choice and medical decision happened two months ago in the southern Brazilian state of Rio Grande do Sul when Adelir de Góes was forced by the police to deliver by cesarean.
The doctors who performed the surgery said she and her baby were in danger and needed the procedure. On the other hand, she argued that she asked for proof of the risk and none wanted to show her the exams.
Regardless who is right or not in this particular case, having a baby by normal delivery in Brazil is not only hard to achieve but often unpleasant. The Oswaldo Cruz Foundation study shows that in 66% of the normal deliveries in Brazil the hospital doesn’t offer anesthesia. Non pharmacological ways to relief the pain, as hot baths and massages, are even rarer, offered only in 26% of the country’s labors.
“When a woman is going to deliver, the first thing many hospitals do is tie her to the bed and put an needle in her arm”, says Granado. “She can’t eat and even drink water, despite the fact that there is no scientific reason for this.”
The use of the oxytocine hormone to speed up the delivery is also a frequent practice, present in 36% of the labors. The problem with this procedure is that it induces the delivery even when the body is not ready, causing pain and stress for the mother.
Even more serious is the artificial rupture of membranes (amniotomy) which is performed in 40% of the normal labors without risks. This intervention can increase the risk of infection, or umbilical cord prolapse and might turn the baby to breech position, making the birth more difficult.
To change this situation, Leal and Granado says that women must seek information and fight for their own welfair. “The doctors need a better formation, but the mothers also need to inform themselves”, says Granado.