Report from Rio January 21st, 2009 Posted by Abby Epstein in C-Sections, Hospital Birth ⋅

By all outward appearances, Rio de Janeiro (and Brazil in general) is amazingly baby-friendly. At the airport, there is a special line for families with children and pregnant women, there are little baby seats attached to the luggage carts when you collect your bags, and on domestic flights there is one bathroom reserved just for women which is very clean and large. (Can you imagine such civility in US airports?) The beach in Rio has special baby-friendly areas with shaded diaper stations and roped-off play centers. Pregnant women proudly stroll the beach at full term wearing tiny little bikinis and new mothers breastfeed everywhere in public. The entire culture is pretty much baby-crazy and everyone stops you on the street to peer into your stroller and offer some unsolicited advice. But what is most amazingly un-baby friendly about Rio is that a recent medical report shows that Rio’s middle class boasts a cesarean rate of 93%. Yes, that’s right - 93%.

Three years ago, during the filming of BOBB, we did some shooting in Rio because this statistic was so staggering that we felt it might be an interesting harbinger of things to come in the US. It was also practical to film in Rio as my partner (and our Dir. of Photography) Paulo is Brazilian and we traveled there regularly. After a test screening of BOBB a month before the Tribeca Film Festival, we decided to pull the short segment on birth in Brazil because it felt out of place within the scope of the movie. But for our upcoming DVD, we thought it made sense to complete some filming in Rio and include it so Paulo and I brought the camera with us for the holidays and re-visited the birth scene in Rio.

On this trip, I was still amazed and shocked talking to OBs and local women about the Cesarean phenomenon. Essentially, what one doctor explained to us is that are “two Brazils”: He placed the overall c-section rate for the poor and those giving birth in public hospitals at just over 30%, the same as most other industrialized countries. (I had read it was closer to 40% and another doctor we interviewed in Rio said the public hospitals in Rio had a C-section rate closer to a 50%.) The “other Brazil” is the middle and upper classes, many of whom give birth in private hospitals. One OB/GYN we talked to estimated the c-section rate for the middle class at 65%-85%, but another doctor laughed at this and told us about a recent study which confirmed the C-section rate among the middle class at 93%.

It´s not difficult to see how the Cesarean became part of the culture for the middle class in Brazil. Firstly, many of these women have mothers who come from lower class backgrounds and gave birth to a large number of babies with no access to anesthesia. Thus, there is a huge fear of the pain of birth and an oral tradition passed down about how tortuous it is. Most of these mothers prefer that their daughters birth via c-section to avoid the suffering they experienced. In fact, many women we spoke with in Rio felt that even the option of an epidural was not sufficient insurance against the pain, but the c-section guaranteed that they would deliver the baby prior to the first twinge of labor. Initially, the doctors were blamed for this soaring c-section rate as it benefited them financially to schedule the majority of their patients. In this way, they could perform more births, still hold office hours in their private practices and avoid the bad Rio traffic and long hours involved in a spontaneous labor. One major difference in Rio is that the private OB/GYNs all work in solo practices and their patients demand that one-on-one care and continuity. It would be unthinkable to have your prenatal care with one OB/GYN and have a stranger attend the birth. So the private OB’s don’t take vacations and they cannot miss any births as they have no partners, no group of physicians backing them up as is common in the US. The situation is the same for the pediatricians in private practice who are expected to attend their client’s births. So you can imagine that the chances are next to zero that a woman could go into spontaneous labor and expect that both her chosen OB/GYN and pediatrician would be available to attend the delivery.

But the doctors are no longer held totally responsible for this escalation of C-sections, as now it seems that women’s preferences are a huge contributing factor. As one doctor told us, “It has now become cultural.” Most women we spoke to do not believe that there are any risks in a surgical delivery and that it is safer than a vaginal delivery. Since few families in the middle class intend on having more than two children, there is no fear of the risks of multiple repeat sections. One older OB/GYN we interviewed who has been in practice for 30 years finds the situation very sad but feels that his patients put him in a corner when it comes to vaginal deliveries. He said that even though he warns expectant mothers that a Cesarean is major surgery and that a vaginal delivery is safer, his patients make it very difficult for him to deliver babies vaginally. Firstly, he claims they insist on “being exactly the same as before the birth” and are terrified of losing any vaginal elasticity or pleasure. Secondly, they refuse to allow him to use forceps if necessary. (Strangely, they don’t have big issues with episiotomy but they don’t want the baby damaged by forceps.) Lastly, even if they will attempt a vaginal delivery with an epidural, (he has a 100% epidural rate) they won’t tolerate a labor any longer than 10 hours so they will demand a cesarean at that point anyway. The OB feels that with this unrealistic criteria, it’s very hard for him to guarantee his patients a speedy, pain-free, vaginal delivery with no interventions like forceps. When I asked this doctor about the risks of a 93% Cesarean rate, like the recent article in USA Today that reported 37% of elective cesareans are performed too early, he replied that all his patients receive 4-5 sonograms so its virtually impossible for him to misjudge a due date. But one pediatrician we spoke to felt otherwise: He said he is always nervous when he attends a scheduled c-section and that babies develop at very different rates in utero. He was not convinced that a sonogram could indicate a baby is “ready” and felt much more comfortable being at a Cesarean when the patient had first gone into labor.

We did speak with one brave woman in Rio, Christina, who delivered two babies vaginally. The second child was almost 4 kilos (over eight pounds) so she was considered practically reckless by her peers! (She had received five sonograms during her prenatal care.) Christina loved her vaginal births simply for the fact that she was up and about so quickly. She knows that she cannot convince her friends or family to follow her example, so she doesn’t even try. Christina said out of her 15 cousins, she was the only one who “could” deliver vaginally. I asked why the others were not able to and she cited reasons like “one baby had a cord around the neck, another wasn’t in the right position, etc…” Apparently out of the 93% of elective cesareans, only 10-15% are medically indicated. One downside that Christina cited for her vaginal birth was that she went into labor on New Year’s eve - so although her OB/GYN attended the birth, her selected pediatrician could not be there due to the holiday. This, she said, was one of the “risks” of a vaginal delivery.

20 Responses to “Report from Rio”

January 24th, 2009 at 3:53 am
Catherine Williams says:
Where is the antenatal education? Where are the midwives? What is it like in the rural areas?

January 24th, 2009 at 10:41 am
Ashleigh DeVolder says:
This is so interesting. How incredibly sad that the women of this culture feel they have no options. I’d be very curious to know the infant/mother mortality rate in Rio.

January 24th, 2009 at 4:38 pm
Magdalena Dudzinska says:
This is shocking. It seems that Brazil is full of women who do not trust or understand their own bodies.

January 24th, 2009 at 7:17 pm
Diane W says:
Having lived in Brazil (3 months) I have always wanted to go give back to the wonderful people I met there. I would love to be able to use my midwifery skills to help women there. If someone could pay my way, I’d gladly volunteer my skills…

January 25th, 2009 at 4:45 am
Jill-- Unnecesarean says:
I’ve read many times about South America’s myth of the “honeymoon vagina” and how c-sections are the key to keeping their partners happy. It makes me wonder at what point an unhealty trend shifts from being institutionally driven (at the behest of doctors) to culturally accepted, then desired and touted. I don’t think it’s always true that the “poor” will desire what the wealthier have. Ironically, of course, the less financially fortunate have it better in this case.

I’m glad this will make it into the sequel.

January 25th, 2009 at 2:40 pm
Michele says:
How can so many women having unnecessary major abdominal surgery be ’safe’? How can it be good for their bodies? Babies? So, they insist on “being exactly the same as before the birth”? Somehow I find it hard to understand this logic–especially how different your body is after major surgery–let alone pregnancy by itself.

I am glad you are going to include this in the new movie. I am looking forward to seeing it!

January 29th, 2009 at 8:32 pm
Wendy Cohen says:
Interestingly enough, a comparison can be made between why (in part) formula became so popular in the 40s and 50s in the states and the popularity of c-sections in Rio now. Economics…

February 6th, 2009 at 10:02 pm
JaneWhite says:
It’s interesting to compare this attitude toward c-section births to the way packaged foods are viewed in Africa. They are more expensive there, but they are often seen as better, despite being less healthy than fresh foods.

February 13th, 2009 at 3:30 pm
Lisa McBeth-Snyder says:
I’m not surprised though, as this goes with their philosophy about plastic surgery. It is doeumented that it is nothing for high school girls to get nose jobs or have breast implants. Their culture is about beauty and it seems that nothing else matters. They talk freely about all of their plastic surgery. My guess is that they can also have a tummy tuck, etc. while in surgery. I would love to know what their maternal and infant mortality rates are. I will have to go look that up.

February 13th, 2009 at 3:38 pm
Gigi says:
Well, dont be shocked at all. Try Athens Greece!
It is about the same in private hospitals.
I was appalled and vowed never to give birth there again! What a scam at the expense of women :(( So sad really……

We are in 2009, and suddenly the right of women to birth in peace, has become a distance freedom of the past………

February 13th, 2009 at 5:18 pm
Ruth says:
Fads in birthing and other customs come and go; the reason many women stopped using birthing stools and switched to laying flat on a bed was because a certain King loved to watch his women give birth and the only way to see the birth was if the birthing mothers were reclining. Forget the comfort and safety of the women; change everything for a voyeur!

I’ve had all three of my children at home; the last when I was 40 years old. My “bible” during those pregnancies was “Immaculate Deception” by Suzanne Arms. I am thankful for what you two are also doing in bringing light to a very important subject. Peace.

February 13th, 2009 at 6:12 pm
dewi says:

This is how it happens when we have a major cultural shift in beliefs and behaviour.

It’s been studied for years how the demand from women in Brazil is to give birth by cesarean. Very sadly I write I can see this happening in the future in the USA. I see it now shifting how mainstream USA is viewing c/sections as normal since almost half the population of births are by c/sections.

I’ve been part of the alternative birth community since 1991 (I’m a past ICAN group cofounder) and the statistics for cesarean births have grown higher each year in the USA, we have a crisis here, and it gets worse. All of us in the birth community have been trying to change the culture and it has had NO effect, as the culture has shifted away from natural birth.

Almost all the cesareans in the USA are still coming from the doctors and institution imposing policy. Thankfully it is not the demand of the pregnant consumer in the USA to have all those Cesarean.

But for how long will it remain institution driven.

At the rate the USA is going will take a decade or so for the shift to happen here?

Just 25 years for this whole shift to happen in Brazil from 40-50% Cesareans in the 1980’s to all women demanding to give birth surgically.

Sorry for such a depressing outlook!
I hope I’m wrong!

February 13th, 2009 at 6:38 pm
Wendy says:
What are the actual numbers? I am wondering if there are a lot of poor and very few middle and upper class women and if so, if that brings the numbers of women who actually have C-sections down to a more believable rate? I am having a hard time believing the percentage.

February 13th, 2009 at 7:32 pm
The Family Journey » 93% Cesarean Rate - Yep, you read that right. says:
[...] out this post on the Business of Being Born blog regarding Brazil’s birth culture. Posted in Activism, Breastfeeding, Cesarean birth, Childbirth, National/International News, [...]

February 14th, 2009 at 10:31 am
Silvia says:
Hi, I thought I could make some points here, since I’m Brazilian and I gave birth in Rio twice - first a vaginal birth with all possible interventions, then a natural birth at a hospital.

Here it is very hard to find an OB who actually goes through with the promises of a vaginal birth. Most do say that it’s what’s best for women, but in the end most of them will find an excuse for a c-section. So, if you want a vaginal birth, you have to look hard for a professional who truly believes that nature has the best way of doing things. These professionals are rare, unfortunately. And expensive. But worth every penny.

There are some support groups here for pregnant women who really want to give birth naturally. A few professionals and other women talk about the trends, talk about the situations where a c-section is actually needed (doctors love to use the “cord around the neck” card to cut their patients open), and how to test your doctor to see if he/she is truly in favor of vaginal births or will rather come up with an excuse for a c-section at week 38.

But one item I believe doesn’t correspond to our reality here is the fact that women choose c-sections because they want to preserve vagina integrity. I have many friends who have had c-sections (well, most of them, actually, unless they are friends from the support group), and there are two things I can say: most wanted a vaginal birth from the beginning; and none of them has chosen a c-section because they wanted their vaginas preserved, but because the doctors led them to believe that the baby’s health was at risk.

So, although the c-section is sadly a cultural thing, women here are not that shallow, and they end up having c-sections because they believe that they are, rather than preserving their vaginas, preserving their babies’ lives.

February 15th, 2009 at 2:13 pm
Sharla Grossman says:
With affluency comes choice…as with alot of cultures who have become more fiancially affluent than just a generation or two ago, there is the perception among its members that if a product or service was out-of-reach financially for their poorer predecessors, it is a sign of upward mobility to “indulge” onself in that product or service. That’s what is happening, and I also believe this mindless indulgence is just oe more sign of the vanity that the Brazillian culture is awash in. The surgical excision of an infant is not “giving birth”…I had 2 vaginal births, was bullied into a c-section by an on-call doc I’d never met, and have since had 2 VBACS. My last baby, who was born 11 months ago, had the same “complication” that the c-section baby had: coming out face-first, facing up. The difference is, the doc I had in 2008 reached up and turned the baby manually and she was born at 9lbs 2 oz without me tearing or needing to be cut (I am a squatter, not a sirrup-user, and go drug-free.) Her cord was wrapped multiple times around her neck the same as her brother’s, but the doc put a finger between her neck and the layers of cord and she never lost a moments oxygen that we could tell. (Is she neurologically sound? She rolled over at 5 weeks by hyperextending her neck backward and throwing her weight sideways in order to sleep on her tummy…and is consistantly ahead of the curve for age-appropriate development.) I live in chronic, daily pain with every single movement that involves the use of the abdominal area because of the c-section. I had to retrain myself (self-taught physical therapy) how to do everything from rolling over in bed to rising from the tiolet or a chair.) I cannot imagine how the women who comprise that 93% tolerate the levels of pain that c-section recovery entails. Do they not realize that with a vaginal labor and delivery you have pain first then its over, but with a surgery the pain may never go away completely?
While I applaud the family-friendly, baby-lovin’ Brazillian society, it is a sad and sorry state of affairs when a culture defies well-researched, documented support for what the female body is designed to do for superficial beauty.

February 16th, 2009 at 12:24 am
Kimberly Johnson says:
I am an American citizen who lived in Rio during my pregnancy and birth. I chose to have a homebirth as I was aware of the Cesarian rates, aware of my mother’s long gestation period, and had always envisioned a homebirth. Homebirth is far more unusual in Brasil than the US, unless you live in the Amazon or a remote area where hospitals are not accessible. I worked with Heloisa Lessa, the Brasilian midwife who appears in the film.

While I agree with most of the characterization of the article, the main influence for the Brazilian women was the cultural of fear around the pain of birth. I interacted with many pregnant women, including friends. Brazilians are known to be candid specifically around sex- no one ever mentioned what one previous poster referred to as a “Honeymoon vagina.” Women mostly talked about the pain, how they did not have the “passageway” (”nao tive passagem”) and that the cord was wrapped around the babies neck.

To characterize Brasilians as superficial is also to mischaracterize. Just like American women have been indoctrinated into identifying with the pain of breastfeeding, Brasilians have been indoctrinated into identifying with the pain of birth. Therefore, many more Brasilians have Cesarians, but far fewer Americans breastfeed.

Women mostly talked about the pain, how they did not have the “passageway” (”nao tive passagem”) and that the cord was wrapped around the babies neck.

The medical system is much more patriarchal there. People do not question the authority of the doctor, as we might be inclined to here.

I was in a prenatal yoga class with 8 women, which seemed to me a propaganda session for natural birth. I felt like I was inundated by information (that I was already exposed to) Everyone in that class was there because they wanted a natural birth and they had the information, and had chosen a doctor they felt was receptive to natural birth. In the end, only two of us had even vaginal deliveries. 6 Cesarians- every one of those women believed they needed it and offered one of those two reasons (no passageway, or the cord was around the neck)

I will be writing more about this and my experience giving birth in another culture in mindful mama magazine, that launches in March.

February 19th, 2009 at 6:59 pm
Lynn Reed says:

February 19th, 2009 at 7:05 pm
Lynn Reed says:
Have you not seen BORN IN BRAZIL? It is an amazingly well produced DVD documentary about this very subject.
You should check it out.
It was doen by Firefly Films.
We showed it at our BABE Film Festival in Augusta, GA & Columbia, SC
Very real & raw. I highly recommend it.

February 19th, 2009 at 7:14 pm
Lynn Reed says:
My daughter just came back from Peru to study Birth in The Upright Position in Cusco, but the govt had just closed down the birthing clinics and she told us that everyone was getting C-sections in the hospital she volunteered in. It is awful. She said about the birthing mothers “all I could do was to try to save alittle of their souls”.

We best WAKE UP!!! We know it is up to 40% and higher in Georgia. Some OB’s rate is 100%- no joke!

I find that my primary job now has become to talk women (who have just found out they are pregnant) ot of a C-section.

The Prenatal Scare or”Predatory Care” that women are receiving is appaulling.

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I am 29 weeks pregnant living in Rome, Italy where the cesarean rates here are above 30%. I believe it's the third after Brazil and the US for cesareans in the world. I have met many mothers who have had c-sections and in fact my first OBGYN had come back to work about a month after a cesarean. This is my first pregnancy and I am a healthy, active 30 year old. I initially asked my provider about her c-section rate and how often she does them. She said it depends on the health of the baby and that in the end, natural labor can lead to vaginal and bladder problems. I knew I needed to find another doctor at that moment. Italy is similar to Brazil in the way of private clinics. There is a much higher rate of c-sections in clinics than in hospitals. I think the main reason for the higher rate is that cesareans pay more to the doctor, they are more convenient and I believe pain isn't tolerated here either. Women aren't educated about their bodies and what is normal during labor and what is unsafe. Generations before tell horror stories about terrible labors and so it scares women into thinking they cannot do it. Italy is also very similar to Brazil in the way of catering to pregnant women and also adoring babies and children. I have found a doctor that I like and will be giving birth in the public hospital. I'm hoping that my wishes will be honored but I think at the time of labor, the moment someone says your baby's health is at risk, you do whatever you can to save your baby. I also have the language barrier here. I'm hoping for the best and hoping to avoid a cesarean. I just wanted to explain that it isn't only Brazil and the US, Italy is also very high.



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