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PAPERS: Joseph E Potter, Elza Berquó, Ignez H O Perpétuo, Ondina Fachel Leal, Kristine Hopkins, Marta Rovery Souza, and Maria Célia de Carvalho Formiga Unwanted caesarean sections among public and private patients in Brazil: prospective study BMJ 2001; 323: 1155-1158 [Abstract] [Full text]

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A change of public opinion about caesaren sections in Brazil

Luis G A Quadros   (16 November 2001)

From the Wall Street Journal about c-sections in Brazil

Leilah McCracken   (17 November 2001)

What obstetricians don’t do.

Rudiger Pittrof   (22 November 2001)

Brazilians are overdoing the Caesareans

Sharad Shinde   (25 November 2001)

A change of public opinion about caesaren sections in Brazil 16 November 2001
Luis G A Quadros, Researcher, Gynaecology Department Federal University of São Paulo, Brazil Send response to journal: Re: A change of public opinion about caesaren sections in Brazil	When I wrote a letter to BMJ, published in April 2000 (Caesarean section controversy - BMJ 2000;320:1072), I wanted to point that the high rate of caesarean sections (CSs) in Brazil reflected not only the obstetrician’s decision, but also the pressure that some patients and relatives put on Doctors, due to the “general belief” that a CS would be better for both the mother and the child. As an Obstetrician that worked “on call” I have been many times pressured to perform a CS by an anxious patient‘s mother, father or husband. The consequence is that, by convenience many private Obstetricians are performing unnecessary elective CSs. The biggest maternity of São Paulo publishes each month that around 80% of the 1000 (one thousand) deliveries are CSs. In medical congresses, Professors try to convince the doctors that CS is NOT better than vaginal delivery in most situations, but it doesn’t seem to change the current practice. But recently I have noticed a change in this scenario: many patients are searching Obstetricians that are willing to conduct a vaginal delivery, because their are becoming aware that CS is not, in most cases, the best solution. This has been confirmed in this week’s paper (Unwanted caesarean sections among public and private patients in Brazil: prospective study Joseph E Potter, Elza Berquó, Ignez H O Perpétuo, Ondina Fachel Leal, Kristine Hopkins, Marta Rovery Souza, and Maria Célia de Carvalho Formiga BMJ 2001; 323: 1155-1158). So I think that the best thing to do is give detailed information to the population, allowing them to make an “informed decision” about what kind of delivery they want, so the will not allow the doctors to perform unwanted CSs.
From the Wall Street Journal about c-sections in Brazil 17 November 2001
Leilah McCracken, childbirth researcher, writer Vancouver, Canada V5Z 2B6 Send response to journal: Re: From the Wall Street Journal about c-sections in Brazil	Two key elements that were only touched on in the paper by Potter et al. (BMJ, 2001) can be brought fully into the light by the Wall Street Journal article: "Routine Surgery: For Brazilian Women, Caesarean Sections Are Surprisingly Popular" (Miriam Jordan, Wall Street Journal, June 14, 2001). First- just how significantly cesarean section contributes to maternal mortality and infant morbidity, and second- the personal motivations physicians have in scheduling cesarean deliveries. From the Wall Street Journal: "In Brazil, the death rate among all women who gave birth by Caesarean in 1998 was five times as high as for those who delivered vaginally, according to the health ministry. Babies born by Caesarean are also more likely to suffer problems such as respiratory distress syndrome, a major killer of newborns." The article also speaks of a mother's chronic pain and infertility after her arguably needless (argued by Marsden Wagner, MD) cesarean section; the mortality and morbidity because of cesarean section is unacceptably high. "...the popularity of Caesareans remains entrenched at Brazil's private hospitals. One reason: Doctors in the private sector are still typically paid per procedure, and they can deliver many more babies by Caesarean than by normal means on any given day. Medical advances have reduced the time it takes to perform a Caesarean to as little as 25 minutes, from at least 70 minutes two decades ago. 'Even a monkey can be taught to do a Caesarean,' says Teresinha Cantarim, an obstetrician in Sao Jose do Rio Preto, a small city about 250 miles northwest of Sao Paulo that boasts the country's highest Caesarean rate." The medical efficiency and profitability of cesarean section as a matter of course will influence physicians' preference for this "barbarous" (Jose Serra, Brazilian Health Minister) mode of delivery. To read the full text of this Wall Street Journal article, go to- <http://www.birthlove.com/pages/activism/brazil.html> How does one reduce the number of cesareans in both private and public sector? One must go beyond the timid steps addressed by both the Wall Street Journal and the BMJ: a connected, well-informed women's movement. Healthy birth will not be delivered to women by physicians... women must claim normal childbirth for themselves- and demand their autonomy be respected. Leilah McCracken www.birthlove.com
What obstetricians don’t do. 22 November 2001
Rudiger Pittrof, SpR GUM St George's Hospital, London, SW17 0QT UK Send response to journal: Re: What obstetricians don’t do.	Editor Patients' choice may be an obvious argument to defend the high rate of caesarean sections in Brazil. Potter and colleagues (2001) show that we may not have this easy escape hatch available to us. They also present data indicating that multiparous women who delivered within the public sector and were certain that they did not want a caesarean section were not at particular high risk (8.5%) of undergoing one (this was provided that they had no previous caesarean section). This suggests that women who know from their own experience that they can deliver vaginally have a low caesarean section rate. The causes of the high caesarean section rates in the public sector may be less related to what obstetricians do than to what they don't do: encouraging women to believe in their ability to have a vaginal delivery. Potter JE, Berqus E, Perpituo I H O, Leal OF , Hopkins K, Souza MR, de Carvalho Formiga M C. Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ 2001; 323: 1155-115 Rudiger Pittrof, St George's Hospital, London, UK, Specialist Registrar in GUM, and London School of Hygiene and Tropical Medicine, Honorary Lecturer in Maternal Health, email: rudiger_pittrof@hotmail.com Vironique Filippi, London School of Hygiene and Tropical Medicine, London, UK, Lecturer in Maternal Health, email:veronique.filippi@lshtm.ac.uk
Brazilians are overdoing the Caesareans 25 November 2001
Sharad Shinde, Senior Gynaecologist in a private hospital Mumbai India 400 053 Send response to journal: Re: Brazilians are overdoing the Caesareans	I am a practising gynaec in Mumbai India for the last 25 years. The C Section rates in Brazil were indeed SHOCKING to say the least. We In Mumbai (India) have A private Clinic C Section rate of about 25 to 30 % . Public hospitals have rate between 15 to 18 %. I will be happy if any Brazilian Gynec could explain the reasons for such a high C Section Rate.