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ASPECTS RELATED TO THE CHOICE OF THE TYPE OF DELIVERY:

A COMPARATIVE STUDY BETWEEN TWO REFERRAL MATERNITY HOSPITALS, ONE PUBLIC, THE
OTHER PRIVATE.

Natalia Ribeiro Mandarino, , Francisco das Chagas Monteiro Junior, Luciane Maria
Oliveira Brito, Elba Gomide Mochel, Jose Albuquerque de Figueiredo Neto, José
Carlos Martins Coelho Júnior, Maria Bethania da Costa Chein.

Post-Graduation Program for Maternal-Child Health, Federal University of Maranhao,


São Luis, Brazil
Mother and Child Health Medical Department 3, Federal University of Maranhao, Sao
Luis, Maranhao, Brazil

Address for correspondence


Maria Bethânia da Costa Chein
Praça Gonçalves Dias, 21, 2º andar, Centro, São Luis, Maranhão, CEP 65.020-240

ABSTRACT

The objective of this research is to analyze aspects related to the choice of the
type of delivery in a public maternity hospital (PU) and another private (PR), in
Sao Luis, Maranhao.
Through a cross-sectional study, 163 primiparous women at a public maternity
hospital (PU) and 89 at a private one (PR), with average ages of 21,63 ± 5,24 and
28,8 ± 5,41 years, respectively, were approached and compared. At the PU, 79,1% of
the mothers said they preferred the vaginal delivery (VD), while 67% of the PR
women preferred a Caesarian section (CS) (p=<0,0001). The satisfaction rate was
high with both types of delivery, at both maternity hospitals, but the intention
to repeat was more frequent with the VD subgroup (71,6 x 41,3% at the PU, and 100
x 65,5% at the PR). At the PU the CS subgroup presented a higher proportion of
Caucasian women, having a higher income. The CS rates were elevated in both
maternity hospitals, but significantly higher at the PR, being observed a greater
preference for VD at the PU and for CS at the PR. Caucasian women having a higher
income were significantly associated with the occurrence of CS at the PU.

Key words: Type of delivery, Caesarian section, Public maternity hospital, Private
maternity hospital

Introduction
The choice of delivery, vaginal (normal) or surgical (Caesarian), is a complex and
polemic subject. A Caesarian, otherwise considered an exceptional procedure,
indicated for high-risk situations either for the mother or the fetus, is actually
in most cases a programmed surgical procedure, not having medically identified any
defined risk, whose choice is frequently attributed to the mother1,2,3,4,5,6,7,8.
The World Health Organization (WHO) alleges a Caesarian rate between 10% and 15%
as an ideal. However, higher universal rates have been observed in general, even
in countries that are considered underdeveloped having a similarity to other
developing countries, Brazil presents higher Caesarian rates to those alleged by
the WHO, surpassing 35% in general and exceeding 70% when only considering the
private sector1,5,10,11,12.
Among the Brazilian federate units there are none that present rates within the
desirable parameters by the WHO. Amapa, located in the extreme north, and Sao
Paulo, in the southeast region (socially/economically more developed), present
respectively the lowest (23,42%) and the highest (53%) proportional rates of
Caesarians performed by the Public Health System (SUS). Such percentages have
placed Brazil in a notable position in the world panorama12,14.
Caesarians bring about an increase of maternal and fetal morbimortality, with the
predominance of primiparous infection and of premature births. It is also
associated with retardation in puerperal recuperation, a longer admittance period,
a longer time of assistance by health professionals, during prolonged admittance
periods, a greater use of medicine, a late start to breastfeed and finally, more
expenses for the health system. It seems like the increase of Caesarians is not
only due to medical reasons, but they’re also influenced by many other factors
related to the mother, such as social-economical inequalities, the geographical
situation, the age group and ethnics5,12,14,15,16.
The doctors, frequently pointed out as prompting interference for convenience’
sake, claim that Caesarians are also justified by the mother’s wish, mainly those
from higher class society, that prefer this means to preserve the external genital
anatomy, to not feel labor pain and among those desiring to limit the number of
offspring, to take advantage of the occasion to tie their fallopian tubes
(surgical sterilization) 5,11,12,14,16,17,18.
The change of assistance in the delivery based on plausible safety of intervening
medical procedures transformed natural childbirth into a passive delivery of
interventions, in other words, of risks. So nowadays, natural childbirth has come
to mean a vaginal delivery directed or guided in a hospital environment. Medical
technology presents itself, in this sense, as a necessary answer to control this
risk, justifying the social, legitimate reason for a Caesarian delivery, as a
safe, painless, modern and ideal procedure for any woman, adapting it to fit into
the general guidance of occidental medicine to benefit (“spare the woman from
pain”) 19.
Under the feminist speech sponsorship about the right of women to choose the type
of delivery, the obstetric practice appropriated itself to this speech to justify
the request of the mother to perform a Caesarian (“Caesarian request”). However,
the apparent “freedom of choice” granted to the woman is many times accompanied by
inadequate information about the risks involved in the procedures related to the
delivery and birth11,20,21.
It is evident that the growing rates of Caesarians not having medical indication,
in developed as well as underdeveloped countries, has motivated various researches
and debates about the legality of the surgical procedure without an identified
medical need. In this context, the International Federation of Gynecology and
Obstetrics (IFGO), that unites all the Brazilian tocogynecologists, by means of
the Brazilian Association of Gynecology and Obstetrics Society (BAGOS), through
their Committee of Ethical Aspects of Human Reproduction, pointed out that the
practice of Caesarians without a formal medical indication is not ethical20.
Contrary to this position, the Committee of Ethics of the American College of
Gynecologists and Obstetricians (ACGO) reaffirms that the mother’s wish should be
respected (“the subject’s autonomy”) to decide the type of delivery, in low-risk
prenatal care, the pregnancy being between 39 and 40 weeks, being that the mother
is clearly informed about the risks and benefits of the surgical procedure and
signs a clarified term of free consent, a position that has raised debates and
ethical questioning6,17,22.
The comprehension of the diversity of factors that interfere in the assistance of
the delivery, culminating in these elevated rates of Caesarians, still lack
consensus in the proposition of solutions to control these rates.
In the municipal area of Sao Luis, Maranhao, there are 13 hospitals that perform
delivery assistance. In 2006, 1435, 5 deliveries were performed monthly, on an
average, in the public sector (including those affiliated to the SUS). Out of
17,226 deliveries performed in that year, 3703 were Caesarians (27, 38%). Data
from the private sector are not officially available. Besides this, other relevant
information, such as the mother’s preference of delivery and the affirmed reasons,
are not all known. Neither do we know if this preference is being corresponded, as
well as if the mothers are satisfied with the type of delivery performed. It is
possible that non-clinical factors, such as the social-economical level,
inadequate information and the doctor’s convenience, really influence the choice
of delivery, as some authors suggest11,12,14,17.
Consequently, the present research proposes to know the mother’s wishes related to
the types of delivery, as well as to verify and compare the frequency of
Caesarians, seeking to identify its indications and other determining variables of
deliveries in our midst.

Materials and Methods


A transversal study was done in two hospital units, one public and another
private, both considered referrals for obstetric and perinatal care in the State,
in the months of February and March in the first, and April and May in the second.
The public sector (PU) is located downtown in the capital and acts as a teaching,
research and extension hospital, 100% of its beds destined to the SUS users. It is
registered in the National Registry of Health Establishments as a public unit to
offer basic care, of medium and high complexity, by means of ambulatory and
emergency care, Diagnostic and Therapeutic Support Services (DTSS) and admittance,
presenting a flux of patients for care, spontaneously and referential in the State
(BRAZIL, 2007).
The private sector (PR) is also located in the capital, in a neighborhood close to
downtown. It is registered in the same organ as a private company, without any
beds destined to SUS users. It has obstetric emergency care 24 hours a day.
All the primiparous consecutively admitted in labor during the referred period or
having medical indication for delivery assistance, including 163 women in the PU
and 89 in the PR. The non- inclusion of multiparous in this study aimed at
avoiding a tendency in the choice of the following delivery. As American
sociologist Hopkins11, who did research in Brazilian hospitals commented, the
type of the first delivery is crucial to determine the type of future deliveries,
because it’s common sense among doctors and women that “once a Caesarian, always a
Caesarian”.
Criterion of exclusion was considered for the presentation of any clinical
condition that in itself required a Caesarian (for example: endocrinopathics,
cardiopathics) and the incapacity to answer the questionnaire without the
participation of another person, not having occurred, however, any case of
exclusion.
In the pre-delivery phase, after explaining the objectives of the research and the
textual consent (signature of Free and Clarified Consent Term- FCCT), all
participated in the first part of the research, answering a questionnaire
containing open and closed questions, about the delivery of their preference.
Elapsing 24 to 36 hours after the delivery, all were submitted to the second part
of the same questionnaire to obtain more information: social-demographical
characteristics (age, race, schooling, profession, conjugal situation, income),
pre-natal assistance, age of the first menstrual period and of the first sexual
relation, type of delivery (vaginal or Caesarian), satisfaction with the type of
delivery and if they would repeat the same type of delivery, and in the case of a
Caesarian, if they had a medical indication (cephalic-pelvic disproportion, fetal
suffering, pelvic presentation, twins and others), considering primarily the
constant notation on file, or obtained information from the interview with the
mother, in the absence of medical notation or an indication.
The age groups were categorized: younger than 20 years (teens), from 20 to 34
years (young adults) and 35 up (adults).
Pre-natal assistance was considered complete when the mother had 6 or more
consultations.
The two samples, from the PU and the PR, were compared in relation to the social-
demographical characteristics, the mother’s preference for delivery, frequency of
Caesarians and the motives for having them and the patients’ satisfaction with the
type of delivery performed. In each sample they sought to identify the variables
associated to the type of delivery performed.
The data obtained was categorized on charts. The qualitative variables were
represented by relative frequency (%) and the continual variables were expressed
by the average and deviation pattern. For the statistical analysis, the Epi-info
version 3.3.2 program was used, adopting as a significant value a p ‹ 0, 05. The
qui-square test was adopted to calculate the significance in the uni-varied
comparison of proportions.
This research was approved by the Committee of Ethics in the University Hospital
in the Federal University of Maranhao nº 33104-0063/2007 and is in agreement with
the ethical principles contained in the Helsinki Declaration.

Results
The average age of the two samples, from the PU and the PR, was 21, 63 ± 5, 24 and
28, 8 ± 5, 41 years, respectively, verifying a predominance of young adults in
both maternity hospitals (57, 7% and 85, 4%, respectively).
In relation to ethnics, in the PU there was a predominance of mixed races (61,3%),
followed by Caucasians (21,5%) and Negros (17,2%), whereas in the PR the
Caucasians predominated (59,6%), followed by mixed races (38,2%), and only 2
Negros (2,2%).
In relation to schooling, only a minority of the women in the PU had college
education (8,6%), being that 55,8% had studied until high school and 35,5% until
elementary school; whereas in the PR there was a predominance in high school and
university level (43,8 and 56,2%, respectively).
In relation to marital status, there was a predominance of married women, or
living together with a mate in both samples (63, 2 and 73%, respectively).
Among the mothers in the PU, the majority had a family income between 1 to 3
minimum salaries, while 94, 4% admitted to the PR reported a family salary
superior to 3 minimum salaries. In relation to the occupation, in the PU 32,5% of
the mothers were unemployed, 29,4% were “housewives”, 14,1% were students and the
remaining 24% had varying professions. In the PR the professions were diversified,
with a slight distinction of students (20, 2%), liberal professionals (15, 73%)
and “housewives” (10, 1%).
Observing Chart 1, it can be seen that the social-demographical characteristics of
the two samples presented significant statistical differences in relation to all
the variables analyzed, except for the marital status.

Chart 1- Distribution of the women according to the social-demographical


characteristics. Sao Luis, Maranhao, 2007
Maternity
Variables PU (n=163) PR (n=89) Significance
p-value
f % f %
Age (years) <0,0001
≤19 years 66 40,5 2 2.2
20-34 94 57,7 76 85,4
≥35 3 1,8 11 12,4
Race <0,0001
Caucasian 35 21,5 53 59,6
Mixed 100 61,3 34 38,2
Negro 28 17,2 2 2,2
Schooling <0,0001
Until elementary 55 35,5 - -
Until high school 91 55,8 39 43,8
Until college 14 8,6 50 56,2
Unknown 3 0,1
Marital status <0,1486
Single/widow 60 36,8 24 27,0
Married/living together 103 63,2 65 73,0
Family income <0,0001
< 1 minimum salary 28 17,2 - -
≥ 1 and < 3 salaries 91 55,8 - -
≥ 3 minimum salaries 18 11,0 84 94,4
Others 26 16,0 5 5,6
Occupation <0,0001
Unemployed 53 32,5 - -
Housewife 48 29,4 9 10,1
Student 23 14,1 18 20,2
Liberal professional - - 14 15,7
Others 39 24 59 54,0

The first menstrual period occurred predominantly between the ages of 12 to 14 for
the women at the PU, and at the same age or superior to 15 for the women at the
PR. The first sexual relation was more frequent between the ages of 15 to 18 in
both groups; however a higher percentage of the women from the PU had sexual
initiation before 15 years of age (chart 2).

Chart 2 – Distribution of the women according to the age of the first menstrual
period and first sexual relation. Sao Luis, Maranhao, 2007

Maternity
Variables PU (n=163) PR (n=89) Significance p-value
f % f %
First period <0,0001
9 to 11 years 29 17,8 - -
12 to 14 years 104 63,8 18 20,2
15 years and over 28 17,2 59 66,3
Unknown 2 1,2 12 13,5
1st sexual relation <0,0016
< 15 years 28 17,2 2 2,2
15 to 18 years 108 66,3 75 84,3
≥ 19 years 23 14,1 8 9,0
Unknown 4 2,5 4 4,5

In relation to the delivery, 79,1% of the women from the PU affirmed their
preference for vaginal delivery, while in the PR the majority of the women (67,4%)
preferred a Caesarian, with a significant statistical difference (p < 0,0001). In
both maternity hospitals, the main motive for having a vaginal delivery was the
fact that recuperation is faster; for the women who preferred a Caesarian, the
motive was fear of feeling pain (chart 3).

Chart 3 – Distribution of the women according to their preference of delivery. Sao


Luis, Maranhao, 2007

Maternity
Variables PU (n=163) PR (n=89)
f % f %
Woman’s preference
Vaginal delivery 129 79,1 29 32,6
Caesarian 34 20,9 60 67,4
Motive for vaginal preference
Faster recuperation 95 73,6 26 89,7
It’s natural 26 20,2 - -
Family habit 5 3,9 - -
Fear of anesthesia - - 2 6,9
Others 3 2,3 1 3,4
Total 129 100,0 29 100,0
Caesarian
Fear of feeling pain 28 82,4 54 90,0
Guidance/indication from friends 1 2,9 3 5,0
To avoid vaginal deformations 2 5,9 2 3,3
Doctor’s recommendation 3 8,8 1 1,7
Total 34 100,0 60 100,0
• p < 0,001

In the PU as well as the PR, the majority of the women had received prenatal
assistance (96,9 % and 98,9 %, respectively), without any statistically
significant difference (p=0,59). This assistance was considered complete in 57% of
the women from the PU and 97,8% from the PR. In the PU 3 women (1,9%0 didn’t know
how many prenatal consultations they had had (chart 4).

Chart 4 – Distribution of the women according to the prenatal assistance received.


Sao Luis, Maranhao, 2007

Maternity
Variables PU (n=163) PR (n=89)
f % f %
•Received prenatal assistance 158 96,9 88 98,9
Prenatal complete 90 57,0 86 97,8
•p = 0, 5925

Caesarians were performed on 75 women (46%) from the PU and on 87 (97,8%) from the
PR (p< 0,0001). 94,7% of the women from the PU had clinical indication for the
Caesarian while in the PR only 63,2% had a clinical indication on their file (p<
0,0001). For the remaining women from the PR that had Caesarians (36,8%) there
were no indications documented, being clarified that it was “requested” in the
women’s information from the post-partum interview (chart 5).

Chart 5 – Distribution of the women according to the delivery performed and motive
for Caesarian. Sao Luis, Maranhao, 2007
Maternity
Variables PU (n=163) PR (n=89) Significance p- value
f % f %
Type of delivery < 0,0001
Vaginal 88 54,0 2 2,2
Caesarian 75 46,0 87 97,8
Motive for Caesarian < 0,0001
Clinical indication 71 94,7 55 63,2
“Requested” 4 5,3 32 36,8

In relation to the clinical indications for Caesarians, there was a greater


frequency of cephalic-pelvic disproportion in both sectors (37,3% and 28,7%,
respectively). Chart 6 relates the frequency for the remaining indications.
Chart 6 – Distribution of the women according to the indications for a Caesarian
delivery.
Maternity
Variables PU (n=71) PR (n=55)
f % f %
Cephalic-pelvic disproportion 31 43,7 25 28,7
•HDSP 21 29,6 12 13,8
Fetal suffering 18 25,3 15 17,2
Twins 1 1,4 3 3,4
•HDSP: Hypertensive disease specific to pregnancy
The concordance rates between the women’s preference and the type of delivery
performed in the PU were 55,8% for vaginal deliveries and 38,2% for Caesarians;
there were 6,9% for vaginal deliveries and 100% for Caesarians in the PR (Chart
7).
Chart 7 – Distribution of the women according to the percentage of concordance
between the preference and the type of delivery performed. Sao Luis, Maranhao,
2007
Maternity
Variables PU (n=163) PR (n=89)
Preference Delivery performed Preference Delivery performed
f (%) f % f (%) f %
Vaginal delivery 129 (100%) 72 55,8 29 (100%) 2 6,9
Caesarian 34 (100%) 13 38,2 60 (100%) 60 100

In both maternity hospitals, the level of satisfaction with both types of delivery
was elevated: 93,8% vaginal and 90,7% abdominal in the PU and 100% with both types
of deliveries in the PR. In the PU 71,6% of the women submitted to vaginal
delivery said they would repeat this type of delivery, against 41,3% of those who
had Caesarians; the percentages for the PR were respectively 100% and 65,5%,
verifying a statistically significant difference for this variable in both samples
(chart 8).
Chart 8 – Distribution of the women according to their satisfaction with the type
of delivery performed and their intention to repeat that type of delivery. Sao
Luis, Maranhao, 2007
Maternity
Variables PU PR
f % f %
Satisfaction with type of delivery
Vaginal 82 93,2 2 100,0
Caesarian 68 90,7 87 100,0
Would repeat type of delivery
Vaginal 63 71,6 2 100,0
Caesarian 31 41,3 57 65,5

Comparing the group that had vaginal deliveries with those who had Caesarians in
the PU, it was verified that there was no significant difference in relation to
the variables: age, marital status, schooling, prenatal assistance and if the
prenatal care was complete or not. In relation to the race there were more
Caucasians who had Caesarians and more of mixed races in the vaginal delivery
group (p=0,0163). In the Caesarian group there was a greater proportion of those
receiving more than 3 minimum salaries (p=0,0001) (chart 9).

Chart 9 – Distribution of the women’s characteristics in the PU, according to the


type of delivery. Sao Luis, Maranhao, 2007
Type of delivery
Variables Vaginal (n=88) Caesarian (n=75) Significance p-value
f % f %
Age (years) P=0,506
≤ 19 years 38 43,2 28 37,3
20-34 48 54,5 46 61,3
≥ 35 2 2,3 1 1,4
Race P=0,0163
Caucasian 12 13,6 23 30,7
Mixed race 62 70,5 38 50,7
Negro 14 15,9 14 18,7
Schooling P=0,0714
Until elementary 36 41,0 20 27,7
Until high school 47 53,4 45 60,0
Until University 5 5,6 10 13,3
Marital status P=0,9721
Single/widow 33 37,5 27 36,0
Married/living together 55 62,5 48 64,0
Family income (minimum salary) < 0,0001
< 1 15 17,0 13 17,3
≥ 1 and < 3 51 58,0 40 53,3
≥ 3 5 5,3 22 29,2
Others 17 19,3 - -
Prenatal assistance 84 95,5 74 98,7 p=0,4656

Debate
The Caesarian rates registered in Brazil greatly differ according to the
institution considered, be it public or private. Consequently, in this research
two maternity hospitals that are considered referrals in the city were chosen for
analysis, one public and another private.
The women cared for in the PR presented higher levels of schooling and income,
predominantly Caucasians; whereas in the PU there was a lower average age group,
predominantly mixed races, and among these was the tendency to an earlier first
menstrual period and first sexual relation. In relation to marital status, there
was no difference observed, predominantly married or living together in both.
In relation to the delivery, almost 80% of the women at the PU manifested a
preference for vaginal delivery, a finding in accordance to other Brazilian
authors5,15,24. In international literature, the indexes in preference for vaginal
deliveries reported even higher percentages: 93,5% in an Australian study, 96,3%
in an Asian study and varying between 86 and 99,7% in a systematic review of 17
articles25,26,27. On the other hand, among the women from the PR of this research,
70% preferred Caesarians, which is not in accordance to all the studies
researched, and reflects a greater incorporation of the alleged “Caesarian
culture” among them.
The main motive for the preference of a vaginal delivery in both maternity
hospitals was the fact of a quicker recuperation, while in both samples the
preference for Caesarians was due to a fear of pain associated to vaginal
delivery. According to Figueiredo et al28. this fear is not justifiable, since the
discomfort experienced by the mothers during childbirth isn’t very different
between the two types of delivery. In other words, even though labor pain is
lessened by the use of analgesic or a Caesarian, it is always present from pre-
partum until post-partum, varying according to the intensity of the physical and
emotional conditions of the woman as well as the assistance she receives during
these moments.
Perpetuo et al. 24 verified that among women who had both types of deliveries, the
lesser pain was cited 10 times more frequently as a motive to prefer vaginal
delivery. Whereas a large part of the Caesarians performed in the PR is elective,
meaning having planned a date and time , without labor, eliminating the algico
component of pre-partum, which could contribute to the choice of this type of
delivery.
On the other hand, contrary to common sense, among the women that manifested a
preference for a Caesarian in both hospitals, a fear of vaginal deformity and the
consequent harm to sexual activity as a motive to avoid a vaginal delivery wasn’t
mentioned very much by these women (5,9% and 3,3%, respectively), a finding
similar to Perpetuo et al. 24
Based on the Caesarian rate alleged by the WHO of up to 15%, the indexes verified
in this study, of 46% and 97,8%, respectively in the PU and PR, can be considered
very high. These rates are also higher than those described for Brazil, around 35%
in general and 70% in private sectors1,29. It’s worth emphasizing that some
specialists have demonstrated that it’s possible to maintain rates lower than 2%
without compromising the quality of assistance and without bringing on the
increase of risk of maternal or fetal morbimortality, which only emphasizes the
importance of the problem being studied30,31.
Considering the fact that the PU is a university institution as a referral for all
the State could justify a greater complexity of the cases being treated and
consequently contribute to the increase of the percentage of Caesarians.
Prenatal assistance has been pointed out as a factor of reduction of risk of
complications and the need for a Caesarian1,32,33. In the present study, however,
in respect to the almost totality of women having received such assistance,
considered complete in 57% of the cases in the PU and 100% in the PR, high rates
of Caesarians were observed. In the PR, according to Domingues et al. 33 a
possible explanation would be the doctor’s influence, presumably in favor of
Caesarians, contributing to these results, apparently paradoxical.
The obstetrician should be available at the minimum 6 to 8 hours accompanying the
patient, doing clinical exams every 2 hours, mainly in the case of primiparous,
when the progress of labor is usually longer. In the assistance performed in the
private sector, the obstetrician could, for various motives, not have this time
available for assistance, and end up indicating a Caesarian. Whereas in the public
sector, when the mother in labor is admitted, she will have a team of
obstetricians on duty at her disposal for periodical clinical exams, which makes a
continuation of accompaniment possible; that way the motive to perform Caesarians
will be more associated to the real medical indications (threat to the maternal-
fetal binomial) than to a “lack of time” and convenience for the obstetrician.
In fact, in corroborating this supposition, it was verified in this study that in
the PR, besides the predominant preference for Caesarians manifested by the
mothers (67,4%), within those favorable to vaginal delivery (29 patients), only 2
(7%) had their desire granted, while 100% of those who preferred Caesarians ended
up having this type of delivery.
In the PU, the concordance rates among the women’s preference and the type of
delivery performed was 55,8% for vaginal deliveries and only 38,2% for Caesarians,
which suggests that the woman’s desire had less importance, and the clinical
indications prevailed for each type of delivery. Consequently, the high rate of
Caesarians verified in the PU could be justified more by other factors, such as
the fact that the study is limited to the primiparous and this institution is
considered of referral for medium and high complexity care, as was already cited.
As Fabri and Murta emphasize32, little or no guidance during prenatal care about
real indications for Caesarians and the benefits and disadvantages of each type of
delivery, associated to the scientific progress and the improvement of surgical
techniques, characterize a model of medical assistance strongly determining the
option for surgical delivery. Barbosa et al. 19 adds that many times the unfounded
idea that Caesarians are safer for the mother and the baby is transmitted to the
mother during prenatal care and therefore a more “modern” form of delivery. Almost
all Caesarians performed in the PU had a clinical indication registered, being a
cephalic-pelvic disproportion, HDSP and fetal suffering as the main ones. In the
PR there was documentation of clinical indication in only a little more than 60%
of the cases, the cephalic-pelvic disproportion being the most referred to,
followed by fetal suffering and HDSP, and the remaining cases titled “requested”.
Besides the type of delivery performed, the level of the mother’s satisfaction was
higher in both samples (higher than 90% in the PU and 100% in the PR), but it
should be pointed out, however, by its subjective character, that satisfaction is
a difficult to interpret in this context by frequently being imbricated with the
quality of medical assistance received and the neonatal results19. However,
intentions to repeat the same type of delivery was more frequent among the women
who had vaginal deliveries in both sectors.
When analyzing only the PU sample, we see a balance between both types of
deliveries, and the Caesarian group presented a better income and higher
proportion of Caucasians. Besides this, there was a higher proportion of
Caesarians among those who had more schooling, which could be why the statistical
significance was not reached due to the small number of women who went to
university in this sample.
These findings, together with the high rate of Caesarians verified among the women
from a better social-economical level cared for in the PR of this study and the
example of others, corroborates the role of non-clinical factors in the choice of
a Caesarian, related to social-cultural aspects of the obstetrician, including
attitudes by the medical team, the woman and her family11,12,24,34.
In relation to the population level, in a study that analyzed 19 countries of
Latin America, Belizan et al. 1 verified a positive and significant correlation
between the Caesarian rate and income per capita, the proportion of the urban
population and the quantity of doctors for 10,000 inhabitants. The social-
economical inequalities in the probability of a Caesarian can reflect differences
of permeability of the medical culture to the woman’s preference and the
differences of medical interpretation for clinical indications of a surgical
delivery. Consequently, it is understood that women who are socially and
economically poorer, and consequently have a greater risk of complications in the
delivery are less probable to have a Caesarian than those with a lower obstetric
risk and higher income12.
In synthesis, as Freitas et al. 12 also commented, when dealing with the Caesarian
culture in Brazil, the Caesarian delivery has come to mean differentiated medical
care (“painless childbirth”, “absence of asphyxia at birth”, “sexuality
preserved”) for the woman and her family, more control medically and of the
obstetricians’ working hours. The data presented here to the similarity of those
cited by Samtos et al35 and Hotimsky et al.36 are very relevant, since the
Caesarian delivery is not risk-free, contributing to the increase of maternal and
fetal morbimortality, besides causing an increase in medical/hospital costs. High
rates of Caesarians in primiparous are especially worrisome, as shown in this
study, because this implies the high probability of future Caesarians, because a
first Caesarian almost always indicates another Caesarian, justifying the saying
“once a Caesarian, always a Caesarian”.
The results of this research that included two municipal hospital sectors
evidently cannot be extrapolated to all the population; however, the findings
confirm the importance of the theme and clearly point out the need for more in-
depth studies, that allow more ample knowledge for our reality.
Final Considerations
The complexity of factors related to prenatal care, delivery and puerperio, raises
questions concerning the quality of assistance offered to the women in the
pregnant-puerperal cycle.
By quality of assistance, we understand not only provision of human resources and
adequate techniques for operating, but also humanized care and a guarantee of
respect for each mother’s needs, including her active participation, providing
adequate information in all the decision-making process not only in relation to
the delivery, but in all other respects referring to the delivery and birth.
Although these actions are foreseen in the Humanization Program of Prenatal Care
and Birth, instituted in 2000 by the Health Ministry, such actions still need to
be incorporated in the day-to-day health services, returning the role of the
delivery to the woman and giving attention to the delivery of her choice and
individual needs.
The rates of Caesarians verified in this research are elevated, even exceeding
those reported in other Brazilian studies. While the proportion of Caesarians
observed in the PU is higher than is recommended, it could be partially justified
by the fact that it’s dealing with a referral unit of medium and high complexity
in the State, which was verified in the PR, where almost all deliveries were
surgical. It’s alarming and clearly denotes a “Caesarian culture”, seeing that in
this unit the majority of the women manifested a preference for a surgical
delivery, contrary to what was observed in the PU and also what has been reported
in studies involving other private maternity hospitals.
Disagreeing with the official position of the American College of Gynecologists
and Obstetricians (ACGO), that proposes the acceptance of solicitation for a
Caesarian by the woman, evoking her right of autonomy, Minkoff defends that the
doctor also has the right to refuse such a solicitation in the absence of a
clinical indication and the duty to try to dissuade her.
The findings of this research reinforce the idea that other factors other than
clinical indications, such as social, cultural, economical, type of assistance and
professional involvement (time x money x dedication), directly interfere in the
process of choice of delivery, reflecting the way that obstetric assistance has
been organized in our health system, marked in a medical culture that transformed
the delivery and birth from physiological events into pathological, and that
privileges the use of technology, disseminating the equivocal notion that a
surgical delivery is more adequate and secure.

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