Why so many c-sections in Venezuela?

CARACAS, Venezuela — When giving birth to her daughter, Carolina Vazquez remembers tiptoeing down the corridors of her clinic as she tried to avoid doctors.

Vazquez was determined to give birth naturally and feared she would be coerced into a cesarean.

“My obstetrician was telling me to hurry up so they wouldn’t see me,” she recalled. “She was arranging for this or that doctor not to come in that day — I always call my daughter’s arrival a clandestine birth.”

Giving birth naturally (or vaginally) in Venezuela is becoming increasingly difficult as doctors and women opt for the perceived safety of a c-section.

Cesarean rates in some private clinics are as high as 90 percent, while even in public hospitals almost three in 10 women go under the knife, according to several doctors.

It’s a worldwide trend that has alarmed some doctors. A recent World Health Organization report said c-sections have reached “epidemic proportions” in many countries.

For Vazquez, the experience inspired her to set up Aquamater, one of just two clinics in Caracas dedicated to offering women the option of a natural labor. The clinic provides all the equipment and expertise for a woman to give birth exactly as she wants, including a birthing bath and facilitators to assist during labor.

But there is also an operating room available in case an emergency cesarean is required, she stressed.

Vazquez is determined to fight the prevailing culture for cesareans in Venezuela. Yet since she set up the clinic more than a decade ago, the cesarean rate in Venezuela has climbed.

Dr. Saul Kizer, an obstetrician at La Arboleda clinic in central Caracas, said the rate had increased by 22 percent between 2000 and 2009 in two private clinics he surveyed (the clinics requested anonymity).

Even at Aquamater, the cesarean rate rose to 45 percent since the clinic began offering a service that provides cheap rates to teenage mothers, many of whom go because of the lower cost not because they want to give birth naturally.

Vazquez, a psychologist by training, believes the cesarean rate in Venezuela may be party driven by profit margins. After all, surgery is quicker than labor (an hour against 10 to 12 hours), pays up to 50 percent more and doctors can schedule deliveries into regular working hours.

That has prompted a kind of strong-arming by doctors who coerce worried mothers into surgery, said Vazquez. “Ignorance makes women easy prisoners of medical manipulation,” she said. “There’s a deification of medicine here — doctors behave and are treated by patients as demi-gods who know everything.”

But Kizer says much of the pressure often comes from women and their families. “In the last two decades a new term has emerged known as the elective cesarean,” he said. “The woman has no indication of medical, obstetric or fetal problem but she still wants to have a cesarean.”

As head of obstetrics during the 1980s at the Concepcion Palacios, Caracas’ largest maternity hospital, Kizer remembers a cesarean delivery rate of about 10 percent of all births.

Public opinion, at least in Venezuela, holds that cesareans are safer and a fear of giving birth vaginally persists. But a 2005 World Health Organization report carried out in 14 countries in Africa and Latin America found the opposite was true. A higher cesarean rate was associated with an increase in infant mortality, the report said.

“These findings demonstrate that high rates of caesarean delivery do not necessarily indicate better perinatal care, and — conversely — may represent harmful practices leading to poor maternal and newborn health outcomes,” the report concluded.

But even some doctors who advocate natural birth warn about too strong a backlash against cesareans. “In reality the cesarean has saved many lives — it’s not evil,” said Dr. Rodolfo Gomez, executive director of the International MotherBaby Childbirth Organization. “But the cesarean should be reserved for those cases in which the life of the mother or the life of the baby is in danger.”

The WHO has set a cap on what it believes the healthy worldwide cesarean rate should be, establishing lower and upper limits of 5 and 15 percent.

Yet a trend toward more cesareans is difficult to reverse. But it’s a culture that some women are determined to combat. Xiomara Barreto, a social worker from Macuto, a seaside town near Caracas’ airport, persuaded the local mayor’s office to fund a center for natural birth above a state-run clinic.

The center boasts nine bedrooms, a birthing room equipped with a large bath for water births, birthing balls and twelve “facilitators” who counsel women through labor much like midwives.

Yet despite the facility's inauguration in December last year, only two women have given birth there so far because of a dispute over pay between the medical staff and the local mayor’s office.

Barreto said they were able to give the local women antenatal classes and that some were threatening to give birth on the street if the mayor did not hire staff to man the clinic. “The mayor said the doctors would not come because they preferred the pay at private clinics,” she said. “Of course they are going to go somewhere else if you don’t pay them a decent salary.”

Part of the center’s aim is to “humanize” labor, she said. Women in state hospitals are often mistreated, their demands ignored because of staff shortages and a lack of education.

In spite of staffing problems, the center had managed to give women the confidence to demand their rights when they went to give birth at the local hospitals.

“When women from here go to the hospital the doctors know,” she said. "They have realized that our pregnant women have a different attitude.”