"While the public sector spends money on costly and unnecessary cesareans, many poor women lack basic care during delivery"

By Paul Constance

Ask a wealthy Chilean woman about the birth of her baby these days, and chances are you won’t hear much about pushing, breathing or Lamaze. That is because in private hospitals and clinics in Chile, more than 60 percent of all babies are delivered by cesarean operations, in which the abdominal wall is opened and an incision is made in the uterus.

This is more than an upper-class phenomenon, however. According to a compilation of statistics presented last April at the World Congress on Perinatal Medicine in Buenos Aires, between 1993 to 1997 the so-called cesarean rate in all of Chile averaged 40 percent—the world’s highest level. In Brazil, the national rate was just above 36 percent during the same period. In Cuba, Mexico, Uruguay and Argentina, the average was over 23 percent.

The curious thing about these numbers is that they are significantly higher than those found in industrialized nations that spend much more on health care than their Latin American counterparts.

In France, which was recently given the top spot in a World Health Organization ranking of countries by the quality of health care, the cesarean rate was 15.9 percent in 1995. Even in the United States, where the cesarean rate grew rapidly during the 1970s and 1980s, it had stabilized at around 21 percent in 1998.

Perceptions and incentives.
The medical justification for a cesarean delivery is the presence of risk factors, such as breech presentation of the fetus, that can endanger the life of mother or child in a normal delivery. Are Latin America’s pregnant women simply at a higher risk of birth complications than those in other regions?

Hardly. According to a growing number of physicians and public health advocates, the soaring cesarean rate in Latin America is an aberration caused by financial, educational and political factors that create incentives for the performance of unnecessary cesareans. Moreover, these critics charge that the operations take scarce resources away from more urgent health problems while exposing mothers and babies to unnecessary risks.

Latin American countries are certainly not alone in the increased use of cesarean surgery. During the last 30 years, use of the procedure has grown steadily, due in part to the spread of fetal monitoring techniques that give doctors a much more detailed (though often inaccurate) picture of each baby’s birth risks. In countries where doctors can be sued for malpractice if something goes wrong during delivery, these technologies are believed to have encouraged the preemptive use of cesarean surgery.

That tendency is often exacerbated by anxious parents who have inaccurate or exaggerated perceptions of the risks of a vaginal delivery, especially when a woman has had a previous cesarean. Doctors often prefer cesareans because they can schedule the procedure to suit their busy schedules, instead of waiting for hours while a woman goes through labor. And the growth of medical insurance schemes, some of which reimburse hospitals and doctors at a higher rate for cesarean deliveries than for normal ones, is believed to have introduced a perverse financial incentive in many settings.

As a result of these factors, the cesarean rate in numerous countries more than doubled during the last quarter of the 20th century. By the late 1980s, when nearly one-quarter of all deliveries in the U.S. were cesareans, consumer groups and some physicians declared a cesarean “epidemic” and called for concerted action by government health authorities to bring the rates down. Similar campaigns emerged in Great Britain and other countries with high rates.

Real costs, real risks.
These reactions provoked a heated debate about what should be the appropriate cesarean rate. In 1985 the World Health Organization set 15 percent as the highest acceptable cesarean rate, based on the rates prevailing in countries that also had the world’s lowest perinatal mortality rates. In 1991 the U.S. Department of Health and Human Services adopted the 15 percent rate as a national target to be reached by the year 2000. (U.S. figures for that year are not yet available, but it is very unlikely that the target was met.)

While no one disputes that cesareans protect the lives of mother and child in emergency situations, recent research has begun to focus on the procedure’s risks. Apart from the obvious dangers to the mother associated with mayor surgery, there is substantial evidence that babies delivered by cesarean are at higher risk of complications (such as breathing difficulties) than those delivered vaginally. A 1991 study of 25 hospitals in Mexico City published in the American Journal of Obstetrics and Gynecology, for example, showed that normal birth weight babies delivered by cesarean were 2.5 times more likely to die in the early neonatal period than those delivered vaginally.

Though physicians continue to debate the relative merits of cesarean delivery, no one disputes the additional cost it imposes on health systems. Various studies have shown that a cesarean delivery typically costs two to three times as much as a vaginal one. Although analysts have yet to calculate how these costs affect health budgets overall, a November 1999 study published in the British Medical Journal makes it possible to arrive at an alarming approximation. The study estimated that “over 850,000 unnecessary cesarean sections are performed each year” in Latin American and Caribbean countries, if the 15 percent cesarean rate is used as a standard. Based on a conservative estimate that a cesarean delivery costs $500 more than a vaginal one, this would indicate that the region’s countries are needlessly spending $425 million per year.

“While the public sector spends money on unnecessary and costly cesareans, many women, and especially the poor, go without any or with low-quality care during their deliveries,” says Amanda Glassman, an IDB health specialist who is studying the issue. “Eliminating these excess cesareans and reallocating spending to prenatal care and expanded basic maternity care will reduce the number of neonatal and maternal deaths—which is still far too high in Latin America.”

Who’s accountable?
Despite growing awareness of the human and financial costs of unnecessary cesareans, government health authorities in most Latin countries have been slow to act. Part of the reason is that the highest cesarean rates are found in private hospitals and clinics where the government has limited influence. In Chile, for example, the cesarean rate is 58 percent in the private sector and 28 percent in public settings.

Even in the public sector, however, policy-makers cannot easily force change. One reason is that good financial management is not rewarded in most public health care systems. “Public hospitals have no incentive to reduce their operating costs by preventing unnecessary cesareans, because if they do their budget will probably get cut next year,” says Ana Langer, a public health expert who has studied the cesarean problem in Brazil and Mexico. Langer, who heads the Mexico office of The Population Council, a New York-based research institution, says the Brazilian government has taken commendable steps by narrowing the difference in the price public hospitals are paid for cesarean versus normal deliveries, for example. But she believes that hospital administrators would be much more likely to put pressure on doctors if savings from reduced cesarean rates could be retained by the hospital.

Even in settings where a concerted effort is being made to reduce the cesarean rate, progress is difficult. Doctors understandably resent any interference in their ability to recommend what they consider best for the patient. And in some countries, patients themselves pose a significant obstacle. Langer says that upper-class Brazilian women routinely request cesareans regardless of whether they have medical reasons to need one. “There are all kinds of misconceptions,” says Langer. “For example, there is a widespread belief that having vaginal delivery can diminish your sexual attractiveness afterwards. Many people also believe that it is simply safer to have a cesarean, and then there is the question of status. Having a baby by cesarean is considered a more modern, upper-class option.”

In theory, doctors have a responsibility to educate their patients and correct such misperceptions. Indeed, some critics of excessive cesarean use claim that doctors’ attitudes, and the advice they give women, can have a decisive influence on the cesarean rate. A study published in the Dec. 7, 1991 edition of The Lancet examined the decisions made by 12 obstetricians at a private hospital in Rosario, Argentina, who delivered 1,974 babies over a nine-month period. The obstetricians all had similar training and experience, and the women they attended presented a similar range of risk factors and socioeconomic and educational backgrounds. Still, the study found that even while controlling for all other factors, one-third of the obstetricians recommended “20-50 percent more cesarean sections” than their colleagues. The authors concluded that an obstetrician’s “clinical attitude” is an important—and subjective—variable in the cesarean rate.

Despite these obstacles, a variety of programs have managed to reduce cesarean rates. According to the IDB’s Glassman, successful programs combine education for both patients and doctors with changes to medical protocol (such as requiring a second opinion before a cesarean can be performed) that encourage vaginal delivery.