Cesarean section rate continues to rise in Brazil; understand the reasons

The number of cesarean sections in Brazil continues to grow and move away from the level recommended by the World Health Organization (WHO), that only 15% of births be unnatural — the estimated percentage of cases in which the procedure is truly necessary.

In the country, approximately 59.7% of births carried out last year, including births through public hospitals, were by cesarean section, compared to 58.1% in 2022. Information from the National Supplementary Health Agency (ANS) shows that, if Considering only health plans, cesarean sections represented around 82% of births in 2022, the most recent data available.

The problem with the plans has led to complaints to the National Consumer Secretariat (Senacon). In the first quarter, there were 78 complaints from consumers on the consumer.gov.br platform for not being able to have a natural birth through the health plan — for comparison, in the same period of 2019 there were no formal complaints on the subject.

In the saga for natural birth, Jéssica first contacted the plan, Bradesco Saúde, to find out the rate of normal births in the accredited care network. An ANS standard allows pregnant women to have access to the percentage of cesarean sections among births carried out under the agreement.

The newspaper O Globo had access to a document that lists information from all 66 doctors and clinics accredited by the plan in the state of Rio de Janeiro. Of this total, 60 performed only cesarean sections in December 2023. Another five had cesarean section rates between 80% and 98% of births. Only one doctor had a rate lower than this level, but still high (50%).

— I asked the plan to recommend me a professional who respected WHO rates — says Jéssica. — They couldn’t recommend me, and they gave me a list of providers, telling me to contact each one. The fifteen recommended offices said that they would not perform natural births, unless I paid extra.

Jéssica then contacted the plan again, who promptly scheduled an appointment with a professional who would supposedly perform the natural birth. After a few minutes of care, the doctor said that there would be no way to take on this responsibility, as he had an appointment on the same day, but he let it slip that the remuneration for the procedure was low, just R$800.

Availability rate

According to psychologist and doula Patrícia Ramos, most doctors say they do not attend births. Some, although they say yes, require the pregnant woman to arrive with advanced labor. Others charge an “availability fee”.

“There are cases where the doctor finds some excuse not to induce, as an induction can take four to five days. Some use this to force a cesarean section, saying that the induction went wrong”, against Patrícia.

Lawyer Sabrina D’avila, a specialist in public and private law, states that there is a judicial understanding that there are no problems in charging the availability fee, as long as the patient agrees. At the same time, there is a contrary interpretation, that this fee is abusive according to the rules of the Consumer Protection Code (CDC).

“The Federal Council of Medicine (CFM) understands that this charge is not for the birth, but for availability. Now, if the patient goes to a doctor in the plan who only performs the procedure for a fee, the plan is obliged to indicate one who does not cover it. If the plan says that the accredited doctor cannot charge a fee, the patient can complain to the plan and to the ANS.”

Edylaine Rodrigues, a lawyer specializing in health and women’s law, states that doctors often receive R$1,000 from the plan for the birth, and charge another R$3,000 from the patient as an extra fee.

“The patient will have problems reimbursing this amount, because this fee, which doctors call obstetric availability, does not have TUSS (Unified Supplementary Health Terminology), that is, it is not a medical procedure”, says Edylaine.

She mentions that, in addition to these problems, women would suffer other violence when giving birth, such as being forced to go without food during labor. Without strength, they would ask for a cesarean section. Other doctors would say things like: “your baby is too big, it’s going to tear you apart.” There is also drug violence, when women receive oxytocin unnecessarily.

Plans

ANS states that it has been working, since the 2000s, to raise awareness in the sector about improving the quality and safety of maternal and neonatal health care. The ANS mentions, for example, the Parto Adequado program, in partnership with the Institute For Healthcare Improvement (IHI) and Albert Einstein Hospital, which led to a gradual reduction in cesarean sections. “The rate of cesarean surgeries has been declining since 2017 in the supplementary health sector, going from approximately 86% in 2017 to approximately 81.8% in 2021 and 2022,” he said.

Bradesco Saúde said it understood that the topic should be addressed with the ANS. Amil states that it has been a supporter of ANS’ Adequate Birth since 2015, which seeks to encourage the most appropriate care for each pregnant woman, to reduce unnecessary cesarean sections.

Marcos Novaes, executive superintendent of Abramge, which represents health plans, states that companies have incentives to carry out natural births, which generally lead to shorter hospital stays and better recovery for the patient.

“We are used to giving birth with the same doctor who provided prenatal care, unlike European countries, such as Portugal, England and France, where monitoring is carried out by a multidisciplinary team. This way, at the time of birth, the pregnant woman will already be used to the team, in case one of them eventually needs to deliver the baby”, says Novaes.

He also states that doctors accredited by the plans cannot charge an availability fee. Furthermore, if the doctor who agreed to perform the birth cannot be present on the day of birth, the plans must offer a team at the hospital or maternity ward to assist the pregnant woman.