The New Latin Labor

Nuevo Leon is Mexico's richest state. Picturesque mountains rise over its industrial parks, BMWs cruise its five-lane highways and automatic-teller machines offer the country's highest daily withdrawal limit. And Nuevo Leon holds another nationwide distinction: king of the cesarean section. Half of all the state's babies are born surgically. In private hospitals, the proportion is 73 percent--the highest in the country and nearly five times the international norm. Women want the operation to avoid the pains of all-night labors, and overworked doctors are happy to oblige with a half-hour insurance-paid procedure before breakfast. "I told the doctor I didn't want a natural birth. I didn't want a long labor," says Paulina Estrada, a mother of two in Monterrey, the state's capital. "In fact, I hardly know anyone who has had a natural birth."

Monterrey may be C-section central, but it is hardly the exception. Across Mexico--and much of Latin America--the number of cesareans is on the rise. In Mexico, the rate in public hospitals jumped from 23.5 percent in 1991 to 31.4 percent in 1999. In private hospitals, where two fifths of babies are born, the rate soared to 52.8 percent in 1999. Chic among the rich, the C-section is also trickling down to the middle and lower classes in Brazil, Argentina, Chile and Colombia. There are several explanations: better early detection of pregnancy complications, fear of malpractice suits for not having performed the surgery in deliveries that ended tragically, the idea among women that a C-section is somehow more civilized than a natural birth and the desire of doctors to maintain a large number of patients without the telephone's ringing at 3 every morning. "Any doctor who says he doesn't do unnecessary cesareans is lying," says Mauro Munoz, a 49-year-old Monterrey gynecologist, who delivers at least three babies a week--65 percent of them by surgery, he estimates. "And they also lie about the number they are doing."

Why do the numbers matter? The C-section is an important procedure in protecting the lives of mothers and their babies, but it also carries higher risks than a vaginal delivery: infections and hemorrhaging in mothers, and respiratory distress syndrome in babies. In 1985 the World Health Organization established 15 percent as the ideal C-section rate, and several countries, including the United States, launched campaigns to reduce the number of surgeries. (After a steady drop, the U.S. rate has risen slightly in the last two years--to about 22 percent--because doctors have grown more reluctant to allow women who have had C-sections in the past to deliver naturally.) But in Latin America, the number of elective C-sections grew steadily throughout the 1990s. A recent study in the British Medical Journal concluded that 850,000 C-sections are needlessly performed throughout the region each year. Yet the real problem is the distribution of C-sections along class lines. While urban, well-to-do women chose surgery--unworried about increasing their risk of delivery complications--many poor, rural women who need the operation don't get it. "There are still lots of women dying at childbirth because they didn't have access to C-sections," says Arachu Castro, a professor at Harvard Medical School who has studied the rates in Mexico. "That is the big irony."

At one extreme is Monterrey, a city of 1.1 million, where C-sections are scheduled like hair appointments. Like her friends, 31-year-old Estrada wanted one when she got pregnant for the first time in 1997. Her mother, who had four natural births, warned her that vaginal deliveries do damage "down there." The C-section has since become something of a tradition in Estrada's family. Last summer she had her second, and her two sisters had their first. Estrada's doctor, 45-year-old Manuel Garcia, contends that after a vaginal delivery, "the sexual satisfaction is not the same." Even so, he says he favors natural births. His hospital, San Jose, has a C-section rate of 77 percent, but Garcia says he has found a way to keep his surgery rate under 35 percent and still deliver 15 babies a month. Heinduces labor in nearly all of his patients who want natur-al births, two each Wednesday and Saturday. "If I have 20 patients who need babies delivered and I'm trying to schedule office visits, I have to be honest with myself."

Viviane Brunet, a Monterrey gynecologist, used to turn away patients who insisted on having C-sections. But 10 years ago, after losing too much business (and having a C-section herself), she changed her mind. "I don't lose patients anymore," says Brunet, 45. "I either convince them or they convince me." As long as her patients know the risks, she sees no ethics problem with serving their desire. She sees such demands as an aspect of Monterrey culture. "In countries of the former Soviet Union, something like 96 percent of births are natural. It's cultural. The people are used to tolerating pain. Here they are not." Another advantage: some expectant mothers in Monterrey print their birth announcements--with the date--before their C-sections.

There are exceptions. In the prenatal world of Monterrey, the city rebels are a pair of 48-year-old Lamaze teachers. Paulina Gonzalez and Elizabeth Cholow, known throughout town as Poly and Eli, prefer to call themselves "birth educators." Ten years ago they opened their center and started preaching the merits of giving birth without anesthesia. At any given time, about 100 couples are enrolled in their $250 course. At a recent introductory session, middle-class wives and husbands gathered around while Poly explained how she delivered all four of her children without anesthesia. Eli was 2-for-2 when her third pregnancy proved difficult and ended with a successful C-section. A slide show alternated shots of births, blooming flowers and smiling families. "We have gained a lot in the workplace over the years," Eli told the class. "But we have lost part of our femininity. Generations before us knew how to give birth. We can be presidents and professionals and drive trucks and fly planes, but we have a lot of problems getting pregnant and having babies."

In most other countries, Lamaze courses are not controversial. Several Monterrey doctors, however, accuse Eli and Poly of planting dangerous ideas in the heads of their patients. "The gynecologists of Monterrey don't like them very much," says Dr. Munoz. "They fall into the extreme. If a patient has a complication during delivery and trusts them more than me, we have a problem." That doesn't happen often. Only about 10 percent of the women who've completed Poly and Eli's class wind up giving birth without anesthesia. Dr. Garcia said one patient made him swear not to tell any of her classmates that she had cried during labor and gave in to surgery.

Lupita Naredo didn't need persuading after she and her husband attended a Lamaze class in 1999. "I came out crying," she recalls. "They showed a video made in Sweden or Switzerland of a women having a baby without anesthesia, in her own house I think. My husband was shocked, too. I couldn't believe my body was capable of doing that." Leaving class, her husband told her: "Don't worry, you'll have a cesarean." The doctor agreed to schedule it for a Saturday, which suited her husband's work schedule, and Valeria was born last March without complications. Most of her friends, she says, use a litany of excuses--"I was retaining water," "the baby was too big," "I was having trouble breathing"--to hide their preference for C-sections. "I can admit it," says Naredo, 26. "I don't like pain."

Should doctors be performing C-sections on women who simply want to avoid pain? A decade ago, insurance companies in Mexico reimbursed women for their C-sections because it was considered an emergency procedure but wouldn't cover natural births. Women had a choice of having the surgery free or shelling out about $1,000 to endure labor. The insurance companies eventually wised up. Now they cover both procedures with the same fee to doctors. The number of surgeries, however, continues to rise. Government officials say the next step would be for insurance companies to determine whether each C-section was necessary, but insurers are reluctant to meddle in the medical decisions of doctors. The Mexican government has started studying the rising numbers and eventually plans to invoke stricter guidelines in public hospitals to bring them down. But the task will prove more difficult at private hospitals, where doctors make most of their money and where patients are more demanding. "My maid has natural births," says Dr. Brunet, "but Mrs. X of the upper class doesn't."