A piece of international research, published in the June 3rd edition of Lancet, one of the most respected medical magazines in the world, brings an alert to doctors and to future mothers and fathers: carrying out surgical births or cesarean sections without a specific medical reason places the health of the woman and child at risk. This is a shake up that is more than necessary for the gynecologists, obstetricians and healthcare administrators throughout the world, who over the last four decades have seen the rate of unnecessary cesarean births grow in an alarming manner without managing to slow it down.
The message from the pages of Lancet assumes particular significance for Latin America, and in particular Brazil, placed second in the world for carrying out cesarean births – one of the main issues related to the reproductive health of women in the country, alongside surgical sterilization and the unnecessary removal of the uterus (hysterectomy). Here the rates of surgical births have insisted in keeping themselves scandalously high since the 1980s, above all among middle to upper class women. Currently, four out of every ten children are born by cesarean sections, in the majority of cases programmed by the mothers and obstetricians well before the end of pregnancy – an exaggerated proportion, two and a half times greater than the rate of 15% accepted by the World Health Organization (WHO).
Difficult to be modified, according to the doctors themselves, this reality is worrying because a large portion of these surgeries are unnecessary and do not always represent the most adequate and safest form of giving birth to a child, as many women believe. In these cases, with a little bit of patience from the mothers and ability from the obstetricians, mother nature could play its role and these babies would be born healthy via a normal delivery.
In this study, coordinated by the WHO and financed by the World Bank, epidemiologists and specialists in female reproductive health evaluated the result of almost 100,000 births carried out between September 2004 and March 2005 in eight Latin American countries (Argentina, Brazil, Cuba, Equator, Mexico, Nicaragua, Paraguay and Peru). The result confirmed what had been feared: unnecessary surgical childbirths do more harm than good.
When the level of cesarean births at a hospital overtakes the band that runs from 10% to 20% of the total of deliveries, the risk of a complication for the mother or baby increases considerably. The probability of the woman dying during childbirth, of presenting serious bleeding or acquiring an infection that demands internment in the intensive treatment unit, is greater. The child runs a greater risk of being born when younger than 37 weeks (premature) through a medical error in calculation, of dying during birth or in the first week of life and of requiring intensive care. Even when the different levels of complexity of the 120 evaluated hospitals were taken into consideration, or that is to say, the capacity to attend to cases of greater or lesser gravity, the dangers for the mother and baby do not diminish. “All of the health indicators for the woman and child get worse”, says the Chilean obstetrician Aníbal Faúndes, one of the most respected international authorities in reproductive health. The coordinator of the team of 90 Brazilians who participated in this study, Faúndes moved to Brazil some 30 years ago, leaving Chile during the Augusto Pinochet dictatorship, then having been the coordinator of the woman’s health program at the start of Salvador Allende’s government.
Unnecessary spending
“As the complications coming from cesareans are relatively rare, doctors usually say: ‘This doesn’t happen with my mothers’”, comments Faúndes, a retired professor at the State University of Campinas (Unicamp) and a researcher at the Reproductive Health Research Center of Campinas (Cemicamp). “But from the population point of view, the consequences of these events are serious and must be taken into consideration”, he says. One of these effects is the increase in public spending on healthcare. In the developed countries an increase of 1% in the levels of cesarean sections represents extra spending of US$ 9.5 million. It is calculated that in Brazil, where 2.5 million children are born per year, there are some 560,000 unnecessary cesarean childbirths that consume almost R$ 84 million. “This is money that could be invested in other forms of care for mothers and their children”, suggests Faúndes.
Although the risk of dying during a cesarean is very much lower than it was almost four centuries ago, when this procedure began to be carried out on live women – before that a cesarean was done only after the death of the mother in order to save the baby’s life –, dispensable surgical childbirths contribute to maintaining the Brazilian maternal mortality rate at a level well above that of developed countries such as the United Kingdom. It is estimated that between 75 and 130 Brazilians in each group of 100,000 die during childbirth or from complications associated with their pregnancy. Among the Queen’s subjects this index is approximately 10 deaths per 100,000.
In spite of the imprecision of the Brazilian data, it is easy to associate a good part of these deaths to cesarean births. International studies point out that close to 100 women lose their lives for every 100,000 cesareans, five times greater than for normal childbirths. Until the 19th century, three out of every four women died from infection or intensive bleeding (hemorrhaging) as a consequence of this surgery. Today during a cesarean birth, the doctor makes an incision of 10 to 15 centimeters into the mother’s abdomen just above the pubic hairs and cuts another five layers of tissue until reaching the uterus in order to remove the baby.
“The degree of abuse of cesarean births in the country is impressive”, says the sociologist Jacqueline Pitanguy, the director of the NGO entitled, Citizenship, Study, Research, Information and Action (Cepia in the Portuguese acronym), which acts in the area of reproductive and sexual rights. “Around here there’s a historic disregard for pregnancy and childbirth”, she says.
The persistence of the rate of cesarean births at such a high level for more than two decades has led the Ministry of Health to adopt some strategies – unfortunately not always sufficient – in order to attempt to reduce the number of cesareans. The most recent is the Incentive towards Normal Childbirth Campaign, launched on May 30th to enlighten the population about the importance of normal birth and to help to knock down the already crystallized idea in society that the surgical birth is better and safer.
The campaign has three goals: to explain the importance of exams that accompany the health of the woman and her baby during pregnancy; to show the benefits of a normal birth and to reinforce the idea that the woman has the right to a more welcoming birth, without carrying out unnecessary medical procedures and with the accompaniment of a person of her choice – this is the so-called humanized birth.
The right road
But why carry out an explanatory campaign for the population and not for the gynecologists and obstetricians, who for ethical reasons must recommend to the woman the most appropriate form of giving birth? “There’s no point in only working with the doctors”, says the epidemiologist Daphne Rattner, from the Woman’s Health Technical Area of the Ministry of Health. “We have to awaken the awareness of people to the importance of normal childbirth so that they then demand this from the health professionals” In the opinion of Jorge Francisco Kuhn dos Santos, a professor of obstetrics at the Federal University of Sao Paulo (UNIFESP), this really is the right road: “It’s fundamental that the woman be better informed about the need to carry out or not a cesarean section or her baby to be born. Only when the mothers know that the umbilical cord is wrapped around the baby’s neck or that there’s a reduction in the amniotic liquid itself alone do not by obligation represent the need for a cesarean birth and that they’re going to fight to improve this picture”.
This is not the first action by the federal government to attempt to reduce the number of unnecessary cesarean births. In 2000 the Ministry of Health made a pact with the states to reduce cesarean sections. An edict from the Ministry determined that the state Secretariats of Health should accompany the number of births in the hospitals affiliated to the public healthcare system to guarantee that the rate of cesarean sections did not increase in the states in which they were below 20% and that they would go down to 25% in those in which they were higher.
But apparently the opposite occurred. “The level of cesarean births is rising”, says Daphne. Some two years ago the Ministry also initiated a series of courses called Obstetrics Attention and Neonatal Humanized, Based on Scientific Evidence as part of the National Policy for the Integral Attention to Women’s Health. Up until May teams had been trained at around 250 maternity units that had promised to implant modifications in order to reduce the level of cesareans and to offer humanized normal childbirth at their hospitals of origin. These teams have also taken the responsibility of passing on their knowledge to the main maternity units within their states, a way of disseminating the information more quickly among the almost 6,000 hospitals in the country. “The expectation is that the more the services offer humanized attention at childbirth the more the professionals will go on to agree with this strategy”, explains Daphne.
It is hoped that the effect of these measures will not be restricted to the public sector in which the absolute number of cesarean births (618,000 per year) is much greater than in the private sector. But certainly other actions will be necessary in order to reduce the index of private surgery childbirths or those paid for by healthcare insurance plans – fewer in absolute terms, 246,000 per year, but proportionally much higher. For this reason the National Supplementary Health Agency (ANS), that regulates the working of these plans and health safety, is uniting its forces to the Ministry. During 2005 the ANS made the first analysis on the level of cesareans in the sector and actually studies a way of reducing the rate of unnecessary cesareans sections of a disturbing 80%.
“We’re evaluating the strategy of making available on the ANS site a points count of each health plan operator, determined by a series of indicators, among them the cesarean index”, says Karla Santa Cruz Coelho, the technical assistance general manager of ANS production. “We pretend to achieve a reduction of 15% over the next three years.” Even these measures are considered timid. “Much more firm action is necessary”, says d professor Santos, from UNIFESP. “The doctor who only does cesareans must be discredited.”
On one point they all agree: the question of unnecessary surgery births is a problem whose solution is complex and depends on as much a change in the attitude of gynecologists and obstetricians as society. “In Brazil there is a medicalized culture surrounding women’s health”, explains Daphne Rattner. Its roots lie at the start of the last century when childbirth stopped being carried out in homes, with the help of a midwife who in general had helped with the birth of almost all of the family, and moved to the hands of doctors in hospital delivery rooms, up until then destined to attend to the poorest classes of the population. Development of the techniques of anesthetics and treatment with antibiotics to prevent infections over the last 50 years have also contributed to considerably reduce the maternal mortality rate and to turn cesarean surgery more popular in the world.
In Brazil the proportion of surgical childbirths doubled during the 1970s and never went down afterwards. Today cesareans correspond to 82% of the childbirths paid for by medical plans, which attend to 14 million Brazilians between the ages of 10 and 49 years, and to 30% of the births done through the public healthcare system, the only way of access to health services for 58 million women of child bearing age.
This increase, nevertheless, cannot be explained only by the attempt to protect the life of the woman and child, as it was identified by Faúndes and José Guilherme Cecatti, from Unicamp, back in 1991 in an article published in the Cadernos de Saúde Pública [Public Health Notebooks]. If cesareans were carried out only through medical circumstance – for example, when insufficient oxygen is getting to the baby during the work of the birth –, one would have expected the rate to be higher among poorer women, known to have more complications during pregnancy and childbirth thon those women who are better nourished. But this is not what is observed in the country, where these surgeries are more common in the middle to upper classes.
Other non-medical factors have also influenced the expansion of the rates of cesareans. Up until 1980 the federal government paid the doctor more for the cesarean birth than for a normal birth, which did not include anesthesia. In an attempt to reduce cesareans, the difference between the value for a normal birth and a cesarean birth was reduced in the public sector – today the SUS pays the hospitals and not the doctors, R$ 317,39 per normal birth and R$ 443,68 for a cesarean –, without much efficiency.
Birth control
As well as this, during that period surgical sterilization became popular, partly as a consequence of the pressure of the developed nations such as the United States for a reduction in the populations of poor countries. In the middle of an authoritarian policy that was in force in the country, preaching birth control was seen as the solution for poverty. The result: three out of every four women had made use of a cesarean birth, often induced by the doctor, in order to carry out a definite sterilization by way of a technique called tubal ligation, in which the surgeon cuts and ties off the ends of the small canals that conduct the eggs to the uterus.
Prohibited by the Family Planning Law during 1997 from being carried out at the same time as a cesarean, tubal ligation remains the anti-conception method most common in the country. In the opinion of Faúndes, there are two reasons why women still opt for this form of contraception, difficult to be reversed in the case of a change of mind: they don’t know of other methods such as an inter-uterus device (DIU) and the three monthly hormones injection are just as efficient as tubal ligation and not always are the alternative methods available in the public sector.
“For more than twenty years now the federal government has been taking measures in the country in an attempt to combat the money effect”, says the sociologist Jacqueline Pitanguy, who in the decade of the 1980s presided over the National Council of Women’s Rights, linked to the Ministry of Justice and the Presidency of the Republic. “But it didn’t have much of an effect.” However, in the private sector this stimulus practically does not exist. The rate paid for private births varies a lot and, although the health plans pay fees almost equal for surgical and normal births, the obstetricians save time and opt for surgery.
“One must not blame only the doctor, who has to pay the costs for maintaining his office , explains Santos. An alternative would be to increase the amount paid for a natural birth, which never has a fixed hour to occur. In this way, who knows, the obstetricians could be encouraged to open up space on their consulting room agenda to patiently accompany the work of the birth, which can take more than 24 hours – in a cesarean pre-set between the doctor and patient, the so-called set time cesarean, the obstetrician is capable of getting himself to the hospital, carrying out the birth and returning to his consulting rooms in less than three hours, even in a city with complicated traffic like Sao Paulo.
But money is not everything. The very doctors themselves feel themselves in better control of the situation when carrying out a cesarean section, even when his patient is not completely aware of the risks that she is running during this surgery. In the end, points out Santos, it is difficult to take action against a doctor for having carried out a cesarean birth done unnecessarily. “Even if there’s a complication people think: ‘At least the doctor used the best technology available’”, he says. This same doctor could be questioned judicially if he had opted, under the same circumstances, for a normal birth.
The medical posture is what the respected American neonatologist and obstetrician Marsden Wagner, ex-director of the area of women and children’s health of the WHO, called defensive obstetrics, a worldwide tendency, in a commentary published in 2000 in Lancet. But, according to Wagner, by carrying out defensive obstetrics, the health professionals violate a fundamental principle of their practice: “What one wants the doctor to do must be, in first place and above all else, for the benefit of his patient”.
The psychologist Ana Cristina Gilbert, the historian Maria Helena Cardoso and the pediatrician Susana Wuillaume have seen that this confidence in the technique already appears during the process of the formation of the specialist within a study involving gynecology and obstetrician residents at the Fernandes Figueira Institute, of the Oswaldo Cruz Foundation in Rio de Janeiro, published in May in Cadernos de Saúde Pública [Public Health Notebooks]. “The residents feel themselves to be more in control of the woman’s health and time during a cesarean birth”, explains psychologist Ana Cristina. “This is important for them, who see themselves professionally undervalued in the profession and are heavily burdened by their patients, who always look for replies to their problems through them.”
One of the motivations for this form of behavior is insecurity in carrying out a normal birth, a consequence of how medical specialization in this area is progressing. After graduation, anyone who wants to become an obstetrician tries for a highly disputed position in a hospital of high complexity, such as the university hospitals. Here this professional above all attends to high risk pregnant women, with an indication for a cesarean birth. As he does not meet up with more simple situations, he loses the habit of carrying out normal childbirth. “These professionals should go through training in childbirth units, where the babies in general are born naturally, accompanied by obstetrician nurses”, says Santos.
Over the last few years teams from Cemicamp and Unicamp have helped to knock down the argument often used by obstetricians to justify the carrying out of cesarean births: namely that women prefer surgery for fear of the pain of a normal birth or for fear of the effects of this type of childbirth upon their female sex life – in some cases it is necessary to make a small cut on the side of the vagina or in the perineum in order to facilitate the passage of the baby’s head. But this fear of pain seems to be only medical chit-chat. “This statement doesn’t hold water”, says Faúndes, who coordinated a study with 656 women who had had more than one birth in public hospitals in the interior of the state of São Paulo and in the city of Recife, in the state of Pernambuco.
For the natural way
Nine out of every ten women who have experienced the two forms of childbirth prefer natural birth. More interestingly: among those who had only experienced cesarean birth, 73% also declared that the best form of childbirth is natural. The reason most often cited by them is that the pain of a normal birth is less intense than the post-operational pain from cesarean birth. “The pain in the normal birth is strong, but passes”, advised Jacqueline Pitanguy, a mother of three children who were born in the natural way after a lot of insistence on her part with the doctor. “Not always is the normal birth synonymous with horrible pain, as had happened thousands of years ago?” In 2001 a survey of 1,600 women from four Brazilian cities showed that some of them who had had a child by cesarean preferred normal childbirth.
The acceptance of cesarean birth by a woman is, in part, a consequence of the imbalance of power in the relationship between doctor and patient. “Childbirth is the moment of most fear for the woman, especially when it’s her first child”, explains Jacqueline. “She feels herself to be powerful for being pregnant, but at the same time fragile. For this reason she believes it to be safer to assume a passive posture and to leave the decision in the hands of the doctor.” The obstetrician, for his part, feels himself more valued when he is dominating the situation. “If the doctor were to say to the mother that her baby was suffering, she would subject herself to anything”, commented professor Santos. This power difference also helps to explain radical treatments such as the removal of the uterus in order to combat benign tumors in cases in which surgery would not always be necessary (16% of the total). This procedure is most frequent among women with lower income and poor schooling, as verified by researcher Renata Aranha, from the State University of Rio de Janeiro (Uerj).
One way of reducing the level of cesarean births is to make a consultation with a more experienced obstetrician obligatory, the well known second opinion, as demonstrated by Maria José Osis, Karla Pádua and Aníbal Faúndes, from Cemicamp, and José Guilherme Cecatti, from Unicamp, in an article published in the Revista de Saúde Pública [Public Health Magazine] of April. Also, carrying out of births at home could be stimulated, as still done in England in almost half of the cases. In 2005 the University of São Paulo (USP) reopened, after some 33 years, the tertiary level course for the formation of mid-wives, an activity exercised informally today by between 40,000 and 60,000 women in the North and Northeast of the country. “The question of childbirth is a policy problem because there are doctors and nurses legally qualified to exercise this function”, says Santos, “and now yet again there will be mid-wives”. The solution certainly is not a single one, nor will it come about in a short period of time.
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