Gabriela Furlan

Naum Neskoski

November 4, 2014

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Cesarean and Episiotomy scenario in Brazil

The development of technologies has influenced several medical

practices, including the process of birth. New tools and techniques were
introduced with the purpose of improving the labor's safety and the health of
women and newborns.
Although, not all labor practices are justified by this purpose. Non-clinical
reasons and obstetrical abuse are the causes of two very frequent obstetric
interventions: scheduled cesarean1 and episiotomy2. These procedures have a
very high rate in Brazil and may lead to severe consequences to the puerperal3
and the newborns.

Context and statistics

Brazil's cesarean section rate is considered one of the highest in the
world. Hopkins, Amaral, and Moro's research indicates a steadily rise in
cesarean rate between 1998 and 2003 and a dramatically increase in 2008 "[the
rate] jumped to 53 percent in 2008 ()" (170-171). The episiotomy percentage in
Brazil is even higher than the cesarean rate; according to Wey's et al. research,
during 2001 and 2002 in So Paulo, 1837 normal deliveries were executed and
1

Cesarean section is defined as a method used to deliver a fetus throughout a cut in the abdomen and in the uterus.

Episiotomy is characterized as the procedure to enlarge the perineum. The physician makes an incision in the
perineum during the labor using a scissor or a blade, and, usually, a stitch is necessary for its correction. (Carvalho,
Souza, and Moraes Filho 333)
2

Puerperal is a postpartum period comprehended by immediately after the birth of a child and six weeks later.

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91.5% of them with episiotomy (8). The national rate is slightly greater: 94.2%
(Diniz, and Chacham 104).

(Table from Hopkins, Amaral, and Mouro 171)

All of these rates are very superior compared with those recommended by
the World Health Organization. WHO suggests a cesarean section rate below
15% (Ribeiro 1211), and the episiotomy amount should be less than 10%
(Carvalho, Souza, and Moraes Filho 335). Not only most of developed countries
have lower occurrences, but also developing countries, such as Bolivia and Peru
"() have prevalences of 15% an 13%, respectively (). In the developed
countries in Europe, prevalences of 10% in Switzerland and 14% in Netherlands
are observed" (Rebelo et al. 904).

Why cesarean is very common in Brazil?

A very large number of researchers are studying the reasons why physicians and
patients choose some practices unnecessarily. In Brazil, this phenomenon can be
explained basically by two aspects: non-clinical reasons and obstetrical abuse.

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The non-clinical reasons are comprehended by various attitudes taken under

cultural influence and economic situation; and these attitudes may be supported by
several professionals healthcare, specially obstetric doctors.
"There are many cultural and economic factors underlying this trend - in
some social groups caesarean sections are regarded as the most modern and
safe way of giving birth. This notion seems to be reinforced by doctors who
likewise see these operations as safe and convenient." (Barros et al. 168)

Women that are older than the average, belong to a higher socioeconomic group,
can pay for private hospitals, and is most-schooled have the highest rate of scheduled
cesarean (Hopkins, Amaral, and Mouro 175). Most of these women believe that
cesarean is the best choice due a misconception about this subject and only few nurses
and doctors are willing to change this paradigm in Brazil.
Another non-clinical reason is the trade of midwifery practice by medical doctors in
supervising births (Rebelo et al. 907). Before, the knowledge was transmitted from
women to women in the family, now it is a nursing professions domain. Not only there is
a lack of professionals in this area, but also Brazil needs modern regimentation for it.
Diniz and Chacham introduce a term called "the conveyor-belt approach" to
classify the way women are treated in Brazilian hospitals when they are in labor. This
approach puts another concerns above than womens safety and bodily integrity, and,
among with others invasive procedures, it can be considered obstetrical abuse.
One reason used by hospitals and doctors to validate abusive techniques which
speed up the delivery is the lack of beds. A note from a medical resident speech can
illustrate the scenario: "Leaving women for too long in a bed during labour is a waste of
space and limits the number of cases we can attend to. That is the reason why they
have to induce all deliveries" (102).

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Nevertheless, this approach not only leads to risks and pain to women and
newborns but also contributes to a bigger problem: the shortage of neonatal intensive
care bed. Since an "uncomplicated vaginal delivery means a hospital stay of 24 hours,
against 72 hours for an uncomplicated caesarean" is evident that cesareans should not
be the first choice. Furthermore, whenever neonatal beds are unavailable, hospitals
cannot accept more women - among them, may be a women high-risk pregnancy (102).

Why episiotomy is very common in Brazil?

The reason why episiotomy has been used a lot is because of the assumption that
it helps birth and protects womens genital. Despite it does not have any support from
consistent clinical researches, it became a routine practice and a completely truth in
almost every obstetric service. As in the case of cesarean sections, episiotomy is also
practiced to reduce the labour deliveries time. It is quicker and easier to cut the
perineum area than to wait until cervical and vaginal dilatation (Carvalho, Souza, and
Moraes Filho 333-335).
Another reason comes from the fact that there are women who does not know it is
possible to have a baby without being sutured; think that episiotomy depends of how big
the fetal is; and believe that the women who do not have any kind of suture on the
perineal will remain "open" forever. All these presupposition are not true nor scientifically
proven.
I had 3 baby deliveries and needed stitches in all of them. Some women
told me that they didnt need stitches, I find a bit weird, because the fact is that
the passing of the baby tears the mother. Are you going to remain with that
open? I find a bit weird, can you imagine, a huge hole!! (Wey et al. 5-6)

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Nowadays different studies have demonstrated that episiotomy have no scientific

basis to be adopted and, in fact, it can lead to post-operative issues. Since this is an
unnecessary and very painful technique, it can be regarded as an obstetric abuse.
Despite the endorsement contrary to episiotomy, in Brazil, it is still recommended by the
most used obstetrics handbook. This medical position and approach prevents a
substantial change to happen.

Risks and serious consequences

Although the cesarean deliveries are occasionally lifesaving for both mother and
infant, these practice can likewise drive to an growth in maternal morbidity and in the
risk of premature birth - because of a miscalculated expected date of labor (Barros et al.
167). Ribeiro et al. assert that an elevated rate of cesarean section can be related to an
large use of antibiotic after the delivery as well as rise fetal and neonatal mobility and
mortality (1218).
Diniz and Chacham argue that episiotomy "has no benefit for mother and infant,
increases the need for suturing of the perineum and the risk of complications at seven
days postpartum ()" (106). Moreover, the episiotomy was considered a risk factor for
the incidence of spontaneous lacerations successive deliveries; the cutaneous
contusions and abrasions and the post-operative pain and hemorrhage (Carvalho,
Souza, and Moraes Filho 337-338). For women who had their perineum cut, the pain
and laceration in the puerperium4 were very significant. It has bad influence in simple
activities, for example, going to the bathroom, sitting down and standing up, as well as
pain and troubles in returning to have sexual relations. (Wey et al. 8).

The same meaning as puerperal.

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Conclusion
Analyzing all statistics, information as well as physicians and womens speeches,
is possible to observe that women have wrong ideas about various obstetrical
interventions, mainly episiotomy and cesarean section, and doctors are responsible to
perpetuate these misconceptions. Several non-clinical reasons are used to legitimate
these practices - considered unnecessary most of the time. The obstetrical abuse
demonstrated to be very common either.
One way to change this scenario in Brazil is to start a dialogue between public
politics, healthcare professional and women. All pregnant should have the right to know
the correct informations and decide how they want to have their babies.
Another way is to promote the midwifery practice. In fact, in Brazil there is a current
endorsement of profession called "doula": accompanying childbirth professionals,
responsible for the physical and emotional comfort of the mother during the antepartum,
birth and postpartum.
Finally, a set of actions is needed to have a fundamental change in obstetrics. Only
with the effort of doctors, women and government it will be possible to reduce the rate of
episiotomy an cesarean deliveries in Brazil and its bad consequences.

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Works Cited

Barros, Fernando Celso de, et al. "Epidemic of caesarean sections in Brazil." The Lancet !
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338.8760 (1991): 167-169.!

Carvalho, Cynthia Coelho Medeiros de, Alex Sandro Rolland Souza, and Olmpio Barbosa !
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Moraes Filho. "Prevalence and factors associated with practice of episiotomy at a !
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maternity school in Recife, Pernambuco, Brazil." Revista da Associao Mdica ! !
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Brasileira 56.3 (2010): 333-339.!

Diniz, Simone G., and Alessandra S. Chacham. "The cut above and the cut below: the abuse
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of caesareans and episiotomy in So Paulo, Brazil." Reproductive Health Matters 12.23 !
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(2004): 100-110.!

Hopkins, Kristine, Ernesto Friedrich Lima Amaral, and Aline Nogueira Menezes Mouro. "The !
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impact of payment source and hospital type on rising cesarean section rates in Brazil, !
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1998 to 2008." Birth 41.2 (2014): 169-177.!

Rebelo, Fernanda, et al. "High cesarean prevalence in a national populationbased study in !

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Brazil: the role of private practice." Acta obstetricia et gynecologica Scandinavica 89.7 !
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(2010): 903-908.!

Ribeiro, Valdinar Sousa, et al. "Why are the rates of cesarean section in Brazil higher in more !
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developed cities than in less developed ones?." Brazilian Journal of Medical and !!
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Biological Research 40.9 (2007): 1211-1220.!

Wey, Chang, Natlia Rejane Salim, Hudson Pires de Oliveira Santos Junior, and Dulce Maria !
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Rosa Gualda. "The practice of episiotomy: a qualitative study on perceptions of a group !
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of women." Online Brazilian Journal of Nursing [Online], 10.2 (2011): 1-11 Web. 3 Nov. !
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2014.