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Brazzil - Health - May 2004

Being Born Still Too Dangerous in Brazil

Recent Brazilian 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 a month. Brazil's
Health Ministry has promised to decrease the current indexes
of maternal and neonatal mortality by 75 percent by 2015.

Irene Lôbo


Picture Of the 2.2 million childbirths performed in Brazil's SUS (Sistema Único de Saúde—Unified 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 deaths—in 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 America—the 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 Mortality

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 a month.

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.

Birthing Houses

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.

Cláudio Albuquerque, 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," he informs.

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.

Doulas' Role

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.

"Humanized childbirth 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," they affirm.

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 lia@radiobras.gov.br.
Translated from the Portuguese by David Silberstein.

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