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Editor—Several recent papers present evidence that in Brazil consumer demand for caesarean sections is much lower than previously assumed.1,2 Langer and Villar3 state that the results reported by Béhague et al contradict these findings.4 We are surprised by this assertion.
Despite using the term consumer demand in their title, Béhague et al do not present an estimate of the demand for caesarean sections in the population they studied—mothers giving birth in 1993 in a medium sized city in southern Brazil. The only statistic that relates to demand is the proportion of a subsample of mothers (32/80) who stated that when they went to the hospital they expected to deliver by caesarean section. But the type of delivery that a woman expects may not be the type of birth she would prefer, especially in the private sector, where most caesareans are scheduled.
Also puzzling is Béhague et al's failure to distinguish their sample by sector of care. Studies in Brazil and elsewhere have shown dramatic differences in caesarean section rates depending on whether the woman delivered in the public sector (rate of 25-30%) or private sector (rate of 70%).5
Our most striking finding was that despite these large differences in rates there were no significant differences in women's preference for vaginal delivery, which was about 80% in both sectors.2 Although the remainder who prefer caesarean section are by no means the majority, we commend Béhague et al for giving voice to them. Notably absent from their discussion, however, is tubal ligation—one of the primary reasons why women, especially poor women, actively seek to deliver by caesarean section in Brazil.
Among most of the approximately 3000 women in the new studies who stated their preference for vaginal delivery, the most frequently expressed reason from both rich and poor women was that vaginal delivery affords a faster recovery (followed by “it's more natural”).1,2 A faster recovery is important for poor women, who know that they would have little support while recovering from a caesarean section.
Perhaps the most troubling aspect of the analysis by Béhague et al is that, lacking a direct assessment of demand for caesarean delivery and information on how and when the decision to operate was taken, they seem to infer demand from differentials in caesarean rates. Recent research has shown that such differentials may be misleading.1,2,5
References
1.Hopkins K. Are Brazilian women really choosing to deliver by caesarean? Soc Sci Med. 2000;51:725–740. doi: 10.1016/s0277-9536(99)00480-3. [DOI] [PubMed] [Google Scholar]
2.Potter JE, Berquó E, Perpétuo IHO, Leal OF, Hopkins K, Souza MR, et al . Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ. 2001;323:1155–1158. [Google Scholar]
3.Langer A, Villar J. Promoting evidence based practice in maternal care. BMJ. 2002;324:928–929. doi: 10.1136/bmj.324.7343.928. . (20 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: population based cohort study linking ethnographic and epidemiological methods. BMJ. 2002;324:942–945. doi: 10.1136/bmj.324.7343.942. . (20 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Murray SF. Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study. BMJ. 2000;321:1501–1505. doi: 10.1136/bmj.321.7275.1501. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Aug 10;325(7359):335.
Demand is affected by mothers' perception of good health care
Editor—Béhague et al highlighted mothers' preferences for caesarean section on the basis of their perception of poor quality of care for vaginal deliveries.1-1 Data from two birth cohorts born 15 years apart (1978-9 and 1994) in Ribeirão Preto, one of the richest areas in Brazil, showed that the caesarean section rate increased from 30.3% to 50.8%.1-2 Over the same period the rate of low birth weight increased from 7.2% to 10.6% and of preterm births from 7.6% to 13.6%.1-3 Thus maternal beliefs that caesarean section is good quality care may not be supported by evidence.
We were concerned that Béhague et al did not fully explore the influence of doctors' convenience on mothers' preferences.1-1 In our studies caesarean section was more commonly performed in daylight hours and evenings among women attended by the same doctor during prenatal care and delivery and who had more antenatal visits than others did.1-2
Similar results were found in 1997 in São Luís, in one of the poorest regions in Brazil.1-4 The caesarean section rate was 33.7%, and the risk was higher for primiparous, married, and better educated mothers; those attended by the same doctor during prenatal care and delivery; deliveries done in private hospitals, daylight hours, or evenings; and mothers who had adequate prenatal care.
These findings are consistent with a recent report showing that, contrary to popular belief, nearly all women wanted a vaginal delivery despite the higher caesarean section rate among women in the private sector (72%) than in the public one (31%).1-5 The differences in births by caesarean section between the two groups were due to higher rates of unwanted caesarean section among private patients rather than to differences in preferences about type of delivery.
We believe that by focusing on maternal preferences Béhague et al are dealing with the effect rather than the cause of the problem. Maternal preferences regarding delivery by caesarean section may be related to the mother's perception of doctors' behaviour during the antenatal and delivery period. Scheduling caesarean sections is how obstetricians accommodate their working and leisure time. Although caesarean sections are commoner among private patients, the trend to caesarean sections may have a knock-on effect on the socially unprivileged women seeking what they perceive to be good health care during delivery.
Efforts should be made to change doctors' behaviour and the healthcare context in which they operate. We fear that education alone, regardless of target population, will be ineffective.
References
1-1.Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: population based birth cohort study linking ethnographic and epidemiological methods. BMJ. 2002;324:942–945. doi: 10.1136/bmj.324.7343.942. . (20 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2.Gomes UA, Silva AAM, Bettiol H, Barbieri MA. Risk factors for the increasing caesarean section rate in southeast Brazil: a comparison of two births cohorts, 1978-1979 and 1994. Int J Epidemiol. 1999;28:687–694. doi: 10.1093/ije/28.4.687. [DOI] [PubMed] [Google Scholar]
1-3.Bettiol H, Rona RJ, Chinn S, Goldani M, Barbieri MA. Factors associated with preterm births in southeast Brazil: a comparison of two births cohorts born 15 years apart. Paediatr Perinat Epidemiol. 2000;14:30–38. doi: 10.1046/j.1365-3016.2000.00222.x. [DOI] [PubMed] [Google Scholar]
1-4.Silva AA, Lamy-Filho F, Alves MT, Coimbra LC, Bettiol H, Barbieri MA. Risk factors for low birthright in north-east Brazil: the role of caesarean section. Paediatr Perinat Epidemiol. 2001;15:257–264. doi: 10.1046/j.1365-3016.2001.00358.x. [DOI] [PubMed] [Google Scholar]
1-5.Potter JE, Berquó E, Perpétuo IHO, Leal OF, Hopkins K, Souza MR, et al. Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ. 2001;323:1155–1158. [Google Scholar]
BMJ. 2002 Aug 10;325(7359):335.
Episiotomy rates may change after evidence based intervention
Editor—Althabe et al report on caesarean section rates among women in Brazil.2-1 In 1984 a retrospective study in one maternity hospital in Dublin showed an episiotomy rate of 54% in primigravid women having normal deliveries. The practice of 20 experienced labour ward midwives was found to differ significantly (χ2=72.4, df=38, P<0.001), with episiotomy rates varying from 6% to 84%.2-2
Full results of the study, with accompanying literature showing that the only indication for episiotomy in a normal delivery is fetal distress, were presented to staff both orally and in written form. Much discussion ensued, and many of the midwives requested their own confidential data in order to learn their position in the table ranking midwives according to the rate of “no suture.”
Six months later a follow up study was carried out over a further six months. The episiotomy rates had decreased from 54% to 34% in primigravidas, from 25% to 7% in the para 1 group, and from 5% to 2% in the para 2 or greater group. There was no increase in second degree lacerations (defined as those requiring suturing) in the primigravid or para 1 group, and there was a significant decrease in second degree lacerations in the para 2 or greater group, from 18% to 11%.2-2
Providing evidence relating to practitioners' performance compared with that of their peers, together with research based rationales for changing, has led to major changes in midwives' practice in this hospital.
References
2-1.Althabe F, Belizán JM, Bergel E. Episiotomy rates in primiparous women in Latin America: hospital based descriptive study. BMJ. 2002;324:945–946. doi: 10.1136/bmj.324.7343.945. . (20 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2-2.Begley CM. Episiotomy—a change in midwives' practice. Irish Nursing Forum and Health Services Journal. 1987;Nov/Dec:12–14. , 34. [Google Scholar]
