Alexis Jang

The New York Times
August, 2018

by Vanessa Barbara
Contributing Opinion Op-ed Writer

SÃO PAULO, Brazil — It takes determination to have a normal childbirth in Brazil, and I’m not talking about just getting through labor.

My country has one of the highest rates of cesarean sections in the world: In 2015, they accounted for 55 percent of all births. (By comparison, that same year, the United States had a C-section rate of 32 percent, while in Sweden, they accounted for just 17.4 percent of births.) Sure, C-sections are necessary and lifesaving in certain situations, like cord prolapses or placental abruptions. But according to the World Health Organization, once C-section rates climb higher than 10 percent, there is no evidence that they help reduce maternal and newborn mortality; on the contrary, the surgery can lead to significant complications, which is why the W.H.O. recommends it only be undertaken when medically necessary.

That’s definitely not the case here. In Brazilian private facilities, C-section rates are even higher than in public hospitals, reaching 84.6 percent. The procedure is more profitable for these institutions, which must think about money, and more convenient for doctors, who don’t have to wait hours for the natural processes of labor to unfold. And so, C-sections are routinely prescribed under an endless number of pretexts, many of them as implausible as: placental allergies, asthma, scoliosis, gingivitis, an excessively hairy baby, a soccer match between Atlético and Cruzeiro, and — most creative of all — the assumption that evolution made the female body incompatible with labor.

Surgery is the rule; vaginal childbirth is the exception.

So when I expressed my desire to let nature take its course ahead of the birth of my daughter two months ago, my ob-gyn told me she would assent “only if everything goes perfectly until the due date.” She didn’t seem to notice that her logic was inverted — natural labor should be the default unless something goes wrong — but perhaps that was to be expected from a physician who, according to insurance records, has an 80 percent C-section rate. When I asked why she hadn’t overseen more vaginal births, she said that nowadays, most of her patients face complications in their pregnancies. Brazil, it seems, is the land of statistical anomalies.

Those of us who want a normal delivery must often resort to small birthing centers with a staff of midwives and nurses, where epidurals are usually not available, or to public hospitals, where, according to a study by the Brazilian think tank Fundação Perseu Abramo, women are more likely to suffer obstetric violence — that is, physical, sexual, and verbal abuse from medical staff during labor. A third option is to hire a whole “birth team” of out-of-network professionals (composed of an obstetrician or midwife, a nurse, a doula, an anesthetist and a neonatologist) who attend to the patient at her home or in a private hospital. But most women cannot afford their fees, which hover around $4,000.

In any case, it’s necessary to prepare beforehand — I, for instance, read the W.H.O.’s “Intrapartum Care for a Positive Childbirth Experience” — and write down a birth plan with one’s choices concerning labor and delivery. Mine contained demands which should be self-evident, such as the ability to move around freely during labor, to choose the delivery position, and to have my husband present in the delivery room, as well as a long list of potentially harmful, but nonetheless routine interventions that I didn’t want, such as pubic shaving, the administration of an evacuation enema, and the artificial rupture of membranes.

In my research I also learned that there is a lack of evidence for the effectiveness of a procedure called an episiotomy, a surgical incision of the vagina that is performed to, supposedly, protect the pelvic floor from lacerations. The procedure was widely adopted in the past, but has undergone a steady decline over the last four decades as studies have shown that it not only does not provide benefits, but might even contribute to more severe lacerations and pelvic floor dysfunction. But in Brazil, episiotomies are still performed in 53.5 percent of births.

So, when my ob-gyn said, “I do perform episiotomies, every time,” I decided to find another doctor. (She also said, “Nobody deserves a 12-hour labor, right?” even though I would have been fine with it.)

Instead of a whole team, I decided to hire only an obstetrician and a nurse, who would be complemented by the staff at the hospital. The contractions began on a Sunday morning, in the middle of the World Cup match between England and Panama. I was at home when I started to feel weird and spotted some blood. By the time Japan vsSenegal had begun, I was vomiting orange juice and frantically calling the nurse. At some point, I saw a black vulture landing on the roof of a neighboring building (seriously).

When the nurse arrived, four hours into the start of labor and many hot showers later, I was almost 8 centimeters dilated. We rushed to one of the hospitals in my insurance plan’s network (with a C-section rate of 88.8 percent), where they gave me a combined spinal-epidural block that made life beautiful again.

The next stage took seven hours of exercises, massages, and a few lindy hop steps to the sounds of “Fly Me to the Moon.” The hospital staff sometimes fell into the same routine procedures drilled into them by thousands of C-section births: The obsession with sterility, for example, was absurd. I clearly remember a nurse aimlessly trying to change a dirty sheet under me while I tried to concentrate on a contraction, even though there was already blood and vomit everywhere in the room. Later, they would check me over many times for surgery stitches that didn’t exist.

During the whole process, the hospital’s anesthesiologist wouldn’t allow me to eat or drink anything, just in case it turned out I needed a C-section. (A recent review by Cochrane, a global independent organization that produces systematic assessments of evidence on health care, found no evidence supporting this protocol.) Who could have guessed that without any food, enduring hours of labor would start to feel impossible and a cesarean would start to look like a sensible choice? Luckily my obstetrician smuggled in several cups of water and peach Jell-O, and that was how I managed to deliver my daughter, Mabel: with the help of anesthetics, exercise and Jell-O. It was almost midnight.

The fact that I could do this by myself, and then immediately hold Mabel in my arms and nurse her for an hour was a little miracle of its own in such a medicalized, paternalistic setting. It’s a shame that it takes so much effort — and money, and knowledge — for a woman to get what should be normal. A vaginal birth is, after all, the wish of 72 percent of Brazilian women at the beginning of their pregnancies; then so many of them are persuaded to have a C-section in the months that follow, sometimes only for the convenience of their doctors.

But when you think about it, this is not a surprise in a country where abortion is still illegal. On childbirth, as on so many other matters concerning women’s rights, everybody wants to have a say in what we should do. Here, the real miracle is a woman being heard at all.


Vanessa Barbara, a contributing opinion writer, is the editor of the literary website A Hortaliça and the author of two novels and two nonfiction books in Portuguese.

A version of this article appears in print on , on Page A23 of the New York edition with the headline: Land of the C-Section.