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Cad. Saúde Pública vol.28 n.8 Rio de Janeiro Aug. 2012
Maria do Carmo Leal
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. firstname.lastname@example.org
Pregnancy brings many changes and expectations for women and their families, since it entails new emotional, social, and legal responsibilities that accompany motherhood. Last year in Brazil, only 45% of the pregnancies resulting in births had been planned for the time at which they eventually occurred. Although 97% of pregnant women in Brazil received prenatal care and 99% of births occurred in hospitals, problems persist with the quality of care provided (Lancet 2011; 377:1863-76).
A study in Rio de Janeiro focusing on hospitals under the so-called Supplementary Healthcare System (i.e., private services outsourced by the public Brazilian Unified National Health System) showed that during pregnancy, Brazilian women change their minds on the type of delivery they want. In the first trimester, only 30% report they would prefer a cesarean, but by the time they come to the maternity hospital this figure reaches 70%, and only 10% end up having a vaginal delivery. Fear of pain is the main initial reason for wanting to have a cesarean and is also an important factor for women who change their minds during pregnancy. Protective factors against cesareans include being well-informed about the advantages of vaginal delivery and the husband's desire for the wife to choose this birthing modality (Ciênc Saúde Coletiva 2008; 13:1521-34).
A cesarean section should not be viewed as a trivial surgical intervention, since it increases the risk of postpartum hemorrhage, ICU admission, mortality, and uterine rupture in subsequent pregnancies with abnormal placentation. For the newborn, potential complications include increased need for ventilatory support at birth and greater use of the neonatal ICU.
In public healthcare services in Brazil, pregnant women undergoing vaginal delivery also suffer excessive manipulation, remain confined to bed, are prevented from walking or eating, receive ocytocin, and give birth in the supine position with the aid of an episiotomy. None of these procedures is still recommended by the World Health Organization.
The model of care based on appropriate technologies for delivery and birth (also known as humanized childbirth), conducted by midwives and common in nearly all European countries, has shown excellent perinatal results, in stark contrast to the model we have implemented here in Brazil. With a cesarean rate exceeding 50%, more and more Brazilian women give birth under anesthesia, going through labor and delivery without feeling pain, but also without feeling the birth of their children. Meanwhile, the majority of Brazilian infants are removed from the uterus by physicians, thus alienating them from this vital and highly significant human experience. We have no evaluation of the middle and long-term impacts on children born under Brazil's extremely medicalized model for childbirth care, but it takes little effort to recognize that it represents a break with the way previous generations of Brazilians were born, and from the population perspective, it is an experience that has not been evaluated previously.
A movement is currently under way in Brazil to adopt a model based on appropriate technologies for delivery and birth. Important initiatives by the Ministry of Health include the Program for Humanization of Prenatal Care and Delivery, the Law on the Accompanying Person's Rights, the Program for Upgrading Maternity Hospitals in the Northeast and Legal Amazonia, and more recently the Rede Cegonha or "Stork Network". In parallel, the country has witnessed a rebirth of women's social movements to reclaim women's protagonist role in conducting their own labor and delivery and the birth of their children. For Brazilian women and children, there is now a consensus about the urgent need to reform the care provided during pregnancy, delivery, and birth.