When the United States experienced a steep increase in their cesarean rate beginning in 1996, there were regular references to the case of Brazil which was seen as the archetype of countries that had accepted the inevitability of a rising cesarean rate. The popular explanation for Brazil’s high rate of interventions was that mothers there preferred cesareans, a rationale that was then applied by media outlets to the rising rate in the U.S. with stories on “patient choice” cesareans. The U.S. National Institutes of Health in 2006 even held a meeting on the Cesarean Delivery on Maternal Request. While media coverage would invariably include a vivid anecdote concerning a mother who sought a primary cesarean, no one was systematically asking mothers about the phenomenon. When researchers finally did begin surveying mothers in the U.S., however, they discovered that maternal request for a primary cesarean with no medical indication accounted for about 1% of all primary cesareans, hardly enough to drive the 50% rise in cesareans in the US between 1996 and 2009. The lesson was clear – if one intends to speak about mothers’ intentions and experiences, try directly asking and listening to mothers.

As one of the researchers who has been engaged for more than a decade in the process of surveying mothers about their childbearing experiences, I’m fully aware of the multiple challenges associated with the process, but two facts have become clear: (1) mothers are, not surprisingly, accurate reporters of this extraordinary event in their lives; and (2) they are generally more than willing to discuss their experiences. Leal and colleagues’ remarkable series of studies of Birth in Brazil take full advantage of these tendencies to explore low risk mothers’ experiences in vaginal as well as cesarean birth. Their very large sample from a wide array of geographically and economically diverse sites provides them with a unique opportunity to explore rare outcomes and subgroups within the population. Their finding that 56.8% of their respondents met their strict criteria for low risk is in itself of interest. Applying their criteria to US birthing mothers as closely as possible given different datasets, the comparable rate for low risk births was 55% ¹1  Declercq E, Sakala C, Corry M, Heirlich A. Listening to mothers III. New York: Childbirth Connection; 2013., though the cesarean rate for these U.S. mothers was 26% as opposed to the 46% found in the Brazilian sample.

Of perhaps greater importance is the analysis by Leal et al., of mothers’ experiences in vaginal birth. The considerable emphasis on cesarean birth in recent years is understandable, but a culture of medical intervention in birth is hardly limited to cesareans and Leal et al. find exceptionally high rates of intervention in vaginal birth, most notably a 56% episiotomy rate (as opposed to 17% in vaginal births in the U.S.); use of the lithotomy position in 92% of births (69% in vaginal births in U.S.); and 37% of mothers experiencing fundal pressure (25% in U.S.). As the authors note, the routine use of these practices is not supported by the best evidence. While the use of positive practices like eating in labor (26% in Brazilian survey; 40% in U.S.); and freedom of movement in labor (46% Brazil; 43% in U.S.) are heartening to see, they are far from universal and the Leal study was focusing on precisely the low risk births where these practices might be expected to be most common.

The variation in the use of best practices within Brazil by region and most notably by insurance status further undermines claims to evidence based practice. Are the low risk women served by the public health system so physically different than those in the private system that they require a different standard of care? Why are women in the public system more likely to report higher rates of evidence based practices such as eating and mobility in labor and the use of non-pharmacological pain relief? The authors suggest this is probably a result of a campaign by the Brazilian Ministry of Health to advocate for a more humane model of childbirth, a point which deserves greater attention from Brazilian researchers to address two related questions. First, is it true that such a campaign truly influenced maternity care practices? Determining a causal link between Ministry of Health initiatives and widespread behavior changes is a major challenge. Secondly, assuming there was an impact, how was that influence manifested? Was it through changes in the structure of health care institutions (e.g. the introduction of birthing centers?), the model for financing clinicians and hospitals or an education campaign concerning best practices? There’s little evidence that merely informing clinicians of best practices can bring about change without a corresponding change in institutional and/or financing arrangements.

Will a more informed public demand changes? While there’s some indication of women led movements calling for less intervention in childbirth in different countries, the evidence is limited and the nature of the childbirth experience does not lend itself to long term consumer advocacy. At precisely the point when women are most interested in childbirth practices they’re either pregnant or caring for an infant – neither a condition conducive to the kind of long term commitment necessary to alter long standing institutional behaviors or cultural norms. The attitudinal data from the Birth in Brazil project can shed some light on those matters, particularly if there’s a commitment to long term funding for future surveys that can track changes over time. For example, in our U.S. surveys, we’ve found a clear growth in the last decade in the number of women who view birth as a process that should not be interfered with unless medically necessary (45% in 2001 to 58% in 2012). There was also considerable interest among US mothers in using a different setting, specifically a birth center, for future births, with 39% of mothers willing to consider them and another 25% saying they definitely wanted to utilize one ¹1  Declercq E, Sakala C, Corry M, Heirlich A. Listening to mothers III. New York: Childbirth Connection; 2013..

So is a rising tide of intervention inevitable in Brazil? Data from other countries would suggest not. Cesarean rates have been leveling off in most industrialized countries in recent years. The latest data from the Organization for Economic and Cooperative Development shows that Italy, South Korea and the U.S., all countries with cesarean rates above 30%, have seen their rates level off or decline in recent years and a systematic study of cross national cesarean rates found the same trend cross nationally ²2  Declercq E, Ecker J, Cabral H, Young R. Is a rising cesarean rate inevitable? Birth 2011; 38:99-104.. Will Brazil be the exception and continue to increase medical intervention in childbirth or will efforts, such as those noted in Leal et al., lead to a more balanced approach to maternity care practices? Experience from other countries would suggest consumer and interest group activism combined with institutional (i.e. Brazilian Ministry of Health) support for a more evidence based approach to care can contribute to the improved outcomes Brazil has manifested without the iatrogenic harm associated with overuse of interventions. Following the example of Leal et al. and giving mothers a voice in the process is an essential first step in that process.

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