Demand should be assessed rather than inferred

EDITOR—Several recent papers present evidence that in Brazil consumer demand for caesarean sections is much lower than previously assumed. 1 2 Langer and Villar3 state that the results reported by Béhague et al contradict these findings.4 We are surprised by this assertion.

Despite using the term consumer demand in their title, Béhague et al do not present an estimateof the demand for caesarean sections in the population they studied—mothers giving birth in 1993 in a medium sized city in southern Brazil. The only statistic that relates to demand is the proportion of a subsample of mothers (32/80) who stated that when they went to the hospital they expected to deliver by caesarean section. But the type of delivery that a woman expects may not be the type of birth she would prefer, especially in the private sector, where most caesareans are scheduled.

Also puzzling is Béhague et al's failure to distinguish their sample by sector of care. Studiesin Brazil and elsewhere have shown dramatic differences in caesarean section rates depending on whether the woman delivered in the public sector (rate of 25-30%) or private sector (rate of 70%).5

Our most striking finding was that despite these large differences in rates there were no significant differences in women's …