SÃO PAULO — Seven months into her pregnancy, Rosineide Moreira chose her first child’s birthday.
An hour after surgeons sliced painlessly into her, the 31-year-old chemical engineer from São Paulo was cradling her newborn daughter, Mariana, as planned — on 5 January 2015.
“We set a date that was convenient for both my husband and me,” Moreira said. “The doctor gave me the option of a natural birth, but we weighed up the pros and cons and decided we’d go with the c-section.”
Moreira’s story is not uncommon in Brazil, particularly in the country’s private health care network used by more than a quarter of the population, where 84.6 percent of babies are delivered by caesarean.
Even though Brazil’s public national health system, the SUS, carries out fewer caesareans proportionally, overall this still means that upwards of 55 percent of babies born here are delivered by c-section, one of the highest rates in the world.
In Latin American and Caribbean nations, the rate is also generally high, at around 40 percent in 2014, according to UNICEF figures. In comparison, around 33 percent of all births in 2012 in the U.S. were by c-sections; in the UK, in 2013 it was 25.5 percent.
The World Health Organization says only 15 percent of births should require a caesarean.
A day after Moreira’s daughter was born, health officials in Brazil announced new rules to reduce caesarean rates and new programmes to promote natural births.
“The epidemic of caesarean sections that we see in our country is unacceptable, and we have no option other than to treat it as a serious public health issue,” Health Minister Arthur Chioro said. “We cannot … consider caesarean sections as normal births.”
Among the new measures is a delivery record that doctors will have to submit, justifying the procedure, in order to receive payment for the procedure, and which the government will use to monitor caesarean rates.
Health plan providers will also be obliged to provide expectant mothers with information about the risks of unnecessary c-sections, such as an elevated risk of infection; and information on caesarean rates among specific doctors, hospitals, and providers. Those who fail to comply will face a fine.
Ana Maria Malik, professor of health at the Fundação Getúlio Vargas, or FGV, a higher education institute and think tank in São Paulo, says the public system has already defined “much lower c-section rates and been successful at least with hospitals that are paid on a contract basis”, but that the private sector has been virtually untouched by the measures, until now.
“Health officials have now set some quality indicators, including c-section rates, to be achieved by third party payers and this will include financial rewards — or sanctions — for the providers,” Malik said, while admitting that Brazil would likely remain among the world’s c-section leaders “for some time”.
Such high rates stem from cultural norms established among patients and physicians, Malik said. “Brazilian medical schools have been perceived to teach c-sections as the normal childbirth … which is now considered exceptional.”
With women, caesareans can be seen as a status symbol, and many body-conscious Brazilians also turned to c-sections to reduce the impact a natural birth can have.
But an FGV study showed that most who opt for c-sections simply want a convenient birth, at the time of their choosing. Physicians also favor the practice, as its predictability mean doctors can more efficiently plan bed and staff rotations.
Although Moreira’s doctor gave her a choice, other mothers have felt pressured to undergo the procedure.
“I more or less begged to have a natural birth, but the doctor convinced me having a c-section was the best option, safety-wise,” said Maria Luiza Guimarães, a 40-year-old lawyer and mother of three from São Paulo.
All Guimarães’s children, including her five-month-old daughter, have been delivered by c-section at private hospitals.
“One doctor we saw, but didn’t proceed with, said a natural birth would cost twice as much as a caesarean – 18,000 reais ($6,800) instead of 9,000 reais – because his team would be kept on standby, unlike with a planned c-section,” Guimarães said.
Announcing the new rules, Chioro warned that doctors charging such extra “availability fees” for natural births, typically not covered by health plans, were breaking the law.
While Brazil has doctors specialising in natural births, including those who cater to mothers who want to have multiple future pregnancies, many women say doctors insist c-sections are the right course, while others choose this path for reasons of convenience.
Guimarães says she understands these women, but wishes she had had a doctor more open to natural births.
“Even now I don’t know whether any of my c-sections were really necessary.”