|- 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
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
"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
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
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
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
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."