A Cut Above? Cesarean Sections in Brazil
In the opening scene of The Knick, Steven Soderbergh’s period drama about a fictionalized version of the Knickerbocker Hospital in turn-of-the-century New York City, Drs. John W. Thackery (played by Clive Owens) and his mentor Dr. J.M. Christiansen attempt to perform a cesarean section on a woman suffering from placenta previa (a condition in which the placenta covers the cervical opening). While the doctors fail to save either the mother or the baby, the gruesome, bloody scene transports us to another era in which childbirth was dangerous for both mother and infant, and no viable surgical options (such as safe cesarean sections) were available in the case of obstetric complications. The scene forces us to think about the good that has come out of medical and surgical innovations. A woman and her newborn infant are no longer marked for death if the woman suffers from complications such as placenta previa or cord prolapse (when the umbilical cord drops into the cervix before the baby).
Before the nineteenth century, cesarean sections in the Western world were seen as an “option of last resort,” and doctors only performed them on dead or dying women in the hope to save the newborn. With the transformation of the field of surgery in the nineteenth century, however, cesarean sections became safer, and by the early twentieth century, physicians performed them in the hope of saving both mother and child. The adoption of anesthesia in the mid-nineteenth century, the acceptance of germ theory, and the modern understanding of bacteriology in the late-nineteenth century drastically changed medical surgery. The practices of antisepsis and asepsis began to “make inroads” into post-surgical infections, such as septicemia and peritonitis. As the scene in The Knick demonstrates, blood loss was also a major cause of death during the procedure, and only with an improvement in uterine sutures in the late-nineteenth century would cesareans become safer. Between the 1880s and 1920s, physicians also adopted the practice of transverse incisions (lower in the uterus), resulting in reduced rates of both infection and uterine rupture in subsequent pregnancies. With the discovering of penicillin by Alexander Fleming in 1928, and its purification as a drug in 1940, the procedure became even safer.1
While cesarean sections are necessary and lifesaving in certain instances, the rates of c-sections worldwide have risen dramatically in the past thirty years. The World Health Organization (WHO) recommends the ideal rate for cesarean sections to be between 10 and 15 percent of all births. The WHO states, “When medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity.” When c-sections comprise up to 15 percent of all births, they are associated with a decrease in maternal, neonatal, and infant mortality. But when the rate rises above 15 percent, the procedure is no longer associated with reduced maternal or perinatal mortality. And for women or infants who do not need the procedure, there is no evidence of benefits. Moreover, like any surgical procedure, cesarean sections increase the risk of infection and post-surgical complications.2 Interestingly enough, the country that leads the worldwide rate for cesarean sections is Brazil. A recent study based on extensive country-wide research, Nascer no Brasil (Birth in Brazil), has thoroughly documented what many physicians and health leaders are calling Brazil’s cesarean “epidemic.”
For a country whose history of cesarean sections has followed that of the United States and Europe, the current numbers are stunning. Before the mid-nineteenth century, cesarean sections in Brazil were only performed on dead or dying mothers.3 Only after Brazil’s leading obstetrician Francisco Magalhães implemented methods of combating post-surgical infection in 1915 did the surgery become more widespread.4 In the second half of the twentieth century, the rate of cesarean sections in Brazil began to creep upwards, and by the beginning of the twenty-first century, the rate had skyrocketed to the top of the world’s list.
In 2014, 52 percent of all births in Brazil ended in cesarean sections. For births that occurred in public hospitals, under the care of Brazil’s national Unified Healthcare System (Sistema Único de Saúde, SUS), 46 percent of all births resulted in a cesarean section. Of the births that occurred in private hospitals, the number reaches an alarming 88 percent. One researcher called cesarean sections the modus operandi in the private healthcare sector.5 Nascer no Brasil contends that in Brazil, more than one million women undergo non-medically indicated cesarean sections each year.6
Even in vaginal births, a technologically-driven model dominates clinical practice. One Brazilian researcher defines technocratic birth as a clinical model that “rests on the idea that women are to remain passive, immobile during childbirth, while they undergo interventions by unknown health personnel to shorten the time to birth.”7 This model values technology and medical intervention over human relations and patient needs. In Emily Martin’s groundbreaking cultural analysis of the scientific metaphors surrounding women’s reproductive bodies, she argues that in the U.S., birth is seen as a production-driven process in which the body is viewed as a machine. According to Martin, the metaphor of “body as machine” “both underlies and accounts for our willingness to apply technology to birth and to intervene in the process.”8 These metaphors have serious and tangible consequences in women’s delivery experience, and Martin contends that these metaphors are in part behind the rise of cesarean sections in the United States.
In fact, in 2014 only 5 percent of Brazilian women experienced deliveries without excessive medical interventions. Nascer no Brasil demonstrates that this standard of care was prevalent throughout all geographic regions in both private and public hospitals, forcing the authors to conclude that “the medicalization of birth is a practice disseminated throughout the entire country.” Vaginal births in Brazil are marked by excessive (and often medically unnecessary) obstetric interventions such as the high use of oxytocin to induce labor, episiotomies (a cut between the vagina and the anus), and the Kristeller maneuver, in which the pregnant woman lies on her back while a birth attendant presses on her belly. As the authors of Nascer no Brasil state, when these methods are used without clinical indication, they cause unnecessary pain and suffering.9
While 70 percent of Brazilian women desire a vaginal birth at the beginning of their pregnancy (a percentage that shifts depending on the woman’s reproductive history and whether her healthcare is public or private), there is a gradual shift in preference throughout the course of gestation. The authors of Nascer no Brasil suggest that prenatal care clinicians are influencing women’s decisions to opt for medically-unnecessary cesarean sections.10 One article in the study found that while some believe that women’s desire for cesarean sections is behind the rise in rates, less than 2 percent of the women interviewed discussed their choice of childbirth (cesarean or vaginal) as a “desire” or “wish.”11 Moreover, the same study found that independent of the type of healthcare service (public or private) or reproductive history (primi or multipara), women’s preferences for vaginal births were not supported or encouraged by physicians.12
Emily Martin responded to criticism that her book “romanticized the ‘all-American’, natural birth, earth-mother,” by acknowledging that she extolled unmedicated birthing procedures while simultaneously ignoring the positive consequences of advances in medical technology for women’s reproductive lives.13 But I do not believe that critiquing excessive rates of cesarean sections implies that all medical interventions are “bad.” Surgical techniques can be medically necessary, and they have saved numerous lives. All our lives are better for them. However, Brazil’s rates of cesarean sections serve as a warning for allowing “medical metaphors” like those that Martin describes to take over an experience that women have managed for thousands of years. Nascer no Brasil makes clear that the Brazilian model of birth must center on the experience of the woman and her family.14 Only then, will a humanized model of care take hold.
Further Reading
Boley, J.P. The History of Caesarean Section,” Canadian Medical Association Journal 145, no. 4 (1991): 319-322.
Diniz, Simone. “Materno-Infantilism, Feminism and Maternal Health Policy in Brazil,” Reproductive Health Matters 39, no. 20 (2012): 125-32.
Lurie, Samuel and Marek Glezerman. “The History of Cesarean Technique,” American Journal of Obstetrics and Gynecology 189, no. 6 (2003): 1803-6.
Cadernos de Saúde Pública Vol. 30, Supplemental 1 (Rio de Janeiro: 2014). Cadernos de Saúde Pública.
Notes
- For an overview of the history of cesarean sections see Jane Eliot Sewell, “Cesarean Section: A Brief History” (National Library of Medicine, 1993), https://www.nlm.nih.gov/exhibition/cesarean/index.html. Return to text.
- World Health Organization, “WHO Statement on Caesarean Section Rates” (WHO, 2015). Return to text.
- Maria Lúcia Mott, “Assistência ao parto: do domicílio ao hospital (1830-1960),” Projeto História, São Paulo 25 (December 2002): 13. Return to text.
- Ana Paula Vosne Martins, Visões do feminino: A medicina da mulher nos séculos XIX e XX (Rio de Janeiro: Editora Fiocruz, 2004), 206. Return to text.
- Ricardo Lêdo Chaves, “Birth as a Radical Experience of Change,” Cadernos de Saúde Pública 30, no. Supplemental (2014): S1. Return to text.
- Maria do Carmo Leal et al., “Nascer no Brasil: sumário executivo temático de pesquisa,” Nascer no Brasil: inquérito nacional sobre parto e nascimento (Rio de Janeiro: Fundação Oswaldo Cruz, 2014). Return to text.
- Estela M. L. Aquino, “Reinventing Delivery and Childbirth in Brazil: Back to the Future,” Cadernos de Saúde Pública 30, no. Supplemental (2014): S1. Return to text.
- Emily Martin, The Woman in the Body: A Cultural Analysis of Reproduction (Boston: Beacon Press, 2001), 54. Return to text.
- Leal et al., “Nascer no Brasil.” See also Maria do Carmo Leal et al., “Obstetric Interventions during Labor and Childbirth in Brazilian Low-Risk Women,” Cadernos de Saúde Pública 30, no. Supplemental (2014): S17–47. Return to text.
- Leal et al., “Nascer no Brasil.” Return to text.
- Rosa Maria Soares Madeira Domingues et al., “Process of Decision-Making Regarding the Mode of Birth in Brazil: From the Initial Preference of Women to the Final Mode of Birth,” Cadernos de Saúde Pública 30, no. Supplemental (2014): S110. Return to text.
- Ibid., S112. Return to text.
- Martin, The Woman in the Body, xxvi. Return to text.
- Maria A.S. Mendes Gomes, “Compromisso com a mudança,” Cadernos de Saúde Pública 30, no. Supplemental (2014): S41–42. Return to text.
Post title comes from Simone G. Diniz and Alessandra S. Chacham, “‘The Cut Above’ and ‘The Cut Below’: The Abuse of Caesareans and Episiotomy in São Paulo, Brazil,” Reproductive Health Matters 12, no. 23 (2004): 100–110.
Cassia received her PhD in Latin American History with a Concentration in Gender Studies from the University of California, Los Angeles. Her book manuscript, titled A Miscarriage of Justice: Reproduction, Medicine, and the Law in Rio de Janeiro, Brazil (1890-1940), examines reproductive health in relation to legal and medical policy in turn-of-the-century Rio de Janeiro. Cassia’s research has been supported by the Woodrow Wilson Foundation, the Coordinating Council for Women in History, the Fulbright IIE, and the National Science Foundation.