167
Epidemic of caesarean sections in Brazil
Brazil has one of the highest rates of caesarean
section in the world. Patterns of caesarean sections
were studied in a cohort of 5960 mothers followed
from 1982 to 1986 in southern Brazil. Overall, 27·9%
were delivered by caesarean section in 1982, this
proportion being 30% for nulliparae, 80% for second
deliveries when the first was by caesarean, and over
99% for third births when the first two were by
caesarean. Socioeconomic status and requests for
sterilisation by tubal ligation were important
underlying factors. 9·4% of the women were
sterilised during a caesarean section (3·7% in the
lowest income group and 20·2% in the highest). 31%
of women who had had their first child by a
caesarean section and who were having a second
operative delivery were sterilised. The high rates of
caesarean sections and accompanying sterilisations
reflect the lack of appropriate reproductive and
contraceptive policies in the country.
Introduction
The global increase in the proportion of caesarean section
deliveries is a matter of widespread concern. 1-4 Although the
decline in perinatal mortality rates in some areas can partly
be ascribed to increased use of caesarean sections,s it should
be possible to achieve important reductions in perinatal
mortality without a concomitant increase in operative
deliveries.*’ Caesarean sections are sometimes lifesaving
for both mother and baby, but these operations can also lead
to an increase in maternal morbidity7 and even in the risk of
pre-term births if the expected date of delivery has been
miscalculated.8 Operative deliveries place a considerable
economic burden on health services of developing countries
because they are more expensive than normal deliveries.
Brazil has one of the highest proportions of operative
deliveries in the world. A nationwide study of patients
enrolled in the social security system showed an increase in
the proportion of caesarean sections from 15% in 1974 to
31 % in 1980.9 In urban areas, such as the city of Sao Paulo,
rates as high as 75% have been described among private
patients. 10 If the existing rate of increase is maintained, over
two-thirds of babies will be born by caesarean section by the
year 2000 (fig 1).
What arethe reasons for the Brazilian epidemic of
caesarean deliveries? Economic factors are important, since
the proportion of operative deliveries increases with family
income." Another reason could be strict adherence by
doctors to the dogma "once a caesarean always a caesarean".
Moreover, many caesarean sections are done to carry out an
intraoperative sterilisation via tubal ligation. In Brazil,
sterilisations are allowed only under very special
circumstances (eg, when two independent physicians certify
that future pregnancies would be contraindicated) and are
not reimbursed by the national health insurance
programme. Consequently, doctors and families usually
agree that the sterilisation should be carried out during a
caesarean section; doctors then charge the women an extra
fee and may give other reasons for the operation in the
hospital case-notes.
Fig 1-increase in caesarean section rates in Brazil.
We now describe the patterns of caesarean sections in a
cohort of 5960 mothers followed from 1982 to 1986 in the
city of Pelotas, southern Brazil. Since information about
previous and subsequent pregnancies was available, we were
able to investigate risk factors for operative deliveries in this
population.
Methods
Pelotas has a population of 250 000. Details of the cohort study
have been published elsewhere." In 1982, all 6011 hospital births
(5914 livebirths) to 5960 women in the city were studied (over 99%
of births take place in hospitals). Mothers were interviewed soon
after delivery and asked about reproductive history, including mode
of any previous deliveries. Information on reasons for caesarean
section, including tubal ligations, was obtained from the mothers
themselves because hospital case-notes frequently do not mention
sterilisation for legal reasons.
From December, 1985, to April, 1986, when the children were
aged between 35 and 52 months (mean 43 months), a city-wide
census was conducted and mothers were questioned about
pregnancies after the birth of the cohort child; information was
collected for the first three such births. Recorded details included
whether the pregnancy was wanted and its outcome,13 and
information about contraceptive methods. Of the original 5914
livebirths, 4978 (84%) were traced. In relation to birthweight and
birth order, children who were traced did not differ significantly
from those who were not, although those from the highest and
lowest family income groups (in US dollars) were less likely to be
found. Overall, at least 80% of children in each income group were
traced. 12
ADDRESSES: Department of Social Medicine, Universidade
Federal de Pelotas, Pelotas RS, Brazil (F. C. Barros, PhD, C. E.
Victora, PhD), Department of Public Health and Policy (Prof J. P.
Vaughan, FRCP(E)), and Maternal and Child Epidemiology Unit
(S. R. A. Huttly, MSc), London School of Hygiene and Tropical
Medicine, London, UK. Correspondence to Dr F. C. Barros,
Department of Social Medicine, Universidade Federal de Pelotas, CP
464 96001 Pelotas RS, Brazil.
 168
Results
27-9% of the women had their babies by caesarean section
and there was a close association between operative
deliveries and socioeconomic status-16.4% in the lowest
income category vs 46-7% in the highest. This association
has been discussed elsewhere."
Table I shows the percentage of mothers who had a
caesarean section in 1982, in relation to the number of
previous births and of previous caesarean deliveries. 30% of
nulliparae had a caesarean section; this figure increased to
80% for second deliveries when the previous one had been a
caesarean, and to over 99% for third births when preceded
by two caesareans.
TABLE I-PERCENTAGE OF MOTHERS WHO DELIVERED COHORT
CHILDREN BY CAESAREAN SECTION ACCORDING TO BIRTH
ORDER AND NUMBER OF PREVIOUS CAESAREAN SECTIONS
Number of mothers in parentheses.
Fig 2 shows the variations in the frequency of caesarean
sections according to family income and parity. For all parity
groups the chances of being delivered by a caesarean
increased with family income-eg, for nulliparae the rate
was 22% among the poorest women vs 42% for the richest.
For the two poorest groups the frequency of caesarean
sections was highest for nulliparae.
Table n shows the proportion of caesarean sections
during which tubal ligations were carried out, according to
the number of previous births and caesareans. Among the
women who had had their first child by a vaginal delivery
and had undergone a caesarean for the second delivery,
almost one third (31 %) were sterilised; for women with two
previous normal births and a third child by caesarean, 68%
were sterilised; and for those with three previous normal
deliveries and a fourth birth by caesarean, 80% were
sterilised.
The proportion of tubal ligations was 23 % among women
who had had their first child by a caesarean section and were
undergoing a second operative delivery vs 84% among
women undergoing their third consecutive caesarean. 8-3%
of all women who were traced in 1986 had had a tubal
ligation during a caesarean section for the cohort child in
son -,
Fig 2-Proportion of caesarean sections according to parity and
family income, Pelotas, Brazil, 1982-86.
. <$50; D$51-150; $151-300; B$301-500; >$500
TABLE II-PERCENTAGE OF WOMEN HAVING A TUBAL LIGATION
DURING A CAESAREAN SECTION ACCORDING TO BIRTH ORDER
AND NUMBER OF PREVIOUS CAESAREAN SECTIONS
1982 and a further 1-1% were sterilised in the period
1982-86.
Fig 3 shows that both the tubal ligations carried out
during the 1982 caesarean sections and the subsequent
sterilisations were closely associated with socioeconomic
status. Whereas 3-0% of the mothers in the income group
< 50 US$were sterilised during an operative delivery in
1982 and only another 0.7% were sterilised in the period
1982-86, among women of the highest income group,
17-9% were sterilised during the 1982 caesarean section and
2-3% thereafter.
Discussion
Our study reveals some of the reasons for the epidemic of
caesarean sections in southern Brazil. First, there is a
striking association between socioeconomic status and
operative deliveries. In any parity group, mothers belonging
to wealthier families are much more likely to be delivered by
a caesarean section than those of low economic groups. If
only medical reasons were operative, the reverse would be
the case since we have shown that poor women are more
likely to have risk factors that could justify intervention.14
The increase in operative deliveries among high-income
groups has been observed in other countries--eg, the
USA 15,16-and is deeply worrying. There are many cultural
and economic factors underlying this trend-in some social
groups caesarean sections are regarded as the most modem
and safe way of giving birth. This notion seems to be
reinforced by doctors who likewise see these operations as
safe and convenient.
Our results also show that doctors seem to follow the rule
of once a caesarean always a caesarean, with 80% of the
mothers who had a first caesarean birth being delivered
again by a caesarean section, this proportion being virtually
100% in cases of two previous operative deliveries. These
practices should be reviewed because labour may be safely
allowed in women who have had a caesarean section.17
Fig 3-Tubal ligation and caesarean sections by family income,
Pelotas, Brazil, 1982-86.
D Tubal ligation after caesarean section (1982); interval sterilisation
since last delivery

Moreover, labour can be safe even in women who have had
more than one previous caesarean. 18
Sterilisation is clearly an important reason for doing a
caesarean section. Tubal ligations were carried out in 40%
of the elective caesareans and it is reasonable to assume that
sterilisation was the main indication for most of these
operations. Tubal ligations were also closely connected to
the family’s socioeconomic status-18% in the highest
income group vs 3% in the lowest group in 1982.
Sterilisation during the subsequent 4 years (1983-86) was
also more common among the wealthier women.
The status of female sterilisation shown in this study has
been also described in other areas of southeast Brazil. In Sao
Paulo, the country’s richest state, female sterilisation is the
second most common method of contraception, and 25 % of
the married women aged between 15 and 44 years have been
sterilised.19 Studies carried out in northeastern states
indicate that 60% of the sterilisations were carried out
during a caesarean.19
The practice of widespread sterilisation is a major cause of
the decline in fertility observed between 1970 and 1985 in
Brazil, from 5 8 births per women to 3-3. With 27% of the
country’s married women aged 15-44 already sterilised ’20 by
comparison with 7% in developed countries,21 it would be
expected that contraceptive sterilisation would be available
on demand. However, female sterilisation is legal only under
very special circumstances, and a pregnant woman who
previously underwent a caesarean is regarded as being at
high risk, and so sterilisation is allowed on medical grounds
during the next caesarean delivery.
The rates of caesarean section and tubal ligations
described in this study reflect the lack of appropriate
reproductive and contraceptive policies in Brazil. As a start
some short-term policies should be incorporated by the
health authorities-eg, changes in the policies of payment
for sterilisations by the national insurance system,
availability of other methods of contraception, and audits of
caesarean sections. Finally, there is a need for a national
campaign of health education, not only for the general
population but also for doctors and medical students,
emphasising the risks and proper indications for operative
delivery.
We thank Dr Hajo Wildschut and Dr Ivo Behle for their helpful comments
on early drafts of this paper. We are very grateful for long-term support for
this research from the Overseas Development Administration, UK, and
DRC, Canada.
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20. Rutemberg N, Ferraz EA. Female sterilization and its demographic
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DESIGNING A DOCTOR
Becoming a doctor in China
When the People’s Republic of China was founded in
1949, the country’s medical services consisted of a tiny core
of elite western-style doctors, who worked mainly in the
largest cities. The rest of the huge country saw nothing of
western medicine, but was entirely served by traditional
Chinese medicine. As elsewhere in the developing world,
infective and parasitic disease was dominant. Life ex-
pectancy was below 40 years. One of Chairman Mao Ze
Dong’s earliest and most enlightened dictates was "Put
prevention first". This article reviews briefly the way in
which the slogan was put into practice, through a health care
system perhaps better fitted to the available resources than
any other in the developing world.
The first and most important difference is that China has
developed a three-tiered system for delivery of health care
and for training its doctors. Trainees in these three distinct
tiers all emerge with the title "doctor", and are accorded
respect and status in society. Even their salaries may not be
far apart, with only a threefold difference between a
western-style specialist at one extreme and a basic rural
doctor at the other. Nevertheless they have totally different
degrees of training behind them, administered through
separate structures. After qualification, the strict bureaucra-
tic control of Chinese society enables doctors of various
grades to be distributed according to population needs and
discourages mobility within a career. The result is a
ADDRESSES: Clinical Trial Service Unit, Radcliffe Infirmary,
University of Oxford, Oxford OX2 6HE, UK (Zheng-Ming Chen,
MB); Southampton University Hospitals, Southampton SO9 4XY
(R. C. Godfrey, MD). Correspondence to Dr Chen.