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Letters

Should women who elect to have caesarean sections pay for them?

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7190.1070 (Published 17 April 1999) Cite this as: BMJ 1999;318:1070

Rapid Response:

Cesarian culture

Dear Sirs,

I have just accessed the BMJ website and discovered the
articles and correspondence regarding the debate on cesarians and whether
women should be charged for a cesarian on request.

I am an anthropologist, and have spent the last two years researching
cesarian section in Vitoria, a coastal city in south east Brazil, where
the cesarian rate is currently around 25%in public hospitals, and around
98% for women who have access to private medicine (mainly through health
insurance schemes). The "cesarian culture" took hold in Brazil over thirty
years ago (in 1970 the cesarian rate was 20.2%).

The situation is very complex, and involves questions, not only of
the history of obstetric procedures, but also cultural questions, specific
to Brazil. However, I believe that some comparisons can be made.

1. all births are attended by obstetricians:

despite the tentative training of nurse midwives they

find it difficult to obtain employment

2. due to a long period of high cesarian rates,
obstetricians receive very little training and practice

in handling even marginally difficult vaginal deliveries and
choose cesarian as an "easy option"

3. doctors are now paid the same rate for both normal and

cesarian births, by both the public health system and private
health insurance schemes. However, they are not prepared to wait hours
for their patients to deliver when they can do a cesarian in an
hour.

4. cesarian has a certain status symbol. In a society which
places a high value on modernity and technology cesarian is equated
with these qualities, whereas normal birth is now seen as
"alternative" if opted for by a middle class woman, and is
generally associated with the

lower classes, black people and the poor.

5. Brazilian concepts of the body as cultural rather than
natural. Womens bodies are perceived as sexual rather than maternal;
despite an intense Marian culture, the genitals are for sex rather
than for childbearing.

I find it worrying that childbirth in Britain is being discussed in
the terms of this debate. Most European countries are held up as an
example of "human" birth. It would be ironic if Britain were the follow
the Brazilian path, especially with the increase of private medicine, when
the high cesarian rate here is at least acknowledged, even if
obstetricians have no intention of trying to reduce it.

Yours faithfully,

Christine Nuttall.

Competing interests: No competing interests

09 October 1999
Christine Nuttall
independent researcher
Vitoria, Espirito Santo, Brazil