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.
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."

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Olga Khazan is a staff writer at The Atlantic, where she covers health.

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