The Wall Street Journal via Dow Jones, 14/junho/2001

Routine Surgery: For Brazilian Women, Caesarean Sections Are Surprisingly Popular

Miriam Jordan

- Routine Surgery: For Brazilian Women, Caesarean Sections Are Surprisingly Popular
- To Save Time, Make Money, Many Doctors Operate Even if It's Unnecessary
- Becoming Sterile at Age 22
By Miriam Jordan - Staff Reporter of The Wall Street Journal
SAO PAULO, Brazil -- By the time Rosana Muszkat Besborodco was ready to deliver her third child, she had the routine down pat. The 37-year-old English teacher picked the date for her baby shower -- and scheduled a Caesarean section for the following day.

"I checked into the hospital the next morning like I was checking into a hotel," she says. "Why go  through all the anxiety, when you can arrange everything in advance?"

Ms. Besborodco's enthusiasm for this major surgical procedure is shared by many Brazilian women -- and their doctors. As recently as two years ago, 40% of all Brazilian babies were delivered by Caesarean section. In public hospitals, that rate has recently dropped sharply, after government officials expressed concerns about the cost and danger of Caesareans. Still, at private hospitals, the Caesarean rate remains a staggering 80% to 90%. That's roughly four times the overall rate in the U.S. It's also far higher than the 5% to 15% Caesarean birthrate considered to be an acceptable range by the World Health Organization.

In Brazil, the culture of the Caesarean is deeply ingrained. In much of the rest of the world, the procedure is intended only for high-risk pregnancies. Here, Caesareans -- removing a baby through an incision in the abdominal wall -- have come to be seen by many women as modern and desirable, as opposed to normal childbirth, which is often derided as primitive. Part of that is driven by Brazil's mostly male doctors, whose decisions are often not questioned by patients.

In some cases, doctors encourage reluctant women to undergo Caesareans by arguing that a normal delivery would stretch their "honeymoon vagina." Caesareans have also been popularized by influential celebrities. In 1998, for example, Brazilian television interrupted programming to announce that TV host and model Xuxa Meneghel had given birth to her daughter by Caesarean.

Underlying the cultural phenomenon are two fundamental issues: time and money. Doctors say they often find it more convenient to schedule a Caesarean rather than let nature take its course. In Sao Paulo, Caesareans planned for Friday afternoon are nicknamed "beach Caesareans" because doctors typically cram them into their schedule so they won't be interrupted over the weekend. On a recent Tuesday at Santa Joana hospital, just before Brazil's four-day "Carnival" holiday, some 70 babies were born by Caesarean, compared with 46 on the prior Tuesday, which didn't precede a holiday.

The economics of Brazilian medicine have also favored surgical deliveries. In the 1970s, the Brazilian government reimbursed hospitals in the public-health system about twice as much for a Caesarean as for a vaginal delivery -- on the theory that surgical deliveries are more complicated and costly. The public-health system, which paid doctors per birth, also set doctors' fees higher for Caesareans than for normal deliveries. At the same time, the government reimbursed hospitals for epidural anesthesia only during Caesareans, which discouraged hospitals from using anesthesia during normal deliveries. This system helped cement the notion among many women that having a Caesarean would avoid the pain of normal childbirth.

By 1980, the Brazilian government equalized payments for the two types of deliveries, and began reimbursing public hospitals for epidurals during normal deliveries. Also, many doctors at public hospitals were put on salary -- rather than being paid per procedure, as before -- so they no longer had the same financial incentive to perform Caesareans. But it was too late. "We had already instituted the culture of the Caesarean," says Tania Lago, chief of women's programs in the Health Ministry.

The risks of Caesareans are well-documented. For instance, according to a 1999 study in The Lancet, a British medical journal, even when emergency Caesareans are excluded, maternal mortality occurs nearly three times as often in Caesarean deliveries as in normal births. In Brazil, the death rate among all women who gave birth by Caesarean in 1998 was five times as high as for those who delivered vaginally, acccording to the health ministry. Babies born by Caesarean are also more likely to suffer problems such as respiratory distress syndrome, a major killer of newborns.

"Unnecessary Caesareans are an expensive and dangerous luxury," says Marsden Wagner, a former director of maternal and child health at the WHO. Brazil's Health Minister, Jose Serra, is more succinct on the subject of Brazil's Caesarean rate: "It's barbarous," he says.

When the procedure goes awry, the consequences can be dire. On a November evening six years ago, Katia Quintas Figueiredo, who says she had "an excellent pregnancy," went into labor at full term -- eight-and-a-half months. Her family took her to Santa Joana hospital, one of the finest private hospitals in Sao Paulo. In keeping with the common practice, Ms. Figueiredo was given a Caesarean section. She gave birth to a daughter, Juliane.

Two weeks later, the new mother felt such pain in her abdomen that she "rolled on the ground," she recalls. It turned out that "placental remains" were left in her uterus and caused an infection, according to medical records. She was forced to undergo another surgery to save her life.

Today, chronic pain prevents Ms. Figueiredo from carrying heavy objects, holding a full-time job, or having sex with her husband, she says. And then there is this: "At 22, I became sterile," she says.

It couldn't be determined if Ms. Figueiredo's surgery was medically necessary, or if she was given a Caesarean as a matter of custom. Her medical records cited "dystocia" as the reason for the surgical birth. Dystocia, which means that labor isn't progressing fast enough, "is the diagnosis of choice when you want to do an unnecessary Caesarean," says Dr. Wagner, the former WHO official, because it is "based entirely on a judgment call by the doctor."

After several failed surgeries to restore her fertility, Ms. Figueiredo filed a grievance in 1999 with the Regional Medical Council of Sao Paulo, a professional body that investigates complaints against doctors and hospitals and can revoke their licenses. Separately, the Association for Victims of Medical Errors, a volunteer group, is trying to find a lawyer willing to represent Ms. Figueiredo free of charge.

An attorney for Santa Joana hospital, Andrea Rodrigues Pimentel, denies that the hospital did anything wrong, stressing that privacy considerations prevent her from elaborating. "We cannot expose the intimate life of a patient," she says. "We are secure about what happened inside our hospital."

In another case, Iara Aparecida Braz, a 36-year-old part-time housecleaner, died after a Caesarean. According to a lawsuit filed by her family, the private hospital outside Sao Paulo where Ms. Braz delivered her baby failed to diagnose an infection that was caused by the surgery. Ms. Braz spent a few days in excruciating pain, unable to breastfeed her newborn daughter, running a high fever and vomiting "a green substance," court papers say. By the time another hospital diagnosed the problem, the infection had become so serious that she couldn't be saved. Ms. Braz's husband, Helio, is suing the first hospital for $1.5 million.

In court papers, the first hospital, called Jandira, denies wrongdoing. The hospital claims it wasn't responsible for the actions of the doctor who performed the surgery because he wasn't a hospital employee but rather used its facilities only to see patients from the public-health system.

Now, as the Brazilian government, health professionals and women's groups raise awareness about the dangers of Caesareans, a backlash is gaining force.

Troubled by the high costs and health risks of Caesareans, the government has embarked on an ambitious campaign to reduce their prevalence. Led by Mr. Serra, the government in 1998 set a goal of a public-hospital Caesarean rate of 25% or lower in every Brazilian state by 2007. To discourage Caesareans, public hospitals that surpass a 30% rate aren't reimbursed for any Caesareans above that. Last year, the average Caesarean rate in Brazil's public hospitals dropped to 24%, from 32.4% in 1995. Brazil's public-hospital Caesarean rate is now lower than such other developing countries as Mexico and No. 1-ranked Chile.

However, the popularity of Caesareans remains entrenched at Brazil's private hospitals. One reason: Doctors in the private sector are still typically paid per procedure, and they can deliver many more babies by Caesarean than by normal means on any given day. Medical advances have reduced the time it takes to perform a Caesarean to as little as 25 minutes, from at least 70 minutes two decades ago. "Even a monkey can be taught to do a Caesarean," says Teresinha Cantarim, an obstetrician in Sao Jose do Rio Preto, a small city about 250 miles northwest of Sao Paulo that boasts the country's highest Caesarean rate.

In defense of the practice, some doctors point out that it is simply not feasible for doctors to be on call at all times to all their patients. In Brazil, doctors are expected to perform the delivery themselves rather than assigning it to a colleague if they are unavailable. Also, doctors are expected to perform many duties that are consigned to obstetrical nurses in the U.S.

What's more, many Brazilian physicians are relatively low-paid and must juggle duties at more than one hospital or office. "A doctor has on average three jobs," says Antonio Fernandes Lages, president of the obstetrical society of Brazil's second most-populous state, Minas Gerais. "How can he be at the bedside of a woman in labor for 12 hours?"

Some Brazilian doctors also claim that Caesareans are actually safer for many women than a normal delivery. Malcolm Montgomery, a Sao Paulo obstetrician who champions Caesareans, lists a variety of complications that normal delivery can cause, including hemorrhoids and bladder problems. "A vaginal delivery is much more violent for a woman than a Caesarean," he says.

The large numbers of Caesareans and their toll on women's health galvanized Mr. Serra, the health minister. Soon after taking office in 1998, the Cornell University-trained economist made several high-level appointments of women who were determined to address the issue. Not long after, he made a trip to central Brazil, the region where Caesareans are most prevalent. "I looked at the women and said, `I don't see any anatomical defect to justify more than half of you giving birth by Caesarean section,' " Mr. Serra recalls.

Mr. Serra's reaction cheered Brazil's nascent feminist movement, which had been agitating for better women's health programs. It also made sound fiscal sense: Brazil's public-health-care system was groaning under some 550,000 unnecessary Caesareans each year, which cost millions of dollars in extra drugs and hospital resources, sometimes for postsurgical complications.

Under Mr. Serra's program, the government not only set limits on the number of reimbursable Caesareans in state hospitals but also expanded the role of obstetrical nurses in deliveries. For years, such nurses had been relegated to doing administrative work in maternity wards. Government officials believe that giving them a greater role in delivering babies is one way to cut down on Caesareans, since they are allowed to perform only normal deliveries.

The government believes it has a model for the future: The Sofia Feldman hospital, a three-story, brick-and-cement structure in the rundown outskirts of Belo Horizonte, Brazil's third-largest city. It opened in 1977 as an outpatient clinic for the poor. Unable to pay doctors on his staff, chief obstetrician Ivo Lopes began enlisting nurses to deliver babies there a few years later. The first baby born at Sofia Feldman came into the world in 1982 by vaginal delivery. (She was named Sofia, in honor of the institution.) Ever since, nurses at Sofia Feldman have delivered the babies of all women whose pregnancies are deemed risk-free. The Caesarean rate at Sofia Feldman has hovered around 14%, the lowest in the city, and the mortality rates for mothers and babies have remained below the national average.

Still, most of Brazil's medical establishment has only half-heartedly championed the cause. Daphne Rattner, a Sao Paulo public-health physician who has helped the government shape its strategy, believes it will take decades to reduce the Caesarean rate in private hospitals, where about one million babies are born a year. "Nothing is changing in the private sector," says Dr. Rattner.

On a Wednesday in February, just before Carnival weekend, the obstetrical ward at Santa Joana, a state-of-the art private hospital, was crowded and hectic. At the hospital, which charges $2,200 regardless of whether a baby is born by Caesarean or by normal delivery, the Caesarean rate is 80%.

Like people waiting in line for their number to be called at a bank, six women sat nervously on vinyl chairs. Not one had completed a full 40 weeks of gestation.

One patient, Katia Soares Cordeiro, had an appointment for a Caesarean at 3 p.m., even though she said her 38-week pregnancy has been problem-free. "I know you recover faster from a normal delivery," said the 25-year-old. "But the doctor thought it was better to do a Caesarean."

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