How Brazil became the world leader in unneeded C-sections

McClatchy NewspapersJuly 9, 2008 

WORLD NEWS CHILDBIRTH 2 MCT

A women nurses her newborn at the Pro Matre maternity hospital in Rio de Janeiro, Brazil.

DOUGLAS ENGLE — Douglas Engle / MCT

RIO DE JANEIRO, Brazil — When Joyce Provedel went into labor with her first child, she'd planned on giving birth the age-old way, no matter how long it took or how much pain it meant.

Her doctor, however, had his own ideas. He worked for one of Rio de Janeiro's most popular maternity hospitals, and doctors there delivered babies almost only by Caesarian section, whether the mothers needed it or not. Before she knew it, Provedel was being wheeled into an operating room, disappointed but trusting that her doctor knew best.

In fact, she became one of the hundreds of thousands of women every year in Brazil who receive often-unnecessary Caesarean sections, fueling a trend that's turned this country into a world leader in such surgeries.

"The doctor never sat down and said you need to do this because of this," the 37-year-old mother of three said. "I just heard him order me into surgery, and I started crying."

Caesarean sections, in which a baby is extracted through incisions in the abdomen and uterus, have become more popular worldwide, especially in developing countries where medical technology is advancing.

According to the World Health Organization, 40.5 percent of births in China in 2000 involved Caesarean sections, ahead of Mexico at 39.1 percent in 2002 and Brazil at 36.7 percent in 1996, all the most recent WHO statistics available.

The organization says the U.S. rate was 24.4 percent in 2001; more recent U.S. government figures show that the percentage jumped to 31.1 percent in 2006.

New statistics from Brazil's Health Ministry also showed a jump in the country's Caesarean rate, to 44 percent of all births in 2006, which means that Brazil could claim the world's highest rate.

That's happened despite Brazilian government attempts to convince more physicians to perform vaginal births and more women to request them.

"Many obstetricians know more about performing surgeries than what to do when there's any irregularity in a normal birth," said Adson Franca, who heads the Health Ministry's anti-birth-mortalities campaign. "We need to train doctors so they know how to act in any emergency and not just switch to Caesareans."

Yet the problem isn't due just to a lack of emergency preparation, Niteroi-based obstetrician Rodrigo Vianna said, but to doctors placing convenience and profit over women's health.

In the two private hospitals where Vianna works, some doctors cram in as many as 16 Caesarean sections in one day so they can receive larger reimbursements from insurance companies, which pay the same rate for Caesareans as vaginal births, Vianna said. A normal birth can drag on for days, while doctors can perform a Caesarean section in as little as 15 minutes.

The Health Ministry found that the rate of Caesarean births hovered near 80 percent in private hospitals while averaging 26 percent in public facilities. Vianna said the rate approached 100 percent at the hospitals where he worked.

The profit factor is the difference: Public hospital doctors aren't paid according to the number of deliveries they handle. On top of that, Caesarean births have become so ingrained in Brazilian culture that many women request the surgery, hoping to avoid the pain of vaginal childbirth.

"It can be like an assembly line of babies," Vianna said. "But it's also a cultural issue. A lot of women will come into the hospital and cry and shout, 'For the love of God, I want to be operated on!' "

The problem is that Caesarean sections are more dangerous and expensive than giving birth vaginally, said physician Monir Islam, the director of the WHO's Making Pregnancy Safer program. The WHO recommends that Caesarean sections be performed in at most only 15 percent of live births.

Among other complications, the surgery aggravates the risks of infant respiratory problems because doctors often schedule deliveries prematurely, before babies' lungs have finished developing, Islam said. Such surgeries also can cost five to 10 times more than vaginal births because of higher anesthesia costs and longer hospitalization for mothers and infants, Islam said.

"Do we really need a 40 percent Caesarean-section rate?" Islam asked. "Normal childbirth is not a danger. It presents less dangers than if you opt for interventions."

Brazilian doctors counter that technological advances have made Caesarean sections much safer, said physician Ricardo Oliveira, the director of the Gynecology and Obstetrics Society of Rio de Janeiro State.

Oliveira denied that Brazilian physicians were performing the surgery to earn more, although he admitted that private hospitals sometimes push Caesarean sections to pay for expensive medical equipment.

"The fact is private hospitals need to invest in very expensive technology, and the patient is the one who has to pay for it," Oliveira said. "The normal birth doesn't use technology, so hospitals don't have any interest in reserving beds for normal births."

Brazilian officials are trying to counter the trend by running television spots featuring celebrities who've given birth vaginally and by distributing hundreds of thousands of posters around the country urging women to choose normal birth.

In Rio state, health officials have stopped reimbursing public hospitals for performing Caesarean sections when they surpass a quarter of all births. Advocacy groups have set up networks of midwives and health educators to help women give birth vaginally, sparking fierce opposition from physicians associations.

"There's an entire system that's built around women having Caesarean births," said Daniela Buono, a spokeswoman for the mothers' support group Parto do Principio. "We're working so that women who want normal births can have them."

That message seemingly had reached several new mothers at a public maternity hospital in Rio, where vaginal births were the rule one recent morning.

In a room full of more than a dozen new mothers, everyone said she'd given birth normally. A chart posted in the hospital's administrative offices showed that Caesarean sections accounted for 37.2 percent of all births in April.

"My friends all said I would suffer a lot if I didn't get a Caesarean," said Celia Pereira, 27, as she breast-fed her 1-day-old daughter. "But this was what I wanted. It hurt a lot, but it was worth it."

McClatchy Newspapers 2008

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