Rates and implications of caesarean sections in Latin America: ecological study

Results

Table 1 gives information about population, annual births, institutional deliveries, urban population, doctors per 10 000 population, mortality, and caesarean section rates of the countries. Seven countries had caesarean section rates below 15%. The range for the remaining 12 countries was 16.8% to 40.0%. These 12 countries represent 81% of the deliveries in the region. Information about rates of caesarean section in different types of hospitals were available for Argentina, Brazil, Chile, Colombia, Mexico, and Paraguay. In all of them, the proportion of caesarean section in women in private hospitals was much higher than that of women in public hospitals. Three countries had caesarean section rates over 50% in private hospitals (table 1). Countries with caesarean section rates below 15% also showed lower proportions of hospital deliveries or births assisted by skilled attendants (28% to 67%) than countries with caesarean section rates above 15% (59% to 100%)

Table 2.

Estimated annual number of caesarean sections and annual number of caesarean sections above 15% upper limit suggested by WHO for Latin American countries

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A positive and significant correlation was observed between rates of caesarean section and the gross national product per capita (rs=0.746, n=18, P<0.0001; figure), the proportion of urban population (rs=0.730, n=19, P<0.0001), and the number of doctors per 10 000 population (rs=0.690, n=19, P=0.001). All but one of the countries with gross national product per capita below £2800 showed caesarean section rates below 15%, while all but one of the countries with gross national product per capita above £2800 had caesarean section rates above 15%. The exception is Dominican Republic, with a gross national product per capita of £2740 and a caesarean section rate of 25.9%.

Correlation between the gross national product per capita (£) and caesarean section rates in 18 Latin American countries (r_s=0.746)

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In the 12 countries with caesarean section figures above 15%, around 2.2 million caesarean sections were performed each year. Taking 15% as the medically justified rate, we calculate that around 850 000 unnecessary caesarean sections were performed each year in the region (table 2).

Commentary: all women should have a choice

The first woman in England powerful enough to demand chloroform in childbirth was Queen Victoria. At the end of the 20th century, medical and social prejudices against women sidestepping their biblical sentence to painful childbirth are still with us. The study on caesarean section in Latin America establishes that the rate of caesarean is higher in private hospitals and among a more prosperous sector of the population. But its conclusions that this rise represents an “epidemic of caesarean section” that has “no medical justification” are based on arbitrary guidelines, insufficient data, and outmoded thinking about women's reproductive needs.

The implication is that wealthy women are wasting the time and money of healthcare providers because they are evading natural childbirth for the selfish convenience of a caesarean section. Because higher caesarean rates are related to higher income and social class does not prove that they are a luxury like plastic surgery. Indeed, the reasons for the increased rates of caesarean section in western societies are both medically and socially complex. According to the 1999 Confidential Enquiry into Stillbirths and Deaths in Infancy, more and more large babies are being born in Britain because of the better nutrition and health of modern mothers. 1 Caesarean section is safer than ever before. The really serious issues around caesarean sections can be seen in underdeveloped countries where they are denied or unavailable to most women, rather than in those western societies where their rates have increased.

A rigorous assessment would investigate the average weight of babies, proportional maternal weight gain, the rates of surgical complications and fetal and maternal death, and the contexts of the medical decision before sounding the alarm. Possibly the increase in rates in Latin American countries reflects an improvement in medical services and education. Possibly it reflects better monitoring for detecting fetal distress.

In a recent article Caroline da Costa noted that “the high rate of caesarean sections in most western countries is now regarded as a major public health problem and has spawned much discussion, numerous publications and meetings, varied recommendations, and some success in reducing the rate in certain hospitals, although without any agreement as to what the optimum rate should be, and with some indications—uterine dystocia and fetal distress—not well defined.” 2 But, she pointed out, the real issue is the discrepancy in maternal health care for women because of economic, political, or religious factors. The World Health Organisation guidelines of 15% for national caesarean section rates are arbitrarily chosen and need to be reviewed. Women's equal access to quality medical services, rather than assumptions about the proper form of labour and delivery, should be our central concern.

Commentary: increase in caesarean sections may reflect medical control not women's choice

Although safer caesarean sections help reduce maternal and infant morbidity and mortality, they remain a major surgical procedure that carries risk, particularly respiratory complications and neurological impairment for the newborn.1 When not medically indicated, therefore, a caesarean section is less safe than a vaginal birth. It also increases the use of medical and healthcare resources. In addition to these public health arguments, women's voices need to be included in the strategies designed to decrease the incidence of caesarean sections.

Belizán et al present a snapshot showing the high proportion of caesarean sections in Latin America and its association with improved socioeconomic conditions. This association is linked to women's increased access to health services and to the increased availability and use of technical procedures for birth. However, the fact that the proportion of caesarean sections rises as socioeconomic conditions improve does not necessarily mean that the quality of care in the management of labour improves. Actually, it might be otherwise.

Firstly, the systematic use of medical technology, justified by the underlying idea that a woman's body is not capable of giving birth without medical intervention, seems to be more directed towards the convenience of healthcare professionals than the benefit of women in labour. For healthcare professionals, having the woman under control in a horizontal position and stuck to the oxytocin perfusion, the epidural anaesthesia and, although less common in public hospitals in Latin America, the electronic fetal monitor, creates the impression that she is being taken care of. But women tend to perceive such an experience as painful, frightening, and confusing, especially in the many hospitals where they cannot be accompanied by the person they choose.2 The medicalisation of birth seems to preclude the use of less technical, less expensive, and more women centred approaches to birth such as the provision of psychosocial support during labour.

Secondly, the increase of caesarean sections does not necessarily mean that women prefer or request them. 2 3 Our experience in Mexico is that obstetricians, partly because of personal financial benefits, create the high demand for caesarean sections by offering them to the higher socioeconomic groups as a distinctive way of giving birth or by presenting them as a frequent outcome in cases of relative indications for a caesarean section With time, people from other social groups start to imitate this trend, assuming that if the more privileged prefer it, it must be better, and thus it becomes the standard. As a result, many obstetricians end up being better trained to perform a caesarean section than to attend births that could have been safely delivered vaginally. The increase of caesarean sections can thus be regarded as a process in which women are finally given less information and less choice and in which obstetricians appropriate the central role of childbirth at the expense of women.

Finally, “violence” is a strong word, and labelling unnecessary caesarean sections as form of violence against women could be disturbing. But for many women, a caesarean section that could have been avoided is a violation of their bodily integrity, just like having routine episiotomy (or perineal cutting), epidural anesthesia without consent, non-indicated oxytocin induction or augmentation, multiple and painful vaginal examination, non-indicated amniotomy, or pubic shaving, needless exposure of sexual parts in common labour rooms, or even transcaesarean tubal ligations when women do not understand the permanent nature of the procedure. In order to give back to women the central role in childbirth, new guidelines aimed at restricting the use of caesarean sections and other birth technologies by improving the quality of care should be welcomed.

Commentary: “health has become secondary to a sexually attractive body”

I am one of those women who see the experience of birth as a profoundly important life event. I gave birth to both my children at home. Some women (including many of the medically trained 1) may think I mortgaged my sexual future and my continence for something trivial, but I would not agree.

I am also a consumer advocate, with a strong commitment to individual rights My personal birth choice was a minority one in my community, of which many disapprove—some would even like to outlaw it. From that position, my commitment lies automatically with women's individual choices. I do not believe that anyone has the right to demand women give birth vaginally—just as no one should force me to have a caesarean.

But national caesarean section rates of up to 40%? In countries where many women in poor health are receiving little health care? Back in the early 1980s, caesarean rates of 75% were already being reported in some urban Brazilian clinics.2 Since then, the national rate has soared but not women's socioeconomic or sociopolitical status. That raises two critical questions: is caesarean section for some Latin American women becoming almost universal? If so, what will that mean for all women in those societies?

At one level, the trend is not so different from that among at least some well off women everywhere. Even in the United Kingdom, where the caesarean section rate is low, a survey of women obstetricians found that 31% of them would choose a caesarean without any medical indication.1 They would do this for much the same reasons as Latin American women do3: mostly to avoid genital damage.

Belizán et al have highlighted an international phenomenon. It is just perhaps more dramatic in countries with “a popular obsession with maintaining a sexually appealing body.”3 Large numbers of women in many wealthy societies starve themselves and take up smoking to achieve a desired body image. That they would choose major surgery for similar reasons is no surprise What, however, is the role of the medical profession in this phenomenon?

High caesarean section rates are partly a consequence of having a surgical specialty responsible for care around birth and as yet poorly understood features of the relationship between private specialists and pregnant women. Brazilian anthropologist Cecilia de Mello E Souza has shown how obstetricians appropriated women's fear of labour pain, body disfigurement, and concern for sexual performance to justify the profession's own preference for surgical birth.3 She believes that as a result “health has become secondary to the production of a sexually attractive body.”3

The medical profession has other overall responsibilities here. Definitive evidence about issues of concern to women (such as pain before and after birth, postpartum depression, and sexual and continence outcomes) is lacking. Other issues that narrow women's choices around childbirth in some countries are not addressed by the profession. De Mello E Souza points out that tubal ligation is illegal and thus can be done only surreptitiously during a caesarean in Brazil. In many hospitals, epidural pain relief is not allowed for vaginal birth.3

If the fashion for caesarean section spreads beyond healthy women with small families, this public health problem could grow into something far worse.1 We saw something similar when upper class women abandoned breast feeding last century. It is poorer families who continue to pay the enormous cost generations later. For a medical community and society that brings women to the point of preferring major surgery to childbirth, serious questions need to be asked—preferably before women start paying for this trend with their lives.