- Email: [email protected]
The incidence of caesarean deliveries in Belo Horizonte, Brazil: Social and economic determinants
Alessandra Sampafo Chacham and Ignez Helena Oliva Perp&uo Caesarean rates have increased worldwide since the 197Os, but the elevated rates in Brazil, which are much higher than those found in other countries, cannotbe attributed to medical causes. This paper analyses the social and economic determinants and demographic factors affecting the incidence of caesarean sections in Belo Horizonte, the capital of the state of Minas Gerais, using data from birth records for 1994. Itshows thatindependent ofwomen’s education, age orparity, doctors who workin the private health sector, with private or insured patients, are much more likely to perform caesarean deliveries. The woman’s level ofeducation was the second mostimportant factor, Although other demographic factors, e.g. parity and age, have some influence on the caesarean rate, the type ofhospital where women gave birth was the most important determinant of the incidence of caesarean section. To have a baby in a private hospital instead of a public hospital was the most important risk factor in determining whether a caesarean was likely to takeplace.
INCE the 198Os, Brazil has had the dubious honour of having the highest rate of caesarean deliveries in the world.1,2 The proportion of caesarean sections among all deliveries paid for by the Brazilian public health system jumped from 15 per cent in 1974 to 31 per cent in 1980.” In 1996, according to the Demographic and Health Survey,4 surgical deliveries represented 36.4 per cent of all deliveries. If rural areas are excluded, the rate was 41.8 per cent. These rates show no sign of stabilising.5 A caesarean section is a life-saving procedure for both mother and baby when medically indicated, and in many cases it ensures a live birth and avoids neurological damage to the baby. However, the indiscriminate use of this intervention considerably increases maternal morbidity and mortality, and increases a woman’s discomfort after a birth, which may in turn create difficulties in the care OFthe newborn and for breastfeeding. Unnecessary caesareans generate higher expenditure, but they do not reduce neonatal or infant death rates nor prevent the birth of newborns with neurological damage. Moreover, they increase the risk of premature
birth and the number of babies with low birthweight and respiratory problems.5,6 The World Health Organization considers the maximum rate of necessary caesarean sections to be 15 per cent.7 The fact that Brazil’s rate is so much higher is cause for concern to those working in women’s reproductive health. Caesarean delivery rates have increased all over the world since the 197Os, but the rates in Brazil are much greater than those found in any other country. In the United States, which has the highest number of caesarean sections for a developed country, the proportion reached 23.6 per cent of total deliveries in 199L8 Japan, on the other hand, had a rate of only 7 per cent in 1992, and most European countries have caesarean rates below 15 per cent.g These countries also have very low maternal and neonatal mortality rates. In Brazil, the elevated numbers of caesarean deliveries cannot be attributed to medical factors.*” Recent studies show a positive correlation between caesarean rates and women’s income and education levels in Brazil.ll According to Fadndes and Cecatti,6 a combination of social, cultural and institutional 115
Chacham
and Perpetuo
factors play a important part in maintaining the high rate of caesarean deliveries in Brazil. Based on doctors’ impressions, they hypothesise that a great number of women, mainly middle- and upper-class women, are opting for caesareans in the absence of any medical indication. Among the reasons given by both women and doctors to justify this is the desire lo avoid the pain of labour, and the belief that vaginal delivery will ‘spoil’ a woman’s future sexual performance and her husband’s p1easure.l’ Another important reason why the caesarean section rates are high is the strong relationship with the provision of sterilisation immediately following a caesarean in Brazil. Many women have a caesarean because they want to be sterilised and many women are sterilised after a history of caesarean deIiveries.l”13 Sterilisation used to be technically illegal as a procedure in Brazil, but the law has recently been changed. The most common way to get a sterilisation is following a caesarean, which is paid for by the government, with an extra fee to the doctor. The model upon which the health system was developed under the military dictatorship in the 1960s has contributed to the ‘caesarean culture’. This model favoured interventionist medicine, support for technical medical solutions and the growth of the private health sector. During the period up to 1980, the government reimbursed both doctors and hospitals more for a caesarean than for a vaginal delivery, which worked as an extra incentive to carry out caesareans. The discontinuation of this policy in 1980 had no real impact on the growing caesarean rate, due to the fact that caesareans remain more profitable and are more convenient for doctors. In most hospitals in Brazil, only doctors attend births; there are no midwives or other trained birth attendants. Caesareans demand less of a doctor’s time than attending normal deliveries, and doctors have been shown to take a more interventionist approach to birth than midwives.14 In this sense, women who are assisted only by doctors face an increased chance of intervention. In several European countries, such as the Netherlands, Germany, France and England, where midwives are responsible for attending most normal deliveries and there is a national health service, there are very low caesarean rates, all below 15 per cent. Thus, it is probable that the elevated caesarean rates in Brazil could 116
be reduced without sacrificing the safety of women or infants. Rather, a reduction should even help to improve maternal mortality and morbidity rates. These observations make it imperative, in our opinion, to study the determinants of such high caesarean rates.
Caesarean deliveries in Belo Horizonte Our research used hospital and birth records from the city of Belo Horizonte, capital of the state of Minas Gerais, with over 3500,000 inhabitants, the third largest metropolitan area in the country. A state with a strong agricultural tradition, it has since the 1970s gone through a major process of industrialisation. There is a relative lack of information about this city as research on reproductive health tends to be concentrated on Rio de Janeiro and Srio Paulo. In 1994, there were 41,404 births in Belo Horizonte,15 of which 2.1 per cent were multiple births. Multiple births are excluded from the analysis, as they are more likely to result in caesarean deliveries and in order to avoid counting the same women twice. The dala come from SINASC (System of Information on Live Births),15 a record of nationwide information about births, initiated by the Ministry of Health in 1992, though so far operating only in the state capitals. Under SIN ASC, a hospital fills out a ‘Declaration of Live Birth’, which includes information about length of pregnancy, type of delivery, birth weight, apgar score, and mother’s age, address, level of education and parity. One copy is sent to the City Secretary of Health, where it is processed and is available for research purposes. ‘There are significant weaknesses in the data - there is an estimated under-registration of births of 6 per cent and information is missing, especially about the mothers.16 However, these data are the most complete source of information about mothers and births, and allow a comparison of women to determine risk factors. As far as we know, this is the first time these data have been used to evaluate the socio-economic determinants of caesarean deliveries anywhere in Brazil. Level of education was used as a proxy for socio-economic status. The variables compared were the mothers’ age and parity and the type of hospital where they gave birth. The caesarean
Reproductive
Table 1. Distribution of total births by type of delivery and hospital (%), Belo Horizonte City Type of hospital
Proportion all births
of
Vaginal delivery
Caesarean delivery
Fully private
23.4
32.2
67.8
Partially private
66.4
65.1
34.9
Public
10.2
63.8
36.2
TOTAL
100.0
57.3
42.7
Source: SINASC, 1994
in 1994 in Belo Horizonte was for live births 42.7 per cent, similar to the rate of 41.8 per cent found in urban areas of Brazil as a whole in 1996.4 Table ‘I shows the type of delivery, vaginal or caesarean, by type of hospital. Since 1988, Brazil’s National Health Service (Sistema Unico de Saude, SUS) has offered health care coverage for the whole population, through public institutions and those private institutions which accept a certain number of SUS patients. Thus, hospitals are either public, fully private (attended only by private patients), or partially private (attended by both private and public patients). The quality of the public services is so poor, however, that most people who can afford it get private health insurance and attend private institutions. As a consequence, public (SUS) hospitals tend to see poorer people, while people getting private care are in general from the upper and middle classes. The caesarean rate in the fully private hospitals is practically double that of the other two types of hospital; although they attended twice as many births as public hospitals, they carried out only a few per cent more of the total vaginal deliveries than the public hospitals. And although they attended only a quarter of all births, they carried out about 37 per cent of all caesareans. In spite of the low numbers of total births they attended, the public hospitals perform a fundamental function within the city’s overall obstetrics services, in that they are referral centres for high-risk pregnancies. It is well known that the private sector hospitals who accept SUS patients send potentially complicated cases to the public sector, because the SUS rate
Health Matters, Vol. 6, No. 11, May 1998
system of payment does not cover the additional costs incurred in cases of complications. In spite of their low-risk clientele, however, the rate of caesareans in these SUS-affiliated private hospitals is almost as high as in the public sector. The private hospitals with SUS patients were responsible for two-thirds of all deliveries; however, although they carried out about threequarters of all vaginal deliveries, they also carried out over half of all the caesareans. The public sector, with 10 per cent of total births, performed less than 10 per cent of all caesareans, despite the greater proportion of complicated cases they would have seen. If the caesarean rate in the public hospitals can be explained at least in part by a high-risk patient profile, nothing justifies the high numbers found in the SUS-affiliated private sector, where there are clearly an excessive number of caesareans. This suggests that the abuse of this practice is spreading and crossing class barriers, rather than affecting mainly upperand middle-class women. Yet the aggregate data still show a greater correlation between caesarean deliveries and higher social and economic status among women giving birth. To get a clearer picture of the influence of socio-economic factors we divided the mother’s level of education into five groups: no education, primary level not completed, primary level completed, secondary level completed, college education. (Table 2) The figures show a very significant relationship between the caesarean rate and the level of education of the mother, with the caesarean rate
Table 2. Distribution of total births by type of delivery and mothers’ level of education (%I, Belo Horizonte City Level of education
Proportion all births
No education
of
Vaginal delivery
Caesarean delivery
2.4
73.9
26.1
Primary-incomplete
55.9
67.4
32.6
Primary-
14.5
54.8
45.2
18.4
41.1
58.9
8.8
28.4
71.6
100.0
57.3
42.7
completed
Secondary College TOTAL
Source: SINASC, 1994
117
Chachamand
Perpktuo
Table 3. Caesarean
rates by mother’s
age, parity and degree of education, Degree of Education
<25
level
College
25-34 3%
~25
25-34
35t
38
50
61
49
66
83
63
73
85
38
48
64
43
60
72
48
68
77
41
37
56
29
42
48
_
72
61
50
24
28
_
37
43
-
50
100
42
40
52
40
51
62
56
66
81
Sli’VASC, 1994
increasing steadily as the mother’s educational level rises, from a ‘low’ of 26 per cent to a very high 71 per cent. These findings are another way of showing that better educated women can afford to give birth in the fully private hospitals, where the caesarean rate was 67.8 per cent. A similar tendency has been found among more affluent women in other parts of the country,ll even though they could be expected to have less complicated pregnancies and deliveries. According to the medical literature, the variables OF age and parity are also important factors in the risk of caesarean delivery,17 in that women at different educational levels are also diverse in age and parity.18 However, research in other countries has found that when the variables of age and parity are included, the relationship between the caesarean rate and income or education becomes less meaningfd. This is because women with higher education tend to postpone their first births, making them more likely to have a caesarean delivery.*,l” In general, both primiparae and older mothers are more likely to have a caesarean. Older women tend to have more complications during the pregnancy and delivery, and also tend to have bigger babies.20 In addition, doctors tend to perform more caesareans in older women, mainly in older primiparae, even in the absence of complications.z1 In Belo Horizonte, 46.2 per cent of primiparae of all ages had a caesarean. This has a significant 118
1994
of the Mother Secondary completed
Source:
Belo Horizonte,
demographic impact; it limits the number of children a woman can have, since in Brazil, having one caesarean implies that all subsequent deliveries will be caesareans.22 As the level of risk rises with each subsequent caesarean, sterilisation after the third caesarean has become routine in Brazil. We calculated the caesarean rates across different levels or education, controlling for age and parity. (Table 3) At every level of education, caesarean rates increased as age increased, and decreased with increasing parity. Nevertheless, the previously observed differences by educational level remained unaffected. For example, while the caesarean rate for women below 25 years of age, with no previous children and without any formal education, was 31 per ceni, it was as high as 63 per cent among women with college education in the same age and parity groups. The same happened in the group of women who were older than 35 years of age; the caesarean rate was 44 per cent for women of all parities with no formal education and reached as high as 81 per cent among the women with a college education. In order to observe the extent to which specific institutional factors in each type of hospital led to a greater propensity for caesarean delivery compared to the other types of hospitals, and to evaluate the isolated effect of each variable (education, age, parity and type of hospital) while
Reproductive
controlling for the other variables, we fitted a step-wise logistic regression equation to the data.23 This analysis allowed us to evaluate the relative importance of each variable to the probability of a woman having a caesarean. The type of hospital where a birth took place emerged as the most important variable. To have a baby in a public hospital or in a private hospital affiliated to the SUS diminished the chances of having a caesarean by more than 20 per cent, as compared to giving birth in a fully private hospital. Thus, independent of a woman’s education, age or parity, the practice of the doctors who work in the private sector is to favour caesarean delivery. Education is the second most important variable; with each incremental increase in the woman’s level of education, there is a 22 per cent increase in the probability of having a caesarean. In relation to the variables of age and parity, for every year added to the woman’s age, the chance of a caesarean increased by 7 per ceni, while for each additional vaginal delivery in the past, the probability of the present birth being a caesarean delivery diminished by 20 per cent.
Health Matters,
Vol. 6, No. 1 I, May 1998
Conclusions The profile of the Brazilian woman most likely to have a caesarean delivery is an educated woman, older than 25 years of age, with a small number of children, who attends a private hospital. In short, the women most likely to give birth by caesarean in Brazil are women who have access to the best medical assistance in the country. The hospitals where these women give birth have a high responsibility for the high rates of caesareans in Brazil. As elsewhere in Brazil,Z4-Z6a surprisingly high number of primaparae women who did not want a caesarean birth at the outset of pregnancy ended up having one, especially those who had their babies in a private hospital. This goes against the more common explanatior6,ll that women themselves are responsible for the high caesarean rates. However, more research is needed to verify the impact of medical practice on women’s own beliefs and preferences, and to find out whether caesarean birth, especially for more affluent women, is now seen as the more ‘normal’ and desirable type of birth, even as a consumer good, as some authors assert.5
119
Chacham
and Perpetuo
In Brazil, contemporary medical culture favours an interventionist approach to the management of birth. Our findings suggest that women must be offered the option of delivering their babies vaginally. A number of obstetric practices which are considered obsolete or even unsafe,27 such as shaving of pubic hair, enemas, isolation of the mother and use of the supine position for labour and vaginal delivery, to name only a few, are still routine in Brazilian obstetric care. Lack of interest in good practice and humanisation of care for vaginal deliveries is another consequence of a ‘caesarean culture’. There is a growing consensus among experts in the field that the lack of nurses and trained midwives in Brazil is a serious obstacle to a safer and more humanised experience of birth, with fewer unnecessary interventions.“,a8 A national movement for safer motherhood and a more humane approach to birth, which has brought together both feminists and medical professionals, is seeking the legalisation of the profession of midwifery (which is not formally recognised in
Brazil) and to open schools to train midwives. A high rate of unnecessary caesareans can have serious consequences for women’s health and raises health care costs. The reduction of these rates should be a priority for any reproductive health programme in Brazil in order to improve the quality of obstetric care and reduce the number of maternal deaths and morbidity. Brazil’s situation may serve as a caution to other countries, given the growing tendency to medicalise birth, to find a middle ground that guarantees women’s safety and, at the same time, would transfer back to women control of the birthing experience.
Acknowledgements Thanks to Lisa and critical
Gerber
reading
for her valuable
comments
of the manuscript.
Correspondence Alessandra Rua
Chacham,
Curitiba
30170-120,
832/g’ Brazil.
CEDEPLAWFACEkJFMG, andar,
E-mail:
BeJo
Horizonte,
MC,
[email protected]
References and Notes I. The caesarean delivery rate is defined as the number of caesarean deliveries over the total number of deliveries. 2. Hurst M, Summey PS, 1984. Childbirth and social class: the case of caesarean delivery. Social Science and Medicine. 1(8):621-31. 3. Barros FC et al. 1991. Epidemic of caesarean sections in Brazil. Lancet. 338(July 20): 167-69. 4. Pesquisa National sobre Dcmografia e Safide: Relatorio Preliminar. BEMFAM and Demographic and Health Survey (DHS). Rio de Janeiro, Brazil, 1996. No nationwide figures are available for 1994, except for Ministry of Health figures of caesarean sections done by the public health sector. This figure for 1996 is based on a sample as part of the DHS. 5. Rattncr D, 1996. Sobre a hipotese de estabilizacao das taxas de cesarea do Estado de Sao Paulo, Brasil. Revista de Salidc Ptilica. 30(1):19-33.
120
6. Faundes A, Cecatti JG, 1991. A opera@0 cesarea no Brasil. Incidencia, tendencias, causas, consequencias e proposlas de acao. Cadernos dc Sadde Pbblica, RI. 7(2):150-73. 7. World Health Organization, 1985. technology for birth. Appropriate Lancet. (August 24):436-37. 8. Scully D, 1994. Men Who Control Women’s Health: The Miseducation of Obstetrician-Gyneco logists. Teachers College Press, Columbia University, New York. 9. Notzon FC et al, 1994. Caesarean section delivery in the 1980s: international comparison by indication. American Journal of’ Obstetrics and Gynecology. 170(February):495-504. 10. Melo CG, 2977. Safide eAssist&cia Medica no Brasil. CebesHucitec, Rio de Janeiro. p 127. 11. Berquo E, 1993. Brasil, Urn case exemplar - anticoncepcao e part0 cirkgicos - a espera de ulna acao exemplar. Estudos feministas. 1(2):366-82.
12. Mello e Souxa C, 1994. C-sections as ideal births: the cultural constructions ofbeneficencc and patients’ rights in Brazil. Cambridge Quarterly of Healthcare Ethics. 3:358-66. 13. Rutenberg N, Fcrraz E, 1988. Female sterilisation and its demographic impact on Brazil. JnternationaJFamiJyPJanning Perspectives. 14(2). 14. Pel M, Heres MHB, Hart AAM et al, 1995. Provider-associated factors in obstetric interventions. European Journal of Obstetics and Gynaecology: Reproductive Biology. 15. System of Information on Live Births 1994 (SINASC). Secretary of Health, Belo Horizonte, 1994. 16. Perpetuo IHO, Mendonca EF, 1996. Avaliacao das estatisticas dc nascimentos em Belo Horizonte. Paper presented at X Encontro National de Estudos Populacionais, Caxambu, Brazil, 7-11 October 1996. 17. Bottoms SF et al. 1980. The
Reproductive
increase in the caesarean birth rate. Medical Intelligence. 302(10):559-65. 18. The proportion of women with up to two childrenvaries from 73.2 per cent in the group of women with no schooling to 98.3 per cent in the group of women with college education. In relation to age, 61.5 per cent of women with no schooling are less than 30 years old, while in the group with college education only 38.3 per cent are under 30. 19. Parazzine F et al, 1992. Determinants of caesarean section rates in Italy. Brifish Journal of Obstetrics and Gynaecology. 99203-06. 20. Adashek JA et al. 1993. Factors contributing to the increased birth rate in older parturient women. Am&can Journal of Obstetrics and Gynecology.
169:936-40. 21. Peippert JF, Bracken MB, 1993. Maternal age: an independent
risk factor for caesarean delivery Obstetrics and Gynecology. 81:200-05. 22. Although a vaginal birth after a caesarean (VBAC) is safe for at least 60 per cent of women with a previous caesarean section, this practice is not yet commonly followed in Brazil. See Petroni A, 1992. Costo beneficio en parto ces&ea. Por Uma Maternidade Sin Riscos. Fundacidn para Estudos e Investigacibn de la MujerLJNlCEF, Buenos Aires. 23. Chacham AS, Perp&uo IHO, 1996. Determinantes s6cioeconamicos da incid&ncia de partos cir6rgicos em Belo Horizonte. Paper presented at X Encontro National de Estudos PopulaGionais, Caxambu, Brazil, 7-11 October 1996. 24. Carranza M, 1994. De cessreas, mulheres e mCdicos: uma aproxima@o mbdico-antropol6gica ao parto ces&-eo no Bra&. Tese de Mestrado. UNB. Brasilia, Brazil.
Health
Matters,
Vol. 6, No. 11, May 1998
25. Hopkins K, 1996. CesBreas,
partos normais e esteriliza$bes feminina no Brasil: quem quer, quem decide, quem consegue. Paper presented at X Encontro National de Estudos PopulaGionais, Caxambu, Brazil, 7-11 October 1996. 26. Mello e Souza C, 1996. Intervencoes mCdicas e a integridade do corpo feminino na cultura reprodutiva Brasileira. Paper presented at X Encontro National de Estudos Popula@onais, Caxambu, Brazil, 7-11 October 1996. 27. Care in Normal Birth: A Practical
Guide. Report ofa Technical Working Group. WHOffRHI MSM/96.24. World Health Organization. Geneva, 1996. 28. Sakala C, 1993. Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary caesarean section births? Social
Science and Medicine. 37(10):1233-50
R&urn6
Resumen
Le nombre de cksariennes a notablement augment6 dans le monde depuis les annkes 70, mais les taux klevks que l’on trouve au BrCsil (beaucoup plus forts que dans d’autres pays) ne peuvent se justifier par des raisons mkdicales. S’appuyant sur des donnbes tirkes des registres des naissances pour l’annke 1994, l’auteur analyse les facteurs Qconomiques, sociaux et dkmographiques dhterminant les cbsariennes g Be10 Horizonte, capitale de Ill&at de Minas Gerais. 11 apparait que les mkdecins travaillant dans le secteur privk, avec des patientes relevant ou non des caisses d’assurances, sont beaucoup plus favorables aux naissances par cksarienne, quels que soient le niveau d’kducation, 1’5ge et le nombre de grossesses des femmes. Le second dkterminant, par ordre d’importance, est le niveau d’education de la femme. Si d’au-tres facteurs d6mographiques, comme la pariti: et I’sge, influencent le taux de kariennes, le determinant qui joue le plus grand rble est le type d’hhpital oti a lieu la naissance. Le principal facteur de risque de chsarienne, c’est d’aller dans une clinique privke plut6t que dans un hBpita1 public.
La tasa de ces&-eas ha aumentado mundialmente desde 10s aiios 70; sin embargo su alta incidencia en Brasil, cuya tasa es considerablemente mayor que la de otros paises, no puede ser atribuida a razones mkdicas. Este ensayo examina 10s motivos econ6micos y factores demogrkficos que afectan la incidencia de intervenciones ceskeas en Belo Horizonte, capital de1 estado de Minas Gerais, partiendo de datos procedentes de 10s registros de nacimientos correspondientes a 1994. El estudio demuestra que independientemente de1 grado de educacibn, edad o igualdad de la mujer, 10s mkdicos de1 sector privado favorecen mucho m8s 10s partos por ceskea, tanto con pacientes particulares coma aseguradas. El nivel educational de la mujer es el Segundo factor m&s importante. Si bien otros factores demogr%icos, coma la igualdad y la edad, influyen en la tasa de ceskeas, el tipo de hospital donde la mujer de a luz es el factor m&s determinante en cuanto a la incidencia de las intervenciones ceskeas. El tener un bebk en un hospital privado en lugar de uno pliblico constituye el factor de riesgo m&s determinante a la hora de efectuar o no una Ceskea.
122
INCE the 198Os, Brazil has had the dubious honour of having the highest rate of caesarean deliveries in the world.1,2 The proportion of caesarean sections among all deliveries paid for by the Brazilian public health system jumped from 15 per cent in 1974 to 31 per cent in 1980.” In 1996, according to the Demographic and Health Survey,4 surgical deliveries represented 36.4 per cent of all deliveries. If rural areas are excluded, the rate was 41.8 per cent. These rates show no sign of stabilising.5 A caesarean section is a life-saving procedure for both mother and baby when medically indicated, and in many cases it ensures a live birth and avoids neurological damage to the baby. However, the indiscriminate use of this intervention considerably increases maternal morbidity and mortality, and increases a woman’s discomfort after a birth, which may in turn create difficulties in the care OFthe newborn and for breastfeeding. Unnecessary caesareans generate higher expenditure, but they do not reduce neonatal or infant death rates nor prevent the birth of newborns with neurological damage. Moreover, they increase the risk of premature
birth and the number of babies with low birthweight and respiratory problems.5,6 The World Health Organization considers the maximum rate of necessary caesarean sections to be 15 per cent.7 The fact that Brazil’s rate is so much higher is cause for concern to those working in women’s reproductive health. Caesarean delivery rates have increased all over the world since the 197Os, but the rates in Brazil are much greater than those found in any other country. In the United States, which has the highest number of caesarean sections for a developed country, the proportion reached 23.6 per cent of total deliveries in 199L8 Japan, on the other hand, had a rate of only 7 per cent in 1992, and most European countries have caesarean rates below 15 per cent.g These countries also have very low maternal and neonatal mortality rates. In Brazil, the elevated numbers of caesarean deliveries cannot be attributed to medical factors.*” Recent studies show a positive correlation between caesarean rates and women’s income and education levels in Brazil.ll According to Fadndes and Cecatti,6 a combination of social, cultural and institutional 115
Chacham
and Perpetuo
factors play a important part in maintaining the high rate of caesarean deliveries in Brazil. Based on doctors’ impressions, they hypothesise that a great number of women, mainly middle- and upper-class women, are opting for caesareans in the absence of any medical indication. Among the reasons given by both women and doctors to justify this is the desire lo avoid the pain of labour, and the belief that vaginal delivery will ‘spoil’ a woman’s future sexual performance and her husband’s p1easure.l’ Another important reason why the caesarean section rates are high is the strong relationship with the provision of sterilisation immediately following a caesarean in Brazil. Many women have a caesarean because they want to be sterilised and many women are sterilised after a history of caesarean deIiveries.l”13 Sterilisation used to be technically illegal as a procedure in Brazil, but the law has recently been changed. The most common way to get a sterilisation is following a caesarean, which is paid for by the government, with an extra fee to the doctor. The model upon which the health system was developed under the military dictatorship in the 1960s has contributed to the ‘caesarean culture’. This model favoured interventionist medicine, support for technical medical solutions and the growth of the private health sector. During the period up to 1980, the government reimbursed both doctors and hospitals more for a caesarean than for a vaginal delivery, which worked as an extra incentive to carry out caesareans. The discontinuation of this policy in 1980 had no real impact on the growing caesarean rate, due to the fact that caesareans remain more profitable and are more convenient for doctors. In most hospitals in Brazil, only doctors attend births; there are no midwives or other trained birth attendants. Caesareans demand less of a doctor’s time than attending normal deliveries, and doctors have been shown to take a more interventionist approach to birth than midwives.14 In this sense, women who are assisted only by doctors face an increased chance of intervention. In several European countries, such as the Netherlands, Germany, France and England, where midwives are responsible for attending most normal deliveries and there is a national health service, there are very low caesarean rates, all below 15 per cent. Thus, it is probable that the elevated caesarean rates in Brazil could 116
be reduced without sacrificing the safety of women or infants. Rather, a reduction should even help to improve maternal mortality and morbidity rates. These observations make it imperative, in our opinion, to study the determinants of such high caesarean rates.
Caesarean deliveries in Belo Horizonte Our research used hospital and birth records from the city of Belo Horizonte, capital of the state of Minas Gerais, with over 3500,000 inhabitants, the third largest metropolitan area in the country. A state with a strong agricultural tradition, it has since the 1970s gone through a major process of industrialisation. There is a relative lack of information about this city as research on reproductive health tends to be concentrated on Rio de Janeiro and Srio Paulo. In 1994, there were 41,404 births in Belo Horizonte,15 of which 2.1 per cent were multiple births. Multiple births are excluded from the analysis, as they are more likely to result in caesarean deliveries and in order to avoid counting the same women twice. The dala come from SINASC (System of Information on Live Births),15 a record of nationwide information about births, initiated by the Ministry of Health in 1992, though so far operating only in the state capitals. Under SIN ASC, a hospital fills out a ‘Declaration of Live Birth’, which includes information about length of pregnancy, type of delivery, birth weight, apgar score, and mother’s age, address, level of education and parity. One copy is sent to the City Secretary of Health, where it is processed and is available for research purposes. ‘There are significant weaknesses in the data - there is an estimated under-registration of births of 6 per cent and information is missing, especially about the mothers.16 However, these data are the most complete source of information about mothers and births, and allow a comparison of women to determine risk factors. As far as we know, this is the first time these data have been used to evaluate the socio-economic determinants of caesarean deliveries anywhere in Brazil. Level of education was used as a proxy for socio-economic status. The variables compared were the mothers’ age and parity and the type of hospital where they gave birth. The caesarean
Reproductive
Table 1. Distribution of total births by type of delivery and hospital (%), Belo Horizonte City Type of hospital
Proportion all births
of
Vaginal delivery
Caesarean delivery
Fully private
23.4
32.2
67.8
Partially private
66.4
65.1
34.9
Public
10.2
63.8
36.2
TOTAL
100.0
57.3
42.7
Source: SINASC, 1994
in 1994 in Belo Horizonte was for live births 42.7 per cent, similar to the rate of 41.8 per cent found in urban areas of Brazil as a whole in 1996.4 Table ‘I shows the type of delivery, vaginal or caesarean, by type of hospital. Since 1988, Brazil’s National Health Service (Sistema Unico de Saude, SUS) has offered health care coverage for the whole population, through public institutions and those private institutions which accept a certain number of SUS patients. Thus, hospitals are either public, fully private (attended only by private patients), or partially private (attended by both private and public patients). The quality of the public services is so poor, however, that most people who can afford it get private health insurance and attend private institutions. As a consequence, public (SUS) hospitals tend to see poorer people, while people getting private care are in general from the upper and middle classes. The caesarean rate in the fully private hospitals is practically double that of the other two types of hospital; although they attended twice as many births as public hospitals, they carried out only a few per cent more of the total vaginal deliveries than the public hospitals. And although they attended only a quarter of all births, they carried out about 37 per cent of all caesareans. In spite of the low numbers of total births they attended, the public hospitals perform a fundamental function within the city’s overall obstetrics services, in that they are referral centres for high-risk pregnancies. It is well known that the private sector hospitals who accept SUS patients send potentially complicated cases to the public sector, because the SUS rate
Health Matters, Vol. 6, No. 11, May 1998
system of payment does not cover the additional costs incurred in cases of complications. In spite of their low-risk clientele, however, the rate of caesareans in these SUS-affiliated private hospitals is almost as high as in the public sector. The private hospitals with SUS patients were responsible for two-thirds of all deliveries; however, although they carried out about threequarters of all vaginal deliveries, they also carried out over half of all the caesareans. The public sector, with 10 per cent of total births, performed less than 10 per cent of all caesareans, despite the greater proportion of complicated cases they would have seen. If the caesarean rate in the public hospitals can be explained at least in part by a high-risk patient profile, nothing justifies the high numbers found in the SUS-affiliated private sector, where there are clearly an excessive number of caesareans. This suggests that the abuse of this practice is spreading and crossing class barriers, rather than affecting mainly upperand middle-class women. Yet the aggregate data still show a greater correlation between caesarean deliveries and higher social and economic status among women giving birth. To get a clearer picture of the influence of socio-economic factors we divided the mother’s level of education into five groups: no education, primary level not completed, primary level completed, secondary level completed, college education. (Table 2) The figures show a very significant relationship between the caesarean rate and the level of education of the mother, with the caesarean rate
Table 2. Distribution of total births by type of delivery and mothers’ level of education (%I, Belo Horizonte City Level of education
Proportion all births
No education
of
Vaginal delivery
Caesarean delivery
2.4
73.9
26.1
Primary-incomplete
55.9
67.4
32.6
Primary-
14.5
54.8
45.2
18.4
41.1
58.9
8.8
28.4
71.6
100.0
57.3
42.7
completed
Secondary College TOTAL
Source: SINASC, 1994
117
Chachamand
Perpktuo
Table 3. Caesarean
rates by mother’s
age, parity and degree of education, Degree of Education
<25
level
College
25-34 3%
~25
25-34
35t
38
50
61
49
66
83
63
73
85
38
48
64
43
60
72
48
68
77
41
37
56
29
42
48
_
72
61
50
24
28
_
37
43
-
50
100
42
40
52
40
51
62
56
66
81
Sli’VASC, 1994
increasing steadily as the mother’s educational level rises, from a ‘low’ of 26 per cent to a very high 71 per cent. These findings are another way of showing that better educated women can afford to give birth in the fully private hospitals, where the caesarean rate was 67.8 per cent. A similar tendency has been found among more affluent women in other parts of the country,ll even though they could be expected to have less complicated pregnancies and deliveries. According to the medical literature, the variables OF age and parity are also important factors in the risk of caesarean delivery,17 in that women at different educational levels are also diverse in age and parity.18 However, research in other countries has found that when the variables of age and parity are included, the relationship between the caesarean rate and income or education becomes less meaningfd. This is because women with higher education tend to postpone their first births, making them more likely to have a caesarean delivery.*,l” In general, both primiparae and older mothers are more likely to have a caesarean. Older women tend to have more complications during the pregnancy and delivery, and also tend to have bigger babies.20 In addition, doctors tend to perform more caesareans in older women, mainly in older primiparae, even in the absence of complications.z1 In Belo Horizonte, 46.2 per cent of primiparae of all ages had a caesarean. This has a significant 118
1994
of the Mother Secondary completed
Source:
Belo Horizonte,
demographic impact; it limits the number of children a woman can have, since in Brazil, having one caesarean implies that all subsequent deliveries will be caesareans.22 As the level of risk rises with each subsequent caesarean, sterilisation after the third caesarean has become routine in Brazil. We calculated the caesarean rates across different levels or education, controlling for age and parity. (Table 3) At every level of education, caesarean rates increased as age increased, and decreased with increasing parity. Nevertheless, the previously observed differences by educational level remained unaffected. For example, while the caesarean rate for women below 25 years of age, with no previous children and without any formal education, was 31 per ceni, it was as high as 63 per cent among women with college education in the same age and parity groups. The same happened in the group of women who were older than 35 years of age; the caesarean rate was 44 per cent for women of all parities with no formal education and reached as high as 81 per cent among the women with a college education. In order to observe the extent to which specific institutional factors in each type of hospital led to a greater propensity for caesarean delivery compared to the other types of hospitals, and to evaluate the isolated effect of each variable (education, age, parity and type of hospital) while
Reproductive
controlling for the other variables, we fitted a step-wise logistic regression equation to the data.23 This analysis allowed us to evaluate the relative importance of each variable to the probability of a woman having a caesarean. The type of hospital where a birth took place emerged as the most important variable. To have a baby in a public hospital or in a private hospital affiliated to the SUS diminished the chances of having a caesarean by more than 20 per cent, as compared to giving birth in a fully private hospital. Thus, independent of a woman’s education, age or parity, the practice of the doctors who work in the private sector is to favour caesarean delivery. Education is the second most important variable; with each incremental increase in the woman’s level of education, there is a 22 per cent increase in the probability of having a caesarean. In relation to the variables of age and parity, for every year added to the woman’s age, the chance of a caesarean increased by 7 per ceni, while for each additional vaginal delivery in the past, the probability of the present birth being a caesarean delivery diminished by 20 per cent.
Health Matters,
Vol. 6, No. 1 I, May 1998
Conclusions The profile of the Brazilian woman most likely to have a caesarean delivery is an educated woman, older than 25 years of age, with a small number of children, who attends a private hospital. In short, the women most likely to give birth by caesarean in Brazil are women who have access to the best medical assistance in the country. The hospitals where these women give birth have a high responsibility for the high rates of caesareans in Brazil. As elsewhere in Brazil,Z4-Z6a surprisingly high number of primaparae women who did not want a caesarean birth at the outset of pregnancy ended up having one, especially those who had their babies in a private hospital. This goes against the more common explanatior6,ll that women themselves are responsible for the high caesarean rates. However, more research is needed to verify the impact of medical practice on women’s own beliefs and preferences, and to find out whether caesarean birth, especially for more affluent women, is now seen as the more ‘normal’ and desirable type of birth, even as a consumer good, as some authors assert.5
119
Chacham
and Perpetuo
In Brazil, contemporary medical culture favours an interventionist approach to the management of birth. Our findings suggest that women must be offered the option of delivering their babies vaginally. A number of obstetric practices which are considered obsolete or even unsafe,27 such as shaving of pubic hair, enemas, isolation of the mother and use of the supine position for labour and vaginal delivery, to name only a few, are still routine in Brazilian obstetric care. Lack of interest in good practice and humanisation of care for vaginal deliveries is another consequence of a ‘caesarean culture’. There is a growing consensus among experts in the field that the lack of nurses and trained midwives in Brazil is a serious obstacle to a safer and more humanised experience of birth, with fewer unnecessary interventions.“,a8 A national movement for safer motherhood and a more humane approach to birth, which has brought together both feminists and medical professionals, is seeking the legalisation of the profession of midwifery (which is not formally recognised in
Brazil) and to open schools to train midwives. A high rate of unnecessary caesareans can have serious consequences for women’s health and raises health care costs. The reduction of these rates should be a priority for any reproductive health programme in Brazil in order to improve the quality of obstetric care and reduce the number of maternal deaths and morbidity. Brazil’s situation may serve as a caution to other countries, given the growing tendency to medicalise birth, to find a middle ground that guarantees women’s safety and, at the same time, would transfer back to women control of the birthing experience.
Acknowledgements Thanks to Lisa and critical
Gerber
reading
for her valuable
comments
of the manuscript.
Correspondence Alessandra Rua
Chacham,
Curitiba
30170-120,
832/g’ Brazil.
CEDEPLAWFACEkJFMG, andar,
E-mail:
BeJo
Horizonte,
MC,
[email protected]
References and Notes I. The caesarean delivery rate is defined as the number of caesarean deliveries over the total number of deliveries. 2. Hurst M, Summey PS, 1984. Childbirth and social class: the case of caesarean delivery. Social Science and Medicine. 1(8):621-31. 3. Barros FC et al. 1991. Epidemic of caesarean sections in Brazil. Lancet. 338(July 20): 167-69. 4. Pesquisa National sobre Dcmografia e Safide: Relatorio Preliminar. BEMFAM and Demographic and Health Survey (DHS). Rio de Janeiro, Brazil, 1996. No nationwide figures are available for 1994, except for Ministry of Health figures of caesarean sections done by the public health sector. This figure for 1996 is based on a sample as part of the DHS. 5. Rattncr D, 1996. Sobre a hipotese de estabilizacao das taxas de cesarea do Estado de Sao Paulo, Brasil. Revista de Salidc Ptilica. 30(1):19-33.
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6. Faundes A, Cecatti JG, 1991. A opera@0 cesarea no Brasil. Incidencia, tendencias, causas, consequencias e proposlas de acao. Cadernos dc Sadde Pbblica, RI. 7(2):150-73. 7. World Health Organization, 1985. technology for birth. Appropriate Lancet. (August 24):436-37. 8. Scully D, 1994. Men Who Control Women’s Health: The Miseducation of Obstetrician-Gyneco logists. Teachers College Press, Columbia University, New York. 9. Notzon FC et al, 1994. Caesarean section delivery in the 1980s: international comparison by indication. American Journal of’ Obstetrics and Gynecology. 170(February):495-504. 10. Melo CG, 2977. Safide eAssist&cia Medica no Brasil. CebesHucitec, Rio de Janeiro. p 127. 11. Berquo E, 1993. Brasil, Urn case exemplar - anticoncepcao e part0 cirkgicos - a espera de ulna acao exemplar. Estudos feministas. 1(2):366-82.
12. Mello e Souxa C, 1994. C-sections as ideal births: the cultural constructions ofbeneficencc and patients’ rights in Brazil. Cambridge Quarterly of Healthcare Ethics. 3:358-66. 13. Rutenberg N, Fcrraz E, 1988. Female sterilisation and its demographic impact on Brazil. JnternationaJFamiJyPJanning Perspectives. 14(2). 14. Pel M, Heres MHB, Hart AAM et al, 1995. Provider-associated factors in obstetric interventions. European Journal of Obstetics and Gynaecology: Reproductive Biology. 15. System of Information on Live Births 1994 (SINASC). Secretary of Health, Belo Horizonte, 1994. 16. Perpetuo IHO, Mendonca EF, 1996. Avaliacao das estatisticas dc nascimentos em Belo Horizonte. Paper presented at X Encontro National de Estudos Populacionais, Caxambu, Brazil, 7-11 October 1996. 17. Bottoms SF et al. 1980. The
Reproductive
increase in the caesarean birth rate. Medical Intelligence. 302(10):559-65. 18. The proportion of women with up to two childrenvaries from 73.2 per cent in the group of women with no schooling to 98.3 per cent in the group of women with college education. In relation to age, 61.5 per cent of women with no schooling are less than 30 years old, while in the group with college education only 38.3 per cent are under 30. 19. Parazzine F et al, 1992. Determinants of caesarean section rates in Italy. Brifish Journal of Obstetrics and Gynaecology. 99203-06. 20. Adashek JA et al. 1993. Factors contributing to the increased birth rate in older parturient women. Am&can Journal of Obstetrics and Gynecology.
169:936-40. 21. Peippert JF, Bracken MB, 1993. Maternal age: an independent
risk factor for caesarean delivery Obstetrics and Gynecology. 81:200-05. 22. Although a vaginal birth after a caesarean (VBAC) is safe for at least 60 per cent of women with a previous caesarean section, this practice is not yet commonly followed in Brazil. See Petroni A, 1992. Costo beneficio en parto ces&ea. Por Uma Maternidade Sin Riscos. Fundacidn para Estudos e Investigacibn de la MujerLJNlCEF, Buenos Aires. 23. Chacham AS, Perp&uo IHO, 1996. Determinantes s6cioeconamicos da incid&ncia de partos cir6rgicos em Belo Horizonte. Paper presented at X Encontro National de Estudos PopulaGionais, Caxambu, Brazil, 7-11 October 1996. 24. Carranza M, 1994. De cessreas, mulheres e mCdicos: uma aproxima@o mbdico-antropol6gica ao parto ces&-eo no Bra&. Tese de Mestrado. UNB. Brasilia, Brazil.
Health
Matters,
Vol. 6, No. 11, May 1998
25. Hopkins K, 1996. CesBreas,
partos normais e esteriliza$bes feminina no Brasil: quem quer, quem decide, quem consegue. Paper presented at X Encontro National de Estudos PopulaGionais, Caxambu, Brazil, 7-11 October 1996. 26. Mello e Souza C, 1996. Intervencoes mCdicas e a integridade do corpo feminino na cultura reprodutiva Brasileira. Paper presented at X Encontro National de Estudos Popula@onais, Caxambu, Brazil, 7-11 October 1996. 27. Care in Normal Birth: A Practical
Guide. Report ofa Technical Working Group. WHOffRHI MSM/96.24. World Health Organization. Geneva, 1996. 28. Sakala C, 1993. Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary caesarean section births? Social
Science and Medicine. 37(10):1233-50
R&urn6
Resumen
Le nombre de cksariennes a notablement augment6 dans le monde depuis les annkes 70, mais les taux klevks que l’on trouve au BrCsil (beaucoup plus forts que dans d’autres pays) ne peuvent se justifier par des raisons mkdicales. S’appuyant sur des donnbes tirkes des registres des naissances pour l’annke 1994, l’auteur analyse les facteurs Qconomiques, sociaux et dkmographiques dhterminant les cbsariennes g Be10 Horizonte, capitale de Ill&at de Minas Gerais. 11 apparait que les mkdecins travaillant dans le secteur privk, avec des patientes relevant ou non des caisses d’assurances, sont beaucoup plus favorables aux naissances par cksarienne, quels que soient le niveau d’kducation, 1’5ge et le nombre de grossesses des femmes. Le second dkterminant, par ordre d’importance, est le niveau d’education de la femme. Si d’au-tres facteurs d6mographiques, comme la pariti: et I’sge, influencent le taux de kariennes, le determinant qui joue le plus grand rble est le type d’hhpital oti a lieu la naissance. Le principal facteur de risque de chsarienne, c’est d’aller dans une clinique privke plut6t que dans un hBpita1 public.
La tasa de ces&-eas ha aumentado mundialmente desde 10s aiios 70; sin embargo su alta incidencia en Brasil, cuya tasa es considerablemente mayor que la de otros paises, no puede ser atribuida a razones mkdicas. Este ensayo examina 10s motivos econ6micos y factores demogrkficos que afectan la incidencia de intervenciones ceskeas en Belo Horizonte, capital de1 estado de Minas Gerais, partiendo de datos procedentes de 10s registros de nacimientos correspondientes a 1994. El estudio demuestra que independientemente de1 grado de educacibn, edad o igualdad de la mujer, 10s mkdicos de1 sector privado favorecen mucho m8s 10s partos por ceskea, tanto con pacientes particulares coma aseguradas. El nivel educational de la mujer es el Segundo factor m&s importante. Si bien otros factores demogr%icos, coma la igualdad y la edad, influyen en la tasa de ceskeas, el tipo de hospital donde la mujer de a luz es el factor m&s determinante en cuanto a la incidencia de las intervenciones ceskeas. El tener un bebk en un hospital privado en lugar de uno pliblico constituye el factor de riesgo m&s determinante a la hora de efectuar o no una Ceskea.
122