Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods

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Abstract
Objectives: To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment. Design: Population based birth cohort study, using ethnographic and epidemiological methods. Setting: Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed. Participants: 5304 women who gave birth in any of the city's hospitals in 1993. Main outcome measures: Birth by caesarean section or vaginal delivery. Results: In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education. Conclusions: Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed. What is already known on this topic Women's preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequences Efforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveries What this study adds In Brazil, many women prefer caesarean sections because they consider it good quality care Rich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior care Poor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birth Interventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient