MC Callum Explaining Cesarean Section in Bahia

Sociology of Health & Illness Vol. 27 No. 2 2005 ISSN 0141–9889, pp.
215–242
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Explaining caesarean section in Salvador da

Bahia, Brazil
Cecilia McCallum
Institute de Saúde Coletiva, Federal University of Bahia, Brazil
Abstract In Salvador da Bahia the caesarean section rate is excessive, as it

is in Brazil as a whole. It is the standard form of delivery in private
hospitals, though vaginal delivery still predominates in the public
sector. This paper investigates the social context of these styles of
childbirth, arguing that the connections between both sectors
sustain this situation. Exploring the factors leading to the
preference in private and insurance-funded maternity wards, it
examines critically two diverging positions on the cause of the rate:
that women’s cultural preferences for abdominal birth lie behind
it; or that obstetricians’ self-interest is to blame. The paper
critiques the theory of culture behind the first stance and questions
the theoretical weight placed on individual action in the second.
It argues that no particular social group is the principal cause of
the excessive use of caesarean section to deliver babies. Rather, a
host of factors converge in sustaining this practice. Finally, the
paper stresses that the system as a whole, not any particular group,
must be changed if the rate is to be lowered significantly. For this,
political will is required.
Keywords: childbirth culture, caesarean, obstetrics, Brazil, Salvador da

Bahia
Introduction
Any conversation about birth in Brazil leads naturally to the question of

caesarean section. Nearly 40 per cent of births between 1994 and 1998 were
by caesarean (DATASUS). In the city of Salvador, it is the ‘normal’ form of
childbirth in private hospitals, where rates vary between 70 per cent and 99
per cent. In 1998, while interviewing obstetricians, I asked why this was so.
Some claimed, in response, that women want and indeed demand caesareans,
considering it a modern and painless form of childbirth. Women’s choice,
others added, was culturally generated, by their participation in the project
© Blackwell Publishing Ltd/Foundation for the Sociology of Health & Illness 2005. Published by Blackwell
Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden MA 02148, USA
216 Cecilia McCallum
of modernity and by their condition as Latin women. The doctors also

spoke of other pressures, such as their own need to maximise their use of
time, and I soon realised that claims that the women themselves are to blame
are exaggerated. Women’s attitudes and actions, as structured by and struc-
turing of gender, contribute significantly to the high rate of caesarean section
in the private sector, but they do not explain the caesarean rate to the extent
that some obstetricians suggested. A host of other factors also contribute.
In this paper I explore these factors, drawing on research in Salvador
and a survey of the literature. Discussing the socio-economic frame of child-
birth, I show that much more than culturally-conditioned choice or the
self-interest of obstetricians is at stake. My argument is that ‘culture’ and
‘self-interest’ are enmeshed in and generated by the day-to-day workings of
specific socio-economic and political orders. In Salvador, births of all kinds
take place within a series of nested contexts that make up this order – the
familial, the institutional, the inter-institutional, the regional, the national
(and ultimately the global). This makes up a system of stratified reproduc-
tion, where the overall order shapes experiences at either end (Ginsburg and
Rapp 1995). Thus it is not enough to focus on the choices made by the
subjects who participate in the events surrounding childbirth. Rather, sub-
jects’ understandings and actions only make sense when seen in relation to
the context that conditions their actions.
The basis for this argument is present in the existing literature, though
with some notable exceptions this has tended to focus on issues of ‘choice’
and ‘self-interest’. The topic of the high rate of caesarean section in Brazil
received growing investigative attention during the 1990s. Researchers from
diverse disciplines used a range of methodologies to explore the subject, but
the discussion was set from within the ‘harder’ social sciences – population
studies, epidemiology and studies within the sociology of medicine using a
quantitative methodology1. These set out the broad contours of the problem
and suggested possible causes. Other studies, based on qualitative research,
began to explore the questions of value and meaning touched upon in the
population-based studies, as well as the structural basis of the phenomenon2.
In conjunction with new surveys and statistical analysis, they cast light on
the complex aetiology of childbirth practices and outcomes in Brazil,
explored some aspects of regional differences and throw into doubt some of
the earlier hypotheses.
Earlier discussions suggested that two social groups lay behind the high
rate of caesarean section in Brazil, though opinions about who was most to
blame differed. There was a ‘culture’ of caesareans, it was suggested, among
women, who were said to prefer such delivery. The cultural pressure was sup-
posed to originate among educated, higher-income women who had twice
as many caesareans as their low-income compatriots (Janowitz et al. 1985,
Barros et al. 1991). Fear of pain during labour and fear of permanent dam-
age to the genital region lay behind this supposed preference. Moreover, due
to restrictive legislation, surgeons found it easiest to perform sterilisation by
© Blackwell Publishing Ltd/Foundation for the Sociology of Health & Illness 2005
Caesarean section in Salvador da Bahia, Brazil 217
tubal ligation in conjunction with the caesarean operation, leading to a

significant rise in the rates (Ministério da Saúde 1982, Potter et al. 2001).
Obstetricians reinforced the view that women’s choice was behind the rise in
rates, suggesting that it reflected doctors’ responses to women’s fears and
demands (Berquó 1998, Potter et al. 2001).
But some analysts began to question the idea that consumers of private
healthcare – women – were principally to blame, shifting the responsibility
to the doctors, who found caesareans more convenient, less likely to result
in prosecution in case of a poor outcome for mother or child, and more
lucrative (Faúndes and Cecatti 1991, 1993). Mello e Souza (1994) argued
that focusing on women’s choice obscured the fact that more c-sections
served obstetricians’ interests, not their patients’. By working fewer hours
and controlling their time better, doctors gained more. As Hopkins (2000:
739) notes, ‘doctors are very active participants in the ongoing construction
of caesarean section in Brazil’. Similar observations have been made else-
where in Latin America, such as in Chile (Murray 2000) and in Mexico
(Castro 1999 quoted in Hopkins). In the light of these arguments, it began
to seem that the real cause of the high caesarean section rate in Brazil, and
elsewhere in Latin America, was the self-interest of health professionals.
It is now accepted that newly-pregnant women do not, on the whole,
arrive at a doctor’s surgery insisting on a pre-programmed caesarean. Recent
population-based studies and ethnographic research show that, when asked
directly, most Brazilian women say that ideally they would prefer vaginal
delivery. For example, Potter et al. (2001), in a study conducted in four cities
(São Paulo, Natal, Porto Alegre and Belo Horizonte), found that 70–80 per
cent of women in both the private and the public sector stated a preference
for vaginal delivery. Hopkins, in her survey conducted in Natal and Porto
Alegre, found a similar proportion expressed this opinion, as did Perpétuo
et al. (1998) in their study of 400 pregnant women in Belo Horizonte. Osis
et al. (2001) surveyed the views of 1,082 women in Recife and in São Paulo
state, and compared the opinions of women who had delivered both vagi-
nally and abdominally. The majority considered vaginal delivery best. No
similar study has been conducted for the private sector in Salvador. How-
ever, in our ethnographic research in a public maternity hospital in 2002–
2003, the overwhelming majority of women we contacted expressed clear
preference for vaginal delivery.
One problem with surveys is that they neither capture the social and
economic dramas lived by the women who respond to their questionnaires,
nor explore the process of pregnancy and childbirth as it is shaped by the
ongoing struggle for quality care. Béhague et al.’s (2002) ethnographic
study of 80 women in Pelotas, Southern Brazil, draws attention to these
issues3. In this particular case, researchers found that a significant number
of low-income women sought to give birth by caesarean section and some
of their informants described how they had elaborated strategies to this end.
The main reason for this was the perception of ‘normal’ childbirth in public
hospitals, which they described as an extremely unpleasant experience.

Unfriendly health professionals were said to harbour prejudice towards poor
people, teenage mothers and other such low-status categories. Parturients in
these places thus ran the risk of being treated badly or neglected. Caesarean
delivery, by contrast, was described as the best-quality care usually reserved
for those who can pay. If a woman could persuade medical staff to perform a
caesarean section, she could avoid the suffering attendant on vaginal delivery
in a public hospital setting.
In other words, considerations born from their own understanding of
their socio-economic circumstances weighed very heavily in these women’s
‘preference’ for caesarean. They understand pain or risk during labour as
occurring within social relations, not as physiological occurrences in isolated
as ‘biological’ bodies. If I understand Béhague et al. correctly, their inform-
ants saw these aspects of birth as embedded in particular social experiences,
not as universal conditions apt to affect all women equally, regardless of race
and class. When women described their strategies in seeking a caesarean
section, they did not explain their behaviour as the result of rational,
informed decision-making about the best form of childbirth in an abstract
sense, but as the best form under their own difficult social and economic
circumstances.
The present paper is in broad agreement with the points raised by
Behague et al. The high caesarean rate in Salvador is a complex phenome-
non engendered socially. Thus, there is no primary cause of the caesarean
section rate, such as women’s ‘cultural choices’ or health professional’s self-
interest. The discussion, therefore, highlights the overall organisation of
reproductive services in the city, in parallel with its examination of the
motives and actions of individuals within specific institutions, as a funda-
mental contributing factor.
Methodology
The principal approach adopted in this paper is anthropological. It is based

on: ethnographic research in diverse sites in Salvador, over a period of eleven
years residence there (1990–2001); a bibliographical review; and qualitative
research into childbirth and pregnancy (1997–1998). An ethnographic study
of a maternity hospital (2001–2003) also contributed to understanding the
issues discussed here.
I began to study childbirth and pregnancy in Salvador in 1993, during
fieldwork in a low-income neighbourhood, as part of a study of popular
notions of health and illness4. Since I was pregnant at that time, the topic of
child-bearing naturally emerged in the course of conversation. Many women
described their difficult experiences of birth in public maternity hospitals
(McCallum 1998). During my own pregnancy, I anxiously investigated pos-
sible options for giving birth. Without initially intending to do so, I migrated
from one obstetrician to another, before eventually choosing the only clinic
where I felt I would be unlikely to have a caesarean, Aqua Mater5. This
search for obstetric care constituted participant observation in the most
complete sense of the phrase. After my daughter was born, I continued to
gather information on experiences of birth in Salvador, listening to mothers
from across the class spectrum. I began to plan formal research, which
began in 1997.
The project that initially gave rise to this paper aimed to understand the
attitudes and principles guiding obstetric practice in Salvador. In particular,
I wished to uncover the perspectives of health professionals, and especially
of obstetricians themselves. My plan was to interview practitioners using a
schedule and to frame these recorded semi-structured interviews with ana-
lysis of the historical, political and socio-economic contexts in which they
worked. I was inspired by recent work in the anthropology of reproduction
(Ginsburg 1989, Ginsburg and Rapp 1995). To do this, I located published
and unpublished secondary sources in Salvador’s scattered and disorganised
libraries and sought out health professionals, activists and researchers
specialising in gender and health, requesting unstructured interviews6. Dur-
ing March–July l998 I consulted 15 such specialists in this way, through
personal contacts and using a snowballing technique. I also recorded
eleven semi-structured interviews: eight with obstetricians7, one with an
anaesthesiologist8 and two with nurses working in obstetric wards9.
Organising the interviews required considerable patience, given the busy
schedules of the professionals, especially the obstetricians. Many telephone
calls were required to set up one interview (sometimes cancelled at the last
moment). I spent hours in doctor’s waiting rooms, watching patients enter
and come out, until a precious slot became available.
The interview schedule for the semi-structured interviews elicited an
account of the social origins and training of the informant, before turning to
contemporary obstetrics in Salvador. I asked how she or he had come to the
field of obstetrics and for description of ‘becoming a professional’. What was
the content of the course? What was the specific experience of the informant?
How did he or she see the current situation? I asked about contemporary
childbirth and obstetric services in both public and private spheres. Did col-
leagues view patients in each sphere differently? What had changed over the
informants’ professional lifetime? Finally, I asked for a step-by-step descrip-
tion of the procedures adopted during normal births in the city’s public and
private hospitals and the rationale behind it. I treated the interview schedule
as flexible and the discussion developed in unexpected directions, depending
on each interviewee. It often turned to the ongoing debate within the obstet-
ric community about the relative virtues of vaginal versus abdominal birth,
sparked by a national campaign to reduce the caesarean rate.
I treated the interviewees as anthropologist’s informants, that is, as expert
natives offering both information on childbirth and obstetrics, and also
meta-commentary on current debates (Bernard 1995). However, my approach
was marked by an outsider’s stance, for I sought to uncover specific dis-

courses on medical science, technology, gender, race, class and the body
adhered to and reworked by informants, and to pinpoint the cultural under-
standings shaping their diverse approaches to professional practice. In this
sense I was simultaneously a naïve and a sceptical questioner (Agar 1980).
The discussion of the interviews offered here thus treats them as both
objects for analysis and also as sources of information, as is common in
anthropology.
As I became immersed in the new fieldwork, naivety was tempered with a
capacity to assess critically the information given in interviews. Treated
alone, the recorded interviews afford a limited view of childbirth in Salvador
and the analysis offered here also draws upon the other components of
research mentioned above. For example, the understanding that I had
already gained of the social and economic contexts framing the work of
health professionals in the city, marked by race, class and gender inequality,
was an important guide when planning the interviews and later in interpret-
ing research data. During the 1998 study, I did not limit research to the
interviews. I kept notes on media portrayals of pregnancy and childbirth (a
favourite topic in soap operas) and attended the courses for pregnant women
and couples organised in several private hospitals. I continued to talk to
women who had given birth. The analysis is also shaped by diverse data
obtained during the unstructured interviews. I talked to doctors, nurses,
nursing auxiliaries, university lecturers, a childbirth instructor, a lay midwife,
the director of a family planning clinic, feminist activists and academic
researchers10. I listened to obstetricians’ stories about their formative years,
to diatribes against ‘natural’ birth, to descriptions of political conflicts
between feminist groups and politically-influential health professionals. I
recorded any information that seemed relevant in field notes. In other words,
I ‘did fieldwork’ day and night, immersed in understanding the relationships
between the diverse topics dealt with in these accounts. As is standard in
anthropological research, I was not ‘testing a hypothesis’, but rather follow-
ing all avenues that seemed to have a bearing on the social and cultural
processes structuring pregnancy and childbirth in Salvador.
Formal and informal interviews took place in a range of settings, from
clinics, hospitals and research centres to bars and interlocutors’ homes. The
process of achieving an interview led to occasions for exploratory observa-
tion. For example, I attended a course on forceps delivery for obstetricians
at a public maternity hospital at an informant’s invitation. I accompanied a
woman who had come to term to a private hospital and through a window,
together with her family, I watched her baby delivered by caesarean. The
director of a public maternity hospital took it upon himself to give me a
guided tour, and so on. The research process itself thus provided an intro-
duction into the lived world of childbirth and obstetrics in the city, beyond
my own experiences during pregnancy. It was enough to ground interpreta-
tion of the interviews, but not enough to warrant the title of ethnography.
These experiences therefore led me to design an ethnographic project.

From 2001 to 2003 I took part in this study of a public maternity hospital
and the community it serves11. Analysis is still ongoing12. Participation in
this project has shaped the understanding of childbirth in Salvador
expounded here. It has contributed to re-writing this paper by reinforcing
certain observations, by adding new insights and by refining others13.
In sum, the methodological approach adopted here uses a combination of
methods and taps diverse sources to approach the ‘epidemic’ of caesarean
section in Brazil, including a period of intense fieldwork aimed at capturing
the diversity and social origins of the ‘native points-of-view’. In this sense it
is ‘anthropological’.
The social-economic context of childbirth
Brazil is known for entrenched and extreme socio-economic inequality and

Bahia, often portrayed as the most ‘African’ of its states, is strongly affected
by the problems this brings. Salvador, the state capital, is located in the
Recôncavo, a coastal region where significant quantities of sugar were once
produced by slave labour. About 80 per cent of the contemporary popula-
tion of the city (of about 2.5 million) is black or brown and most of these
people are in the low-income sector. Thus, racial inequality is largely con-
gruent with class difference; the overwhelming majority of the upper and
middle classes are Euro-Brazilian in appearance and most of the low-income
population are brown or black14. Opportunities for social mobility were
opened up after the discovery of oil and the implantation of industrial
centres during the 1970s, so that a new and relatively well-off ‘black work-
ing class’ emerged (Guimarães 1987, 1992). The new generation, however,
suffers from a long-lasting recession and lack of employment opportun-
ities. Twenty years of military dictatorship (1964–1984) stifled democracy,
but stimulated the growth of locally-based social and cultural movements,
including a federation of local community associations, diverse feminist
groups, religious associations and a dynamic Afro-Brazilian movement.
However, there is no social movement specifically dedicated to advocating
women’s reproductive rights.
Class differences in Salvador are clearly visible (McCallum 1996). Many
of the upper and middle classes live in modern high-rise apartment blocks
or protected condominiums, whilst the poorer citizens live in self-built
houses along alleyways, usually on squatted land. The better-off move about
in private cars, whilst everyone else uses public transport. A typical lower-
income family has to subsist on between half to three minimum wages
(about U$35 to U$210 a month). By contrast, to maintain a lower middle
class life style, at least ten minimum wages per month are necessary (about
U$700). Family income can be much higher, especially if both husband and
wife are university graduates and working. In general, black women are at
the lowest level on the scale of social inequality, along with their children,
and white males are at the upper end.
Health ‘insurance’ is a crucial marker of class distinction. If a family
cannot afford private health insurance or is not covered by a company pol-
icy, then its members must make use of the over-crowded and under-funded
public health posts and hospitals15. A significant minority of Brazilians are
covered in some way, however, approximately a quarter of the population16.
For these people quality of healthcare and choice are dictated by the price
they or their companies can afford. Many of the ‘health plans’ at the lower
end of the scale restrict users to certain doctors and hospitals. Those at the
upper end give consumers considerable power of decision and a wide choice
amongst private practitioners and hospitals. Only a limited number of the
wealthiest consumers rely entirely on private medicine. These factors influ-
ence public, insurance-based and private maternity care in different ways,
yet these different systems are mutually interlinked and profoundly depend-
ent on each other.
In Salvador, as might be expected in this situation of inequity, the maternal
mortality rate is unacceptably high. In the early 1990s it was 134 in 100,000
(Compte 1995), roughly the Latin American average, but it was about 200
per 100,000 in low-income areas of the city in 199617. Compte’s study stim-
ulated the formation of a municipal maternal mortality committee to press
for better prenatal screening and services and this has been active over the
past seven years, pushing for a number of reforms. Her research showed that
26 per cent of deaths resulted from complications of abortion (which is
illegal in Brazil). Many victims were adolescents. Conditions detectable in
pre-natal screening accounted for the rest: 23.3 per cent died from toxaemias
and eclampsias; 8.2 per cent from infections; and 2.8 per cent from haemor-
rhage18. Dourado (1999) confirmed the unequal distribution of deaths, with
poor areas the worst affected. A new study in 1998 confirmed a high rate of
maternal mortality, corrected to 100 deaths per 100,000 (Menezes 2002).
Most of these deaths were due to avoidable causes, principally abortion.
In the public sector in Salvador, the caesarean rate was 32 per cent in the
mid-1990s, well over the 15 per cent recommended by WHO (Jornal do
CREMEB 1998). This would act to push up the maternal morbidity and
mortality rates (Sabatino et al. 1996, Faúndes and Cecatti 1991). Yet, given
the inadequacies of prenatal screening and admissions procedures to public
maternity hospitals, low-income women with high-risk pregnancies who
might require a caesarean are less likely to benefit from one than low-risk,
high-income women.19 A high rate does not reflect an excessive incidence of
high-risk pregnancies. In rural areas of Bahia state, lay midwives or parteiras
with little or no medical training attended up to 30 per cent of births at the
start of the 1990s (BEMFAM 1994). By contrast, nearly all births in the city
of Salvador took place in maternity wards or maternity hospitals. The
situation is similar in 2003. Yet, as a rule, giving birth in a public hospital
in Salvador is difficult, painful and often psychologically distressing. For
example, epidural analgesia is not available to parturients nor are they

allowed companions to give them support during labour. They are sub-
jected to routine procedures that WHO recommends be abandoned or used
with caution, such as trichotomy and episiotomy. The health professional-
parturient relationship in public hospitals in Salvador is often hurried and
virtually anonymous, as elsewhere in Brazil (Nuttall 1998). Women often feel
that the professionals act roughly or insensitively (McCallum 1998, Ferreira
1996, McCallum with dos Reis in press, Nascimento et al. 1996).
Safe motherhood and the humanisation of childbirth in Brazil and in Salvador
Salvador’s obstetricians are aware of the failings of care during childbirth in

both public and private sectors. The respective merits of vaginal versus
abdominal birth are a matter of debate among them, despite the overwhelm-
ing statistical predominance of abdominal birth in private hospitals.
National efforts to ‘humanise’ childbirth and to make motherhood safe play
an important role in this debate.
In Brazil as a whole, organised defence of vaginal birth tends to go hand
in hand with campaigns defending the ‘rehumanisation’ of childbirth. This
concept developed in different regions of Brazil over the 1980s and 1990s.
Misago et al. (2001) place its origins in Ceará state in the 1970s, where an
obstetrician, Professor Araujo, ran a pioneering maternal care project linking
rural TBAs (traditional birth attendants) with health services. The concept
became clearer over time. In 1996 a new project, Projeto Luz, began retrain-
ing birth attendants who had become accustomed to a ‘culture of dehuman-
isation of childbirth’, drawing on the expertise of Japanese midwives. It
defined humanised maternity care as having the following attributes: It is
empowering to women and care providers; women should be active partici-
pants; physicians and non-physicians work together as equals; it is evidence-
based, including evidence-based technology; it is decentralised with high
priority for community-based primary care; it is financially feasible20.
A movement for humanisation also developed in Southern Brazil. Torn-
quist (2002) locates its origin at the end of the 1980s. As she points out, the
1985 WHO worldwide initiative on safe motherhood was important. WHO
proposed changes in care during medicalised childbirth, such as encouraging
vaginal delivery and the presence of a companion during labour. According to
Jorge Sá (personal communication), the founder of the humanisation move-
ment was Dr. Hugo Sabatino, an obstetrician based at UNICAMP (the
University of Campinas, São Paulo State), who pioneered a form of active
birth in Brazil known as ‘parto de cócoras’ (squatting birth)21. Sabatino par-
ticipated in setting up REHUNA, a network and pressure group dedicated
to supporting humanised birth, in the early 1990s22. A public event in Sal-
vador in 1993 aimed to create public support for REHUNA’s objectives, but
the local initiative stalled. Its organiser, Dr. Sá himself, explains that he grew
disaffected with the founder’s preoccupation with paperwork (for which he

has no patience).
Thus obstetricians spearheaded the humanisation of birth movement, but
it did not succeed in mobilising significantly wider support, especially in
Salvador. It did, however, enjoy greater success in Southern Brazil, where
a number of public maternity hospitals have introduced changes such as
allowing women companions during birth and permitting active labour and
upright delivery (Carvalho 2001, Diniz 2001).
In 1998 the federal government launched a new campaign, Maternidade
Segura (Safe Motherhood), aimed at encouraging safer, more humanitarian
and less interventionist childbirth23. In the years that followed, the Min-
istério de Saúde (Ministry of Health) adopted a series of measures aimed at
reducing maternal mortality. These measures aimed to reduce the caesarean
rate and improve care during childbirth. They cover a number of important
areas, such as the financing of care, the restructuring of services, the training
of health professionals and also support for the humanisation of birth24.
New initiatives in partnership with non-governmental and professional
organisations resulted. Despite these initiatives, the response at the local
level in the country was patchy and uneven.
Unfortunately in Salvador itself the campaign received little political
support, although it elicited a response from the medical community in the
form of an article in the regional medical ethical council’s monthly paper
(Jornal do CREMEB 1998). In this journal, the fierce opposition that the
defence of normal birth confronted from some quarters in Salvador is clear.
In our research in a maternity hospital, we found that many health profes-
sionals were resentful of the idea that humanisation is necessary. Little
inroad has been made on normal practice in the city’s medical community.
There is political inertia in acting to change the status quo.
One reason for this is that many doctors dislike what they perceive as
the romantic naturalism espoused by some of the movement’s supporters,
who often use the phrase ‘natural birth’. This refers to the idea that women
are able to give birth without medical intervention. In respecting nature,
doctors should stand back and allow women themselves to dictate the
timing and course of the birth. The experience should empower them, before
it empowers their attendants. Jorge Sá feels that doctors must learn to be
humble and to avoid the temptation to dominate the proceedings. This
restraint should also apply in the use of technology. The more doctors apply
technology, the more intervention is required. From the perspective of
‘natural birth’, intervention degrades and obfuscates a universal female
capacity. If this discourse is taken to an extreme, an essentialist vision of
gender, where women are innately close to nature, is embedded (Tornquist
2002). However, as she also emphasises, supporters of humanisation es-
pouse a diversity of positions and are not limited to an essentialist position.
Sabatino himself, for example, supports use of evidence-based medicine if
required. As it develops, the humanisation movement draws upon rhetoric,
talk about ‘natural birth’, for instance; but it is also built upon day-to-day
medical practice.
It seems likely that in Salvador the association between naturalism and
the humanisation of birth movement works to the latter’s disadvantage. Like
the majority of the city’s residents, most doctors do not romanticise ‘nature’
and ‘the natural’. As one doctor told me, in questioning the view that vagi-
nal delivery is best: ‘But death is natural too!’ he made this observation even
though I did not describe vaginal delivery as ‘natural’, but rather as ‘parto
normal ’ (normal childbirth), which is the most common way of referring to
vaginal delivery in Bahia. Behind his reaction is a complex set of meanings,
where value is ascribed to markers of progress and of modernity. The dis-
cussion in the next section explores this point in greater detail.
Culture at fault? Divided approaches to the two styles of birth
Childbirth in Salvador is shaped by the profound racial and class inequality

into which the healthcare system is integrated. As we have seen, broadly
speaking, two styles of delivery are available, one to lighter-skinned, or white
middle and upper income mothers, the other to poor dark-skinned women,
and analysts have attributed this, writing about elsewhere in Brazil, to a
‘culture of caesarean’ (for the rich) and a ‘culture of dehumanisation’ (for
the poor)25. In what follows, I explore the theme of culture, analysing the
symbolic baggage that talk about childbirth carries. I draw attention, too, to
the importance of the theory of culture brought to the analysis.
It is important to note from the outset that both types of birth are closely
connected, for they are part of the same overarching national and regional
system. Without the public sector, private medicine could not survive in its
present form. This connection is both logistic and symbolic. That is, the
meanings about birth that are constituted in the social relations characteristic
of each sphere are mutually grounded. More precisely, the personnel who
transit back and forth on a daily basis between public and private institu-
tions give form and content to the symbolic relationship between both, in
their praxis. The organisational connections sustain the process of semantic
generation. Because the same health professionals attend in both settings,
they act as the cultural mediators between the two.
The obstetricians, in particular, have a special role in this mediation.
Anthropologists of childbirth have argued that, where childbirth is managed
according to a biomedical or ‘technocratic’ model, the presiding doctors
detain and constantly achieve authoritative knowledge over the event (Jor-
dan 1997). Such knowledge is not just ‘technical’ in nature, but also laden
with meanings about gender, power, nature and culture that are reproduced
and reworked on each occasion (Davis-Floyd 1992). In Brazil, the very expe-
rience of attending births in public hospitals is bound to shape health pro-
fessionals’ feelings about ‘normal birth’, quite possibly inclining them to a
negative perception. There is a clear association with low status and poverty,
as well as the sense that vaginal delivery is somehow more ‘primitive’.
Whatever their point-of-view on the medicalisation of childbirth, obstetri-
cians in Salvador make frequent use of a notion of ‘culture’. At the end of
an interview in 1998, ‘Dr. Santos’ (fictitious name), then head of obstetrics
at a respected medical school in Salvador, told me that vaginal childbirth
was a thing of the past and that it will be supplanted by abdominal birth.
He outlined the specific ‘cultural features’ surrounding birth practices in
Brazil, in a passage that one may read as a rich rendering of the symbolic
field generated by birth in Bahia. He said:
Brazil is different from Europe. Because the Brazilian Woman is a Latin,

her body has a special significance. More and more, the vulva and the
vagina are becoming the organs of sexuality and not of parturition.
She doesn’t want to touch them, mess them up. For the Latin man gives
them great value . . . The Latin woman believes that birth will damage
the genital organs. One may not say that this is entirely true. Not every
woman who has a natural birth will have a (damaged perineum). But
13 per cent do – and that is something! . . . If you were to analyse it,
from a physiological point of view, it is absurd that women stand up.
It is absurd that women get pregnant. It is awful that women give birth
because of the damage that it may cause to the pelvic region . . . Is there
anything worse for a woman than that she smell of urine? No worse thing
can happen to a woman than that her husband take a mistress because
(her vagina) is slack . . . So if a woman asks (me as) her doctor ‘What can
I do to avoid this?’ Then I have to say that caesareans are safe, practical
and cause no aesthetic damage (Dr. Santos, 08/05/98)26.
In this rendering of the ‘culture of the caesarean’, Dr. Santos tells a parti-
cular tale about the role of sexuality in constituting a healthy, modern
femininity – one that is quintessentially Latin in nature. The sexually adapted,
attractive and active female body – the proper condition of modern Brazilian
women – is represented by untouched and aesthetically pleasing genitalia.
These genitalia, if also used for giving birth, lose their power to signify
modernity and progress27. On the contrary, when sexuality and reproduction
become inter-linked through vaginal childbirth, the meanings attached to
the genitalia’s referent (the female body) are inverted. Such a body is
pre-modern, damaged. It is repulsive to others. Modern female gender is
constructed in opposition to other possible forms of gender, those where
there is no sexual exclusivity of the genitalia and where the body is subject
to the reproductive laws of nature. That this old-fashioned form of birth is
also seen as ‘natural’ confers no value on it whatsoever. On the contrary,
nature itself is devalued, measured against the gains conferred by science
and technology. Abdominal birth lends modernity, and thus continued
value, to women’s bodies. Furthermore, the symbolic opposition between
sexuality and reproduction is surgically effected and its exclusive agents are
the obstetricians themselves. Doctors are the midwives to modernity, so to
speak. And women are agents only in so far as they ‘choose’ the knife – and,
by this token, ‘modernity’.
Dr. Santos slips from description of the basis of women’s ‘culture of the
caesarean’ to conferral of a scientifically grounded blessing upon it. As long
as women’s choices are congruent with scientific evidence, the high caesarean
rate is justified. He also mentioned concern with perinatal mortality as a
justification for the growth in caesarean rates worldwide. He said that obste-
tricians who defend the routine use of caesarean section claim that it
increases the likelihood of a safe outcome for the baby, holding that perina-
tal mortality and trauma are higher during vaginal birth. Dr. Santos assured
me that these are largely ‘problems of the past’. He continued: ‘What most
stimulated doctors to choose caesarean section was loss of the foetus during
labour. Even in England, a country of the first world, the principal cause of
foetal death was during labour (sic)’ (08/05/98)28.
Dr. Santos’s approach to childbirth and gender may be widely diffused
but it would be wrong to ascribe his views to all obstetricians in Salvador.
The normality of caesareans is also under attack. For example, Dr. Artur,
another leading obstetrician in Salvador, supports vaginal delivery. Like
Dr. Santos, he considered ‘culture’ a key factor, though he differed in his
interpretation of the caesarean. He said:
You have the cultural aspect, the culture of caesarean as belonging to

‘modernity’ (in inverted commas) – the culture that giving birth vaginally,
. . . ‘naturally’, is something of the past, that what is modern is surgical
birth, caesarean . . . Then this is a very dangerous culture, one that is
present both among health professionals, but also very strongly among
the women themselves (Dr. Artur, 22/04/98).
Dr. Artur stressed the danger of an excessive emphasis on abdominal birth.

He named influential teachers and practitioners of obstetrics in Bahia who
advocated vaginal deliveries (including Dr. Santos) and he criticised col-
leagues whom he said ceded too readily to what he perceived as women’s
demands for caesareans. In fact, many obstetricians are convinced that a
majority of women prefer abdominal delivery. Women’s attitudes do seem to
contribute to Salvador’s high caesarean rate, but the factors pushing women
into this position are many, whilst the odds against those who do not desire
it are highly stacked. Over the decade I lived in Bahia, I often met young
pregnant women who expressed a desire to give birth ‘normally’, and whose
obstetricians had agreed to this with the proviso that all went well. Yet none
of these women had vaginal deliveries, for one ‘medical’ reason or another.
They reported afterwards that there was no dilation, or that the baby was
too big, or that there was no passage, or that the umbilical cord was
wrapped around the baby’s neck, or that the baby was late, or that it was
too dangerous to wait for twins, and so on. I found it hard not to conclude
(like the studies cited above) that in fact, women do not exercise much power
to choose.
Hopkins (2000) describes the interactions between obstetrician, parturient
and family during private hospital births in Natal and in Porto Alegre. In
two of the cases Hopkins describes, a short attempt at ‘normal’ birth ended
in a caesarean. The women were unable to insist on an alternative as the
event unfolded. As labour progressed, the doctors continually suggested that
the parturients really wanted a caesarean, or that they were afraid of the
pain. Although there are no ethnographic studies of childbirth in private
and policy-funded hospitals in Salvador, it is likely that women confront
similar difficulties in imposing their views, in the face of the exercise of
medical authority.
Why are women’s voices so weak? In Salvador, when a pregnant woman
with health insurance first enters her chosen obstetrician’s surgery, her atti-
tudes are shaped by many influences, such as the media or hearsay from
friends and relatives. Fear of pain (a commonly cited reason for ‘choosing’
a caesarean) is constantly stimulated in these stories. Women rarely hear
about good experiences of normal birth. The nightly TV soap operas fre-
quently depict childbirth as agonising, dangerous and primitive. Such births
take place in rural areas, in Amazonian forests and other spaces associated
with the wild, or else set in the past. In soap operas set in the modern
metropolises of Rio de Janeiro or São Paulo, on the other hand, middle class
characters invariably have their babies by C-section in stylish and spanking
new clinics. Thus media portrayal both reinforces women’s fear of vaginal
delivery and also constructs a symbolic opposition between the two types of
delivery.
The stories told by women also contribute to fear of normal delivery. Only
a small portion of older women in Bahia gave birth attended by an obste-
trician in a hospital. Until the 1960s most gave birth at home with the help
of a lay midwife – a parteira – or (infrequently) a family doctor. Their
daughters sometimes cite their mothers’ tales of pain endured and babies
lost or damaged, to explain the fear that surrounds ‘natural’ childbirth.
Frequently, they hear stories from their maids or from friends whose health
plans did not cover childbirth about unpleasant experiences in public mater-
nities. But on the whole, these women and their own daughters make up the
generation that knows caesarean section as the normal, modern and high
status form of childbirth. Even so, there is a feeling that the choice is avail-
able, though in practice it is severely limited. Thus the standard question
asked of pregnant women (in middle class circles) is: ‘Will you have a nor-
mal birth or will you have a caesarean?’.
The problem with this question, or the problem with the notion of choice,
is that it deflects attention from the social relationships within which the
supposed choice is made. The doctor-patient relationship in the private sec-
tor stands in sharp contrast to that in the public sector, where it is usually
hurried and anonymous. The major insurance plans allow women consider-
able choice of obstetrician. This means that a woman who is determined to
have a pre-arranged caesarean will be able to have one. As we have seen,
however, this logic does not operate with regard to vaginal childbirth. Obste-
tricians will agree to a ‘normal’ birth, whilst in practice they may not facil-
itate one. In order to be sure that she will be allowed to try to give birth
vaginally, a woman must search for one of those exceptional local obstetri-
cians with a low caesarean rate.
Women usually choose their obstetricians on the advice of friends and
relatives. A relationship may develop between the women in an extended
family and a particular doctor, who performs their pre-natal check-ups and
also attends the births of their children. The relationship is often personal
and friendly, though it is by no means symmetrical. Dr. Manuel drew on the
image of a ‘Latin doctor’, a professional who is sympathetic to the delicate
emotional state of his patients during their pregnancies, who can be kind
and sensitive, but still maintain his professional distance. He compared this
style of consultation with the cold and distant manner of obstetricians
whom he had observed in Europe, where he had once studied. Dr. Rita
explained to me wearily, women look to their obstetricians as their eventual
saviours ‘in case it all goes wrong’. Pregnant women focus upon the doctor,
she said, in order to assuage their fears. Dr. Ruy observed that women place
themselves in their chosen doctor’s hands, viewing him (or her) as a father
figure or even as a ‘semi-god’. He added that obstetricians tend to play up to
this image and even exacerbate it, by failing to inform patients adequately,
say, about the possibility that women participate actively in the birth, or that
their fears of pain or of damage to the baby are exaggerated. As a result,
women insist on their own obstetrician’s presence from the start of labour
and all through childbirth. It seems likely that this emotional reliance on her
obstetrician is another important factor in the overall set of pressures lead-
ing to the high c-section rate. As several doctors told me, ‘After 12 hours of
labour everyone’s patience has run out, not just the obstetrician’s!’
The most common source of information about pregnancy and birth
are magazines such as Pais e Filhos and, to a lesser extent, books. Without
research on this issue, it is hard to know how such reading shapes attitudes.
It seems clear, nevertheless, that when women in Salvador come to term,
they are often unaware that they may be able to cope without anaesthetics
during labour or even that epidural anaesthesia will be available29. During
antenatal consultations, doctors do not usually suggest to their patients that
they enrol on a course to prepare for birth. The hegemonic position of the
doctor-figure is thus preserved.
During the 1990s there were attempts to better inform private and policy-
holder patients. A number of private hospitals ran courses for ‘pregnant
couples’, funded in some cases by insurance companies aiming to reduce the
number of caesareans30. In two courses that I attended, an anaesthesiologist
explained the use of epidurals during ‘normal’ childbirth. Other lecture topics
included breast-feeding and post-natal tooth-care. The obstetric nurse in

charge of the mother and baby unit described hospital procedures during and
after birth, but nothing was said on the woman’s role in labour. When asked,
she replied that the birthing women normally lay in bed and complained of
the pain. The speakers during these courses placed all the power to influence
outcome – to get the baby born safely – squarely in the hands of the medical
team and the hospital. The women remained excluded as active agents.
In the light of this discussion, the notion that women ‘choose’ a caesarean
does seem problematic. Two questions spring to mind. What is ‘choice’ here?
And are these ‘choices’ cultural? The language of choice leads us to re-
consider the notion of culture. Subjects act within the limits imposed by the
social contexts of their actions. As they do so they are in a constant process
of learning, of adapting, of creating meaning, or, as Béhague et al. (2002)
emphasise, of planning strategies. ‘Culture’, from this perspective, is
dynamic, signifying action and reaction. Claims as to its pre-given ‘exist-
ence’, like that implied in Dr. Santos’s musings about the ‘Latin Woman’s’
cultural take on sexuality, cannot be taken at face value. Cultural under-
standings emerge from a plethora of influences, as I have shown, but they
are, importantly, also an outcome of the relationships acted out in contexts
such as in doctor’s surgeries, hospital courses and obstetric centres, to which
actors bring different knowledge, emotions and expectations. As Hopkins
shows beautifully in her study, even in the private sphere, women have little
power to resist the doctor’s claims to authoritative knowledge. Thus,
women’s capacity to choose is severely compromised from the start.
The absence of developed critical discourses or an organised movement
questioning the current system of care during childbirth in Salvador facili-
tates women’s inability to act. Women in the private sphere who really do
wish for a ‘normal’ birth have no ammunition to draw upon in the doctor’s
surgery and none comes to hand as their pregnancy progresses, unless they
‘go alternative’. The humanisation of birth movement has few public
advocates. Its discourse lacks appeal. In general, the idea of a ‘return to
nature’ falls on deaf ears in Salvador, where progress is conceived as tech-
nological and man-made, and high status is achieved by sporting emblems
of modernity such as new cars, mobile phones, the latest fashions and
‘cyborg’ babies. Yet, as the studies of ‘what women want’ cited above dem-
onstrate, even in this climate women may not really want their babies deliv-
ered abdominally, were a safe, relatively comfortable alternative available.
From this, it follows, that what some read as women’s ‘cultural’ inclination
towards abdominal birth may simply be compliance, born in the absence of
both a coherent, culturally appropriate critique of existing practices and
knowledge about vaginal delivery. Indeed, the discursive silence sustains
women’s attitudes and responses during prenatal examinations and birth.
But, even so, their attitudes are only one of many factors contributing to the
high incidence of caesarean section, for the very system through which they
come to access such services is crucially to blame.
The system at fault: organizational and logistic foundations of the high

caesarean rate
The organisation of reproductive services in Brazil strongly supports a con-

tinued high caesarean rate. The ways in which this system acts in favour of
the excessive rate are many, ranging from the organisation of medical edu-
cation, to the form that private childbirth funding takes. I explore some of
these factors in this section.
In interview, some obstetricians cited the peculiarity of medical school
education in Bahia as a reason for the high c-section rate. Dr. Ruy stressed
its inadequacies. He himself was campaigning to reshape the educational
system in Salvador’s medical schools, for example, to include more training
in general medicine during the residencies in obstetrics. Poorly-trained doc-
tors, he explained, opt to perform a caesarean as a safer course of action in
difficult cases. In fact, once most doctors graduate from basic training, they
are unable to find residencies in the under-funded teaching hospitals. Going
straight into practice, they ‘learn from their mistakes’, as Dr. Artur put it to
me. In some ways, however, basic training prepares them well. As under-
graduates, medical students often begin to practise or at least observe clini-
cal encounters. Several doctors told me that surgical skills are more highly
developed in Brazil than in Europe or the United States, because students
learn to perform surgeries earlier. Hence, caesareans may be a preferred
option in childbirth simply because the doctors are more confident of their
surgical skills than their midwifery ones. Training in less interventionist tech-
niques and in the use of low technology receives less emphasis in obstetric
education. By 1998 the regional SOGIBA (Society of Gynaecologists and
Obstetricians), recognising this bias, was providing short courses for practis-
ing obstetricians to improve such skills, for example, the use of forceps in
difficult labours. In some of the local medical schools, obstetric training had
not included this skill.
I asked my informants to describe the special features of obstetric training
in Bahia. It was suggested to me that European influences weigh most heav-
ily in obstetric practice there. Indeed, the public maternity hospital we stud-
ied used the active management of labour to maximise use of the obstetric
centre beds31. The duration of labour is an important consideration in this
model of managing childbirth. As in North America, the orthodoxy is that
‘normal’ birth should not endure beyond a limited number of hours. The
technocratic model of birth imposes a time limit on labour (Davis-Floyd
1992). If dilation of the cervix does not proceed according to an allotted
time-scale, intervention is required. Critics of this time-based model point
out that it encourages female passivity and a corresponding need for greater
medical intervention, including the use of technology such as electronic
foetal monitoring (unavailable in most private hospitals in Salvador). It
seems safe to say that the need of private physicians to finish swiftly and
safely, as much as the Bahian use of the ‘technocratic model’, is responsible

for cutting many labours short. Recognising this, several informants stressed
that if responsibility for deliveries were to be attributed to shifts of obstetric
teams, instead of one time-pressed individual, as it is now, then there would
be less hurry to get babies delivered.
Opting to perform elective c-sections helps an obstetrician to earn a
reasonable living and to maintain a middle class lifestyle. Medical students,
unlike others, cannot spend time working whilst they study, so they and their
families might amass considerable debts. Even those lucky few who receive
a higher degree of training find it hard to make ends meet at the start of
their careers. Social pressures are also heavy, so, according to my informants,
it is not unusual for a doctor to aim for a very high standard of living. In
order to achieve a reasonable income, doctors accumulate jobs, often run-
ning breathlessly from one to another. Usually one of these jobs is in the
public sector – in a maternity hospital, for example. Here pay is very low but
the post functions to secure a steady income, social benefits and also per-
sonal contacts, providing a basis for a career in the private sector. In this
situation, opting against ‘natural’ childbirth in the private sector is one route
to a higher income. Although health insurance companies (at the time of
research in 1998) paid the same for caesareans as for vaginal deliveries,
doctors could save much time and fit in many more activities by scheduling
caesareans32. In this way, they could considerably increase their net earnings,
like their colleagues in Chile (Murray 2000)33.
Murray reports that in Chile private obstetricians programme births using
both induction and elective caesarean. They employ midwives to provide early
labour care to women who have been induced, thus fitting more into their
busy schedules. In Salvador, the profession of trained direct entry midwife
(obstetriz) is defunct34. The parallel profession of obstetric nurse (enfermeira
obstetrica) does seem to be on the increase, however. In one private hospital
in the city, the Aliança, obstetricians now have a team of obstetric nurses to
monitor their patients in labour. The nurses keep the doctor informed of the
progress of labour by mobile phone, so that he or she can arrive when
delivery is closer. In the other hospitals, however, this service is not available.
An enfermeira obstetrica is a university-educated nurse who has special-
ised, after graduation, in obstetrics. The emphasis during this training is on
medicalised birth using the technocratic model, though recently there has
been a strong movement within the ranks of the nurse’s professional associ-
ation (ABENFO) in defence of a humanised model of childbirth, along the
lines proposed by the Ministry of Health and REHUNA.
The limited numbers of these professionals has been linked to the high
caesarean rate in Brazil (Osava 1996). It has been suggested that if such
nurses (or midwives) were to attend at births, it would help lower the cae-
sarean rate, since they are cheaper and more patient than doctors. Dr. Juca,
an obstetrician who only works with private patients, lamented the lack of
midwives and suggested that it was urgent that they be reintroduced so as
to attend women’s labours, allowing the doctor to appear only at the

moment of delivery ‘as they do in the USA and Europe’. Recognising the
relationship between the lack of midwives and the high caesarean rate, as
part of the national campaign to make motherhood safer, the Ministry of
Health began to finance specialisation courses in obstetric nursing from
1999 (Riesco and Tsunechiro 2002). But the newly-trained nurses face an
uphill challenge in establishing midwifery as an independent, woman-
centred profession. ABENFO, their professional association, campaigns to
this end. During the national conference, held in Salvador in 2002, the well-
known critic of the technocratic model of birth, the anthropologist Robbie
Davis-Floyd, was their invited speaker.
In the view of some of my informants, the same disrepute that taints
TBAs also clings to medically-trained midwives. Dr. Dias, an anaesthesiologist
and a firm supporter of routine caesareans, told me indignantly: ‘It is illegal for
nurses to perform deliveries!’ This is not the case. Under current law an
obstetric nurse is qualified to deliver a baby. There is evidence that support
for the reintroduction of midwives among obstetricians is lacking. In 1993
FEBRASGO (the Brazilian Federation of Obstetric and Gynaecological
Societies) surveyed 177 members about their views on caesarean section.
Over 90 per cent of respondents felt that the incidence of caesareans was too
high but thought responses as to what was to be done were mixed35, only four
doctors felt that trained midwives were the solution and only five felt that
lay midwives should be sought out and given basic training. One, inexplicably,
felt that the solution was to banish midwives from hospitals altogether.
At present, there are more qualified obstetric nurses practising in Salvador’s
maternity wards, though they are still out-numbered by both obstetricians
and non-specialist nurses. A 1999 survey of the 10 leading public maternity
hospitals and hospitals with childbirth facilities in Salvador counted 173
obstetricians and 168 nurses, many of whom were not trained in midwifery
(Menezes, personal communication). This was the case with Nurse Ana, who
worked in an obstetric ward in a private hospital. She explained to me that
she did not need midwifery training, since most of the ward’s babies were
born by caesarean section. Even where nurses have such a qualification,
ratified by ABENFO, they do not, in fact, deliver many babies, because of
continued hostility from doctors and other factors. One may be that many
nurses lack enthusiasm for normal delivery36. Then there are economic
factors, with many incentives to move to other areas. In Southern Brazil,
obstetric nurses experience ‘overwork, frustration, lack of motivation, con-
formism and submission’ (Riesco and Tsunechiro 2002: 457). In Salvador,
nursing graduates often drop out of the profession or go on to other activ-
ities, given the low status and pay of hands-on nursing, and the unsocial
hours (Nascimento 1996). The relatively few trained university-level nurses
in Salvador frequently move to administration. Poorly paid and trained
nursing auxiliaries are the backbone of nursing assistance, making up the
bulk of the workforce in both public and private hospitals37.
Concluding remarks
Although knowledge of causes of and solutions to the excessive use of

caesareans has been available in Brazil for the past few decades, the political
will to effect recommended changes has been lacking. Thus, in 1982 a Health
Ministry report recommended improving pre-natal services and including
courses for pregnant women, better training for obstetricians, and the
encouragement of team-work rather than reliance on the doctor as the key
figure (Ministério da Saúde et al. 1982). A 1993 report by FEBRASGO
recommended the following:
1. Legal measures to reopen schools for midwives (obstetrizes) linked to

medical faculties so as to reduce obstetricians’ workloads.
2. Reintroduction of midwives in public and private maternities, contracted
for periods of 12 to 24 hours.
3. Public campaigns about available services to stimulate the population to
attend prenatal clinics in urban situations.
4. Training and support for rural lay midwives. (FEBRASGO 1993).
The report also recommended specific socio-political and administrative

measures in relation ‘to institutions, to doctors, and to society’. Women
themselves are neither mentioned as possible active agents in these changes,
nor as targets of campaigns. Yet although some of the recommendations
had begun to be implemented in the late 1990s, such as the training and
hiring of obstetric nurses, the other factors sustaining the high caesarean
rate were still in place. Abdominal birth has become even more entrenched.
As the authors of the report suggest, and as I have argued, in explaining
the maintenance of an excessive caesarean rate in Brazil, one must consider
the broader context. Working through the logistic and structural causes of the
high rate in Salvador, I showed that blame for this situation should not be
directed at any one group of individuals. Further, I argued that middle class
women’s experiences of pregnancy and birth take place in an environment
that stimulates them to accept the status quo (routine caesarean deliveries),
when they do not demand it. Rather than coming to the obstetrician with a ready-
made ‘culture of caesarean’, the series of social encounters during pregnancy
and childbirth lead them to accept the surgery. Thus ‘culture’ emerges within
specific social relationships, like that between doctor and patient, rather than
existing independently of them. Following Brigitte Jordan (1997), I have
insisted that hegemonic culture is negotiated and imposed at a quotidian level,
not pre-existing as an abstract conscience collective. If such a view mitigates
the blame directed at women for the high caesarean rate in Brazil, since it
deconstructs the notion that there is a ‘Brazilian Culture’, it also forces us to
reconsider the idea that doctors are especially to blame for the situation. It
follows that health professionals are not so much socialised into a ‘culture of
dehumanisation’, as subject to the effects of accumulated experiences in differ-

ent institutions (private and public) and the impositions of their day-to-day
routines. The organisational features of public and private obstetrics channel
them to practise as they do. Finally, it is important to emphasise that in this
system of stratified reproduction, each social context is enmeshed in or en-
compassed by others. The stark inequalities of race, class and gender are struc-
tural features of childbirth in Salvador in a double sense, for they mark the
symbolism of birthing arrangements, and they sustain the system as a whole.
Acknowledgements
Research on obstetrics in Salvador was financed by the Brazilian National Research

Funding Body CAPES, whilst I was a Visiting Professor at the Postgraduate Pro-
gramme in Social Sciences at the Federal University of Bahia (UFBA) from 1997 to
1998. I am grateful to the doctors and nurses and others who allowed me to inter-
view them and thus made possible the writing of this paper. Earlier research in the
city was funded by the British Academy, the Nuffield Foundation (SOC/100(303)),
the Research Institute for the Study of Man, New York, (RISM Landes Fellowship
1993–1994), and the ESRC of Great Britain (ROOO234961). I am grateful to all of
these bodies and to the Anthropology Department at the University of Manchester,
where I was based as a Simon Fellow from 2001 to 2004, whilst writing this article.
Thanks also to the Institute of Collective Health, at UFBA, where I am associated
as a researcher at MUSA (the Programme for Research in Gender and Health).
Discussions with colleagues there, especially Greice Menezes and Ana Paula dos
Reis, contributed importantly. Thanks also to Brenda Fearon and her colleagues for
the opportunity to present an earlier version at the conference Women’s Reproductive
Health: Educating for Our Future, held at Cambridge, 16–17 July, 1998 and to Christine
Nuttall for stimulating discussion and collaboration at that time. I am grateful to
Soraya Tremayne for inviting me to give a rewritten version of the paper to a Fertility
and Reproduction Seminar, held at the Institute of Anthropology of Oxford Univer-
sity in November 2002, and to Luisa E. Belaunde for suggesting it. I benefited from
participants’ comments and I was inspired to conclude an argument that I had only
just begun. Finally, thanks to the anonymous referees and the editors of this journal
for their valuable comments. All responsibility for opinions and any errors is mine.
Address for correspondence: Cecilia McCallum, Avenida Princesa Isabel 801,
Ed. Firenze #204, Barra Avenida, Salvador, Bahia 40130-030 Brazil
e-mail: cecilia.mccallum@uol.com.br
Notes
1 For example, Faúndes and Cecatti 1991, 1993, Barros et al. 1991, BEMFAM
1997, Osis et al. 2001, Berquó 1997.
2 For example, Carranza 1994, Mello e Souza 1994, Hopkins 2000. For a detailed
bibliographical review of published and unpublished work on childbirth in
Brazil between 1972–2002 see Mott (org.) 2002.
3 See also Béhague 2002.

4 Nuffield Foundation, Grant No. SOC/100(303).
5 The founder of this small clinic, Dr. Jorge Sá, supports woman-centred child-
birth with minimum medical intervention (hence ‘natural’). He was influenced
by Leboyer and developed his own style of water-birth independently from
Michel Odent.
6 On distinct interviewing methods see Bernard 1995.
7 Referred to here as Drs. Vera, Santos, Artur, Juca, Silva, Ruy, Manuel and Rita.
8 Referred to here as Dr. Dias.
9 Referred to here as Nurses Ana and Maria.
10 To protect their anonymity, I do not list these informants except for those
acknowledged above or quoted in the text, who gave me permission to cite them.
11 This project is funded by WHO, as part of their Social Science Research Initia-
tive on Adolescent Sexual and Reproductive Health.
12 A co-authored book manuscript is in preparation, with Ana Paula dos Reis,
provisionally entitled Bearing Inequality: Youth, Childbirth and Reproductive
Health Services in Brazil. See Aquino et al. (2003); McCallum with dos Reis
(in press) and McCallum and Dos Reis (ms 2003).
13 See exact references to analysis of this new research where appropriate in the text.
14 The literature on race in Brazil abounds in discussions of the close relationship
between racial inequality on the one hand and class structure on the other, but
also emphasises the distinctive features of such Latin American systems, where
racial classification is ambiguous and racial identity less crisply defined than in
other areas of the African diaspora, such as the United States. For recent critical
discussion see Wade (1997).
15 The national public healthcare system, the SUS, is also insurance based
(conveniada), but few private hospitals accept SUS patients because the pay-
ments are so low. Usually, patients must resort to the government-funded public
hospitals. A recent study found that 115 million people (73 per cent of the
Brazilian population) depend on SUS (Bargas Negri and Di Giovanni (eds.)
2001). The latter cite research by IBOPE in 1998, as follows: 38 per cent use
SUS exclusively, 20 per cent frequently; and 22 per cent occasionally. Therefore
only 15 per cent of the Brazilian population does not use SUS services, whether
conveniados or public.
16 About 40,000,000 in 1997 (Dr. Adson França, personal communication).
ABRAMGE (2002) gives the number of beneficiaries of Brazil’s four main
forms of non-state health plan or health insurance (the document calls them
‘supplementary health plans’) as 41.6 million in 2002.
17 A Tarde newspaper, 1/8/96, quoting Greice Menezes, member of the Municipal
Maternal Mortality Committee in Salvador.
18 Ferreira and Nascimento (1997) note that in other regions of Brazil the highest
percentage of maternal deaths is caused by toxaemias and eclampsias, not by
abortion. They also caution against blind acceptance of official statistics.
19 This is also the case in Pelotas, Southern Brazil. See Béhague et al. 2002.
20 According to Misago et al. (2001), ‘At the end of the project it was realised that
‘humanisation’ was a concept not definable in details, but a continuous dynamic
process of transformation of each person at each stage’ (2001: S71). Training
‘transformed’ the birth attendants, equipping them to ‘rehumanise’ the birth
experience, seen as interactive and dynamic.
21 See Sabatino et al. 1992.

22 REHUNA – Rede para a Humanização do Parto e Nascimento (Network for the
Humanisation of Delivery and Birth). See www.amigasdoparto.com.br.rehuna.html
or www.doulas.com.br/rehuna.html.
23 The campaign ‘Maternidade Segura’ aimed both to reduce high national levels
of maternal and perinatal mortality via the reduction of the rate of abdominal
birth, and to humanise the experience of birth. It recommended eight steps to be
taken by health services:
1. Guarantee information about reproductive health and rights to women.
2. Guarantee family planning and prenatal, postnatal and natal services.
3. Encourage and humanise normal birth.
4. Make available written routines detailing norms in labour wards and maternities.
5. Training the health teams to implement the routines.
6. Possessing adequate facilities.
7. Possessing archives and an information system.
8. Periodic evaluation of maternal and perinatal health indicadors. (Min-
istério da Saúde et al. 1995).
24 For example: Financing Care: payment for analgesics during birth was intro-
duced; the amount paid for vaginal delivery was increased by 160 per cent;
payment for attendance and delivery by obstetric nurses was authorised; a per-
centage ceiling was imposed on payment for caesareans. Restructuring Services:
R$ 101 million were earmarked for state systems for treating high risk pregnan-
cies, to fund equipment, train professionals and install centralised systems for
regulating admission to hospitals and maternities. The Ministry instituted a
programme for humanising antenatal attendance and childbirth, and created a
prize, the Prêmio Galba Araújo, for services that treated women humanely. It
supported a handbook created by the National Feminist Network of Reproduc-
tive Rights, and distributed technical manuals produced by FEBRASGO, the
Brazilian Federation of Obstetric and Gynaecological Societies and ABENFO,
the Brazilian Association of Obstetric Nurses. See www.saude.gov.br for details.
I am grateful to Greice Menezes for this information.
25 See for example, Misago et al. (2001) on the ‘culture of dehumanisation’; and
see Mello e Souza (1994) on ‘the culture of caesarean’.
26 In conformity with standard ethical practices, the anonymity of informants is
preserved, except where they gave permission for citation.
27 I use the terms ‘modernity’ (and ‘progress’) in an ethnographically specific sense,
not in reference to use of the term in sociological theory.
28 Ichiahara (2002) analysed neonatal mortality in Salvador between 1993 and
1998. She showed that during this time the mortality rate for infants under seven
days old remained high, and that most causes of death were avoidable respira-
tory complaints, such as asphyxia and hypoxia. She found the rate to be higher
in public hospitals than in private ones.
29 See McCallum and dos Reis (ms. 2003) on users of the public sector’s lack of
knowledge about analgesia available during childbirth.
30 At least one local branch of a medical insurance company (UNIMED in Espirito
Santo state) professed this aim in 1998 (Nuttall, personal communication).
31 The ‘active management of labor’ was first advocated in Ireland. Women are
subjected to routine amniotomy soon after admission, followed by regulated
intravenous infusion of oxytocin hormone. Hourly vaginal examinations to
check dilation tell the physician if dilation is progessing at a rate of less than
1cm. per hour, in which case further oxytocin is applied (WHO 1996).
32 SUS, the national health insurance scheme that funds the public sector, paid
more for vaginal births.
33 On Chilean obstetricians she writes: ‘Conflicting demands arise from peripatetic
work schedules and the need to provide personalised care for private patients.
These are resolved by liberal use of caesarean section, with maximum efficiency
in use of time. The prevailing business ethos in healthcare encourages such
pragmatism among those doctors who do not have a moral objection to non-
medical caesarean section’ (Murray 2000: 1504–5)
34 The profession of lay midwife or parteira was attacked by the medical profession
in the 19th century and is still held in disrepute (Borges 1992, Mott 1992). Lay
midwives and other female authorities on reproductive issues have to operate in
a semi-clandestine fashion, even though they are the only recourse of many
women in rural areas. The situation is different in other states, such as Ceará,
where lay midwives were offered training by the state health administration
(Bailey et al. 1991). In the 19th century, medical schools set up and ran courses
for midwives (obstetrizes) who were to substitute the parteiras (Mott 1992), but
by the early 1990s this profession had little significance in the Brazilian medical
system. In the mid-20th century, obstetric nurses opposed the running of sepa-
rate courses for obstetrizes by obstetricians. These were eventually assimilated
into nursing faculties, thus virtually ending the profession of direct-entry midwife
in Brazil (Riesco and Tsunechiro 2002).
35 Only just over half felt that doctors were wrong to agree to perform one if the
patient so requested. Asked what measures were to be adopted to reduce the rate,
replies were very mixed. About 15 per cent felt that obstetricians should be better
trained. 12 per cent felt that patients should be better informed. The rest felt that
the doctors should be paid better (10%); that there should be a public information
campaign (9.5%); and, finally, that doctors should be subject to a campaign (8.3%).
36 A study of obstetric nurses in São Paulo notes that most preferred to have their
own babies by caesarean (Osava and Mamede 1995).
37 An auxiliary is generally present on the labour wards of public hospitals to
perform basic nursing duties, and to call a doctor or an obstetric nurse to the
ward when necessary. In rural areas, auxiliaries sometimes deliver babies in the
absence of a doctor, although they are not officially qualified to do so. Auxilia-
ries belong to the same social class as their patients in public hospitals and many
are black or brown. The older generation of auxiliaries had to have at least four
years of schooling (primary school level). After a short course they found
employment in public or private sectors, where, with time, they could achieve
considerable competence. Nowadays auxiliaries must complete secondary school
and then study at one of Salvador’s nursing auxiliary training colleges, whence
they are recruited as apprentices in the hospitals and clinics of the city, after
completion of a year’s basic course.
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MC Callum Explaining Cesarean Section in Bahia

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MC Callum Explaining Cesarean Section in Bahia

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Sociology of Health & Illness Vol. 27 No. 2 2005 ISSN 0141–9889, pp.

Explaining caesarean section in Salvador da

Abstract In Salvador da Bahia the caesarean section rate is excessive, as it

Keywords: childbirth culture, caesarean, obstetrics, Brazil, Salvador da

Any conversation about birth in Brazil leads naturally to the question of

of modernity and by their condition as Latin women. The doctors also

tubal ligation in conjunction with the caesarean operation, leading to a

hospitals, which they described as an extremely unpleasant experience.

The principal approach adopted in this paper is anthropological. It is based

was marked by an outsider’s stance, for I sought to uncover speciﬁc dis-

These experiences therefore led me to design an ethnographic project.

The social-economic context of childbirth

Brazil is known for entrenched and extreme socio-economic inequality and

example, epidural analgesia is not available to parturients nor are they

Safe motherhood and the humanisation of childbirth in Brazil and in Salvador

Salvador’s obstetricians are aware of the failings of care during childbirth in

disaffected with the founder’s preoccupation with paperwork (for which he

Culture at fault? Divided approaches to the two styles of birth

Childbirth in Salvador is shaped by the profound racial and class inequality

Brazil is different from Europe. Because the Brazilian Woman is a Latin,

You have the cultural aspect, the culture of caesarean as belonging to

Dr. Artur stressed the danger of an excessive emphasis on abdominal birth.

included breast-feeding and post-natal tooth-care. The obstetric nurse in

The system at fault: organizational and logistic foundations of the high

The organisation of reproductive services in Brazil strongly supports a con-

safely, as much as the Bahian use of the ‘technocratic model’, is responsible

to attend women’s labours, allowing the doctor to appear only at the

Although knowledge of causes of and solutions to the excessive use of

1. Legal measures to reopen schools for midwives (obstetrizes) linked to

The report also recommended speciﬁc socio-political and administrative

dehumanisation’, as subject to the effects of accumulated experiences in differ-

Research on obstetrics in Salvador was ﬁnanced by the Brazilian National Research

3 See also Béhague 2002.

21 See Sabatino et al. 1992.

ABRAMGE (Associação Brasileira de Medicina de Grupo). See website

Agar, M. (1980) The Professional Stranger. NY: Academic Press.

McCallum, C. (1998) Parto como violência em Salvador: Perspectivas antropológi-

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