Why Most Brazilian Women Get C-Sections

In many parts of the world, women are having more Cesarean sections than medically necessary. Recent abuses of pregnant women in Brazil have sparked a small, vocal movement of activists who want mothers to have more say in the delivery room.
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A newborn lies in an incubator at the Perinatal Clinic in Rio de Janeiro, Brazil, after birth via cesarean section. (Felipe Dana/AP)

RECIFE, Brazil — When Ivana Borges learned she was pregnant, she told her obstetrician that she wanted a natural birth. Her mother had delivered five children without surgery or medication, and Borges wanted to follow her example.

But when she returned to the hospital after her water broke, the same doctor began persuading her that she should instead deliver by caesarean section.

“He told me I wasn’t getting dilated enough,” Borges told me the other day in Recife. “I said, ‘I can wait!’ Then he started joking that I couldn’t handle the pain.”

He pestered her while she labored for six hours, and gradually the then-24-year-old Borges began feeling powerless and overwhelmed. She caved. The C-section commenced, but that wasn’t the end of the doctor’s heckling.

“He was saying, ‘I was at a birthday party, and I want this done fast because I want to go back and finish my whiskey,’” she said.

Borges said the experience was so traumatic that she sought psychiatric help for depression after the birth.

Doctors and activists here say Borges's experience is fairly common among women who give birth in the country’s private hospitals, where 82 percent of all babies are born by C-section. Brazil has a free, public healthcare system, but many of its wealthier residents–about a quarter of the population–use a private insurance scheme that functions much like the U.S. medical system.

With the higher price of the private system comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

“It’s a money machine,” Borges said.

The economics of private insurance certainly play a role, but culture is a big part of what drives the C-section epidemic here.

“Childbirth is something that is primitive, ugly, nasty, inconvenient,” Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo, said. “It takes long, and the idea is we have to make it fast. It’s impolite for doctors to leave cases for the doctors on the next shift–there’s a sense that you need to either accelerate it or do a C-section.”

Even in public hospitals, the C-section rate is roughly half. Because so many patients are booked in advance for C-section procedures, women who want natural births find themselves on zero-hour sojourns to find free beds. One Sao Paulo doctor told me that some physicians ask for bribes in exchange for allowing mothers to deliver naturally. And in an extreme example from earlier this month, a woman named Adelir Carmen Lemos de Goés was forced by police to deliver by C-section in the southern Brazilian state of Rio Grande do Sul.       

Poster for the Brazilian C-section protests (Rafael Ricoy)

"There is no doubt that, even if it contains unnecessary or even greater risk to the mother or the newborn, ceasarean section has a much lower risk for the obstetrician,” wrote a 2005 editorial in the Brazilian Journal of Obstetrics and Gynecology.

Granted, many women ask for the procedure of their own accord, seeing the convenience and sterility of it all as a marker of liberation rather than oppression. Rio and Sao Paulo are dotted with upscale C-section resort clinics where women get post-op manicures and room service.

But a 2001 study of Brazilian women published in the British Medical Journal concluded that the country’s rise in C-sections was driven primarily by unwanted procedures rather than personal preference. And some women elect to go under the knife only after hearing about the rough treatment of mothers who choose the alternative.

"Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can't walk, can't take a bath, can't hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies," Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation, told the AP. "What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women."

Many physicians’ attitudes toward childbirth weave together Brazil’s macho culture with traditional sexual mores.

“There’s the idea that the experience of childbirth should be humiliating,” Diniz said. “When women are in labor, some doctors say, ‘When you were doing it, you didn't complain, but now that you're here, you cry.’”

This brashness manifests itself in other types of interventions during labor. Though Brazilian law mandates that all women be allowed doulas or birthing companions, few moms are actually accompanied by such helpers. In past years, some Brazilian cities tried to bar companions from hospitals entirely.

Diniz said many doctors unnecessarily overuse fundal pressure – pushing on the pregnant woman’s stomach – to speed things along, and that they administer the labor hormone oxytocin more frequently than needed. The vast majority of women who give birth vaginally also have episiotomies, or surgical cuts to the vagina that are intended to make delivery easier.

“We have a really serious problem in Brazil that the doctors over-cite evidence [of fetal distress],” said Paula Viana, head of a women’s rights nonprofit in Recife. “They think they can interfere as they would like."

***

Mariana Bahia holds a sign at a protest against obstetric
violence in Recife. (Olga Khazan)

There’s nothing wrong with C-sections, of course – they can be life-saving for women with distressed babies or difficult deliveries. And most of the activists who are concerned about rising C-section rates think women should be able to opt for the procedure if they really want one.

But it’s still a major abdominal surgery that brings with it a chance of complications, infection, and neonatal challenges, not to mention placental problems that might impact future births. Women who have C-sections that are not medically necessary are at a greater risk of death, blood transfusions, and hysterectomies, a 2010 World Health Organization study found. The WHO has, until recently, recommended that C-sections be limited to only 15 percent of all births.

But the rate in many other countries, including Brazil, is much higher. In China, nearly half of all babies are delivered this way, with some women finding it a simple way to choose a “lucky” birthday. In the U.S., the rate has reached 30 percent after rising for decades. Experts say that among American doctors, fear of litigation is what prompts them to reach for the scalpel.

The increase is “really based on protecting the institution and ourselves,” obstetrician Peter Doelger told WNPR. “And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution."

Jesusa Ricoy-Olariaga, a Spanish childbirth educator, helped organize a series of rallies in multiple countries on Friday that called for the improved treatment of women in labor worldwide. The protesters used the social media hashtag #SomosTodasAdelir – we are all Adelir.

“Brazil has highlighted this issue, but it's shouting a secret,” Ricoy-Olariaga told me by phone. “The issue is the same in other countries, but in a different manner. There are countries where birth is industrialized and dominated by men, and there's very little input from women.”

For its part, Brazil is working to reverse course and promote natural births. The federal government is spending $4 billion on a program – dubbed “the Stork Network” – that plans to educate both mothers and doctors about the benefits of giving birth the old-fashioned way.

But women at the small #SomosTodasAdelir rally in Recife on Friday said it will take a major cultural shift, as well. Mariana Bahia told me that when she miscarried a few months ago, her obstetrician treated her brusquely because she suspected Bahia had attempted to abort her fetus, which is illegal here.

Bahia said she wants to see women wield greater autonomy in the maternity ward – and to see doctors’ bullying behavior punished.

“There’s no horizontality between patients and doctors,” Bahia said. “Doctors are always above us.”


Olga Khazan is reporting from Brazil as a fellow with the International Reporting Project.

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Olga Khazan is an associate editor at The Atlantic, where she covers health.

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