Brasília, May 7, 2004 (Agência Brasil) - Of the 2.2 million childbirths performed in the Unified Health System (SUS) in 2003, 25% were cesarean sections. Although the trend in surgical deliveries is on the downswing in Brazil, the quantity is still greater than what is recommended by the World Health Organization (WHO), which claims "there is no justification for regional cesarean rates to exceed 15%."

This orientation by the WHO is an attempt to reduce the number of maternal deaths - in Brazil, 74.5 women in every 100 thousand births. This risk is seven times greater in cesarean births, according to studies conducted by the Latin American Center for Perinatology and Human Development (CLAP).

Another problem involves the cost of cesarean sections. According to WHO studies, this type of delivery adds considerably to the burden of female health care. In Brazil each cesarean winds up 32% more expensive for the SUS, which pays US$ 86.50 (R$ 263.49) for a normal childbirth and US$ 127.10 (R$ 387.50) for a cesarean.

Several other studies on cesareans have been done in Brazil. The National Health and Demographics Survey, carried out by the Brazilian Institute of Geography and Statistics (IBGE) in 1996, informs that 36% of the deliveries performed that year were cesarean sections. Of the total number of childbirths, 83% presented no difficulties, indicating that many of these surgical procedures were scheduled in advance or were unnecessary.

The analyses and studies cited by the researcher Elza Berquó in "Fertility, Reproductive Health, and Poverty in Latin America - the Brazilian Case," also bolster the argument that cesareans increase the number of deaths due to postnatal infection and anesthesiological risk. Nevertheless, there are still instances in which cesareans are the only childbirth option, as when the mother is suffering from a serious health problem, such as a cardiopathy or renal insufficiency, or when the child is undergoing fetal distress.

"The advantage of a cesarean section is being able to remove the fetus at the right moment, with greater speed, when there are difficulties in performing the delivery through normal channels; this is the primary reason for a cesarean. Before the existence of cesareans, women died, and children died, because it wasn't possible to interrupt the pregnancy at the right time," explains the physician Elenice Ferraz, head of obstetrics at the University Hospital of Brasília (HUB), at the University of Brasília (UnB).

The physician says she is in favor of every delivery's being normal, but she opposes the idea of non-hospitalization. "During the process of birth and the postpartum period, grave complications, such as uterine hemmorhaging, can occur. This can be fatal, if you're in a place without a blood bank or a surgical center with a doctor able to stop a uterine rupture. Besides the complications that can happen to the baby," Ferraz warns.

But she is also against the idea that a delivery should be cesarean just because a woman doesn't want to experience pain or because her doctor doesn't want to waste time on labor. "The indication of a cesarean should be responsible."

MATERNAL AND NEONATAL MORTALITY

Making the birthing process more qualified and humane is one of the steps proposed by the Ministry of Health to reduce the indexes of maternal and neonatal mortality in Brazil. Recent statistics show that 74.5 women die in every 100 thousand live births. In the case of infants, in every thousand live births, 18.3 die before completing a month.

To alter this situation, in March the Ministry launched a national pact to decrease the current indexes of maternal and neonatal mortality by 15% by the end of 2006 and 75% by 2015.

A reduction in the number of cesareans could also be an alternative. According to the WHO, the lowest rates of postnatal mortality occur in countries in which cesarean births represent less than 10% of the total. In Brazil, where there is an average of 2.5 million births every year, according to the IBGE, and around 89% of them take place in establishments that are part of the SUS, the majority of maternal deaths are the result of hypertension during pregnancy, hemorrhages, infections, and abortions.

BIRTHING HOUSES

The diminution of maternal and infant mortality has another ally in Brazil. A recent experiment is modifying the pattern of female health care during childbirth. These are the so-called "Birthing Houses," regulated by the Ministry of Health through an administrative decree issued in August, 1999.

One year later, in the Federal District, the local government inaugurated the Saint Sebastian Birthing House. Set up to operate as a pilot project, the unit is located in one of Brasília's poorest satellite cities. An average of 70 deliveries are performed each month.

The place doesn't resemble a hospital. The walls are painted beige, and many of them are decorated with wallpaper, paintings of flowers, and posters explaining the benefits of breast-feeding. In the delivery room, a special bed allows women to choose the best position to give birth. The room also has an air conditioner, a ball for pelvic massage (which helps to position the baby), music, and space for a companion.

Cláudio Albuquerque, an obstetrician who is the head of Gynecology, relates that the idea of birthing houses arose in order to lighten the burden on large health centers and humanize childbirth. But these units only perform low-risk, normal deliveries, that is, ones that developed well during pregnancy and are at the right moment for the birth to occur. "For this reason the Ministry of Health determined that the birthing houses should be no more than an hour away from a reference hospital, where high-risk births are sent," he informs.

Besides the setting, another big difference between birthing houses and traditional maternity wards is the way expectant mothers are treated. "They receive special attention, are examined every half hour prior to delivery, and when the baby is born, it goes right to its mother's breast," the physician explains. He remarks that one of their objectives is to include the assistance of "doulas" (birthing companions) at the moment of birth. "In our case, they are volunteers from the community itself," Albuquerque adds.

Translator: David Silberstein