A 2004 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2004;12(23):100–110 0968-8080/04 $ – see front matter www.rhm-elsevier.com PII: S 096 8-80 80 (0 4)2311 2-3 www.rhmjournal.org.uk ‘‘The Cut Above’’ and ‘‘the Cut Below’’: The Abuse of Caesareans and Episiotomy in Sa˜oPaulo,Brazil Simone G Diniz,a Alessandra S Chachamb a Research Director, Coletivo Feminista Sexualidade e Sau´ de, Sa˜o Paulo, Brazil. E-mail: [email protected] b Associate Professor, Department of Social Sciences, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil Abstract: In the last 50 years, a rapid increase in the use of technology to start, augment, accelerate, regulate and monitor the process of birth has frequently led to the adoption of inadequate, unnecessary and sometimes dangerous interventions. Although research has shown that the least amount of interference compatible with safety is the paradigm to follow, vaginal birth is still being treated as if it carries a high risk to women’s health and sexual life in Brazil. This paper describes the impact of the intervention model on women’s birth experience, and discusses how the organisation of public and private maternity services in Brazil influences the quality of obstetric care. Brazil is known for high rates of unnecessary caesarean section (‘‘the cut above’’), performed in over two-thirds of births in the private sector, where 30% of women give birth. The 94.2% rate of episiotomy (‘‘the cut below’’) in women who give birth vaginally, affecting the 70% of poor women using the public sector most, receives less attention. A change in the understanding of women’s bodies is required before a change in the procedures themselves can be expected. Since 1993, inspired by campaigns against female genital mutilation, a national movement of providers, feminists and consumer groups has been promoting evidence-based care and humanisation of childbirth in Brazil, to reduce unnecessary surgical procedures. A 2004 Reproductive Health Matters. All rights reserved. Keywords: evidence-based medicine, caesarean section, episiotomy, medicalisation of childbirth, humanisation of childbirth, Brazil ‘‘If I were a woman I would have started, I don’t health. In this process, both in developed and know, an armed insurrection, because there is too developing countries, the search for ways to much violence... She goes to the maternity improve the quality of assistance at birthing hospital, and either they cut her belly, unneces- has frequently led to its medicalisation and an sarily most of the time, or her perineum. Anyway uncritical adoption of inadequate, unnecessary someone is going to assault her with a knife.’’ and sometimes dangerous interventions, with- (A. Atallah, Brazilian Cochrane Centre)1 out proper evaluation of their effectiveness or safety.2,3 N the last 50 years, there has been a rapid However, by the end of the century, an in- increase in the use of technologies whose ternational movement had grown that cam- Ipurpose is to start, augment, accelerate, reg- paigned for medical care based on empirical ulate and monitor the process of birth, all with evidence of safety and effectiveness of medical the aim of making it ‘‘more normal’’ and to procedures in all specialities, evidence-based improve the outcome for women and infants’ medicine (EBM). In the case of pregnancy and 100 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 assistance at birth, practices are used in the some kind of private health insurance, and the course of a process that is usually though not poorer 70% who depend on the Brazilian Public always normal. Scientific evaluation has shown Health System (Sistema U´ nico de Sau´de, SUS). that minimal intervention – the least amount of According to the Brazilian Constitution (1988) interference compatible with safety – is the para- access to health care is a universal right and it is digm to follow for a normal birth. Thus, during a duty of the state to provide it. Both in the delivery and birth there must be a valid reason public and the private sectors, good and bad to intervene in a natural process, which is to do standards of care can be found, but substandard entirely with complications in the woman or care is prevalent. Health Ministry data show that the infant.2–4 in 2002 only 5% of pregnant women enrolled in The incorporation of these changes in Latin antenatal care programmes had received the American countries has been very slow and has standard antenatal care services.11 met great resistance,5 including from teaching Private health services and private health in- institutions. In most medical schools in Brazil, surance are favoured by anyone who can afford providers are still taught the intervention model. them. Within the diversity of health plans and Surgical ability and sophisticated pathology insurance available, there is normally a group of assistance are highly valued, while comparative- specified health care providers and hospitals that ly little attention is paid to women-centred care women must use. The most expensive health for normal deliveries, and good communication insurance gives women the right to choose and interaction with all birthing women.6,7 which doctor will assist her during birth, usually This paper describes and discusses the impact the same one she sees for antenatal care. This on women’s health and sexuality of the inter- continuity of care is highly valued but it is vention model on women’s birth experience in generally not available for women who use the Brazil, drawing on information from qualitative SUS. They will see a doctor for antenatal care at and quantitative studies in the published lite- the health centre and will be attended by any rature. Quotes from interviews with doctors, doctor who happens to be on duty in the hospital nurses and patients collected in the course of when they arrive, whom they have most likely our own studies in this area are also presented. never before met. Since doctors do not necessar- These illustrate how the organisation of mater- ily introduce themselves in these circumstances, nity services in the public and private sectors women often do not even learn the names of influences the quality of obstetric care, leading those who assisted them.6 to high rates of unnecessary caesarean section and episiotomy. The obstetric pilgrimage Women who use the SUS for antenatal care Giving birth in Brazil frequently cannot secure a place in advance In Brazil, 96.5% of births take place in hospitals.8 where they can deliver. The guidelines for ante- This does not indicate that Brazilian women re- natal care instruct public health providers to ceive good assistance, however. According to the give women a referral letter to a hospital by the Brazilian Ministry of Health, the maternal mortal- end of pregnancy, to help them to secure a bed ity ratio in 2002 was 74.8 deaths per 100,000 live when in labour. Providers joke that this is an births,9 while the UNDP Development Report 2003 alvara´ de vire-se (license to look after yourself) gives a (contested in Brazil) estimate of 260 per because often it does not secure anything.12 100,000.10 Most maternal deaths were in women Frequently, their first choice of hospital is full who had had antenatal care. Hypertensive disor- and women have to go looking for a bed on ders in pregnancy and haemorrhage are the most their own, sometimes to more than one hospital. commoncausesofdeath,followedbycomplica- A study in the city of Sa˜o Paulo in 2002 found tions of unsafe abortion.6 that among low-income women, 76% had had Inequality is a significant characteristic of to go to more than one hospital during labour health care in Brazil, with social, economic and to find a bed – 61% went to two institutions and regional parameters. Brazilian women can be 15% to three or more.13 For women with high- divided into the more affluent 30%, who have risk pregnancies, this ‘‘pilgrimage’’ to find a 101 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 bed can be lethal; in Sa˜o Paulo, 55% of mater- The conveyor-belt approach: risking nal deaths occurred during or shortly after a women’s safety and bodily integrity 14 woman’s search for a bed. A third problem is that the shortage of beds is Several public initiatives have taken up this used to justify interventions not based on evi- problem in the last decade. In 2000 the Ministry dence. Thus, many doctors think that labour of Health launched the Programme for Human- should be induced to free up beds, especially in isation of Childbirth and gave health authorities public hospitals. in several cities incentives to find solutions to this problem. In Belo Horizonte, the third largest ‘‘Leaving women for too long in a bed during city in Brazil, since 2002 each of the nine health labour is a waste of space and limits the number districts has its own reference hospital. Women of cases we can attend to. That is the reason why from that district go directly there and if the they have to induce all deliveries.’’ (Medical hospital is full, the hospital has to find a bed resident, Sa˜o Paulo)7 elsewhere and take the woman there. Anecdotal evidence indicates that most women, but not all, ‘‘I compare this to a construction site: you now find a place or are taken to another hospi- cannot stop. You cannot go by the book, nor wait for nature to act. I put everybody on pitocin.’’ tal. However, women now complain that their 6 choice is limited as they have to go to the local (Obstetrician-gynaecologist, Rio de Janeiro) ˆ hospital whether they like it or not (Dr Sonia Apart from the medical risks, induction and ac- Lansky, Maternal Mortality Committee, Belo celeration of labour are considered very painful Horizonte, personal communication, 2003).