Discussion
Although we did not use a probabilistic sample to represent the obstetricians of the state of Rio de Janeiro, our convenience sample was relatively large, comprising nearly 20% of the 2,748 registered obstetricians in the state of Rio de Janeiro, and only a few of those approached refused to answer the questionnaire.
Our main finding was that most of the obstetricians delivered their own children through Caesarean. The prevalence of 76% that we found was even higher than the prevalence in the general Brazilian population of primiparous women, of 55%.2 The prevalence of Caesareans among obstetricians was higher in Rio de Janeiro than in most other countries where we found analogous studies5-13and similar to another city in Brazil;16 the highest prevalence that we found outside Brazil was in Thailand and China, with 80% and 70% of obstetricians delivering their own children through Caesareans, respectively in these two countries.7,12If the main reason for the high number of C-sections in Brazil were perverse financial incentives for physicians, we would expect that obstetricians would deliver the children of their patients through C-section but their own children through vaginal birth. As we found that they deliver their own children mostly through C-section, it appears that there are other more important reasons for the high prevalence of C-sections such as concerns for the health of the mother and child, and the mother’s preference.
Interestingly, most obstetricians (72%) claimed they would prefer a vaginal birth for their own children, but only a third of those (34%) delivered vaginally. Similarly, in the general Brazilian population 72% of primiparous women claimed at the beginning of their pregnancy they preferred vaginal birth, but only 43% ended up delivering vaginally in the same pregnancy.2 Therefore, obstetricians do to their patients what they do to themselves.
The preference for a Caesarean was high among the obstetricians in our study, nearly 30%, but lower than in a few other countries such as Argentina (30%), the USA (46%), China (53%) and Iran (34%),7, 17-19 and higher than in most countries, including England (between 10% and 17%), Israel (9%), Canada (6%), Norway (2%) and Holland (less than 2%) 5-6, 8, 11-12, 20-27.
As expected, most Caesareans among participants who preferred vaginal birth were justified on the basis of a medical necessity (nearly nine in ten). More difficult to explain was the far fewer Caesareans that could be justified on the basis of a medical necessity among participants who preferred Caesarean birth (nearly five in ten); after all, medical necessity for a Caesarean should be the same regardless of the preference of the mother for one or other mode of delivery. Maybe, as a Caesarean was already the choice of the mother anyway, regardless of a medical necessity, they were not always informed of the medical necessity or the necessity was not yet clear before the Caesarean procedure started.
In any case, the number of Caesareans for medical reasons was too high compared to other countries. It appears that when any unexpected event happens that might create any difficulty during birth, the obstetrician turns to the C-section. This could explain the paradox why so many obstetricians say they prefer vaginal birth for their own children, but ended up having a Caesarean. Maybe, due to characteristics of their training or specialist education, they lack skills and or confidence to perform a vaginal birth or trust more their skills to perform a Caesarean.
Another alternative to explain this paradox is the social pressure that a woman faces when deciding the mode of delivery for her child. Society expects women to choose the natural alternative. Caesarean is considered the “wrong” option when there is no medical necessity. Women in general and possibly even more so obstetricians, are under pressure to fight against the excess of Caesareans in Brazil. In these circumstances women may say they prefer vaginal birth, but in reality prefer and therefore end up delivering through Caesarean; they may genuinely believe that C-section is the safest mode of delivery nowadays.
In addition to a medical necessity, the Caesarean is also a new medical technology that aims to improve the quality of the birth experience, rather like, for example, some psychotropic drugs and plastic surgeries that are employed not necessarily to treat a disease, but to improve quality of life of people who are not sick. Thus, the increase in the rates of Caesareans may also be a result of the mother’s desire for a more convenient, less painful, less traumatic and safer mode of delivery (even if there is no scientific evidence for that). This desire is expected to be as common among obstetricians as in the general population, and our findings are coherent with this reasoning.
This is not to say that excess of unnecessary Caesareans is not a problem; many obstetricians may be ill informed, ill trained or give way to perverse financial incentives, which lead to C-sections in many instances when the best alternative is a vaginal birth; for example, when the woman prefers a vaginal birth and there is no clear medical reason to perform a Caesarean. Maternities should be well equipped and structured, and professionals well trained and qualified to meet the demands of women who desire a vaginal birth; most obstetricians in our study claimed that their ideal mode of delivery was vaginal, but ended up having a C-section. On the other hand, we also must caution against a too strong and ill informed reaction against the excess of Caesarean births, because it may lead to the stigmatization of women who legitimately choose to have a Caesarean in the absence of a medical necessity.
Maybe one of the motivations for an ill informed reaction against the Caesarean birth is that it is not natural. People tend to believe that what is natural is good – the naturalistic fallacy.28However, there are many things in life that are natural but are not good, for example, the tendency to be violent and selfish. The fallacy is that what happens in nature is right. But “nature does not dictate what we should accept or how we should live our lives”.29 Vasectomy, the pill, and to choose to be childless are all unnatural legitimate options in a modern world. Giving birth vaginally is not easy for women; often it is a long, painful and dangerous event. There are many imperfections of the human body and mind that are responsible for much human suffering and put life in danger.30-31 “The body is a bundle of trade-offs. Everything could be better, but only at a cost… Your brain could have been bigger, but at the risk of death during birth”. The birth canal is too narrow.31 There are several examples of modern preferences for artificial alternatives that are more convenient and agreeable than their natural counterparts. The argument that vaginal birth should be the preferred alternative as opposed to Caesarean based only on the fact that the first is natural and the second artificial, is fallacious and therefore does not help the debate. A rational and useful debate should consider the advantages and disadvantages of each mode of delivery, including the risks and benefits for the health of the mother and the baby (i.e., safety issues), the costs for society and the preferences of the mother. The result of a well informed debate about this issue may be that different societies, different groups within societies and different women within societies may show contrasting attitudes towards the Caesarean and therefore, its rates may vary within and across societies for perfectly legitimate reasons.
Culture is to do the same things in different ways. In every human society, ancient and modern, women deliver babies with assistance at the time of birth, so it is rarely a solitary event. However, the type of help varies between and within societies. For example, women in Holland usually deliver their babies with the assistance of a midwife rather than a physician and often at home rather than in a hospital. Probably a result from this birth configuration is one of the lowest rates of Caesareans in a modern society.22 On the other side of this spectrum are women in Brazil who usually deliver their babies in a hospital and with the assistance of a physician; this birth configuration is arguably one of the reasons for Brazil’s highest rates of Caesareans.2
In a study similar to ours in Norway, in which the prevalence of Caesareans was 27% among obstetricians, the authors concluded that “The rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section”;32 even more so in Rio de Janeiro, where we found this prevalence to be 76%. Thus, as in Norway, we concluded that the debate about C-section versus vaginal birth should not focus exclusively on perverse incentives for physicians, on the defence of the natural alternative, or on physicians forcing powerless women to have C-sections against their will.