Expectations: Brazil’s Cesarean section problem

This is the third post in a blog series called “Expectations" written by deputy editor of global health Marissa Miley. Expecting a child herself, Miley is reporting in Brazil to better understand how women experience pregnancy and childbirth. Read Part I and Part II.

RECIFE, Brazil—My doctor has not yet broached the topic of my baby’s delivery. She has not mentioned anything about anesthesia or drugs, about doulas or birthing coaches – not about how I’m supposed to train to breathe now that it seems Lamaze classes have fallen out of fashion. I’m not concerned. As I get closer to my due date, I know we — my doctor, my husband, and I — will talk about all of these things and that I’ll be informed and empowered to make the right decisions for me.

One choice I won’t make, though, will be whether to have a Cesarean section. In the United States, this procedure — where the baby is surgically removed from the womb — is generally reserved for medical complications or high-risk pregnancies. C-sections, after all, carry greater risks of infection and complications, and their rapid increase in recent decades has mobilized concerned US doctors to curb the trend with new guidelines. Still, the overwhelming majority of American babies — two-thirds — are delivered by vaginal delivery each year.

In Brazil, however, C-sections are far more common than vaginal births. On the surface, this appears to be because women prefer them. In private hospitals, where an estimated one-quarter of Brazilians receive their care and can afford to pay a premium, more than 80 percent of babies are born by C-section. In the more widely used public health system, this proportion is lower —around half of all births— but that’s still a higher percentage than in the US. And it’s dramatically higher than the World Health Organization’s recommendation that no more than 15 percent of babies be delivered by C-section. 

But dig a little deeper behind the numbers in Brazil and it becomes clear that C-sections are not always something women choose. Nor are C-sections always performed because they’re medically needed, according to many women and doctors I’ve spoken with here. In fact, many believe that there is a pervasive culture of disrespect in the Brazilian health care system for women’s autonomy around this issue.

Earlier this month, social activists in Brazil and around the world were outraged when they learned about the forced C-section of Adelir Carmen Lemos de Góes, a 29-year-old married mother of two from southern Brazil. Adelir’s previous children had been born by C-section, but she wanted her third child to be delivered vaginally — a “safe and appropriate choice” for some women, according to the American College of Obstetricians and Gynecologists. 

Despite her wishes, Adelir’s obstetrician was so intent on the young woman delivering by C-section that the hospital obtained a court order. When Adelir was in labor, police came to her home and forced her to go to the hospital to have the surgery. “I couldn't refuse – it was either do what the court order said or be handcuffed. And I was so scared, I was really frightened,” Adelir told the Telegraph last week. 

Adelir’s case infuriated activists and galvanized protests from Sao Paulo to London on April 11. In Brazil, where health is, a human right by constitutional law, how could a doctor’s wishes prevail over those of a patient?

The matter was complicated by the fact that Adelir was a patient in SUS, Brazil’s public health care system, which has a long history of discrimination. Poorly educated and black women, for example, are significantly less likely to have an adequate number of prenatal visits compared to women who are better off and white.

Here in Recife, on that same April day, women from local health and women’s rights groups rallied to end what they call “obstetric violence” and to support a woman’s right to vaginal childbirth. In a plaza area downtown, the same central site where Carnival celebrations usually take place, roughly two dozen women in red T-shirts stood silently with large black and red signs, printed on some the words: “My body, my child, my delivery.”

“What happened to Adelir affects me as well, as a mother, as an activist, as a feminist, and especially as a woman,” said Patricia Brandão, a doula who participated in the Recife protest.

“The doctors, for them, it’s better to take birth with C-section. But it’s not better for the babies, for the women,” said Nélia de Paulo, a mother of two young boys who helped organize the event.

Simone Diniz, an associate professor at the University of Sao Paulo School of Public Health, offered several reasons for the perception that C-sections are better in Brazil. Many women fear vaginal birth, she said, because they view it to be “aggressive” and “violent,” where labor takes a long time, and some doctors may refuse pain relief or even verbally abuse the women during delivery.

Cesarean sections, on the other hand, are considered quick, “modern” and in line with the preferred “culture of schedule” in Brazil, said Diniz, who works in the school’s department of child and maternal health. Many doctors charge a premium for vaginal deliveries because they take longer, and C-sections can be more convenient for the health care system—hospital beds can be scheduled in advance. Women seeking vaginal birth, Dimiz said, “have a pilgrimage in labor to find a bed.”

For those like Brandão and de Paulo, Adelir’s case crystallized an entrenched problem in the Brazilian public health care system.

But there are doctors who say that these criticisms don’t take into account the medical community’s obligations.

The doctor was probably practicing “defensive medicine,” said Thomaz Gollop, a veteran obstetrician in São Paulo. As is the case in the US, he said, the doctor can be held liable if something tragic happens during childbirth. And because Adelir had two previous C-sections, her third pregnancy was high risk. To avoid potential uterine rupture, complications, or even fetal death, a C-section was necessary, Gollop said.

“A lot of judges are saying that the obstetrician was in the wrong position,” he said. “No! She said what every obstetrician would say in Brazil, and in the world.”

Gollop agreed that in Brazil’s penal code, “you have no right to go against women’s autonomy,” and noted that it was the court, not the doctor or hospital, who brought Adelir back for surgery. But in the end, he said, Adelir was healthy, and delivered a healthy baby girl.

On the same day of the protests in Recife and elsewhere around the world, the Brazilian government issued a statement sympathizing with Adelir and reiterating the country’s commitment to “humane and safe obstetric care.” 

Marissa Miley reported from Brazil as a fellow with the International Reporting Project.

More from GlobalPost: A mother-to-be heads to Brazil to report