Cesareans and unnecessary medical procedures are the daily reality of labor in Brazil. Here, 52% of all babies are born by cesarean, a rate three times bigger than the accepted as healthy by the World Health Organization (WHO). When it comes only to the private health system, the number is even higher: 88% of births are from cesareans. Brazil has a free and public health care system, but a quarter of the population (which has a wealthier condition) use private insurance.

According to the WHO, cesarean must be the exception and not the rule. This procedure can indeed save lives, but must only be used when there are health risks for the baby or for the mother. Babies born from cesarean don’t have the chance to get the good microbes provided by the contact with their mother’s vagina during the labor. This exposure is vital for the maturation of the immune system. The lack of this contact is associated with an increased risk of developing a series of diseases, such as diabetes and asthma.

Besides all the risks usually involved in the surgery, the cesarean also leaves profound marks in the mother, which can be harmful to future pregnancies. The uterine scar left by the C-section can affect the egg fixation and also increases the risk of uterine rupture and some placenta problems during another pregnancy.

According to the doctor Maria do Carmo Leal, who coordinated one the biggest research ever done on pregnancies in Brazil, by the Oswaldo Cruz Foundation, what is happening is an ‘epidemic’ of unnecessary cesareans. “There is no clinical justification for such a high number of cesareans,” she says. “We are talking about healthy pregnancies. Women are being exposed to risks, and the health system has unnecessary costs to support a medical culture that prioritizes C-sections.”

In the private health system, the high number of cesareans can be explained by monetary reasons. For a normal vaginal delivery, a physician may receive about R$440 (195 dollars), while for a cesarean, the price can reach R$800 (355 dollars).

Another reason pointed out by doctor Silvana Granado, which applies both to the private health system and the public one, is simply a matter of convenience for the doctor. “Physicians tend to choose cesareans because, with this procedure, they can finish more deliveries in less time,” she says. “Instead of losing 12 to 30 hours doing a vaginal delivery, they can schedule more than one cesarean delivery at the same time. I have visited public hospitals in small cities where there is the ‘C-section day’ when the doctor perform cesareans in all pregnant women.”

Despite being prevalent, cesareans aren’t the first choice among pregnant women in Brazil. The Oswaldo Cruz Foundation research, which interviewed 23 thousand pregnant women before and after delivery, shows that only 28% of them wanted a C-section – most of them fearing the labor pain.

The same research shows that many women changed their minds about doing a c-section during pregnancy. While doing prenatal care, 36% of them shifted from vaginal delivery to cesarean. When arriving at the hospital, 67% reported wanting a cesarean. This change of mind may be influenced by doctor pressure.

“Lots of women change their minds due to inadequate prenatal care,” says Leal. “Unfortunately, many physicians don’t inform the woman about the real risks of a cesarean.”

Not normal

The reality is that it is becoming more and more difficult for women who desire normal vaginal labor. Often the hospital has so many cesareans scheduled that there is no room for women who want to wait for the traditional labor.

C., a 30-year-old mother of a 3-year-old child, pregnant for the second time, says she always planned vaginal delivery, but she was persuaded by the doctor at the last minute. “I didn’t know at that time of the risks of a cesarean, so when the doctor told it would be better to do a cesarean, I believed him,” she recalls. “I fell like I am not in control of my choices, and I don’t want this to happen again.”

An extreme example of the tension between personal choice and medical decision happened two months ago in the southern Brazilian state of Rio Grande do Sul when Adelir de Góes was forced by the police to deliver by cesarean.

The doctors who performed the surgery said she and her baby were in danger and needed the procedure. On the other hand, she argued that she asked for proof of the risk, and none wanted to show her the exams.

Regardless of who is right or not in this particular case, having a baby by vaginal delivery in Brazil is not only hard to achieve but often unpleasant. The Oswaldo Cruz Foundation study shows that in 66% of the vaginal deliveries in Brazil, the hospital doesn’t offer anesthesia. Nonpharmacological ways to relieve pain, as hot baths and massages, are even rarer, offered only in 26% of the country’s births.

“When a woman is going to deliver, the first thing many hospitals do is tie her to the bed and put a needle in her arm,” says Granado. “She can’t eat and even drink water, even though there is no scientific reason for this.”

The use of the oxytocin hormone to speed up the delivery is also a frequent practice, present in 36% of the labors. The problem with this procedure is that it induces the delivery even when the body is not ready, causing pain and stress for the mother.

Even more severe is the artificial rupture of membranes (amniotomy), which is performed in 40% of the vaginal deliveries without risks. This intervention can increase the risk of infection, or umbilical cord prolapse and might turn the baby to breech position, making the birth more difficult.

To change this situation, Leal and Granado say that women must seek information and fight for their own welfare. “The doctors need a better formation, but the mothers also need to inform themselves,” says Granado.