San José, Costa Rica, since 1956

Caesareans All the Rage

Andrea Naranjo arrived at the public CaritHospital in san José intending to get a Caesarean section to avoid the pain of giving birth to her first child.

But doctors talked her out of it.

“I’m happy with my decision,” said the 23-year-old mother. “At first, i just wanted to avoid the pain. But this way, you feel a much stronger bond with your baby because you’re not asleep during the whole thing.”

Naranjo is one of many soon-to-be mothers whom public hospital doctors here try to talk out of getting the surgical procedure — the delivery of a baby by cutting the abdominal and uterine walls — when not a medical necessity.

But C-sections have reached high levels in private clinics. in Clinica Bíblica, for example, doctors performed 910 — 79 percent of the hospital’s 1,140 births in 2007. That is a dramatic increase from 1993, when C-sections at Bíblica were 55 percent (TT, Nov. 25, 1994).

That number of C-sections in the Social Security System, or Caja, hospitals has hovered at 22 percent since 2001.

Both statistics are well above the international standards of 10 to 15 percent recommended by the World Health Organization decades ago to keep C-sections, a surgery with inherent risks, under control.

“A vaginal birth is always better,” said Dr. Jorge Barboza, the head of prenatal gynecology at the CalderónGuardiaHospital in San José. “It’s regrettable that (women) come in with these ideas stuck in their heads.”

Caja doctors, who often work in both the public and private sector, say the difference in C-section rates between the Caja and private clinic statistics are the rules they play by.

In Caja hospitals, doctors are not allowed to schedule C-sections without a compelling medical reason. They have a policy of advising mothers not to have the surgery done absent compelling medical reasons. And they have no economic incentive in recommending them.

“C-sections are not an elective surgery,” Barboza said. “They are being abused. (In most cases), it’s a decision to be made after labor starts and they should not be scheduled in advance. In cases where C-sections are not a medical necessity, women who undergo them are four times more likely to suffer from surgical complications, such as hemorrhaging, infections, intestinal or bladder complications, a bad reaction to the anesthesia and respiratory problems in the offspring.”

The private clinics do not have similar rules governing the use of C-sections, according to Carlos Pericón, CaritaHospital head of obstetrics, who said he works in both the public and private sector. Many private doctors, he said, in contrast to Caja doctors, consistently advise women to get them because they are faster and doctors have to spend less time with their patients.

According to Pericón, a C-section can be completed within 30 to 45 minutes, while a natural labor and delivery can take 24 hours or more.

“The problem is many private doctors advise women to get C-sections,” he said. “A vaginal birth is much more laborious, and it demands more work for both the woman and the doctor.”

Dr. Maria Solano, head of the maternity ward at Clínica Bíblica, said she is not a fan of the upward trend in C-sections, but the bottom line is it’s up to the mothers.

“In private clinics, the clients have complete freedom to get whatever surgeries they want, and most women who ask for C-sections do so because they want to avoid the pain of childbirth,” she said.

Barboza and Pericón said the C-section phenomenon should be blamed on both the clients, for demanding a pain-free birth, and the doctors, because of their economic interests. At Clínica Bíblica, a vaginal birth costs about ¢510,000 (about $950) and a C-section costs ¢735,000 (about $1,361), but that figure does not include doctor’s fees, which each doctor charges differently.

Barboza said most doctors will charge about ¢1.5 million (about $2,777) for a C-section.

“Now, there is a lot of technology that is of great help, but we need to manage it carefully and not abuse it,” Barboza said. “Many (women) come in and say, ‘I want a C-section,’ and I say ‘No,’ but sometimes they go looking for other doctors who will say yes until they find one. And as far as doctors go, unfortunately there are those who don’t want to make their lives complicated. They want to get in and out and be back at home instead of working through a potentially long labor.”

Pericón likened the burgeoning C-section numbers to a fashion trend buttressed by private doctor’s economic interests.

“C-sections are a fashion, a fad, a craze,” he said. “People hear it on the street from their friends, family members: ‘Go get a C-section.’ Giving birth means pain, suffering, and that’s something many women are no longer willing to endure. And, of course, one of the obvious reasons for the trend is because of doctors’ economic factors.”

It is a fad that appears to have stood the test of time, however. The trend first started in 1960s and has only increased over the decades.

The C-section versus vaginal birth debate has consumed the birthing industry here.

The doctors on each side even have names. Those who favor vaginal birth are called vaginalistas. Those who favor C-sections are called caesaristas. There is a fair amount of enmity between the two sides.

C-sections have been on the rise worldwide for decades, although far below the rates seen in Costa Rica, in countries such as China, Brazil, the Dominican Republic and Portugal lead the world in C-sections, with percentages in the 30s and 40s. The United States, by comparison, has a 23 percent Csection rate, according to WHO.

Despite the potential health complications from a C-section, Barboza said that advances in surgical technology have reduced complications to about 5 percent.

Officials at the Panamerican Health Organization in San José, a branch office of the WHO, declined to comment on this story, saying they had no statistics on C-section trends.

The private CIMAHospital declined to provide its C-section and birth statistics.

Choose Carefully

These are among the legitimate medical reasons to get a C-section, according to Caja doctors:

• Oversize baby.

• Premature baby whose skull and brain could be damaged by exiting normally.

• Significant heart rate decreases in baby.

• Mother is diabetic.

• Tearing of the uterus.

• Placenta comes out before baby.

• Baby in breech position.

• Severe high blood pressure in the mother.

• Seizures of the mother during labor.


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