Pushing for change in Brazil’s cesarean-reliant birthing culture

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Barbara Saboya was trapped in a bed, hours into labour with her second child last October, when her doctor told her he was booking a cesarean section. She and the fetus were in fine health, but her doctor had plans and didn't feel like waiting for her labour to progress; he said someone else needed the room.

So Ms. Saboya took a deep breath, told a sweet-faced lie – and made a run for it. She told the doctor she needed a few minutes to organize things, made her way down the hospital hallway, grabbed her husband (who wasn't permitted to be with her in the labour room), jumped in a car and headed for Rio de Janeiro. All through the five-hour drive, she looked up hospitals on her phone – in case she didn't get there in time and had to give birth on the way.

Ms. Saboya, a 32-year-old drama teacher who lives in a town 170 kilometres north of Rio, had her first baby in 2011. She was perfectly healthy, yet no doctor she saw through her private health insurer would let her plan the natural birth she wanted. In the end, although her labour was normal, a doctor eager to begin a vacation performed a C-section – and Ms. Saboya joined the 84 per cent of Brazilian women who give birth surgically in the private health system, the highest such rate in the world.

When the time came to have her second daughter last October, she was determined it would be different. In the end, that meant a late-night sprint to Rio and its one hospital famous for encouraging natural birth. There, other patients pointed and whispered in the hallways: "That's the woman who ran from the knife!"

Insurance coverage lost

Now Brazil's government is making a renewed push to change birth culture and cut the dramatic rate of C-sections in this country. Under new rules, insurance companies will no longer pay for cesareans if doctors cannot prove they were medically necessary. Women must be provided with risk sheets that show that C-sections carry substantially higher risks of mortality and complications than does natural birth (the widely held belief is the opposite here). And every doctor is obliged to tell prospective patients what his or her rates of C-sections and natural deliveries are, as compared to the national figure.

"The epidemic of C-sections is unacceptable, and there is no other way to treat this issue but to consider it a public health problem," said Health Minister Arthur Chioro, announcing the new measures this month.

The overall C-section rate in Brazil is 52 per cent of births – that combines the 84 per cent of births in the private system with 40 per cent in the public. Nationally, 20 per cent of women use the private system, although in some big cities, such as Sao Paulo, half of them do.

The World Health Organization says that 15 per cent of births normally require C-sections.

Under the new regulations, doctors will have to submit a "partograph" that tracks the labour and shows developments that necessitated a C-section. "I've seen women's charts that list as the reason for a cesarean , 'woman in labour,'" said Marcos Dias, an obstetrician and advocate for natural child birth who has been working with the Ministry of Health for 19 years to try to change birth practices here. "It sounds funny, but it's awful, actually."

Sudden change of heart

Karla Coelho, a manager with the government board that regulates the private system, said a major new study of pregnant women across Brazil found that, at the start of pregnancy, 70 per cent want a natural birth – but near the end, only 30 per cent of those in the private system say so.

"Something happens with these women that changes their mind – it's the doctors: they say a lot of things that fill the women with fear. They tell them it's the best choice for women and for babies," she said. "Why are they doing this? There's no ethical motive. If we ask, why do they choose a technology, a surgery? … We end up talking about capitalism, and love of technology."

Doctors who schedule C-sections can perform many in a day, leading to higher billing than they can charge for unpredictable and lengthy natural deliveries.

But Dr. Dias says there is more to it than that, noting that when insurance companies have experimented with offering similar payments for both types of births, the rates of C-sections haven't changed. "Of course, doctors want more money, but they don't want to stay with a woman through a labour, hold her hand in a contraction, explain the developments – they don't want to do this, stay at a woman's side."

Brazil has a highly medicalized view of health care that favours maximum intervention, and birth is no exception, he explained. "Doctors view it as an illness to be treated." Midwives are rare here, and used only in the public system.

But Junia Dias, an obstetrician in Rio (no relation to Marcos), says the new measures are political, designed to pander to the women's movement and look as if the left-wing government is facing down wealthy doctors. There is no way that the number of natural births can be increased, she said, since there is insufficient space, as it is, for labouring women in most hospitals. "Where would we put all these people? Without a routine, without being able to organize everything, it's too hard."

Doctors battle back

The Association of Obstetricians and Gynecologists of the state of Sao Paulo echoed her concerns in a recent letter to the government, saying "the new rules will have no effect and they hide the main causes of the abusive number of surgical deliveries in Brazil … to imagine that the solution to the problem is to categorize obstetricians as good or bad using the percentage of C-sections they do reveals, in the best-case scenario, a deep lack of understanding of the problem."

Junia Dias said the surgeries she performs on the two days a week she works with a public hospital are for women with high-risk pregnancies and complications; in her private practice, she does 90 per cent C-sections. "The majority of women who come here say, 'Please, I want no contractions – I don't want to go into labour, for the love of God,'" she said.

And she does not try to change their minds. "Is there some enormous advantage to being in labour for 25 hours? The whole system is built to avoid that – there is no need to deliver babies in pain. This was natural a hundred years ago. And the mortality of fetuses and mothers was huge. Today we have technology to make that better."

Ms. Coelho said the government will put resources into expanding facilities for labouring women (a typical private facility has four times as many spots for surgical delivery as for natural ones). Also, it will work to change birth culture – to inform women they have the right to have someone accompany them in the delivery room, and make them aware of techniques such as massage, engaging a doula, and pain-control interventions to make natural delivery less uncomfortable.

'Let's squat now'

Junia Dias doesn't buy it: Newly pregnant women have all kinds of baseless ideas, she said. "People want to have babies squatting… They tell me this and I say, 'Look, let's squat now – squat for five whole minutes, and let's see how you feel.'

"The other thing is delivering in the water. Who is going to put their hand in the water, with blood, feces, amniotic fluid? I'm not going to put my hand in there."

Individual women who decide on natural birth face this kind of opposition from their doctors, but also from the larger community. "My mother-in-law told me that natural birth was for animals and native people in the jungle," said a 40-year-old Rio sales manager, who asked not to be identified by name.

Marcos Dias said that previous efforts to rein in doctors have failed because they have great autonomy in the Brazilian system. And they will still be able to fake a partograph, if they choose, to show that a cesarean was necessary. But Dr. Dias also said the culture is beginning to change in ways that will make that increasingly unviable.

"It will be very difficult for the Ministry of Health or the insurance companies to see if [the chart] is real, but it will be a risk for doctors to lie – because now women are looking into this," he explained. "There are really good groups of women's activists who are doing a terrific job challenging doctors and systems."

Online communities of activists circulate information on doctors and their C-section rates when insurance companies are afraid to do, he said.

Midwives will help, too, he said, and he hopes government will move quickly to increase the number who are trained and licensed, and push private facilities to hire them. In the private hospitals where midwifery has been piloted, the C-section rate falls from 90 per cent to 40, he said. The Rio obstetricians' association, however, has tried (and so far failed) to have doulas and midwives banned from assisting at hospital births, and to ban home births.

Ms. Coelho noted that 30 years ago almost no Brazilian women breastfed, while today nearly all do – that culture was changed through education, and birth culture can, too.

Barbara Saboya had the delivery she had hoped for in Rio, using warm water and a birth ball to assist her labour. But she still crosses the street whenever she sees her former obstetrician coming toward her. "Nothing terrible happened, my daughter is fine," she said. "But it was traumatic. They didn't respect my wishes. It was inhumane."