“On time to be born”: why are there so many cesarean sections in Portugal?

The cesarean section rate in Portugal is the 7th highest in the European Union. In public hospitals it is already over 30% and more than double (66%) in private hospitals. In some private institutions the rate is 100% because they don’t even perform vaginal births.

There are several reasons that can explain these numbers, which many experts consider high and which have been growing in recent years, despite the risks associated with surgical birth.

Risks of cesarean section

“As a surgery, it will put us in contact with organs that, in principle, would not be involved if we had a vaginal birth, namely the organs neighboring the uterus”, explains obstetrician Marcela Forjaz.

In a cesarean section, the risk of infection and bleeding is 11 times higher, the woman is four times more likely to need a blood transfusion and the risk of death for the mother is five times greater than in a vaginal birth.

There are also differences for the baby, who in a normal birth, “when passing through the birth canal, is necessarily rubbed in the vaginal fluid, which is colonized with numerous bacteria. Friendly bacteria, which in high numbers have protective effects against infection and allergies”, says Luís Pereira da Silva.

The neonatologist at Hospital Dona Estefânia says that when the baby is born by cesarean section “there is a gap of more or less 10 days until the intestinal flora is established, while in vaginal birth this happens 3 days later. This period in which you are deprived of this advantage, It completely changes immune regulation, predisposing to asthma.”

Cesarean section with option

“Before I was pregnant, I already wanted a cesarean section. A day that I chose, so that our daughter’s arrival could be scheduled”, says Jéssica Duarte.

Pregnant for the first time, she says she is aware of the risks but still prefers a cesarean section to a vaginal birth. “I completely understand that it is more comfortable, at least for people who like to have their lives planned. The problem is that the disadvantages are so important that they outweigh all these potential advantages”, argues the obstetrician and president of the European Society of Perinatal Medicine, Diogo Ayres de Campos.

Andreia Baleizão had three children, all three by cesarean section. The first birth was surgical on the doctor’s recommendation, but from then on it was Andreia’s choice to always have her children by cesarean section.

“There is this myth that those who have had a cesarean section are less of a mother, because they have not gone through the entire process of a normal, vaginal birth. I don’t feel at all more or less, I feel the same, that is, I feel like a mother”, confesses the photographer from Oeiras.

A Obstetrician Marcela Forjaz argues that vaginal birth should always be the first option for any womanfor health reasons, but understands that “ultimately, the woman is the owner of her body, informed of the risks that a cesarean section may have and if, even so, she intends to have a cesarean section, her will must prevail”.

More than half of private births are cesarean sections

The cesarean section rate in Portugal is 38% but it is mainly in private hospitals that the number of surgical births is highest.

“On the private side, there is really an interest in performing cesarean sections, not only for the sake of scheduling the activity, but also because, in financial terms, it is more remunerative than a natural birth”, explains economist Pedro Pita Barros.

Obstetrician Marcela Forjas, who works in the public and private sector, guarantees that doctors are not pressured by the institutions where they work to perform more cesarean sections for financial reasons, but admits that surgical births can also be more advantageous for doctors, as they are not It takes so many hours to accompany a woman who is in labor and because there are many insurance companies that continue to pay twice as much for a cesarean section compared to a vaginal birth.

“When you tell me that it is more beneficial for the obstetrician, yes, it will be, but it is not that big of a difference and I think there is a tiny proportion of obstetricians who put this type of interest forward”, believes the obstetrician.

There are other causes highlighted by experts that help explain the high rate of cesarean sections in Portugal. The fact that women become pregnant later and later, often with the help of infertility treatments, and even obesity, are clinical issues that, according to the director of obstetrics at Hospital de São João, in Porto, help explain the increasing number greater number of cesarean sections.

Even so, according to Marina Moucho, nothing justifies the existence of health units with cesarean section rates of 100%. “This is completely abnormal”, considers the obstetrician.

Three hospitals in Portugal with rates of 100%

They are all in the north of the country and do not perform more than 30 births per year, but they are all cesarean sections. O Hospital da Boa Nova, in Matosinhos, and Trofa Saúde Vila Real, both from the Trofa Saúde group, performed four and three cesarean sections throughout 2022, respectively. The two refused to answer SIC’s questions, only the Viana do Castelo Private Hospital (HPVC) agreed to give an interview.

The director of the hospital’s clinic, which performed 24 surgical deliveries in 2022, says that only performing cesarean sections is an option for the institution.

“To be able to deliver babies, it is necessary to provide intrapartum healthcare, we have to be licensed, we have to have a license issued by the Health Regulatory Entity (ERS). If we don’t have a license, we can’t do it. Therefore, we are not licensed for intrapartum obstetric care”, explains Domingos de Oliveira.

Questioned by SIC, ERS guarantees that it clarifies that “All health units in the private sector whose purpose is to provide medical and nursing services in obstetrics and neonatology – regardless of the type of birth (eutomy, forceps, suction cup or cesarean section) – must comply with the provisions of the ordinances that establish the minimum requirements relating to the organization and operation, human resources and technical facilities defined for the exercise of this activity“.

It also adds that “obtaining the title – operating license – constitutes a condition for opening and operating the establishment”.

But the truth is that the regulatory entity itself annually includes HPVC in the list of health care providers who perform births. SIC asked ERS why it published data from a hospital that ERS itself did not license but received no response.

António Costa’s government admitted at the beginning of last year to close these private hospitals with cesarean section rates of 100%. But more than a year later, nothing has been done nor have the rules, also announced at that time, been created to reduce the number of surgical births in Portugal.

Problems in the NHS create uncertainty

The rotating closure of maternity wards brought several constraints last year and, even this year, with some maternity wards closing during the weekend, many women opt for the private sector for the sake of predictability.

“More and more women are going private because the public sector is turned upside down. How is it possible to close a maternity hospital like a grocery store?” asks Sara do Vale, from the Portuguese Association for Women’s Rights in Pregnancy and Childbirth.

This, obstetrician Diogo Bruno also believes, may be causing an increase in the rate of cesarean sections in Portugal, because cesareans are more easily performed in the private sector.

“Public hospitals do not so easily accept a request for a cesarean section, it is only done when there is clinical indication for it”, explains the obstetrician at Hospital São Franciso Xavier, in Lisbon, who also adds that “from a health point of view public, performing elective cesarean sections without clinical reasons is not a good idea, because we increase the risk for people and the general population.”