“C-section trends in Latin America: the Brazilian case” Global Trends in Childbirth SEMINAR SERIES Kuopio-Oulu-Tampere-Helsinki 7.-12.12.2015 “C-section trends in Latin America: the Brazilian case” I WOULD LIKE TO THANK THE ORGANIZERS THE INVITATION TO COME TO FINLAND AND THE OPORTUNITY TO DISCUSS SUCH AN IMPORTANTE PROBLEM TO BRASIL Marcos Dias - marcosad@iff.fiocruz.br

in recent decades we have seen the caesarean section rate grow steadily worldwide http://www.nbcnews.com/id/34826186/ns/health-pregnancy/t/c-section-rates-around-globe-epidemic-levels/#.VjCjp7erSUk

although in some regions these rates have reached unimaginable numbers in some countries women still suffer from a lack of access to caesarean section

THE WHO HAS STATED THAT EVERY EFFORT SHOULD BE MADE TO PROVIDE CS TO WOMEN IN NEED, BUT ALSO HAS PROPOSED THAT ON A NATIONAL LEVEL CS RATES SHOULD NOT EXCEED 10-15%. http://www.voanews.com/content/who-warns-against-c-sections-when-not-medically-needed/2715429.html

What happened to the US seems to be repeated in several other countries. The primary cesarean section rates are often increased by excessive medicalization of assistance to labor. Although more women have a uterine scar due to a caesarean the rate of VBAC is falling.

http://www. latintimes http://www.latintimes.com/dominican-republic-c-section-epidemic-highest-rate-world-fueled-unnecessary-cesareans-319375 http://www.argentinaindependent.com/socialissues/development/birth-rights-why-do-argentines-have-so-many-c-sections/ In Latin America many countries face a real cesarean epidemic. Usually Brasil and Chile have the highest rates but it seems that Dominican Republic is now ahead of us. In recent years this excess of unnecessary cesarean has been questioned by the women themselves and for health professionals http://www.theunnecesarean.com/blog/2009/1/25/who-cares-brazils-93-percent-cesarean-rate-in-private-hospit.html

Even in countries with higher rates of indigenous population as Bolivia and Peru the C-section rates are increasing steadily even in countries with HIGH RATES OF indigenous population and traditional practices of childbirth assistance as Peru and Bolivia the rates of CS KEEP growing

Latin America queen in a world full of unnecessary cesareans http://www.elcomercio.com/tendencias/americalatina-cesareas-oms-riesgo-maternidad.html Caesarean section rates between 2008 and 2012 in Peru increased from 15.8% to 25% and Bolivia 14.6% to 19%. Caesarean section rates between 2008 and 2012 in Peru increased from 15.8% to 25% and Bolivia 14.6% to 19%. The press and also professional associations are protesting against these high rates of c-section

The head of the department of gynecology at the hospital, Susana Sanchez, said that an important aspect that can explain why they had 388 caesarean sections in relation to the 166 natural births in 2013 (70%), is that they have good technology equipment in the tertiary level; ie that any complication could be diagnosed early through prenatal care. In private services, many mothers feel that a caesarean section is better. Promotion for natural childbirth has decreased, people decide for different reasons, and professional and private clinics provided to that. "A normal delivery costs about 200 bolivianos, while a Caesarean section around 2,000 bolivianos" RIGHT TO THE HIGHEST POSSIBLE LEVEL OF PHISICAL AND MENTAL HEALTH THIS PAGE BRINGS AN INTERVIEW WITH The head of the department of gynecology at A TERCIARY hospital IN BOLIVIA. She said that an important aspect that can explain why they had 70% of CS in 2013, is that they have good technology equipment so that any complication could be diagnosed early through prenatal care. When you look at the page of the ministry of health it seems to say we are offering better care and it means more C-sections http://www.ine.gob.bo/indicadoresddhh/salu11.asp

a rapid change is happening in childbirth assistance a rapid change is happening in childbirth assistance. Cesarean rates more than doubled in some departments in Bolivia in the last 10 years

we are witnessing a rapid transition from a traditional model to a very medicalized model. It is important to have access to thecnology but its imortant to know if its been used appropriately. Many aspects of the women experience of pregnancy and childbirth have been neglected in this technocratic model.

Correlation between the gross national product per capita (£) and caesarean section rates in 18 Latin American countries (rs=0.746). There is a direct correlation between NPPC and CS rate in latin america.Correlation between the gross national product per capita and caesarean section rates in 18 Latin American countries (rs=0.746)‏ José M Belizán et al. BMJ 1999;319:1397-1402 ©1999 by British Medical Journal Publishing Group

Reasons behind the Increase in Cesarean Sections in Latin America The use of continuous electronic fetal heart rate monitoring instead of intermittent auscultation for low risk deliveries, resulting in increase cesarean rates for false positive results without benefit for the baby. b) The high rate of elective inductions prior to 39 weeks gestation resulting in cesarean birth (almost 40%) in which dystocia is given as the primary diagnosis for cesarean delivery. c) The public misconception that cesarean birth is better for babies. d) Better remuneration for cesarean birth compared to vaginal delivery in some of these countries. e) Fear of litigation. f) Other common reasons include: infertility, advanced maternal age, presence of cord around the fetal neck during sonography, prematurity, breech position and concerns of maternal pelvic floor damage with vaginal delivery. In multiparous women, repeat cesarean section is responsible for over 50% of sections in these patients. It has been stated that the difference in rates between developed countries is based on the different approaches towards labor and delivery. Countries with a less “medical” or less “interventional” approach have lower rates, compared with countries that have more of a “medical” or “interventional” approach. Open Journal of Obstetrics and Gynecology, 2015, 5, 433-435

WOMEN PROTEST IN BUENOS AIRES IN DEFENSE OF BIRTH AT HOME http://www.elmostrador.cl/noticias/pais/2015/11/03/colegio-de-matronas-en-pie-de-guerra-por-altas-tasas-de-cesareas-en-chile-es-hora-de-decir-basta-el-estado-debe-hacerse-cargo/ College of Midwives at war for high cesarean rate in Chile: "It is time to say 'enough', the state must take charge. The good news is that women in different countries in LA are fighting to have a normal birth and more control of the process of parturition. Changing these high rates of c-section is related to the role that women are playing in the struggle for their sexual and reproductive rights . WOMEN PROTEST IN BUENOS AIRES IN DEFENSE OF BIRTH AT HOME http://www1.folha.uol.com.br/mundo/2015/05/1629011-mulheres-protestam-em-buenos-aires-a-favor-do-parto-em-casa.shtml

“C-section trends in Latin America: the Brazilian case Before presenting the C-section rates in Brazil I would like to give you some information about my country “C-section trends in Latin America: the Brazilian case

SOME DATA ABOUT BRAZIL: LANGUAGE: PORTUGUESE 205.000.000 HAB - 85% URBAN 50,7% BLACK+BROWN - 56% SOUTHWEST/SOUTH Brazil has 205.000.000 hab , we are the only country in Latin America that speak Portuguese, 85% of the country population live in urban areas, half is black or brown and most part live in southeast and south regions wich are the most developed areas.

in the last 15 years Brazil has undergone a significant reduction in poverty rates and the HDI has improved significantly in the country

more people began to consume including health plans

Brazil has one of the largest public health systems in the world. To 70% of the population it is the only available resource to health assistance. About two million births are attended in the public system every year.

USE OF THE HEALTH SYSTEM BY PREGNANT WOMEN ACCORDING TO INCOME - Higher income women primarily use private health services; - The poorest women are the ones who most use the public health system; - The called mixed units serve both the public and the private system

USE OF THE HEALTH SYSTEM BY PREGNANT WOMEN ACCORDING TO RACE Black and brown women use more the public services and white women use private services in greater proportion.

CESAREAN RATE ACCORDING MATERNAL EDUCATIONAL LEVEL AND TYPE OF HEALTH SERVICE. In all types of service (private, public or mixed) the higher the education level the higher the CS rates

CESAREAN RATE ACCORDING PARITY AND TYPE OF HEALTH SERVICE CS rate in primiparous – private sistem 92,3% - mixed 53,8% - public 41,7%

Fertility rates in Brazil fell sharply in recent decades. The most recent national data shows a rate of 1.8

Despite the differences between the regions of the country the fall in fertility rates was similar.

The infant mortality rate fell importantly and Brazil reached the MDG related to child health , but it still is twice the rate of developed countries.

Maternal mortality falls 43% in Brazil between 1990 and 2013. MMR 60/100.000 – Despite this fall we didn’t achieve MDG5 regarding MMR MMR are

The epidemic of cesarean section in Brazil . How big is the problem?

http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health BJOG. 2014 Mar;121 Suppl 1:101-9. doi: 10.1111/1471-0528.12631.

Nationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth (2011-2012). The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. 

In the last four decades the cesarean rate in Brazil had a continuous increase and since 2009 this rate exceeded 50% at the national level Despite the fact that many public policies were launched by the ministry of health during the last 15 years the CS rate never stopped to grow.

Caesarean section rates vary between different regions and between the type of service in which the assistance to childbirth is performed.

What information women receive about CS in women magazines in Brazil?

Fig 1 Information on caesarean section presented by 118 articles published in Brazilian women’s magazines, 1988-2008. The portrayal of caesarean section in women’s magazines in Brazil is incomplete and may be leading women to underestimate important maternal and perinatal risks associated with this route of delivery. Most of the articles on caesarean section published over the past two decades in Brazilian women’s magazines have not used good sources of information The portrayal of caesarean section in women’s magazines in Brazil is incomplete and may be leading women to underestimate important maternal and perinatal risks associated with this route of delivery According to Brazilian women’s magazines, avoidance of labour pain and convenience for the family are the two main reasons for women to want a caesarean section Most of the articles on caesarean section published over the past two decades in Brazilian women’s magazines have not used good sources of information Maria Regina Torloni et al. BMJ 2011;342:bmj.d276 ©2011 by British Medical Journal Publishing Group

-convenience for health professionals and family, Fig 2 Information on benefits and risks of caesarean section transmitted to women by magazines in Brazil. The main reported benefits of caesarean section (top right quadrant) were: -reduction of pain during delivery (mentioned by almost half of the articles), -convenience for health professionals and family, - the possibility of choosing when to deliver. The main reported benefits of caesarean section (top right quadrant) were reduction of pain during delivery (mentioned by almost half of the articles), convenience for health professionals and family, and the possibility of choosing when to deliver  Maria Regina Torloni et al. BMJ 2011;342:bmj.d276 ©2011 by British Medical Journal Publishing Group

How is the assistance model to vaginal delivery? The model of care during labor in Brazil is usually full of unnecessary interventions.

Occurrence of violence during childbirth assistance

Social inequalities and women's satisfaction with childbirth care in Brazil: a national hospital-based survey Verbal, physical or psychological abuse was higher among brown or black- colored skin women, of lower school education, age range between 20 and 34 years, of the Northern Region, with vaginal delivery, who had no companion during hospital stay, who were attended by the public sector, or who underwent labor. The proportion of women who considered the different aspects of their interaction with health practitioners as “excellent” was higher for those of white skin color, of the socioeconomic class A/B, with complete higher education, of the Southern Region, with C-section performed, who had a companion throughout her stay, whose care was paid by the private sector, and who did not undergo labor. Labor was associated with a higher chance of abuse. Independent factors associated to higher satisfaction with waiting time included belonging to socioeconomic class A/B, deliveries by the private sector, and the presence of a companion. Brown skin color was associated with lower degree of satisfaction with waiting time. http://www.scielo.br/scielo.php?pid=S0102-311X2014001300021&script=sci_arttext

Obstetric interventions during labor and childbirth in Brazilian low-risk women http://www.scielo.br/pdf/csp/v30s1/en_0102-311X-csp-30-s1-0017.pdf

http://www.scielo.br/pdf/csp/v30s1/en_0102-311X-csp-30-s1-0017.pdf

74,6% episiotomy in primiparous; 37% Kristeller manouver 92% delivering in lithotomy http://www.scielo.br/pdf/csp/v30s1/en_0102-311X-csp-30-s1-0017.pdf

Entrevistas de gestantes na Pesquisa Nascer no Brasil

Do women ask for CS in Brazil? Doctors say that they perform CS because women want to avoid a vaginal birth and ask them for the surgery.

Process of decision-making regarding the mode of birth in Brazil: from the initial preference of women to the final mode of birth

What are the consequences of so many C-sections?

What are the consequences of so many C-sections?

What would you choose? A vaginal birth full of interventions without support and care or A CS without risks with your private doctor? http://www.theguardian.com/commentisfree/2014/apr/10/natural-birth-c-section-choice-brazil-forced-pregnancy

Lots of NGOs and blogs and fanpages etc… http://www.bbc.com/news/world-latin-america-34464268

Women movement begin to press for changes in the model of assistance: Guarantee access to doulas in labor rooms; Issue the National Agency of Supplementary Health to press health insurance companies to demand a maximum cesarean rate for doctors; More obstetric nurses working in public hospitals and also assisting more home births.

THE MEDICAL COUNCIL PROHIBITS BIRTH AT HOME http://g1.globo.com/rio-de-janeiro/noticia/2012/07/cremerj-proibe-parto-em-casa.html

http://www. viomundo. com http://www.viomundo.com.br/blog-da-saude/por-que-as-mulheres-brasileiras-estao-indo-as-ruas-pelo-bom-parto/

http://maternar. blogfolha. uol. com http://maternar.blogfolha.uol.com.br/2014/09/23/justica-anula-resolucao-que-proibia-parto-em-casa-cremerj-vai-recorrer/

http://www.bbc.com/news/world-latin-america-33421376

Proposals to reduce caesarean sections. 1 - access to information; 2 - To ensure the delivery of a card for the pregnant woman and a form with information about risks and benefits of each type of delivery; 3 - Use of partogram to justify the indication of cesarean avoiding elective surgeries http://www1.folha.uol.com.br/equilibrioesaude/2014/10/1532189-ans-lanca-propostas-para-estimular-partos-normais-por-planos-de-saude.shtml

https://docs.google.com/spreadsheets/d/1pYS0k0e8y4WMu1ZXBHpvfyuRjb8QJhoOySP9FlxrNqM/htmlview?pli=1

https://docs.google.com/spreadsheets/d/1T3WLJnHJKsDmWYoqFZPJ8jR6GDdNb-MXc4IOkaI6ruM/edit?pli=1#gid=0

The ministry of health in 2013 began the process of building a guideline for indication of cesarean section built in the same way of the NICE guidelines. Participation of stakeholders; Public consultation; This new guideline will reorganize the payment of CS in the private system. The mother care guidelines: cesarean section

http://noticias. uol. com http://noticias.uol.com.br/saude/ultimas-noticias/estado/2015/10/27/projeto-da-ans-reduz-taxa-de-cesarea-em-8-pontos-porcentuais.htm A new project conducted by the ANS and other institutions in 42 maternities both private and public reduces CS rates in 8%

The Federal Court ruled that the remuneration of health professionals in case of normal delivery is three times higher than for the payment made to do a C-section. The decision applies only to deliveries made by health plans. The second point of decision requires "health operators of private plans and hospitals to accredit and enable the performance of obstetric nurses and midwives during labor monitoring and the delivery itself.“ The third novelty of Justice decision is bound to ANS to create indicators and notes for operators of private plans, as their actions to reduce the number of cesareans.

Thank you! marcosad@iff.fiocruz.br