Of the 2.2 million childbirths performed in Brazil's SUS (Sistema Único
de SaúdeUnified Health System), in 2003, 25 percent were cesarean
sections. Although the trend in surgical deliveries is on the downswing in
Brazil, the quantity is still greater than what is recommended by the World
Health Organization (WHO), which claims "there is no justification for
regional cesarean rates to exceed 15 percent."
This orientation by the
WHO is an attempt to reduce the number of maternal deathsin Brazil,
74.5 women in every 100 thousand births. This risk is seven times greater
in cesarean births, according to studies conducted by the Latin American Center
for Perinatology and Human Development (CLAP).
Another problem involves
the cost of cesarean sections. According to WHO studies, this type of delivery
adds considerably to the burden of female health care. In Brazil, each cesarean
winds up 32 percent more expensive for the SUS, which pays US$ 86.50 (R$ 263.49)
for a normal childbirth and US$ 127.10 (R$ 387.50) for a cesarean.
Several other studies
on cesareans have been done in Brazil. The National Health and Demographics
Survey, carried out by the Brazilian Institute of Geography and Statistics
(IBGE), in 1996, informs that 36 percent of the deliveries performed that
year were cesarean sections. Of the total number of childbirths, 83 percent
presented no difficulties, indicating that many of these surgical procedures
were scheduled in advance or were unnecessary.
The analyses and studies
cited by the researcher Elza Berquó in "Fertility, Reproductive
Health, and Poverty in Latin Americathe Brazilian Case," also bolster
the argument that cesareans increase the number of deaths due to postnatal
infection and anesthesiological risk.
Nevertheless, there are
still instances in which cesareans are the only childbirth option, as when
the mother is suffering from a serious health problem, such as a cardiopathy
or renal insufficiency, or when the child is undergoing fetal distress.
"The advantage of
a cesarean section is being able to remove the fetus at the right moment,
with greater speed, when there are difficulties in performing the delivery
through normal channels; this is the primary reason for a cesarean. Before
the existence of cesareans, women died, and children died, because it wasn't
possible to interrupt the pregnancy at the right time," explains the
physician Elenice Ferraz, head of obstetrics at the University Hospital of
Brasília (HUB), at the University of Brasília (UnB).
The physician says she
is in favor of every delivery's being normal, but she opposes the idea of
non-hospitalization. "During the process of birth and the postpartum
period, grave complications, such as uterine hemorrhaging, can occur. This
can be fatal, if you're in a place without a blood bank or a surgical center
with a doctor able to stop a uterine rupture. Besides the complications that
can happen to the baby," Ferraz warns.
But she is also against
the idea that a delivery should be cesarean just because a woman doesn't want
to experience pain or because her doctor doesn't want to waste time on labor.
"The indication of a cesarean should be responsible."
Maternal and Neonatal
Making the birthing process
more qualified and humane is one of the steps proposed by the Ministry of
Health to reduce the indexes of maternal and neonatal mortality in Brazil.
Recent statistics show that 74.5 women die in every 100 thousand live births.
In the case of infants, in every thousand live births, 18.3 die before completing
To alter this situation,
in March the Ministry launched a national pact to decrease the current indexes
of maternal and neonatal mortality by 15 percent by the end of 2006 and 75
percent by 2015.
A reduction in the number
of cesareans could also be an alternative. According to the WHO, the lowest
rates of postnatal mortality occur in countries in which cesarean births represent
less than 10 percent of the total.
In Brazil, where there
is an average of 2.5 million births every year, according to the IBGE, and
around 89 percent of them take place in establishments that are part of the
SUS, the majority of maternal deaths are the result of hypertension during
pregnancy, hemorrhages, infections, and abortions.
The diminution of maternal
and infant mortality has another ally in Brazil. A recent experiment is modifying
the pattern of female health care during childbirth. These are the so-called
"Birthing Houses," regulated by the Ministry of Health through an
administrative decree issued in August, 1999.
One year later, in the
Federal District, the local government inaugurated the Saint Sebastian Birthing
House. Set up to operate as a pilot project, the unit is located in one of
Brasília's poorest satellite cities. An average of 70 deliveries are
performed each month.
The place doesn't resemble
a hospital. The walls are painted beige, and many of them are decorated with
wallpaper, paintings of flowers, and posters explaining the benefits of breast-feeding.
In the delivery room, a special bed allows women to choose the best position
to give birth. The room also has an air conditioner, a ball for pelvic massage
(which helps to position the baby), music, and space for a companion.
an obstetrician who is the head of Gynecology, relates that the idea of birthing
houses arose in order to lighten the burden on large health centers and humanize
childbirth. But these units only perform low-risk, normal deliveries, that
is, ones that developed well during pregnancy and are at the right moment
for the birth to occur.
"For this reason
the Ministry of Health determined that the birthing houses should be no more
than an hour away from a reference hospital, where high-risk births are sent,"
Besides the setting, another
big difference between birthing houses and traditional maternity wards is
the way expectant mothers are treated. "They receive special attention,
are examined every half hour prior to delivery, and when the baby is born,
it goes right to its mother's breast," the physician explains.
He remarks that one of
their objectives is to include the assistance of "doulas" (birthing
companions) at the moment of birth. "In our case, they are volunteers
from the community itself," Albuquerque adds.
One of the greatest fears
of women on the verge of giving birth, the fear of pain, can be assuaged by
the labor of "doulas," also known as birthing companions. The term
"doula" comes from the Greek and means "servant, woman's helper."
Doulas give massages, teach relaxation exercises, and provide emotional support
at the moment of childbirth.
"What I felt is that
the work of a doula creates a calm atmosphere for the expectant mother. The
doula works on the physical and mental aspect, with relaxation techniques
and exercises for the baby to get into position. This helps the delivery go
well, without pain." This testimony comes from Almir Silva, a 33-year
old public servant who followed the work of a doula a month ago, when his
third child was born.
"To be a doula, all
that is needed are two hands and a heart," explains the educator Renata
Beltrão, who is also a doula. Together with the psychologist Marisa
Rocha, she founded the Gen Space, a center in Brasília that offers
courses in childbirth preparation and doula training.
The discoverers of the
function of doulas, Rocha recalls, were two American physicians who studied
mothers' bonds with their newborns at the moment of childbirth. When they
analyzed the childbirths, they discovered that the easiest ones and the ones
with the best results had in common the presence of an observer, a girl named
Wendy, who also gave caresses, held the hands of the expectant mothers, and
conversed with them.
Ana Cristina Silva, a
civil servant, gave birth to her third child last month. The delivery was
humane, in a squatting position and with the help of a doula. "The doula
was my tranquilizer. She taught me the exercises that helped get the baby
into position," she affirms. In her view, the presence of the doula enhances
a woman's self-esteem at the moment of giving birth.
restored the empowerment of women, the feeling that a woman is capable of
having her baby naturally," affirms the doula Renata Mourão. Ana
Cristina's husband, Almir, agrees. "The human machine is something perfect;
it's the human being that is always trying to undermine this logic. In humanized
childbirth, the woman assumes the leading role," he concludes.
The doulas Renata and
Marisa are in favor of natural childbirth, and they alert to the risk that,
in the name of convenience, this type of delivery will be marginalized. "One
must look for a good doctor, who will only perform a cesarean as a last recourse,"
According to data from
the Ministry of Health, there are over 60 thousand midwives and around 18
thousand obstetricians in Brazil. For Renata and Marisa, this may be a sign
that the work of midwives needs to be recognized and natural childbirth, stimulated.
Irene Lôbo works for Agência Brasil (AB), the official press
agency of the Brazilian government. Comments are welcome at firstname.lastname@example.org.
from the Portuguese by David Silberstein.