– You popped?! How nice! Was it natural?
– Natural, yeah…. For the doctor, right?
Dialogue between a postpartum woman and the author of this article.
It made last week’s headlines the information from the Health Department showing that for the first time, Brazil reported more cesareans than vaginal births in a year: 52% overall. According to an article in Folha de S. Paulo, rate of cesareans in the private sector has been stable since 2004 and is around 80%. In the Public Health System (SUS in Portuguese), that number is increasing and went from 24% to 37% in the last decade.
The term cesarean section does not seem to have anything to do with Julius Caesar, supposedly born of this procedure, as I was taught in college. As Professor Joffre [in Portuguese] emphasizes; “the word cesarean and the expressions cesarean section and cesarean delivery are linked to the Latin verb caedo, caesum, caedere, which is equivalent to the Greek témno, to cut.
From it, derive caesus/a/um, “that which has been cut”; caeso/onis, to slipt or separate; caesura, a cut or cuts; and caesar/aris, the same as decaeso/onis, i.e., one that is taken from the mother’s womb, or “qui caeso matris utero nascitur”.
It is a known fact that Brazil is the world champion in caesareans, and it has been roundly criticized for it (a small collection of links: unnecesarean, guttmacher with a Brazilian reference, another reference in PDF, another Lancet study [subscribers-only], among many others). But as the post title suggests, I would like to make a parallel between abortions and cesarean sections.
Let me first disclaim my conflict of interests; I do not believe in abortion as a contraceptive method in public health because it does not work well as one. But, regardless of what sectors of the Church, the Brazilian Theocratic State, sociologists, doctors, etc want, it is a woman’s prerogative. Abortions should be “accessible, safe and extremely rare,” as it has been said. It is one of the symbols of the gap between Brazilian social classes the way its practice permeates the various segments of the female population of the country: from knitting needles, outlawed abortive pills and pray-for-the-best, to highly-equipped clinics with all the comfort and care of large hospitals. (I won’t even discuss the issues of malformed fetuses and the mother’s risk of death, because it would be too much for this post. See my views on the subject [in Portuguese] here, here and here).
Back to cesareans and the bewilderment caused by it. The cesarean delivery follows the same reasoning as with abortions: it is a woman’s prerogative if she wants to have her baby vaginally or surgically. The problem is that this decision is never fully explained and here enters the role of the physician. I did five natural deliveries during my medical training. In some, I spent the whole night with girls writhing in pain without any relief. If there was no alternative, fine, the gift of motherhood will always compensate for anything, at least that’s what they say. But if there is a different approach in which the risk/benefit ratio is acceptable, why not try it out? Who decides? The MD and the mother, and no one else.
The doctor, however, should play the same as when is presented with someone wanting to have removed an unwanted fetus. Expose, with the highest possible moral exemption, the risks of the procedures and take a position. These are not decisions that are up to patient alone. Saying that one does not do nor prescribe abortive procedures is completely legitimate. The patient should know that this is against Brazilian law and that the doctor who does it is in risk of being sued. With C-sections, the situation is more bland, but similar. There is no law against it, but there are clinical indications more or less needed. If a pregnant woman wants a cesarean section, the physician should explain the risks and take a stand. The problem is that there is a doctor’s bias favoring the procedure. Now we’re putting the fox in the hen house. And with that, I can not agree.
Let’s put some data in this discussion. Obstetricians and the World Health Organization estimates that approximately 15% of deliveries should be cesarean due to complications related to them. If private hospitals in São Paulo City, the rate is around 80%, according to the Folha, there is an excess of 65% in favor of cesarean sections that needs explaining. There is a group called Caesarean Delivery on Maternal Request (CDMR). There are strong indications, according to the Lancet study cited above, that this “movement” has begun in Brazil and spread to other nations. It is estimated that this type of “indication” may account for up to 20% of cases of surgical deliveries. Zhang’s study (below) checked 1.1 millions of non-twin births over 13 years in southeastern China and showed a significant increase in the number of caesarean sections in large part due to CDMR. In some places, the indications at the request of mothers reached 50% of C-sections. In Brazil, Osis and colleagues (below) set out to try to understand why so many cesareans. They studied 656 women in São Paulo and Pernambuco, users of public health services, and divided them into two groups. The first consisted of women who had previously experienced vaginal delivery and then had a cesarean. The other, consisting of women that had gone through only cesarean deliveries. 90.4% of women who had at least one vaginal delivery considered it best, against 75.9% among those who had only cesarean sections (the number of those who had only vaginal deliveries in the study was too small which constitutes an important bias). If those who had cesareans entered into labor, the result would have been similar (45.5% and 42.8%). 47.1% of those who had vaginal delivery said it had no downsides, compared to 30.3% of those who did not. On the other hand, 56.7% of women who only had cesareans reported that having no contractions was the main advantage of the method against 41.7% of the others. The conclusion of the article is that the pain is important, but women classify it as secondary. First comes the child’s health and the recovery from the operation. In addition, in Brazil is very important to be able to perform a tubal ligation (“tying the tubes”) for sterilization and this weighed in choosing the route for delivery. This constitutes a serious flaw of public health policies of those two states with regard to birth control, according to another article. We can not replace one mistake for another.
To conclude this long blog post, I’d say:
1. It is legitimate for a mother to want a cesarean (CDMR), as much as it is legitimate for a mother to not want to carry out an unwanted pregnancy – her prerogatives, exclusively – since she is fully informed of the consequences that such procedures actually involve. (Some people argue about what is “fully informed” saying it is impossible for a layperson to be clarified about procedures with such complex consequences, which creates implications for the informed consent, the instrument without which NO clinical research is done, just so we get a glimpse of the size of the problem we are dealing with).
2. Physicians have a key role in the choice of the delivery route and must rid themselves of their individual preferences to advise the pregnant woman. Given the enormous difficulty in doing this (since a physician trusts their skills for both procedures) is not totally unreasonable to seek a second opinion on the subject. This reduces, without a doubt, any bias. But increases insecurity, another difficult choice.
3. The excess cesareans is an example of the medicalization of Medicine. Like baldness, shyness and restless children [in Portuguese], it shows us how to turn arbitrary “deviations” of normality into technically manageable pathologies.
Photo taken from the blog Parir é Nascer.
Zhang, J., Liu, Y., Meikle, S., Zheng, J., Sun, W., & Li, Z. (2008). Cesarean Delivery on Maternal Request in Southeast China Obstetrics & Gynecology, 111 (5), 1077-1082 DOI: 10.1097/AOG.0b013e31816e349e
Osis MJ, Pádua KS, Duarte GA, Souza TR, & Faúndes A (2001). The opinion of Brazilian women regarding vaginal labor and cesarean section. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 75 Suppl 1 PMID: 11742644