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Voices of Advocates Part 2: Caesarean Births (Chile)

Primal scream.

In the new millennium (2000-2011), there have been nearly 3 million births in Chile (2,751,540 to be exact), 75% of them in the public sector, and the remaining 25% in private institutions. Trends showing the increase in caesareans are clear: while in the year 2000 the total number (that includes both public and private medical institutions) of caesareans represented 36% of all births, in 2011 this figure reached 48%.

For medical anthropologist Michelle Sadler, this is “a sign of a highly medicalised birth model”, in which people are delivered to a “health system without questioning its indications”. Sadler also emphasises that there are several cultural factors related to this phenomenon: “A very hierarchical health system where users have no higher incidence, the idea that using more intervention is synonymous of better health care, the idea that birth is dangerous and must be controlled by specialists, and a great fear of childbirth in general (hazardous event) and pain during treatment, among others.”

When we compare global figures with ours in Chile, the results are not very encouraging. According to world sanitary statistics (World Health Organisation – WHO, 2011) that shows caesarean rates in more than 180 countries in the decade from 2000 to 2010, Chile ranked 4th globally with 40.6 % of caesarean births. Only Cyprus (50.9%), Brazil (43%) and the Dominican Republic (41%) had more caesareans than Chile.

Ricardo Gomez, director of the Center for Perinatal Diagnosis and Research (DPSC), is categorical: “Regardless of the causes that have led to these rates, we must be clear in stating that our current caesarean rate is indefensible.”

It is important to note that in 1985 WHO recommended that countries do not exceed caesarean rates by more than 15% of total births. Some doctors have pointed out that today, the recommended maximum rate should be 20-25%. Nevertheless, both public and private sectors have much higher percentages. The private sector moved in the last 12 years from figures of 60% of caesarean to 70%, which means that  two out of three children born in Chile in a private institution do so through a caesarean, which is so far away from the recommendation 2 out of 10 proposed for these times. Meanwhile the public sector also increased its rates from 30.4% in 2000 to 38% in 2011.

In 2000, Susan Murray, a British researcher, analysed this phenomenon that occurs in ISAPRE, Chile’s private medical sector. She concluded that the model of health insurance in Chile may condition maternity health management. ISAPRE continue to enjoy their juicy profits without ever having referred to this issue. Murray’s study also showed that economic and time factors are crucial when physicians explains the high rate of caesareans.

To some, it does not matter if a child is born the natural way or via a caesarean; they only worry about the risks associated with each of these two models. I think that such arguments are extremely reductionist. Fortunately though, authors who have reviewed the risks, even after we had explained that the difference between the two paths is very low, are emphatic in stating that nothing justifies increasing the caesarean rate. Taking into account only the risks of a certain procedure neglects first of all the preferences of patients, it takes away the spotlight in their own reproductive process, and also it leaves aside the impact of early separation in the bond development and brain development.

All the above occur frequently in our caesareans: after birth the newborn child is almost immediately taken outside the pavilion.

Why is there no change in such behaviour to “humanise” the birth in these ways? I think the answer is clear: those who work with biomedical births in Chile do not consider this as an “outcome” desired by the patient, even as a benefit or a visible impact, ignoring all the evidence that neurosciences have presented in recent years.

Others have pointed out that the high rate of caesareans in Chile is the explanation of our low mortality rates. It is good to remind that our current rates are comparable to those of industrialised countries. However, countries with such  indicators as ours have caesarean rates well below our 41% of the last decade. Just to mention some: Canada 26%, Uruguay 15.8%, Netherlands 15.4%. In addition, Chile has had stable death rates for years, while the number of caesareans keeps rising.

Current childbirth practices in Chile do not cater to the needs and preferences of would-be mothers, as evidenced in a study published in 2006 in the British Journal of Obstetrics and Gynecology by US and Chilean researchers. It indicates that 70% of women in the public and private sectors prefer vaginal birth to caesareans. The study’s authors thus concluded that mothers in Chile do not regard the caesarean as necessary.

It is important to put these arguments on the table as I’m concerned that the discussion on the obstetric violence that mothers in Chile suffer has not been considered to be pertinent or necessary to approach by any of the sectors involved. There exists a persistent and conscious violation of the economic, social and cultural rights of the Chilean women on the part of the system of health, which translates in an unjust and avoidable reproduction of the sanitary inequities from our country.

This opinion piece is published in collaboration with Women Deliver: 100 Young Leaders . Gonzalo Infante Grandón is one of the 100 Young leaders selected for 2012-2013. 

Gonzalo Infante Grandón is from Temuco, Chile. He received his Bachelor’s degree in Midwifery and is pursuing his Master degree in Public Health Community and Local Development. Currently, he serves on the primary care center “General Rural Clinic of Curarrehue”, where he has done clinical trials, administrative work, and taught health. He is teaching at the Department of Public Health and is the coordinator of PIRI of Curarrehue, and tutor of GIS II.

Gonzalo Leiva is a co-author. 

Photo by Rowan Simpson via Flickr under Creative Commons license. 

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