To Push or To Cut? Decision-Making in Childbirth Amid the Brazilian Cesarean Epidemic

Abstract

Policies to lower the rising cesarean section rate in Brazil are hotly debated. Brazil has one of the highest cesarean birth rates in the world, with 55.6% of all births delivered by cesarean section, and 84% of births in the private system. Although cesarean sections can be life-saving procedures when medically indicated, unnecessary cesareans impose significant health risks to both mother and baby. Government officials and scholars assert that the Brazilian "cesarean epidemic" does not seem to be related to changes in obstetric risk, but to socioeconomic and cultural factors. In this thesis, I use a mixed-methods approach to analyze decision-making in childbirth to investigate what influences culminate in the final form of delivery in Brazil. During two months in São Paulo, I conducted 15 semi-structured interviews with mothers, OB-GYNs, midwives, doulas, public health researchers, and activists. To complement this qualitative data, I analyzed childbirth data from the national survey Birth in Brazil for a population-wide view. The interviews reveal that many women received unwanted cesarean sections, whereas the physicians I spoke with claimed that women were demanding more cesarean sections. The data clarifies this contradiction by showing that the majority of women prefer natural birth at the beginning of pregnancy but are not always included in decisions about mode of delivery. Decisions to undergo cesarean sections often go against the initial desires of women and are most strongly driven by physicians. Previous and current policies by Brazil's Ministry of Health largely focus on providing consumers with knowledge on the risks associated with different forms of childbirth deliveries. However, such approaches do not address the apparent tension between women and physicians in deciding on the final form of delivery. To lower Brazil's cesarean birth rate, future policies should regulate physician influence towards cesarean sections and ensure that women have more autonomy in the decisions concerning their own childbirth.