High rates of caesarean section do not reflect women's preferences

November 15, 2001

Unwanted caesarean sections among public and private patients in Brazil: prospective study BMJ Volume 323, pp 1155-58

Editorial: Promoting normality in childbirth BMJ Volume 323, pp 1142-3

Recent concerns surrounding high rates of caesarean section have led to a focus on increasing the numbers of women who have a straightforward vaginal birth. A study in this week's BMJ finds that the extremely high rates of caesarean section in Brazil do not necessarily reflect women's preferences for this type of delivery.

Over 1100 pregnant women in Brazil (717 public patients and 419 private patients) were interviewed three times about their preferences for delivery - twice during their pregnancy and again a month after their expected due date. The rates of caesarean delivery were 31% in the public sector and 72% in the private sector.

Despite large differences in the rates of caesarean section in the two sectors, there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. This finding contradicts the assumed belief that middle and upper class women in Brazil prefer caesarean deliveries. Another finding is many of the patients who had caesarean deliveries never went into labour. Caesarean delivery was decided on before admission in 23% of women in the public sector and 64% of women in the private sector.

Many Brazilian obstetricians may believe that a caesarean section is actually safer for the newborn and more comfortable than a vaginal delivery for most women. Alternatively, doctors may not have the opportunity or skills needed to elicit their patients' preferences and simply assume that their private patients would prefer a caesarean section, suggest the authors.

"While we do not have evidence to support any of these interpretations, we are concerned that the rates of caesarean section in the private sector are above any accepted standard and are inconsistent with women's preferences," say the authors.

"We hope that our results will encourage change in Brazil and counteract the inclination to interpret high or rising rates of caesarean section elsewhere as evidence of demand for surgical delivery," they conclude.

Women and professionals should be encouraged to consider vaginal birth positively, write Richard Johanson and Mary Newburn in an accompanying editorial. New approaches that examine choice and control need to be examined, particularly in a climate where some women are choosing interventions, they conclude.


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