Brazil is a country with shockingly high C-sections rates, upwards of 87% in the private medical system. How does an entire nation lose sight of natural childbirth, one of our basic human functions?
Being pregnant while traveling through Brazil has been a fascinating lesson in cultural differences. My large, almost 7-month belly is a great conversation starter, but as we talk further, people are inevitably shocked to learn about my birth plan – that I hope to have a natural delivery at home, assisted by midwives, with no epidural. Even though I tell them I’ve done it before, almost everyone I’ve spoken to remains skeptical and bewildered by my choice. Such a birth model, I’m discovering, is utterly foreign to most Brazilian women.
Despite having a world-class health care system, Brazil has notoriously high C-section rates – approximately 50 percent of births in the government-funded public hospital system and 87 percent in the private system. Contrast this to the World Health Organization’s recommendation that any country’s C-section rate should be no higher than 15 percent, and you can see that Brazil’s rate is far beyond what’s necessary. (The United States currently hovers around 30 to 35 percent, and it has set a goal of reducing C-sections by 10 percent by 2020.)
Cesarean births are serious abdominal surgery and with that comes the risk of complications and infection. There is a misperception that C-sections, because they're performed so commonly, are just as safe as vaginal birth, but that's not the case. Women who have unnecessary C-sections are at increased risk of death, blood transfusions, and hysterectomies, as well as future placental problems. Babies born by C-section have increased risk of respiratory problems, according to a 2010 survey by the WHO.
The obvious question is WHY?
Through personal conversations and reading online, I’ve encountered a number of reasons. An anesthesiologist who works in both the public and private systems told me that the hospitals are so overcrowded with patients that scheduling a C-section ahead of time guarantees a spot. An article in The Guardian called “Inside the war on natural birth” makes the same point:
“If a woman does go into labor and doesn’t have a C-section scheduled, she can find herself boomeranging from hospital to hospital in search of an open bed. Some doctors request bribes if a woman wants to avoid a C-section, since they find unscheduled vaginal births inconvenient.”
Doctors’ unwillingness to assist natural births is a recurring theme. I heard about one young woman who told her obstetrician early on that she wanted a vaginal delivery. The OB said they’d discuss it later. At 8 months, the mother brought it up again. The OB said, “I only do C-sections. If you want a vaginal birth, you’ll have to find another OB.” At that point, it was too late to look for another doctor and the woman felt coerced into having a C-section.
There is also the infamous story of Adelir Carmen Lemos de Goés, who was forced by police on March 31, 2014, to have a C-section. She had checked herself out of the hospital after being told by doctors that her baby was possibly in breech position. Although she was perfectly willing to give birth in the hospital, she only wanted to avoid surgery, but nobody was willing to deliver a breech baby vaginally. Her forced C-section resulted in protests in many city streets, as well as a Twitter hashtag #SomosTodasAdelir (We are all Adelir), uniting frustrated Brazilian women against "obstetric violence."
There are cultural factors, too, that seem strange to my Canadian perspective. Childbirth is seen as “primitive, ugly, nasty, inconvenient” and “something poor women are supposed to endure.” C-sections performed in hospitals, by contrast, are viewed as modern and liberal, and are a status symbol. Only wealthy people go to private hospitals, which is where most of the C-sections are performed. Natural vaginal delivery is associated with lack of privilege and resources.
Another doubtlessly controversial argument I’ve heard on several occasions is that of persistent machismo. Brazilian men apparently “like their women tight” and hold on to the myth that vaginal deliveries destroy a woman’s pelvic floor. Many women often opt for C-sections in order to have a tubal ligation. “Most men won’t get a vasectomy,” a male journalist told me in Recife. “They think it will make them less of a man.” The anesthesiologist I spoke with agreed, although she says it’s a bigger problem in the north than in the south.
Some positive changes are happening. When I met with Marcely Carvalho, a traditional midwife in Olinda, Pernambuco, for a prenatal consultation of my own, she said there’s growing interest in alternative birthing methods. Women are fed up with the lack of options in the hospital system. Although Carvalho does relatively few home deliveries – about 6 per year in a greater metropolitan region of 4.5 million – she offers pre- and post-natal support that includes ongoing psychological and emotional counseling for both mother and father-to-be, as well as acupuncture treatments, even if the mother chooses to deliver in hospital.
Carvalho told me, “Here, we believe that the first right of every child is to be born the best way possible. In most cases, that is a birth free from the trauma of surgery.” I hope that more women and doctors, in particular, will learn to see the value in her philosophy, and the immeasurable benefits it provides to mothers and newborns alike.