Suzana Silva de Sousa was just three months pregnant when her doctor tried to schedule a cesarean section. De Sousa, 29, asked about a natural birth, but he pushed her towards the C-section surgery.
"I had a natural birth in mind, but I had no idea how hard it would be [to find a doctor]," de Sousa told me in Sao Paulo. "The easiest path was surgery, and that's not normal," she said.
De Sousa is one of thousands of Brazilian women fighting for greater access to natural births in what has become the C-section capital of the world. Here 80-90 percent of women in private hospitals, and 40 percent of women in public hospitals opt for the surgery, versus 32 percent in the United States and 9 percent in England. Compare that to the World Health Organization recommendation of 15 percent. The WHO warns that unnecessary C-sections can harm both the mother and baby. Not to mention they can rack up unnecessary health bills.
But that trend may finally be starting to change. Doulas and home births are becoming increasingly trendy and the Brazilian government has been pushing hospitals to increase their natural birth rates.
Despite a decreasing mortality rate, Brazil ranks alongside Congo and Nigeria as producing the largest number of premature babies in the world. The number of babies born prematurely in Brazil has nearly doubled over the last decade, to 11 percent of all births, according to a 2012 study by the World Health Organization. Researchers see a link between c-section rate and the rise in premature births.
In a country where women regularly undergo plastic surgery, C-sections have become a commonplace status symbol. Luxury hospitals offer everything from manicures to massages and happy hours following the surgery. But while many mothers have been taught to prefer C-sections, the health system does too. Doctors favor the procedure, which is more profitable and allows them to schedule back to back deliveries. Vaginal births cost on average $300 in Brazil, while C-sections can go for as much as $5,000, according to the Brazilian Medical Association.
Low-income mothers like de Sousa have even fewer options when it comes to delivery without surgery. In public hospitals, queues of women waiting to give birth can drive doctors to medically speed up deliveries and rush the process. The popularity of C-sections has also meant that fewer doctors have experience delivering children in any other way. Meanwhile, home births and doulas, increasingly popular options, are expensive and not covered by insurance.
So when de Sousa came across Casa Angela, a natural birth clinic on the outskirts of a favela in Sao Paulo, she knew it was the right place for her. The non-profit clinic, which caters to low-income women, emphasizes minimal interference from doctors. Each room comes equipped with bathtubs, yoga balls and monkey bars to help speed up delivery. The center also offers workshops on breastfeeding, prenatal yoga and welfare referral services.
"Low-income women going through a natural birth in a Brazilian hospital can be emotionally, culturally and physically isolated," said Anke Riedel, a coordinator at the center. "They often have less self esteem and don't know their rights when it comes to births."
Casa Angela is the only clinic of its kind in Sao Paulo, a city of 20 million people. Its services proved so popular that Brazil's upper class women showed up at the center a few years ago, asking to deliver their babies there as well. Today, half of the 400 women who deliver at Casa Angela every year are low-income and pay nothing for their deliveries. The rest pay on a sliding rate with prices up to $2000—the full cost of a birth for the clinic. The clinic is funded partially by the government and partially through private donations.
Brazil's government has now decided to support this shift. It is trying to expand the number of women following de Sousa's path. In an effort to curb what it called a "C-section epidemic" and prevent premature births, Brazil passed a law in June requiring women to sign consent forms acknowledging the risks of a C-section before going into surgery. The government also launched a partnership with 26 hospitals called to promote vaginal births. Since the start of the project one year ago, vaginal births increased by 76 percent and complications during birth in three of the hospitals fell by half. The project is now expanding to 150 hospitals around the country.
But critics say outspoken mothers and government pressure hinder doctors' abilities to use their expertise to decide what's best for the patient.
"It puts the doctor in a difficult situation and interferes in the process of delivery,"said Dr. Gutemberg Fialho, president of the Medical Union of Brasilia. "The government wants us to push for natural birth, but what ends up happening is that if you avoid interfering until the last minute, it can lead to complications or even death for the baby."
Last year a baby died in central Brazil because the mother insisted on a natural birth despite the doctor's objections. Following the incident, a court ruled that doctors were responsible for deciding on the final birthing plan. "It reinforces a doctor's autonomy. Even if the parents want a natural birth, the doctor is not bound by their decision," the Governor Valadares Association, one of the country's oldest doctor's unions, said in a statement.
But more Brazilians are still starting to believe that women should have more control over how they give birth, even if it's inconvenient for their doctors.
"This has really been a movement started by mothers," said Jose Moacir, a doctor at the clinic. "Women are taking the issue into their own hands and demanding that doctors rethink their practice."
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