Introduction
Childbirth is the central event that unifies all of us- it is how we came to be in this world. However, due to the latest innovations in technology and growing medical knowledge, there may be slight variations in the ways in which each of us came into this world. Today, 18.5 million cesarean sections worldwide are performed every year and in some parts of the world cesarean sections have become the default mode of delivering children (Gibbons, 2010). This increase reflects a growing medical field, but it also is representative of increasing consumer demand. Many women, if they have the means to do so, and come from a country that has abundant resources, can choose to elect a cesarean section rather than delivering vaginally. Some believe that this movement towards choice has shifted power from doctors to women (Weaver, 2007) and that it allows women to control their birthing experience, but research has shown that this may not be the case (Hopkins, 2000; Potter, 2001; Potter, 2008; Barros, 2011; Declercq, 2015). The women who chose to receive a cesarean section may not be operating within informed consent, and often they are influenced by hospitals, doctors, and societal perceptions of medicine (Hopkins, 2000; Williams and Matsuoka, 2019). This seems to be an issue in Brazil specifically, which, by many, is considered to be “The Cesarean Capital of the World”[1] due to its high cesarean section rates and the medicalization of birth.
The use of a serious surgical procedure without medical cause does not come without its consequences; emerging evidence demonstrates a potential correlation between worsening maternal and infant mortality rates and high rates of non-medical cesarean sections in many countries, including Brazil (Williams and Matsuoka, 2019). However, a lack of medical supplies and trained personnel in many “third world countries” also contributes to poor maternal health and high mortality and morbidity rates. If cesarean sections are underused women may die but if they are overused women may still die; it is all about balancing needs and the distribution of resources (Gibbons, 2010). This is where matters of race, ethnicity, and status come in. It is often the most impoverished nations (the Global South), and even marginalized communities within affluent nations, who do not have access to adequate care (while many of these resources are being over-used in more privileged communities).
Throughout this article, I will be arguing that the astonishingly high cesarean section rate in Brazil can be attributed to much more than medical necessity or maternal preference and that one’s race and ethnicity is a much more likely predictor of how likely they are to receive a cesarean section or not. In order to better the health of women and children throughout Brazil, we need to both reduce the excessive surgical interventions within the wealthy communities and evenly distribute necessary resources to all, not just the privileged, so that marginalized communities may have access to these resources and procedures. In what follows I will analyze how the increase in cesarean sections in Brazil is correlated, not only to technological advances or medical necessity but also to aforementioned factors such as socioeconomic status, race and ethnicity, allocation of resources, and geographic location.
The Global Rise in Cesarean Sections
❖ The Increase
In recent years there has been a drastic increase in the cesarean sections being administered worldwide. There are many factors that contribute to this increase, medical and non– these non-medical cesarean sections are often political in nature. They are racialized and classed, used as a form of control for the female body, exploited for convenience and monetary gain. For these reasons cesarean section rates in some countries far exceed the recommended (and necessary) amount. While the World Health Organization (WHO) recommends an average cesarean section rate of 10-15%, 50% of countries have a cesarean section rate greater than 15% and some countries have rates that are upwards of 40% (Gibbons, 2010). There is a reason that WHO created these guidelines, and it is important for those who study reproductive health to recognize that while an underutilization of cesarean section can put the safety and well-being of many mothers and children at risk, so too can the overuse and abuse of cesarean sections. The ultimate goal is to make cesarean sections and other surgical procedures more available to countries that are denied access to resources, reduce the number of cesarean sections and surgical procedures used in non-medical circumstances, and redirect the resources used in countries that have excess resources to countries who are in need of medical aid.
What Makes Brazil Special?
❖ Brazil’s Profile
There are a number of countries that have abnormally high cesarean section rates[2], increasing the world average, but Brazil stands alone and is known as a prime case study for cesarean section studies. Accompanying the title of “Cesarean Section Capital” is the misconception that Brazil as a whole has a cesarean section rate verging on 90%, however, it is not that extreme. In actuality, Brazil’s cesarean section rate is around 45% (Gibbons, 2010). Even this number is exceedingly high compared to the recommendation of 10-15%. It is important to keep in mind that although this average is an accurate representation of as Brazil as a country, it may not be an accurate representation of certain marginalized groups living in Brazil. Like the world average, this 45% cesarean section rate is a composite of lower-class Brazilians who are having cesarean sections performed much less frequently and of upper-class Brazilians who are having cesarean sections performed at almost double this rate. So, despite the fact that the national average of cesarean sections is not 90%, there are some communities in Brazil that do have a 90% cesarean section rate. It is because of these wealthy populations, private hospitals, and staggeringly high cesarean section rates that Brazil has gained the reputation as “Cesarean Section Capital of the World.” This title not only heavily stigmatizes Brazilian women, but it also creates a situation in which the plights of the marginalized communities are invisible, and people are completely oblivious to the fact that there are some areas in Brazil that may need more cesarean sections and surgical interventions. Because of the stigmatization placed on to Latin American women, especially those living in Brazil, both well off and impoverished women’s health suffer, along with their infants.
❖ Brazil’s Increase
Much like the global average and distribution, the cesarean section rate in Brazil is both increasing drastically and being distributed unevenly. Just as there are many countries above and below the recommended average provided by WHO, in Brazil there are certain communities and minority groups well below the national average while others surpass it. Most cesarean sections are being performed in the wealthiest communities of Brazil– this can be attributed to their excess of resources, privatized health care, insurance, and metropolitan environment/physical proximity to top hospitals. When studying the increase in cesarean sections in Brazil, scholars found that, “Brazil has one of the world’s highest cesarean section rates in the world (38% of live births in 2000), surpassed only by Chile, with 42% in 1999. Recently, a slight downward trend in the cesarean section rate has been observed in the Brazilian public sector, from 32% in 1994-1997 to 25% in 2001” (D’Orsi et al., 2006, p. 2067). While cesarean sections are being reduced in the public hospitals, the national average continues to grow. This means that despite the fact that the upper class are of a much smaller percentage of Brazil than the middle and lower class are, their incredibly high cesarean section rates have had the greatest impact on the national average and make it seem as if cesarean sections are a cultural “norm.” Cesarean sections are normalized, and almost anticipated, within the wealthy Brazilian communities, but not every child is being delivered via cesarean section in the hospitals in Brazil. Across Brazil, there is a great deal of regional variation in the rates of cesarean sections, “Thus, the cesarean section rate is higher in more developed regions like the Southeast (45%), South (40%), and Central-West (43%) than in the less developed North (27%) and Northeast (25%)” (D’Orsi et al., 2006, p. 2067).
Cesarean Sections in Brazil
❖ Medical Factors
Given that a cesarean section is an incredibly invasive procedure, and some might argue a major surgery, there are going to be “medical” factors that contribute to the expansion of its use. Some of these factors impact maternal health, such as an increase in chronic diseases and decreasing prenatal health, and others jeopardize the safety of the infant– for example if the baby is in a breech position or has the umbilical cord tied around its neck. Some scholars in Brazil have speculated that the increase in cesarean sections could be the result of “failed” vaginal deliveries, emergency circumstances, or the safety and security that is “ensured” in a cesarean section delivery (Declercq, 2015). They believe that doctors simply are not trained to address these situations without using medical interventions or surgical procedures. Many Brazilian women who schedule cesarean sections ahead of time explaining that they fear the “dangers” of vaginal delivery and that they doubt that their doctors can perform a vaginal delivery as well as they can perform a cesarean section. There is a collective perception that cesarean sections are the “magic bullets” that can remedy any complication in pregnancy, and this may be why some women elect to have cesarean sections and schedule the surgery ahead of time. Though electing into a cesarean section does not truly make it medical, many Brazilian women who choose to deliver via cesarean section believe that they made their decision with medical factors in mind (Weaver et al., 2007). This leads us into a discussion of non-medical factors that contribute to the increasing rate of cesarean sections and why a cesarean section may be performed outside of a medical context.
❖ Non-Medical Factors
It is not uncommon for women to report “non-medical” reasons for preferring a cesarean section such as fear, anxiety, lack of confidence in themselves or the doctor, and a desire for control– specifically, controlling the experience and outcome of their labor (Reyes, 2018; Reyes 2019). This fear can stem from many places, but, as previously discussed, in Brazil it often comes from the perception[3] that vaginal deliveries are far too risky and that doctors may not be as competent in performing vaginal deliveries as they are performing cesarean sections (Declercq, 2015). The fear that minority women experience in childbirth is very different from the fear that privileged women experience, and oftentimes it stems from the blatant discrimination and institutional violence that they face on a daily basis. Although the frequency of cesarean section deliveries are directly correlated to income (the wealthiest women are the ones receiving the most surgical procedures), when middle and lower-class women do decide to opt into cesarean sections it is only because they are afraid that prejudice would cost them quality care in a vaginal delivery (Behague et al., 2002). Women who come from marginalized communities not only fear that something may go wrong in their deliveries, but also that the doctors and nurses looking after them may let something go wrong in their deliveries, as their lives are valued less than wealthier or whiter women. Cesarean sections are seen as clean, clinical, efficient procedures and many women feel that it is a superior form of delivery. The minority women who opt into cesarean sections feel that their safety is already being compromised, so it is better to put their faith in a glorified procedure than in an uncertain process.
“Elective” Cesarean Sections in Brazil
❖ “Maternal Request”
Many doctors, including those in Brazil, report that the rapid increase in cesarean sections is largely due to maternal request and elective procedures (Weaver et al., 2007), but have neglected to consider what contributes to maternal requests and who or what may have persuaded them to do so. To contradict this assertion, many women in Brazil report that they originally intended to deliver vaginally at the start of their pregnancy and that by the end of their third term it was, in fact, their doctor who had convinced them to elect a cesarean section (Potter et al., 2001). Scholars need to critically analyze the expression “maternal request” and acknowledge that sometimes, whether a woman receives a cesarean section or not is determined by the insurance she has or the hospital that she gives birth in rather than by the woman herself. In fact, some studies find that preferences among women delivering in private and public hospitals are similar initially, but that women in the private hospitals are convinced to schedule cesarean sections at a certain point in their pregnancy or that they end up receiving unwanted cesarean sections, thus contributing to the abnormally high cesarean section rate in Brazil (Potter et al., 2001). The women who are being convinced by their doctors to schedule cesarean sections ahead of time are almost always giving birth in private hospitals because they are the patients who can afford to do so.
❖ Motivation
Supporting the assertion that often the hospitals are the confounding factor and not the women, Potter et al. (2008) found that the percentage of women that plan to deliver vaginally at the start of their pregnancy is fairly close with approximately 72% in private hospitals and 79% in public hospitals (Potter et al., 2008). What seems to be happening is that somewhere along the way doctors in the private hospitals are convincing their patients to schedule cesarean sections for either non-existent conditions or conditions not “severe enough” to warrant surgery. The result was a 72% cesarean section rate in the private hospitals and 31% in the public hospitals, demonstrating the influence that birth location has on the mode of delivery and birth outcomes (Potter et al., 2008). This also demonstrates that institutional inequality in Brazil has much more control over the individual experience than the individual has over the system.
Hospitals in Brazil
❖ Private Hospitals
There have been a number of studies conducted that contrast the health outcomes of women delivering in private hospitals to those delivering in public hospitals (Potter et al., 2001; D’Orsi et al., 2006; Potter et al., 2008; Barros et al., 2011). Some of these studies are comparative and focus on both sets of hospitals (Potter et al., 2001; Potter et al., 2008), while others focus on private and public hospitals separately (D’Orsi et al., 2006; Barros et al., 2011). When studying private hospitals, Barros et al. (2011) found that there were universal cesarean sections for the “better-off,” or the wealthy women delivering their babies in private hospitals. They argue that “There is widespread evidence that doctors’ attitudes during the prenatal and peri-delivery period may increase the likelihood of a C-section,” and conclude that, “C-sections were almost universal among the wealthier mothers, and strongly correlated to education among SUS (public) patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor’s schedule” (Barros et al., 2011, p. 635). This may be because doctors in private hospitals are in a position to take advantage of their patients’ class status in order to suit their personal preference.
❖ Public Hospitals
In contrast, D’Orsi et al. (2006) studied the factors associated with cesarean sections in public hospitals in Brazil and tried to determine exactly what circumstances warranted a cesarean section for women of the lower class. They found that in public hospitals, “Factors associated with increased odds of cesarean sections were: primiparity, mother’s age 20-34, last birth by cesarean, cervical dilation < 3cm at admission…” (D’Orsi et al., 2006, p. 2067). Whereas births in private hospitals are largely influenced by practitioner preference, these factors are primarily concerned with medical necessity and patient health. Often times, women of low socioeconomic status are not granted the option of electing a cesarean section, as, “Another aspect of inadequate use of cesareans in Brazil is the difficult access to hospital care (particularly in poorer regions of the country)…even in developed metropolitan areas like Rio de Janeiro the excessive use of cesarean sections coexists with its absence when clearly indicated” (D’Orsi et al., 2006, p. 2067). Even in emergency circumstances, impoverished women may be denied access to necessary procedures due to distant hospitals, lack of transportation, and non-comprehensive health insurance.
Social Status and Cesarean Sections
❖ Race in Brazil
Latin America is thought to be a region lacking in racial hierarchy; however, this is inaccurate. In her work on the racial democracy and nationalism in Panama, Guerrón-Montero (2006) emphasized that “In spite of the presence of more fluid and flexible racial boundaries than other regions of the world, Latin America continues to confront racially hegemonic practices. Only recently have Latin American nations begun to respond to racial inequality through governmental policies and programs” (p. 209). The misconception that Brazil, and Latin America as a whole is a homogenous “paradise” creates a situation in which systemic racism cannot be combatted. When scholars outside of Latin America discuss the incredibly high cesarean section rate in Brazil, they talk about the country of Brazil as one demographic and fail to take into consideration certain factors such as inequality and discrimination. Just as the notion that Brazil is a “paradise” for people of color can hurt marginalized communities, the misconception that the national average cesarean section rate is representative of the entire population of Brazil makes minority women who cannot access these medical resources completely invisible. Until we can acknowledge that there continues to be discrimination in Latin America and that this discrimination often threatens the health of Afro-Brazilian and Indigenous women and children, we will not see real change and we will continue to see maternal and infant mortality increasingly worsen.
❖ Distribution of Resources
In terms of the global distribution of resources, while an estimated 3.18 million additional cesarean sections are needed in countries that are lacking them, there were 6.20 million unnecessary cesarean sections that were performed in countries that overuse this procedure; the cost of the global excess was estimated to be 2.32 billion dollars and the cost of needed procedures was 432 million dollars (Gibbons, 2010). Cesarean sections, like most surgical procedures are costly but this does not mean that only the wealthiest should have access to them. Cesarean sections are medical in nature and as such, they should be administered to those who are in need of medical intervention, not simply those who can afford them. Like the distribution of all resources and goods in Brazil, there is often a surplus being directed towards the rich and the privileged rather than the people who need them the most. Women of lower socioeconomic classes experience some of the most severe complications in delivery because of the daily stresses they face such as discrimination, malnutrition, and insecure housing, yet because they are women of the lower-class, they will often have difficulty accessing assistance or comprehensive care. If Brazilian hospitals reduced the excessive surgical procedures being administered to upper-class women and directed some of their resources and efforts to the lower-class women of Brazil, the health outcomes for both demographics could greatly improve.
❖ Race, Ethnicity, and Cesarean Sections
Race and ethnicity are thought to be some of the most accurate predictions of a person’s health and lifespan; it is no coincidence that many of the women who are receiving an excess of cesarean sections (those is the private sector) are of a lighter pigmentation than those who are in need of more medical interventions (those delivering in public hospitals and clinics). While socioeconomic status can be an accurate indication of the likelihood that someone will receive a cesarean section in Brazil, the color of someone’s skin can be a direct indication of what their socioeconomic status is. Race, economics, and access to resources are all linked to one another and in order to gain a better understanding of the stark contrast between the health of wealthy Brazilian women and the health of impoverished Brazilian women, we need to consider intersectionality. Intersectionality is a term coined by Kimberlé Crenshaw to describe the lived experiences of Black women and the multiple sources of oppression that they face—including race, class, and gender (Crenshaw, 1990). We cannot consider one factor like race or social status in isolation; we need to look at these issues as a collective to gain a complete picture of women’s reproductive health in Brazil. When we discuss the distribution of cesarean sections in Brazil it is imperative to have an understanding of the distribution of wealth, but when we talk about socioeconomic status in Brazil, we need to acknowledge that race/ethnicity is one of the strongest defining factors.
Conclusion
There is not merely one sole contributing factor that has caused the recent rise in cesarean sections in Brazil. Women’s reproductive health is a multifaceted issue that encompasses science, politics, biology, culture, economics, and race and ethnicity. Because there is no one cause for the rising prevalence of cesarean sections, there is no single solution either. In order to understand the health care system and medical industry of Brazil, we need to take a deeper look into their racial relations, cultural beliefs, and social structures. As of now, there is a large gap between the upper and lower class in terms of resources, and just as a lack of resources and extremely low rates of medical interventions/procedures can negatively impact the health of a population, excessive procedures can drastically affect a population’s health as well. In the end, both groups will suffer the consequences– either because they are being denied a surgical procedure when needed or because they are being subjected to a surgical procedure when it is medically unnecessary. Extreme economic inequality and deeply ingrained discrimination are detrimental to maternal and infant health in Brazil. By examining the high cesarean section rate in Brazil and mitigating its impacts we can demonstrate an example for many other countries with abnormally high cesarean section rates, which will hopefully lead to healthier women and children around the globe.
Similar to the global average, the cesarean section rate in Brazil is a reflection of two extremes and a racialized divide in the healthcare system. While the average cesarean section rate is fairly high for Brazil, there are some communities that have disturbingly high rates (upwards of 80 to 90%) and there are other communities who have sparse access to necessary cesarean sections. The distribution of cesarean sections is no longer based on who needs them and who does not, it is now determined by who is capable of affording them and who barely has enough money to pay their hospital bills. In order to reduce the rate of cesarean sections in wealthy populations so that it is closer to the recommended average, we need to create change within hospitals and train doctors to only perform surgical interventions when they are medically necessary. Most of all, we need to address the systemic racism and institutional violence that are directed towards women and children of color in Brazil, and around the world. Infant mortality is a direct reflection of a population’s health and if we want to see real improvement in global health, we need to start by protecting women and children. Hopefully, if Brazil and other countries with abnormally high cesarean section rates and economic inequality propose serious institutional reform, the rest of the world will follow suit and we will see all women receiving the health care that they deserve.
| Author | Article | Basis of the Article | Maternally Elected or Not? |
| Barros et al., 2011 | Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off. Revista de saude publica, 45(4), 635-643. | To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries. Looks at the differences between wealthy mothers and impoverished ones. | The overall c-section rate was 45%; 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor’s schedule.
Not maternally elected (doctor preference). |
| Béhague et al., 2002 | Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. Bmj, 324(7343), 942. | To investigate why some women prefer c-sections and how decisions to medicalize birth are influenced by patients, doctors, and the sociomedical environment. Looking at the different reasons for different demographics. | In both samples women from families with higher incomes and higher levels of education had c-sections more often than other women. Many lower to middle class women sought c-sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. Fear of substandard care is behind many poor women’s preferences for a c-section. The unequal distribution of medical technology has altered concepts of good and normal birthing.
Some evidence for maternally elected c-sections, but limited (constrained agency). |
| Declercq, 2015 | Childbirth in Brazil: challenging an interventionist paradigm. Birth, 42(1), 1-4. | Debunks the myth that c-sections are universal in Brazil. To an extent Declercq is right. However, there are some private hospitals and wealthy regions with rates in the 80-90% range which is still concerning. More about distribution of wealth like the global average. | The author claims that in Brazil the high rates can be attributed to “failure” in vaginal deliver (on the doctor’s part, malpractice) rather than a pre-planned procedure. Because vaginal delivery can be so problematic in Brazil specifically (due to the failings of the hospitals), the women feel that their fear is justified and that cesarean sections truly are the more reasonable option. In a way, fear is still a central influence.
Not maternally elected (emergency / medical necessity). |
| D’orsi et al., 2006 | Factors associated with cesarean sections in a public hospital in Rio de Janeiro, Brazil. Cadernos de saude publica, 22, 2067-2078. | This study aimed to identify factors associated with c-sections in a public maternity hospital in Rio de Janeiro. Focus on medical reasons for c-sections in Brazil as well as social factors; all c-sections in general, not just elective. | Factors associated with increased odds of cesarean section were: primiparity; mother’s age 20-34; last birth by cesarean; cervical dilatation < 3cm at admission; patient request; daytime birth; male attending obstetrician; obstetrician on duty for more than 24 hours a week; obstetrician with private practice; gestational hypertension; non-cephalic presentation; and gestational age > 41 weeks. Factors associated with lower odds of cesarean were: gestational age < 37 weeks; leaving home with signs of labor, use of oxytocin; and amniotomy.
Some evidence for maternally elected cesarean sections, some evidence for doctor preference or influence. |
| Hopkins, 2000 | Are Brazilian women really choosing to deliver by cesarean?. Social science & medicine, 51(5), 725-740. | Challenging the idea that there are any elective cesarean sections (as opposed to medical ones) and that any women are actively seeking out c-sections. | Contradicts the notion of the maternally elected c-section–hypothesizes that elective c-sections are not truly elective or initiated by the woman, that they are not contributing to the growing c-section rate, and that doctors are largely responsible for perpetuating these myths. This is specifically in reference to Brazilian hospitals. Quote: “I also show that the majority of women surveyed in two cities in Brazil, particularly first-time mothers, do not seek to deliver by cesarean” (p. 725).
Not maternally elected (doctor preference). |
| Potter et al., 2001 | Unwanted caesarean sections among public and private patients in Brazil: prospective study. Bmj, 323(7322), 1155-1158. | To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. | Quote: “The large difference in the rates of c-sections in women in the public and private sectors is due to more unwanted c-sections among private patients rather than to a difference in preferences for delivery. High or rising rates of c-sections do not necessarily reflect demand for surgical delivery” (p. 1155). This redefines the term “elective.” But are there any truly “elective” c-sections? And if there are, what prompts them?
Not maternally elected (doctor preference). |
| Potter et al., 2008 | Women’s autonomy and scheduled cesarean sections in Brazil: a cautionary tale. Birth, 35(1), 33-40. | Compares and contrasts the experiences of women giving birth in public hospitals and women giving birth in private hospitals (where a majority of women deliver by c-section) in Brazil. | The percentage of women that plan to deliver vaginally at the start of their pregnancy is fairly close (72% to 79%). In the end the c-section rate was 72% in the private hospitals and 31% in the public hospitals. What seems to be happening is that somewhere along the way doctors in the private hospitals are talking their patients into scheduling c-sections for either non-existent conditions or conditions not severe enough to make the procedure necessary. Potential fear elicitation.
Not maternally elected (doctor preference). |
| Weaver et al., 2007 | “Are there “unnecessary” cesarean sections? Perceptions of women and obstetricians about cesarean sections for nonclinical indications.” Birth 34.1 (2007): 32-41. | A study to assess how often patients requested c-sections themselves and in what contexts or circumstances were these requests made. The data was a collection of journal entries recording childbirth planning (some of the women planning c-sections and other planning vaginal delivery). | The women intending to schedule a c-section claimed that there were medical or “psychological” reasons behind the decision (they may have considered it to be mental health as opposed to physical health, but even so a matter of “health”). Women were not only motivated by fear (for the safety of themselves and their babies) but also by assurance (they were under the impression that c-sections were far superior to vaginal delivery). When obstetricians were asked about elective c-sections, they reported that maternal requests were both sparse, yet the main contributing factor to the rising rates of cesarean sections (contradictory).
Some evidence for maternally elected cesarean sections (but they consider them to be medical). |
References
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Béhague, D. P., Victora, C. G., & Barros, F. C. (2002). Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. Bmj, 324(7343), 942.
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