From the day Mariana Migon discovered she was pregnant, she knew she wanted a natural birth. So just weeks before her due date, the first-time mother abandoned her obstetrician, her health plan and her private hospital room for the free public hospital in downtown Rio — where she had a real chance at a vaginal birth.
"If I'd stayed with my health care plan and my doctor, I would have had a C-section," said Migon, as she sat beside the incubator holding her baby girl, who was premature.
In Brazil, where natural childbirth fell out of favor years ago, more than half of all babies are born via cesarean section, a figure that rises to 82 percent for women with private health insurance.
But that trend may be turning around in a country with one of the highest cesarean rates in the world.
More women are pushing for more of a say in childbirth — whether by C-section or naturally, at home or in a hospital, with a midwife or a medical doctor. As patients in doctors' offices and street protesters reject the pressure to have surgical births, the federal government is investing billions of dollars into a natural childbirth campaign, including the building of hospitals devoted to maternal care.
"We need to have a serious discussion in this country to see what can be done to change this culture," said Olimpio Moraes Filho, one of the head doctors with the Brazilian Association of Obstetricians and Gynecologists. "Women are starting to rebel, and they should."
A tipping point came in July, when a medical regulating agency in Rio de Janeiro forbade doctors from doing home births and labor coaches known as doulas from helping out in hospitals, saying "there are many complications possible during labor that require immediate medical attention."
In response, women organized marches in 13 cities. In Sao Paulo, they bared their breasts and carried posters reading "Our Children, Our Decision" while chanting "Brazil, don't follow Rio's example." They enacted natural births using dolls covered with Portuguese words reading "Born Free."
After the resolution was reversed by court order July 30, about 200 people gathered in Rio to celebrate, with yet more banners and painted bellies defending women's freedom to choose how their babies are born. Similar marches took place in 28 other Brazilian cities, where women also defended their right to reject episiotomies — cutting the vaginal opening to prevent tearing — and to have company during the birth. A 2005 law says women should have a companion of their choice during labor, but it's frequently not respected.
The World Health Organization warns against unnecessary surgeries, saying that while there is no ideal C-section rate, the percentage should hover between 10 and 15 percent. In China, which also has a very high cesarean rate, 46 percent of babies were delivered via the surgery in 2008, the latest year for which data is available. In the US, more than a third of births are by C-section.
Because a C-section entails major abdominal surgery, risks for the mother include infections, complications from anesthesia, hemorrhage and dangerous clots, and a longer recovery. For the baby, the procedure is linked to increases in premature births, breathing problems, and generally lower health scores related to depriving babies of the stimulation they normally experience as they travel through the birth canal.
The reasons behind Brazil's high rates are many. Experts say a longstanding interventionist approach to vaginal births made them more painful and stressful than necessary. All this gave C-sections a reputation as being a more predictable, safe, painless and modern way to deliver.
Brazil's statistics worry Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation. She is analyzing a survey of 24,000 birthing mothers across the country and said the high C-Section rate reflects an extreme manifestation of a medical culture that treats delivery as a health problem and not as a natural process.
"Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can't walk, can't take a bath, can't hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies," she said. "What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women."
Private clinics are often happy to make that dream come true by turning delivery into something akin to a weekend retreat in a birth-themed five-star hotel.
At the Perinatal Clinic in Rio de Janeiro, mothers can get free hairstyling, manicures and makeup sessions, and for a fee, can have their rooms decorated in a safari or teddy bear motif. Once the new mom is ready for visitors, a catering service complete with waiters can also be arranged.
"There are patients who absolutely refuse to have natural childbirth, well-informed patients who maintain this position out of fear," said Paulo Marinho, the medical director at Perinatal. "It's a cultural situation. I've seen it develop over generations."
From the doctors' perspective, the issue comes down to familiarity and economics, said Moraes Filho, of the Brazilian Gynecologists and Obstetrics Association.
Brazilian women expect the doctor who sees them throughout their pregnancy to be the one who delivers their baby, not whoever happens to be on call. Second, health care plans generally pay practitioners the same for a C-section taking 30-40 minutes as for a natural birth that can last an entire day.
"We have to change this culture, and get women comfortable having their child with the doctor or nurse on duty," Moraes Filho said.
In public hospitals doctors are paid R$150 ($74) for a C-section, and R$175 ($86) for a natural birth. Three-quarters of Brazilians rely on free public health care. Private doctors receive between R$ 200 ($100) and R$400 ($200) per birth, depending on the health care plan and the procedure.
"It's not that doctors are mercenaries, but what they earn to be present for a very important moment is little more than what a television repairman gets who shows up on his schedule," Moraes Filho said. "This doctor-patient connection where the woman wants her doctor present, the poor remuneration for doctors, their need to juggle several jobs — all this makes it impossible for a practitioner to reconcile his work schedule with unpredictable vaginal births."
In an effort to reverse the trend, Brazil's federal government has invested $1.3 billion over the last year and a half, with another $3.36 billion allocated in a program called "The Stork Network," aimed at "humanizing" the birth experience and educating mothers and health care practitioners on the benefits of natural childbirth.
"We're making a big effort now, offering good prenatal care, a place women trust, information that's pertinent, so women can make their decision," said National Health Care Secretary Helvecio Magalhaes. "We're creating incentives for natural birth."
The program's broad approach creates maternity hospitals focused only on pregnancy, delivery and post-partum care, reaches out to private health care plans to discuss birth options, proposes curriculum revisions in medical schools, and launches educational campaigns aimed at informing mothers of the pros and cons of surgery versus natural childbirth, Magalhaes said.
In the city of Rio, a similar program invites all mothers delivering through the public health system to visit the hospital where they'll give birth. The question — C-sections or natural birth? — came up in a group of 10 pregnant women during a recent tour of a brand new public maternity hospital.
"I never wanted a natural child birth, no way!" said Zelia Leite Alves, who was accompanying her pregnant daughter on the visit. "I wasn't born to feel that kind of pain."
She did her best to talk her daughter, Claudia Larissa, into following in her footsteps. To her surprise, the 20-year-old was determined to have a natural birth, as long as it was safe.
"I have to admit, I'm not calm at all. It's my first time and I'm anxious. I'm very afraid of the contractions. But this helps," she said of the visit. "I can see this was made for us, this space is for mothers. I know the staff will be here for me."