For Immediate Release:	January 5, 2001
Sponsor Organization:	Population Council
RESEARCHER INTERVIEWED HUNDREDS OF WOMEN POSTPARTUM
Brazilian doctors frequently use their medical authority to persuade women to “choose” delivery by cesarean section, according to research reported in the current issue of the Population Council’s quarterly newsletter, Population Briefs. The article, which examines why so many Brazilian women choose cesarean deliveries, was based on research conducted by Kristine Hopkins and published in the September 1, 2000 issue of the journal Social Science & Medicine. Hopkins observed several deliveries and conducted postpartum interviews with 321 women in two public and two private hospitals in Pôrto Alegre and Natal. While scholarly articles on the high rate of cesareans in Brazil usually discuss the motivations of both doctors and women, Hopkins’s study also focuses on the power differences between the two groups in terms of decisionmaking. Her study refutes the assumption that Brazilian women request cesarean deliveries to avoid the pain of vaginal delivery. “Doctors clearly have more decisionmaking leverage in the delivery room,” says Hopkins, currently a research fellow at the University of Texas at Austin. “There is a misconception that women request surgical deliveries, but in many cases the decision is driven by the doctors.” Significance of cesarean deliveries Brazil has one of the highest cesarean rates in the world, with more than 36 percent of all births by cesarean section; many private hospitals report rates in the 80–90 percent range. Articles in the Brazilian popular press typically portray women as actively choosing to deliver surgically. Doctors maintain that women prefer cesarean delivery because it allows them to avoid the pain of vaginal delivery, they recover their figures more quickly, they do not jeopardize future sexual functioning, and they believe it is safer for the baby. Some observers claim that doctors in Brazil prefer cesareans because they make more money and work shorter hours by doing them. As compared to vaginal deliveries, cesarean section deliveries are associated with increased maternal death, injury, and infection. In some cases, scheduled cesarean sections can result in babies being delivered prematurely, with less than fully developed lungs. Furthermore, cesarean deliveries are more costly than vaginal deliveries and require longer hospital stays, Hopkins notes. Delivery choice vs. delivery outcome Hopkins found that nearly three-quarters of first-time mothers in private hospitals initially wanted to give birth vaginally but ended up delivering surgically. In public hospitals that figure reached 80 percent. Three-quarters of women in the private hospital sample who had given birth previously had undergone cesarean section to deliver their last child. However, despite a widespread belief in Brazil that once a woman delivers by cesarean she must always deliver by cesarean, one-third of women with a previous cesarean said that they wanted to deliver vaginally when they entered the hospital. While roughly two-thirds of the women in both public and private hospitals believed that a vaginal birth is more painful than a cesarean section, three-quarters of the women said that cesarean section is very painful after the delivery. Only 22–30 percent of women surveyed believed that cesarean section was safer for the baby, and only 14–18 percent thought the surgery was safer for them. “These results call into question the assumption that women who deliver in private hospitals overwhelmingly clamor for cesareans,” says Hopkins. In the labor room Hopkins witnessed some telling moments during her observation of deliveries. Women in labor frequently cried out, “Oh, I can’t stand it any more.” Doctors’ reactions to this exclamation varied. In public hospitals, doctors calmly ignored women crying out or patted them on the shoulder and told them it would be over soon. In private hospitals, however, doctors complained of pressure put on them by patients expressing their pain. In one instance when a patient cried out, the physician turned to Hopkins and said, “You see? That kind of thing is subliminal. We suffer pressure. Psychological pressure.” “Doctors’ behavior in public hospitals shows that they can resist women’s pressure to perform a cesarean,” counters Hopkins. “Moreover, a cry of pain is not a request for a cesarean.” The Population Council is an international, nonprofit, nongovernmental organization that seeks to improve the wellbeing and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health research and helps build research capacities in developing countries. Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters supports a global network of regional and country offices.