Mayela Sánchez, GPJ, Mexico
Mexico

Cesarean sections are performed in Mexico at triple the rate of the international recommendation for the practice, causing experts to debate the causes of the increase and the effects on mothers, newborns and the public health care system.

MEXICO CITY, MEXICO – Miriam Escuadra, 32, gave birth to her first child via cesarean section in 2013. At the time, she wondered whether having a C-section instead of a vaginal delivery would harm her baby.

“I do not know if there is any difference psychologically – there is nothing confirmed – but, yes, doubt still remains,” she said in a phone interview after the birth. “It is said that when the babies push to get out, something in their little head is created differently than when they are born easily.”

In the final weeks of Escuadra’s pregnancy, her OB-GYN warned that she might need to have a C-section because her ultrasounds indicated the baby’s small size would complicate a vaginal delivery. But both Escuadra and her OB-GYN preferred a vaginal delivery, so the doctor suggested they first induce labor and perform a C-section only if her cervix took too long to dilate.

A delivery date was scheduled, but a fissure in Escuadra’s amniotic sac – the fluid-filled membrane in which a fetus develops – moved the delivery up by 15 days, she says. By the time she arrived at the hospital, she had lost all her amniotic fluid, endangering the life of the child. She had an emergency C-section.

A year after the birth, Escuadra, who lives in Mexico City, the capital of Mexico, reports that she believes her daughter has the most highly developed intelligence and motor skills in her nursery. She says she would opt for a C-section in a future pregnancy, even if she were not at any risk, to avoid complications or pain.

“It was a good choice,” she says. “My baby did not suffer, nor did I struggle with the pain that they say that you feel.”

The number of planned C-sections performed in Mexico’s public and private hospitals has more than doubled since 2000. Health experts attribute the surge to excessive patient loads at public hospitals, economic incentives for private practices, women’s fear of pain and complications, lack of public awareness of C-section risks, insurance policies, and insufficient education for doctors. Some warn that the surge poses health risks for mothers and babies and burdens the national health care system. As experts ask for more regulation of deliveries, national health care bodies plan to carry out a study this year that will inform future policies.

From 2007 to 2012, more than 46 percent of babies born in Mexico were delivered via C-sections, according to a 2012 National Institute of Public Health survey. More than 25 percent of deliveries were emergency C-sections, and more than 20 percent were planned C-sections.

The institute’s report on the survey calls the total “alarming,” as it is more than double the recommended limit of 20 percent set by the Official Mexican Standards, which regulate products, processes or services that could pose a risk to humans and the environment. The survey also demonstrates a nearly 55 percent increase in the rate at which C-sections have been performed since 2000, when they accounted for less than 30 percent of births.

The proportion of deliveries made by C-section in Mexico even further exceeds the World Health Organization’s recommendation.

“There is no justification for any region to have [C-section] rates higher than 10-15 percent,” the WHO states in a 2010 report.

That is the expected percentage of complicated births that need to be resolved with a C-section, which should be a last resort for a high-risk delivery, says Dr. Rufino Luna Gordilla, deputy director general of sexual and reproductive health for the National Center of Gender Equity and Reproductive Health. The center is a governing body under the Ministry of Health that monitors public programs on maternal and reproductive health.

Both public and private hospitals exceeded the recommended percentage of C-sections, according to the 2012 public health institute survey.

Nearly 70 percent of government employees who delivered at public hospitals for people with insurance through the Institute of Security and Social Services for State Workers had C-sections, according to the survey. About 45 percent of employees of private companies who delivered at public hospitals for people with insurance from the Mexican Institute of Social Security had C-sections.

Almost 40 percent of deliveries in Ministry of Health hospitals, which primarily serve people who do not have insurance, were made via C-section. In private hospitals, which mainly treat patients covered by private insurance carriers, almost 70 percent of deliveries were C-sections.

So far, no studies have shown how many of these births were performed for emergency purposes, Luna says. Although the survey distinguishes between emergency C-sections and planned C-sections, Luna sees this distinction with caution.

In public hospitals, Luna says, some doctors justify unnecessary C-sections with diagnoses such as fetal distress or cephalopelvic disproportion – cases in which a baby’s head or body is too large to fit through the mother’s pelvis. But patients’ clinical records may show no evidence to support these diagnoses.

On the other hand, not all C-sections are unnecessary, he says. Doctors must schedule risky deliveries for surgery, Luna says.

In private hospitals, obstetric services are insufficiently supervised, he says. So there is no way to determine how many C-sections are medically justified.

A study is also necessary to determine the causes of the increase in the number of C-sections in Mexico, Luna says. He believes high patient populations at public hospitals and the economic interests of private hospitals have made C-sections attractive because they reduce the amount of attention a woman needs to give birth.

At public hospitals, C-sections diminish the demand on doctors’ time, which mitigates the dearth of obstetricians, Luna says. Meanwhile, private hospitals benefit because they charge more for C-sections than for vaginal deliveries. They also find it more profitable to perform multiple C-sections in one day than to have physicians attend to vaginal deliveries that can take up to 12 hours apiece.

Katia García, a nutritionist and nutritional health researcher for the civic organization El Poder del Consumidor, which means “the power of the consumer,” says the economic benefit to doctors and hospitals is the principal driver of the high percentage of C-sections in the private sector.

“Economic interests should not be above the interests of health,” says García, whose organization defends the rights of the consumer through the study of products, services and public policy. “And the information should reach women so that they not only seek out the easier delivery, but that their decision is informed and they see the benefits for their health and their babies.”

Glenda Furszyfer is a prenatal educator, doula and the president of a nonprofit organization that promotes women’s rights called Parto Libre, which means “free childbirth.” She agrees that the patient strain on public hospitals and the economic interests of private hospitals have provoked the increase in the number of C-sections.

But Dr. Luis Assad Simon, a gynecologist and director of gynecology and obstetrics at Médica Sur Tlalpan, a private hospital in the capital, disagrees.

The difference between the costs of the procedures is not significant enough to motivate doctors to favor C-sections over vaginal deliveries, Simon says in a phone interview. At the hospital where Simon has been working for 18 years, a vaginal delivery costs 34,000 pesos ($2,625), while a C-section costs 45,000 pesos ($3,475).

The preference for C-sections has more to do with comfort, Simon says.

“It is a scheduled event,” he says.

A vaginal delivery can last many hours, depending on the case, which can end up in an emergency.

“On the other [hand], yes, we have much more controlled factors,” he says, “that that, yes, could be one of those factors, in terms of comfort, be it of the patient or of the doctor.”

Mara González, a 28-year-old mother, wanted to get a C-section while pregnant seven years ago because she wanted to avoid pain, she says. But her gynecologist planned a vaginal delivery. During labor at a private hospital, she asked her OB-GYN to give her anesthesia because she felt a lot of pain.

“She told me, ‘If I anesthetize you, it surely is going to have to be a cesarean section,’” González says, “and I was in agreement.”

The C-section was more comfortable, she says.

“I think a cesarean section is much easier than natural labor,” González says. “I think that natural birth is a little more complicated because of the whole crisis situation that occurs in that moment, and I did not know if I was prepared in order to have that event.”

Luna says women’s fear of pain during a vaginal delivery influences their decision to opt for C-sections in private hospitals.

“And the doctors consent because it is the patient who is paying,” Luna says.

Women who give birth in public hospitals, on the other hand, do not express fear of pain because they are not free to choose their type of delivery, he says. Although it is not a law, common practice is that the doctor makes that decision.

Although the doctor’s discretion prevails, doctors should explain to their patients the benefits and risks of their options and ask their opinions, says Leonor Guadalupe Neri Fabián, 22, who was interviewed in her 37th week of pregnancy.

Neri has insurance with the Mexican Institute of Social Security. Neither the doctors who attended to her at her local public clinic nor the doctor who examined her in the public hospital spoke to her about the implications of vaginal delivery and a C-section, she says.

All doctors have told her is that she will have a vaginal delivery and that they will perform a C-section only if her labor becomes complicated, Neri says.

Furszyfer, who has been teaching labor preparatory classes for almost 10 years, says C-sections have become more common because women do not have enough objective information about the risks of C-sections.

Some OB-GYNs have created a demand for C-sections among women from more fortunate socio-economic groups by arguing that the procedure is safer and poses fewer side effects, according to a report from El Poder del Consumidor.

But Simon disagrees. Doctors who work in private hospitals do inform their pregnant patients of both the benefits and risks of C-sections and vaginal delivery, he says. But despite knowing the risks, many mothers still choose C-sections because they are more comfortable.

Doctors have little influence on the delivery method a couple chooses, Simon says.

“The only decision-making power that one has of influencing that is education – to explain the risks and benefits,” he says. “And obviously, the couple will decide, but having major components in order to be able to make a decision.”

González says her gynecologist informed her during her pregnancy of the implications of C-sections and vaginal delivery.

Escuadra also says her obstetrician kept her informed her of possible risks throughout her pregnancy, including the risks of C-sections.

Private insurance companies may also be influencing the increase in the number of C-sections performed at private hospitals, Luna says. Several companies will cover the cost of a C-section – because a doctor has deemed it a necessary surgery – but not that of a vaginal delivery. Insurance companies that cover all deliveries reimburse doctors at a higher rate for C-sections than for vaginal deliveries because surgeries are more expensive.

Eduardo Salim Cabrera, director of government relations for Seguros Monterrey New York Life, an insurance company with a network of 5,690 doctors in Mexico, says all of the company’s health insurance policies cover both vaginal deliveries and C-sections.

Doctors do receive a higher payment for a C-section than for a vaginal delivery, as it is a more expensive procedure, he says. But he rejects the idea that doctors in the company’s network take advantage of this policy.

“It is not looking for the doctor to make deals,” he says in a phone interview. “What we seek is the health of our clients.”

If a doctor were to perform unnecessary C-sections, the only beneficiary would be the doctor, as it would raise the insurer’s costs, he says. To guard against that, the company has a staff member that oversees doctors in its provider network.

Simon confirms that in some cases, mothers choose to have C-sections because their insurance covers that procedure but not vaginal delivery. But he denies that there is a substantial financial incentive for doctors to push for C-sections when both are covered.

Furszyfer asserts that the increase in C-sections also stems from doctors’ lack of professionalism regarding free development delivery – a form of delivery in which a doctor does not induce labor or pressure the mother to push but rather guides her natural delivery process and intervenes only if a problem occurs. Academic programs in universities are obsolete and do not respect the right of mothers to a free development delivery, and doctors fear being sued for complications during vaginal delivery, she says.

“It is not that the doctors do not know the risks of the cesarean section, but they fear the natural birth because they have not been taught about how to assist a natural free development birth,” Furszyfer says. “We have the idea that the doctor is the one who makes things happen, and it is the reverse. The woman is the one who makes the delivery, and the doctor only would have to intervene if something entails risks. And that is what the doctors do not understand and do not tolerate.”

The increase in the rate of C-sections creates health risks for mothers and their babies and places a financial burden on the health care system, local experts say.

Anesthesia- and surgery-related complications during a C-section can cause a baby to die, Luna, García and Furszyfer agree. In addition, scar tissue from a C-section can cause the placenta to obstruct the cervix or fail to detach easily in the mother’s next pregnancy, and either complication could cause a hemorrhage. C-sections also increase the risk of uterine cancer.

Children born by C-section are also more prone to obesity, says García, who has a master’s degree in public health. The recovery time after a C-section can disrupt breastfeeding.

Luna warns of a potential link between the increase in the number of C-sections and increases in the numbers of premature births and babies who are born underweight. In addition, the high C-section rate may be indirectly related to the rate at which mothers with prior illnesses die in childbirth because they are more vulnerable to C-section complications. Luna calls for a study to investigate these topics.

The increase in C-sections means a greater economic burden on the public health care system, Luna says. A C-section requires surgical materials and an operating room. It also demands more medical personnel and triple the hospitalization time that a vaginal delivery requires. Public hospitals provide three days of in-hospital recovery time after an operation, whereas a natural birth requires only about one day for recovery.

“Unnecessary” C-sections – which accounted for 7.5 percent of the nearly 38 percent of deliveries made by C-sections in 2008 – cost Mexico an estimated $123 million that year, according to a 2010 WHO report.

If the number of C-sections performed in Mexico decreased by about 1.6 million in the next five years, the country could save more than 12 billion pesos ($927 million), according to the Federal Commission for Regulatory Improvement, the government body responsible for reviewing the country’s regulatory framework.

Experts call for more regulation to protect the health of mothers and their babies and to create a sustainable health care system.

The fact that nearly half of recent births in the country have been by C-section represents a fault in the health care system, which is the responsibility of the Ministry of Health, García says. The ministry has not implemented mechanisms for surveillance, vigilance and evaluation of births that would enable the regulation of procedures in public and private hospitals.

There is also no control over the prices that private hospitals can set for vaginal deliveries and C-sections, she says.

The private hospital where Escuadra gave birth charged her 15,000 pesos ($1,160) – the same cost as a vaginal delivery. Meanwhile, González’s C-section cost her 82,000 pesos ($6,335) in a private hospital, where a vaginal delivery costs 34,000 pesos ($2,625).

The nation needs legislation that requires the compliance of doctors and hospitals, Furszyfer says. The government-published Official Mexican Standards provide guidelines for healthy pregnancies and safe C-sections, but they do not carry the force of law.

Still, Luna urges medical professionals in all Mexican states to follow those guidelines.

“The truth is that they have not done it,” he says.

Although there are no monitoring systems for births, the Ministry of Health and the National Institute of Public Health plan to conduct a study this year to detect the causes of the rise in C-sections, Luna says. Then they will be able to propose changes to the obstetric care system.

Furszyfer says solutions also must address women’s reluctance to give birth naturally. Women have lost confidence in their instinctive capacity to give birth, preferring an option that requires the least effort, she says.

“Technology is not bad,” Furszyfer says. “We talk of making a rational use of technology, using it when the life of the mom or of the baby is in danger. For that, it is valuable. The problem is when there is an abuse in the use of the technology, as is happening in Mexico. There begin the problems.”

GPJ translated this article from Spanish.