HEALTH POLICY AND PLANNING; 8(1): 33-42 i Oxford University Press 1993

Which policy for caesarian sections in Brazil?An analysis of trends and consequencesANIBAL FAUNDES AND JOSE GUILHERME CECATTIDepartment of Gynaecology and Obstetrics, School of Medicine, University of Campinas, Brazil

This paper analyses the incidence of caesarian sections (C-sections) in Brazil. In the last decade, it hasreached an extremely high level, higher than in any other country in the world. Socioeconomic andregional differences are established, using available national data on the caesarian section rate, which ishigher in more prosperous regions and among wealthier women.

The different factors influencing this high incidence, including sociocultural, obstetric care organizationand legal and institutional considerations are analysed. Special attention is given to the problem of femalesurgical sterilization, which is not officially accepted in the country, but is performed during a C-sectionwith no other maternal or foetal indication. Consequences relating to maternal and perinatal morbidity andmortality, population fertility and the cost of health services are discussed. Interventions to reverse thistrend toward higher caesarian section rates are proposed.

IntroductionThe increase in caesarian sections (C-sections) isa common phenomenon in almost every countryin the world, but the rise in Brazil has beensignificant and the rates are now very high. Thepublished continuous statistics of the SocialSecurity Medical Service (INAMPS),1 whichpays for about 75% of all deliveries in the coun-try, showed an increase in the C-section ratefrom 14.6% in 1970 to 31.0% in 1980 (Table 1).

The National Household Sample Survey(PNAD), carried out in 1982 by the BrazilianInstitute of Geography and Statistics (IBGE),obtained a C-section rate for Brazil of 30.9%,practically identical to the 1980 INAMPS data,although the IBGE only interviewed a represen-tative sample of the general population.2 Thissurvey also showed that in every region of Brazil,the C-section rate was greater among the moreprosperous economic groups (as judged bymonthly family income (Table 2)), confirmingthe result of several smaller studies, which haveshown that the highest incidence has been amongprivate patients, and the lowest among those whopay nothing and have no insurance.3"6

Large differences can also be observed by review-ing the C-section rates by State. The 1981 IBGE

Table 1. Caesarian section rates in INAMPS hospitalsBrazil 1970/1980

Year Total deliveries No. ofcaesarian sections

19701971197219731974197519761977197819791980

602 108700 682766 707766 069874 665021 904211 159376 307379 230490 860591 716

88 115110517131 150148 154177 050235 898306 164354 869378 586446 185493 436

14.615.817.118.620.223.125.325.827.429.931.0

Source: INAMPS, Granado-Neiva J. 1982.'

study shows a large difference between SaoPaulo, the richest state, with a prevalence of43.8%, and poorer states like Ceara (17.7%) andPernambuco (17.9%). The same table shows thatwhile the two richest states (Sao Paulo and Riode Janeiro) had general population C-sectionrates higher than that recorded by INAMPS, theopposite occurred in the poorest states like Cearaand Pernambuco. A possible explanation is thatwhile in Sao Paulo and Rio de Janeiro the

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34 Anibal Faundesand Jos6 G Cecatti

Table 2. Caesarian section rates in several regions of Brazil by family income (%)

Monthly income(minimum salary scale)

< 11-22-33-55-10>10Total

North

26.721.226.123.848.643.228.4

Northeast

12.314.222.927.338.054.020.0

Regions

Southeast

20.727.330.841.948.961.537.6

South

21.623.322.826.440.743.827.0

Midwest

21.928.534.942.550.460.237.4

Brazil

16.722.227.636.345.957.630.9

Source: IBGE, National Household Sample Survey (PNAD), 1982.2

population not covered by social security con-sisted largely of rich, private patients; in thenortheastern states, where unemployment ishigh, those without social security belong to thepoorest groups in society. Thus, depending onthe wealth in the population and the proportionof indigents, the C-section prevalence rates byState were higher or lower than those shown byINAMPS' rates.

Another finding that requires further explana-tion is that in the less developed States, thehighest rates were found in the capital city,whereas the opposite was seen in SSo Paulo.Using the IBGE household survey of 1982 allowsa comparison between Recife, the capital city ofthe State of Pernambuco, which had a C-sectionrate of 28.6% (compared to only 11.7% in therest of the State), with the metropolitan area ofSao Paulo, which had a rate of 41.4% (comparedto 46.7% for the rest of the State (Table 3)).

This last finding was confirmed by a study whichcarried out home interviews with over 2000 low-Table 3. Caesarian section rates in the capital and interior

of Sao Paulo and Pernambuco States, 1981

State

Sao PauloPernambuco

Capital

41.228.6

Caesarian rate (%)

Interior

46.711.7

State total

43.817.9

N

621 803153 158

Source: IBGE, National Household Sample Survey (PNAD),1982.2

income women in the metropolitan area of SaoPaulo and over 1700 in the interior of the State,in 1987. It found a C-section rate of 43.9% inthe capital and a higher rate (52.5%) in the in-terior.7 A possible explanation is that thefacilities for this intervention are easier to find inRecife than in the poor interior of Pernambuco,while the rich interior of the State of Sao Paulohas facilities as good as the capital city, andprobably less well-trained obstetricians, and per-haps less social control over medical practices.

Factors influencing the high rate ofcaesarian sectionThe current exceedingly high rate of C-sectionsin Brazil can not be explained only by efforts toimprove perinatal morbidity and mortality. Infact, as shown before, the lowest rates are foundamong the poor, who have the highest incidenceof obstetric pathology, dystocia and other com-plications of pregnancy and delivery.

In the absence of reliable data, the reasonsbehind the dramatic increase in the Brazilianrates are more difficult to identify. Severalhypotheses can be postulated, mostly based onindirect evidence, to explain the currentpreference for C-sections among women, andamong the doctors who deliver their babies. Bothare undoubtedly influenced by a number ofsociocultural, institutional and legal factorswhich will be discussed below.

Sociocultural factorsWe do not know of any published Brazilianstudy about the influence of sociocultural factors

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Caesarian sections in Brazil 35

on the C-section rate. The discussion thatfollows is based on the collective opinion of aselected group of Brazilian obstetricians andother specialists, who met to review the problemof the increasing caesarian rate in the country,and the possible determining factors.8

Women's reasons for preferring a C-section overvaginal delivery are two-fold. One is the fear ofpain during labour and delivery. The idea is thata C-section, planned in advance for a specificdate and time, will allow the woman to deliverwith no pain at all, provided good and stronganalgesics are administered.

The other is the concept that a C-section allowsthe woman to keep the anatomy and physiologyof the vagina and perineum intact, while avaginal delivery will produce some marked lossof normal coital function. This interpretationhas been encouraged by otherwise distinguishedprofessors of obstetrics, who transmit this ideato their students - so much so that it has becomethe prevalent concept among physicians andamong women themselves.

The aesthetic inconvenience of the abdominalscar after a caesarian section has been generallyavoided by the almost universal use of the lowtransverse Pfannenstiel incision, which leaves thescar covered by the upper limit of the pubic hair.

Another important cultural factor is the popularconcept that a vaginal delivery is more risky forthe foetus than a caesarian one. Thus, a poorneonatal result is frequently attributed to thephysician not having decided for a C-section. Ifa neonatal death is the outcome of a caesarian, itis 'in spite of the 'wise' decision to perform acaesarian, but is never attributed to the route ofdelivery. On the other hand, if a newborn diesafter a forceps delivery, the death will always beattributed to the use of forceps and not to the cir-cumstances that indicated the foetal extraction.These popular beliefs become important factorsfor the obstetricians' selection of the route ofdelivery.

Organization of obstetric care and physicians'safety and convenienceThe preference for caesarian delivery by physi-cians may have several origins, but the presentsituation is dominated by the convenience of an

intervention which can be planned ahead, andwhich will not take more than one hour of theirtime, while a vaginal delivery may occur at anytime of day or night, on weekdays or holidays,and will take a longer and more unpredictableperiod of time. In addition, the uncertainty of apossible foetal hypoxia or trauma during labourand delivery, in the hands of professionals lack-ing a full training in obstetrics, as is the case formost deliveries in Brazil, may have a significantinfluence on the decision to intervene.

The coincidence of these beliefs with incompleteobstetric training and the consequent lack ofphysicians' confidence in their own ability, ex-plains why in many hospitals, only the easiestand fastest labours go on to a vaginal delivery,and why a minimal dystocia, real or imaginary,will lead to an immediate decision to perform acaesarian.

Antenatal care, in general, does not prepare thepregnant woman psychologically for labour anddelivery. The fear and uncertainty that mostpregnant women feel is exaggerated rather thandiminished by antenatal care, and by the socialenvironment in which she waits out her preg-nancy. The fear of pain on giving birth is exacer-bated with the first few uterine contractions atinitiation of labour. At that moment, the normalevolution of labour requires psychological sup-port for the mother. This is practically nonexis-tent in Brazil today, since in the present healthsystem, the figure of the midwife has all butdisappeared.

The absence of midwives also contributes to theloss of the concept and practice of teamwork inobstetric care. With the exception of a few publicservices and university hospitals which retain ateam of residents, interns and clinical staff, mostobstetric care is individualized. One physiciancares for several pregnant women and eachwoman will accept only that physician to takecare of her delivery. Obviously, the routine of aphysician's professional and private life will bedisrupted by a woman in labour, who needs theattending physician at her side for six, eight,twelve or more hours in a row. The doctor maydo that once a week for some time, but when itbecomes too disruptive, the temptation to doa C-section becomes great. There is nobodyto object to, or with whom to discuss, the

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36 Anibal Faundes and Jos6 G Cecatti

indications for the intervention. The hospitalsaccept the decision since they can charge more,and the patient's family is relieved of the tension.

If a physician's clientele becomes large, then aC-section on an appointed date and time is evenmore convenient, particularly if two or more pa-tients can be taken care of in only one operatingsession. Women are offered the convenience of apainless and planned delivery, with all the prac-tical details arranged. Even the exact day thebaby will be born is known in advance.

We have practically no objective data to substan-tiate these explanations, and there is no study inBrazil that has determined the influence of thephysicians on the caesarian rate. There is,however, a recent publication showing the resultsof a US study that found that the identity of thephysician had a very significant influence on thecaesarian rate, second only to nulliparity.9

Institutional and legal factors: surgicalsterilizationThe fact that almost three-quarters of alldeliveries are financed by the Social SecurityMedical Service (INAMPS), which pays doctorsdirectly, is a factor that encourages the practicesdescribed above. Another factor is that INAMPSdoes not pay for epidural analgesia, the mostpopular and effective form of pain relief inBrazil, if labour and delivery are normal, butthey do pay when a C-section is performed. Inother words, if a woman's first priority is theavoidance of pain and her delivery is paid for byINAMPS, she has no other choice but acaesarian. The increased risk for mother andfoetus is either ignored or argued against.

Up to about 1980, INAMPS paid individualphysicians more for a caesarian section than fora vaginal delivery. After verifying that theC-section rate had doubled in 10 years, INAMPSchanged its payment policy and all types ofdeliveries are now paid for at the same rate,whether these are spontaneous vaginal deliveriesor C-sections. All other private health insuranceorganizations have adopted the same paymentpolicy. This change has not, apparently, in-fluenced the trend of increasing caesarian rates.Given identical effective payment rates, theC-section remains the rtiore cost-effective for thephysician, considering the hourly rates of return.

Another important factor is the use of theC-section to perform surgical sterilization. Thereis no law indicating that surgical sterilization is acrime in Brazil. Yet, there is enough ambiguity tojustify a recent interpretation by the FederalCouncil of Medicine stating that it is against thepenal code to do a tubal ligation, except in excep-tional circumstances. This interpretation is basedon a clause in the penal code that proscribes anyaction that will cause 'loss of organ or function'and that tubal ligation results in the loss of thereproductive function. Other lawyers and judges,however, note that physicians with their patients'consent, routinely perform many surgical in-terventions which imply a loss of organs andfunctions, but these are considered legitimate bythe medical profession. A surgical sterilization,with the woman's consent and at her request,usually contributes to her biological, psycho-logical and social well-being, and thus is alsolegitimate.

The ambiguity, however, is enough to make theMinistry of Health and INAMPS excludesurgical sterilization from the accepted alter-natives for fertility regulation. Thus, theMinistry of Health does not have norms fortubal ligations, which are not financed byINAMPS. Since INAMPS pays for about 75%of all medical services, physicians and patientscheat INAMPS by disguising surgical steriliza-tion as a part of other surgery, from breastnodule to ovarian cyst, but mostly as a 'normal'C-section.

The 1986 IBGE National Household SampleSurvey asked about fertility.10 Its findings showthat nationwide, three-fourths of all tubal liga-tions were performed at the time of the lastdelivery, fluctuating from a low of 61.2% in theState of Sergipe in the northeast, to a high of85.9% in the State of Amazonas. Sao Paulo wasa close second with 83%." IBGE did not ask ifsuch deliveries were vaginal or by caesarian, butanother programme evaluation survey foundthat in 1987, in the State of Sao Paulo, 72% ofall surgical sterilizations among low-incomewomen were carried out during a C-section.7 Asother forms of postpartum sterilization are per-formed in only a dozen or so university hospitalsin the country, the percentage found by theIBGE survey should be very close to the totalproportion of tubal ligations carried out during aC-section.

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Health consequences of a high caesariansection rateThe risks of C-section for the newborn are two-fold. One is the risk of premature interruption ofpregnancy by error in the estimation of gesta-tional age, particularly among cases with an ap-pointed date for delivery. The other is the higherrisk of respiratory distress in babies delivered bycaesarian, as compared to vaginal deliveries,even for babies born at term.

The available data suggest that the risk ofprematurity is a real risk for non-medically in-dicated and elective C-sections. It is known thatcaesarians carried out with the purpose ofligating the tubes are usually done on an ap-pointed date, usually before the expected date ofdelivery, thus carrying a higher risk ofprematurity. The 1988 Sao Paulo study found a60% higher rate of prematurity among babiesdelivered by C-section with surgical sterilizationas compared with those born by caesarian with-out tubal ligation.7 Although this is indirectevidence at best, it is reinforced by informalreports of hospitals with very high rates ofcaesarian sections performed, most of them elec-tive, in which the rate of prematurity can reachup to 25%.

The higher maternal mortality and morbidityamong women who delivered by C-section hasbeen a common finding everywhere (Table 4).Brazilian data are limited to the statistics of somehospitals, all of them showing a higher risk ofdeath for C-section than for vaginal births.12

One of the clearest differences in morbidityrelates to puerperal infections, which are severaltimes more frequent after C-section and also oneof the causes of maternal mortality. The otherimportant cause of death during C-section isrelated to anaesthetic accidents, complicationsand the aspiration of vomit, which are some ofthe additional factors that contribute to thehigher risk of maternal death for C-sections.

There are, however, other less evident healthconsequences of C-sections for the mother andbaby. A caesarian section may prolong therecovery of the mother, leading to a longerseparation of mother and baby, as well asdelayed first contact and the initiation ofbreastfeeding. The need to promote breast-feeding in Brazil is a strong argument to avoidunnecessary C-sections.13

When a woman is left with a uterine scar afterthe first baby, her obstetric future is alreadydetermined. For most physicians it will mean arepeated section for the next delivery, without atrial of labour (which can result in vaginaldeliveries of more than half of the second babies,without greater risks for them or the mother).Statistics from California in the US, show that98% of deliveries after a C-section are alsoresolved through repeated section.14 The same isprobably true for Brazil, where only a fewisolated hospitals in both countries have a highrate of vaginal delivery after trial of labour."

The uterine scar may have less influence than in-itially feared over the evolution of labour, but

Table 4. Risk of maternal death according to the method of delivery (several authors)

Author

RubinPetittiMinkollEvrardFrigollettoChevran-BretonMoldinCostaFaundes

Period

1975-6197919771965-751968-781969-791973-7919791979-83

Site

Georgia, USUSN. York, USRhode Isl, USBoston, USRennes, FranceSuecia, BzlRecife, BzlCampinas, Bzl

Maternal

Caesarian

10.511.410.86.90.0

14.52.1

68.38.8

mortality*

Vaginal

0.972.041.700.271.002.10.11.93.6

Odds ratio

10.85.66.3

25.7—6.9

21.035.92.4

•Maternal deaths/10 000 deliveries. Source: Reference 12.

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does increase the risk of several pregnancy com-plications such as placenta previa, haemorrhagicpathologies, neonatal morbidity and puerperalinfections.1617

A final, unintended effect of the highprevalences of C-sections is the limitation placedon conception and fertility. With a low incidenceof caesarians, its incidence is similar or lower forfirst delivery, but as the incidence increases,the C-section rate becomes higher amongnulliparas.18 Where there are very high rates ofC-sections as in Brazil, and where the rules are'after a caesarian, always a caesarian' andsurgical sterilization is routinely practised afterthe third C-section, all these women will have amaximum of three live births." This imposes adecision about family size.

Economic consequences of the high rateof caesarian sectionsTo perform an elective C-section instead ofassisting a vaginal delivery may seem a decisionwith no economic consequences for the physi-cian, but the sum of many similar decisions canseriously affect the cost of maternal and childhealth care. The cost of surgery is easier to iden-tify than the costs of vaginally-assisted births,but there is also the longer stay, and the greateruse of drugs and other consumables. At the StateUniversity of Campinas Hospital, the cost of aC-section is about 50% higher than a vaginally-assisted birth.

Iatrogenic prematurity also increases costs, sincepremature babies require more intensiveneonatal care, and places an increased demandupon health services, at least throughout infancyand early childhood. The average cost ofassisting a premature baby just during intensivecare (as the variations in later cost are too wideand difficult to estimate), was US$1050 in ourhospital, based on a daily cost of US$150, and anaverage stay of seven days.

To calculate the excess cost of unnecessaryC-sections we used a medically justified rate of15%, and then calculated the cost of each 1% in-crease above this rate. Estimating that there are4 000 000 births per year in Brazil, 1 % represents40 000 caesarian deliveries. The excess cost of themother's in-hospital care for these 40 000

C-sections will be US$1 920 000 (US$48 x40 000).

To estimate the cost of iatrogenic prematurity,we used the difference of 5.2% betweenpresumably justified and unjustified C-sectionsfound in the evaluation of the PAISM in theState of Sao Paulo.7 Each 1% increase in the rate,or each 40 000 additional caesarian sectionswould result in 2080 iatrogenically prematurebabies, at a cost of US$2 184 000 (US$1050 x2080).

Considering only the increased cost of mothers'care and the intensive care of prematures,each 1% increase in C-section would costUS$4 104 000. If the 31% rate of 1980 weremaintained, the unnecessary C-sections would be16% (31% less 15% medically justified), at anestimated cost of US$65 664 000. If the rate in-creased to 40%, as could be expected, un-necessary C-sections would be 25% (40% less15% medically justified) or 1 000 000 interven-tions. If this were the case, in 1989 the cost of theunnecessary medical interventions would beUS$102 600 000. About 80% of that moneywould come from public funds, from theFederal, States and city governments.

The estimates listed above, should however, beregarded as a very broad approximation. Thereare factors which might alter the final figures inopposite directions. The actual cost of intensivecare for premature babies may have beenoverestimated, because at present, Brazilianhospitals do not have the resources to providesuch care to 100% of babies born before term.On the other hand, because it does not include allother costs to health services resulting from theincreased demand for care of these small babies,the total is an obvious underestimate. It also failsto include the cost of a reduced rate and durationof breastfeeding, with all the recognized effectson infant morbidity and on demand for services.

Actions and policy changes requiredto slow the increased rate of caesariansectionsThe above analysis of the main causes for the in-crease in the rate of C-sections in Brazil can beused as a guideline for drafting policies to reversethe present trend. In the following section, we

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Caesarian sections in Brazil 39

will try to follow the same order, matchingproblems to possible solutions.

Sociocultural interventionsWe observe that C-sections are a fashion inBrazil. How can we change this fashion so thatnatural births are valued more?

Any messages should first make it clear that acaesarian section does not necessarily mean theabsence of pain, and that vaginal delivery can beachieved with little or no pain at all. The joy of anormal vaginal delivery should be exalted, aswell as the emotional and physical importance ofimmediate mother-baby contact, which is notpossible if a C-section is done. Women who donot succeed in having a normal delivery shouldnot be blamed, while the effort and intention tohave such a delivery should be praised.

Another important message is that sex enjoy-ment is independent of the method of delivery.Sex experts and sex educators, of which there aremany good ones in Brazil, should emphasize thispoint in their conferences, courses, newspaperand magazine articles, as well as during their par-ticipation in gynaecological and obstetric con-gresses.

The third point is that a vaginal delivery is saferfor both mother and baby when all is normal.

Most renowned obstetricians are also the oneswho have the largest and richest clientele. Conse-quently, their practice requires the acceptance ofthe elective C-section at an appointed date, so asto enable them to cope with the demand. Theseobstetricians are also the speakers at congressesand on courses, and those who write in medicaljournals and lay publications. For their socialroles, they need to believe that what they are do-ing is right, and they are sincerely convinced it isso. The process of changing this conviction willnot be easy. The exposure to the results offoreign studies is not sufficient, but the carefulaccumulation of Brazilian data on the variousconsequences of C-sections will be a fundamen-tal requirement if we are to overcome theprevalent attitude.

Changes in the organization of obstetric careThis is one of the most difficult issues, yet we donot see a way out of the present chaos if obstetric

care continues to be viewed as totally in-dividualized. The process of being pregnant andgiving birth is an emotional and personal one,and trust in the person who cares for this processhas an immense psychological value. Nonethe-less, there is nothing preventing the transferenceof that trust from an individual to an obstetricteam.

The team can be made up of just two or threepeople, or it can be a larger group. In private andsocial security practice the team can be a physi-cian and a midwife, or a senior obstetrician withsome assistants and midwives. Psychologists,physiotherapists, health educators and other pro-fessionals can also participate in teamwork dur-ing antenatal preparation for delivery andmotherhood. The advantages of teamwork to theobstetrician and the mother for pregnancy anddelivery are not easy to convey. Physicians areafraid of losing control and mothers are afraid oflosing personalized care. To convince both thatthey have more to gain than to lose will not be aneasy task in Brazil.

An important development would be to reinstatethe midwife as a close collaborator of theobstetrician, as the nurse is to the surgeon or tothe physicians who attend an intensive care unit.Midwifery is no longer recognized as a profes-sion in Brazil, and the process of its recovery willnot be an easy one. This would have to be well-planned at the central government level, and im-plemented as soon as possible, as it will takeseveral years before we see any results.

The shortage of many health professionals, otherthan physicians, is acute, and theoretically, itwould be easy to justify this initiative. The op-position, however, will also be strong, and it willcome as much from the nurses' association asfrom obstetricians.

Finally, there is the question of adequate trainingin the care of a normal labour and delivery, par-ticularly in the undergraduate medical schoolsand at postgraduate levels, where C-sections areseen as best practice. Obstetrics is learnt throughpractice and there are fewer and fewer vaginaldeliveries from which to learn. Obstetricians withthe greatest experience in dealing with a normallabour and delivery are rarely, if ever, availableto teach. It is not difficult to imagine the gigantic

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task involved in improving training; but again, itis a task that requires basic planning, a goodstrategy for implementation and a strongpolitical will to execute it.

Institutional and legal actionsThis is the most encouraging field because it of-fers better possibilities for inducing change in theC-section rate. The fact that over three-quartersof deliveries are paid for with public funds meansthat regulatory and payment modifications maybe more successful.

Health institutions which are paid by INAMPSare certified as hospitals that fulfil acceptablequality requirements. INAMPS has the right toaudit these hospitals' activities, and although thisis normally purely financial, it could also includea technical audit. The C-section rate of eachhospital could be used as a quality marker ofobstetric care, and a limit set as a condition formaintaining the INAMPS certification.

As the C-section rates show great variations byregion, the initial limit could also vary accord-ingly, using for example, the present regionalaverage. Any rate above that limit should requirea detailed explanation from the clinical directorof the hospital. Any hospital which records twosuccessive months in excess of the limit should besubject to a high level technical audit to reviewevery case of caesarian delivery indication andthe maternal and foetal outcomes. A recommen-dation to the clinical director about measures tobe taken to avoid unnecessary C-sections shouldfollow. If, after that, the caesarian rate of thathospital continues to be above the limit, there areat least two alternatives. One would be thesuspension of the hospital's certification forobstetric care, and the other would be to pay fordeliveries only up to the established limit, refus-ing charges for caesarian deliveries above thatrate, for any given month.

Such measures would require detailed legal andpractical considerations, including careful selec-tion of high level technical groups responsible forthe audit. These groups should include arepresentative of the Regional Council ofMedicine (CRM), the president of the hospital'sethical committee (who represents the CRM onethical issues) or both.

Another important policy decision INAMPScould adopt is to authorize payment of periduralanalgesia for labour and delivery in nulliparouswomen. Not only will this change the motivationof women who request a caesarian section toavoid pain, but it will mean a net financial gainfor INAMPS. At present, INAMPS not onlypays both the obstetrician and anaesthetist, butalso at least one assistant, as well as other addi-tional costs. For the vaginal delivery of anullipara, it will have to pay only the first twophysicians. In addition, while a woman with aC-section for her first baby will have a caesarianfor the next child, women whose first delivery isnormal have a much greater chance of normaldeliveries thereafter.

A more difficult but necessary decision refers tosurgical sterilization and postpartum contracep-tion. This item requires two different levels ofanalysis and policy decision. First there is theproblem of a lack of genuine contraceptivechoices for women assisted through INAMPS.The hospitals offering postpartum contraception(other than caesarian-sterilization) are an excep-tion in Brazil today, as are the basic health careunits that offer contraceptive services. There isno doubt that the demand for caesarians as a wayof obtaining a tubal ligation will be much re-duced if women have effective and acceptablecontraceptive alternatives readily available.Although theoretically INAMPS offers such ser-vices, in practice they are almost nonexistent. Areview of the reasons for this failure and theadoption of new plans would contribute toreducing the demand for C-sections and tubalsterilizations.

Many poor women who already have the desirednumber of children get pregnant again in orderto have access to a surgical sterilization per-formed at the same time as the caesarian,illustrating the absurd and dangerous practicesthat the Brazilian health care system has created.The simplest policy change would be to pay forsurgical sterilizations in the same way as for anyother medical service. INAMPS would need toclarify the legal impediments for tubal ligation(and vasectomy). There are, however, politicalimplications connected with such a decision. It isour belief, that the political environment todayfavours this change.

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Changes in obstetric practicesAlthough there is an overlap in the subjectsdiscussed above, actions can also be taken tochange some obstetric practices which havebecome almost routine in Brazilian delivery care.Besides the request for a caesarian by the patient,there are four main obstetric indications forC-section: foetal distress; cephalo-pelvic dis-proportion; breech presentation and previoushistory of a caesarian.

With respect to foetal distress, electronic foetalmonitoring has not yet been used extensivelyenough in Brazil to have any meaningful impacton the indication for caesarians, as seems tobe the case in the US and other developedcountries.20 Lacking the basis for any objectivejudgement, it is not possible for us to makerecommendations on this point.

Cephalo-pelvic disproportion is the most fre-quently stated indication in many hospitals. It isused whenever labour does not progress accor-ding to the obstetrician's expectations, withoutsufficient consideration being given to othercauses of delay. The main action that could helpto reduce this indication is the use of the par-togram, and the adoption of a more active at-titude to correct dysfunctions, when the progressof labour is delayed or arrested. The correct useof analgesia, oxytocin and the artificial ruptureof the membranes, at the appropriate time, forthe right patient, will significantly reduce theneed for surgical interventions. However, theadoption of these recommendations is closelyrelated to that on training, as discussed earlier.

The greater use of C-sections in cases of breechpresentation has resulted in more of these caseshaving C-sections in the US. The better perinatalresults seem to justify this conduct in manycases, but do not justify the indication forcaesarians in all cases of breech presentation, asis presently the case in Brazil. A more carefulselection of the patients, allowing vaginal evolu-tion of labour for those who do not face high riskwith this route of delivery, will prevent a propor-tion of caesarians. However, this is a difficultrecommendation, because it requires an obstet-rician with considerable experience in theassistance of breech deliveries. In addition, sincebreech presentation only occurs in about 2% ofall deliveries, a change in the incidence of

caesarians in this group will not be particularlysignificant, given the epidemic proportions of theproblem in Brazil today.

A much more frequent and rapidly growing in-dication is the history of a previous C-section.The high success rate and the absence of greaterrisk with a trial of labour independent of thecause of the previous caesarian, has beenreported frequently in the international andBrazilian obstetric literature. The introduction ofa routine offer of a trial of labour to women witha previous C-section might reduce the subse-quent rate for this indication by about one-half.Clear criteria for decision on the trial and ap-propriate follow-up of the labour and deliveryprocess are required.15 The use of the partogramcan again be very useful, as can the improve-ment of training for those who take care of thesepatients.

Finally, changes in antenatal care may also havean impact on the C-section rate, by preparing themother for labour and delivery, both physicallyand psychologically. This point is closely relatedto re-establishment of the role of the midwife,together with the training of physicians and otherhealth workers and with the wider use of anobstetric team.

Conclusions

Strategies for the implementation of policychangesThe implementation of the policy changes pro-posed here requires strong social and politicalsupport, which would be helped by appropriatedissemination to the public through the massmedia (press, radio and television). It also re-quires very close and continuous evaluation, soas to introduce corrections when these areneeded.

The strategy for developing and implementingpolicies should be carefully designed, so as togain as many strong allies and as few opponentsas possible, avoiding mistakes that maytransform a potential supporter into an oppo-nent. There is a precedent in an initiative by theCommittee in Perinatology of the Ministry ofHealth. The Committee decided to initiate anational campaign against the high rate ofC-sections, but the way that the decision was

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42 Anibal Faundes and Jos6 G Cecatti

taken and was presented to the public causedunnecessary embarrassment and irritation tothe Brazilian Federation of Gynaecologyand Obstetrics' Societies (FEBRASGO). WithFEBRASGO then in opposition, the campaignlost its impact and had very little influence on thepractice of caesarian surgery.

FEBRASGO, the Federal Council of Medicine,the States' Regional Councils of Medicine, theBrazilian Medical Association and other similargroups, should be informed of all strategies, andtheir active collaboration sought. Other very im-portant contributors would be all women'sgroups, which are becoming larger, stronger andbetter organized.

The fundamental condition for success in revers-ing the C-section trend is a very strong and well-informed political leadership, with a clear visionof the problem and its solutions; but chiefly, it isa leadership with the political will to bring aboutthe necessary changes.

AcknowledgementsThis paper was partially sponsored by The World Bankwhich permitted its publication. The first version of the docu-ment was written at the Rockefeller Foundation's BellagioStudy and Conference Centre, in Italy, where the seniorauthor was appointed as a scholar-in-residence.

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" Berqu6 E. 1988. Contraception in Brazil today. Paperpresented at the XII World Congress of Gynecology andObstetrics, Rio de Janeiro, Brazil.

12 Faundes A, Hermann V and Cecatti JG. 1985. Analise damortalidade materna em partos cesaroes no municipiode Campinas, 1979-1983. Femina 13: 516.

13 Barros FC, Vaughan JP, Victora CG. 1986. Why so manycesarean sections. The need for further policy changein Brazil. Health Policy and Planning 1: 19-29.

14 Petitti DB, Cefalo RC, Shapto S and Whalley P. 1982.In-hospital maternal mortality in the United States: timetrends and relation to method of delivery. Obstetricsand Gynecology 59: 6.

13 Faundes A, Amaral E, Pinto e Silva JL, Gama da Silva JCand Pinotti JA. 1988. Trabalho de parto em pacientescom antecedentes de cicatriz de cesarea. Gin. Obstet.Bras. 11: 103.

16 Faundes A. 1983. C-section scarring: risk to futurereproduction. Xth Congress of Gynecology andObstetrics, San Francisco, USA.

17 Moraguez AJD, Pinto e Silva JL, Pinotti JA and FaundesA. 1981. Prognostico obstdtrico e perinatal da mulherportadora de cicatriz de operacao cesareana. Gin.Obstet. Bras. 4: 173.

18 Petitti DB, Olson RD and Williams RL. 1979. C-sectionsin California: 1960-1975. American Journal ofObstetrics and Gynecology 133: 391.

19 Faundes A. 1986. As cesareas e as modificacoes nos niveisde fecundidade. Populacao e Saude, Volume I. EditoraU N 1 C A M P , Campinas . Pages 7 3 - 9 1 .

2 0 Prentice A and Lind T . 1987. Foetal heart rate monitor ingduring labour - t oo frequent intervention, too littlebenefit? Lancet. Pages 1375-7. December 12.

BiographiesAnibal Faundes MD, is a Professor of Obstetrics, in theDepartment of Gynaecology and Obstetrics at the School ofMedicine, and the Executive Director of the Center for In-tegral Assistance to Women's Health (Women's Hospital),University of Campinas, Brazil. He is also a Senior Associateand Representative of The Population Council in Brazil.

Jose Guilherme Cecatti MD, MSc, is Assistant Professor inthe Department of Gynaecology and Obstetrics, at the Schoolof Medicine, University of Campinas, Brazil. He was a tem-porary adviser for WHO and UNFPA to Portuguese-speaking African countries on safe motherhood, humanreproduction and maternal and child health.

Correspondence: Professor Anibal Faundes, The PopulationCouncil, PO Box 6181, 13081 - Campinas, SP, Brazil.

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