C-section epidemic on the rise in Colombia

When Diana Jimenez was a few months pregnant, she told her gynecologist that she was very afraid of vaginal delivery. Not from contractions or anesthesia. She was terrified that what had happened to a friend a few months earlier would happen to her baby: she had died in the womb and within hours of birth without her having gone into labor. So before deciding how to give birth, Jimenez asked the doctor what the dangers of the two options were.

"He told me what risks there were in both, that the difference was that in a vaginal delivery it was going to hurt before and during, while in the cesarean section it was only going to hurt later," Jiménez explains to EL PAÍS. He wasn't afraid of pain. She just wanted to make sure her baby was okay. "The important thing is that you make the decision that gives you peace of mind," she recalls her obstetrician telling her. And so, without further ado, the cesarean section was scheduled for August 28, 2020.

Agustín was born at 38 weeks and 5 days with a respiratory problem called transient tachypnea of the newborn, and spent 10 days in an intensive care unit. This condition, Jimenez learned just hours after delivery, tends to affect more babies born by cesarean section, because fluid does not come out of the lungs as it does during a vaginal delivery.

Like Jimenez, tens of thousands of women in Colombia are undergoing non-medical C-sections. About 550,000 babies are born in the country each year, about half of whom are born by caesarean section, a number that experts say reaches "epidemic" proportions.

Latin America is the region with the highest proportion of cesarean sections in the world, and Colombia tops that list, well above the 10% to 15% recommended by the World Health Organization (WHO).

Cesarean section or vaginal delivery?

Caesarean section is a necessary surgical procedure in some cases, and increasingly safer. When medically indicated, it can save the lives of a mom and her baby, says Dr. Ana Lucia Ruiz, an obstetrician-gynecologist.

However, it is a surgery in which a cut is made in several layers of the body, from the abdomen to the uterus. Therefore, it carries risks such as infections, heavy bleeding, reactions to anesthesia and serious surgical complications, in addition to having implications in the postpartum period such as a more painful recovery.

In addition, cesarean section "somewhat limits the number of children a woman can have," says Ruiz, because multiple interventions of this type can increase the risk of complications in subsequent pregnancies. While this can also happen after multiple vaginal births, the chances are higher with surgery.

"You have to try to bring pregnancies to a vaginal delivery because there is a faster and less painful recovery; because the hospitalization time is shorter and the hospital collapse too; because women can take care of themselves and their babies almost immediately; and because finally nature made us to be able to give birth to a child, "says Dr. Ruiz.

For babies, C-sections can also bring fatal consequences. Maria Lucia Mesa, a pediatrician and professor of medicine at the Universidad de los Andes, says this type of delivery can cause the baby mild breathing difficulty to very serious problems, including death "if he is not mature enough to be born."

Ms. Mesa says that the immediate separation of a mother and her newborn after a caesarean section is not conducive to bonding and the initiation of breastfeeding, which are crucial for the well-being of both. "The first milk, colostrum, is said to be the baby's first vaccine. It is loaded with proteins and immunoglobulins that makes the baby acquire many defenses against adverse situations that can be found in the environment. If in that first hour he does not receive it, he has a disadvantage compared to those who did receive it and to his own health."

Jimenez remembers being shown Agustín when he was born, but a few seconds later he was taken away while she, in her state of confusion from the anesthesia, tried to understand what was going on around her. "That night was horrible. I cried and blamed myself. If my doctor had told me this could happen to the baby, I wouldn't have made the decision to do it by cesarean section," she says.

She says she wasn't able to live many things with her baby from day one, including skin-to-skin contact and breastfeeding. She was able to feed Agustín the day he was born, but because of his respiratory problem the baby did not tolerate feeding. "When they delivered it to me 10 days later, the milk was not enough because he had not been glued, so he had not stimulated production enough. I feel it was all because of the hospitalization," he concludes.

Perverse incentives

Catalina Alzate broke water at 10 a.m. on a Friday in August 2014. She was 31 years old and had had a healthy, uncomplicated pregnancy. She took a bath, dressed, and removed the nail polish. Two hours later she went to her gynecologist's office, who after checking her told her to have lunch and return to the clinic at four in the afternoon. At five o'clock he had dilated one centimeter. An hour and a half later, he had dilated just two. "I think we're going to end up in a cesarean section,' the doctor told me," Alzate recalls.

At about 10 p.m., the OB-GYN told her there was danger to the baby because she was going to complete 12 hours of labor. "I broke down because I had prepared and romanticized a vaginal birth for nine months." At 23.15pm, Thomas was born by caesarean section.

Nine years passed and Catherine became pregnant again. She changed gynecologists because her doctor was no longer on her insurance. Then, her new doctor explained that most women who rupture membranes can deliver 24 hours later.

"It was easier to have a C-section than to stay with me for 24 hours. If he had given me more time, I could have brought Thomas in a vaginal delivery. It would have been less violent because my son wasn't suffering, he wasn't in danger, and neither was I," Alzate explains. Her situation mirrors that of thousands of women across the country who can't help but harbor a sense of injustice for having had an unnecessary C-section.

Jimmy Castañeda, medical director of the Education department of the Colombian Federation of Obstetrics and Gynecology, says the high rates of cesarean sections are due to a problem with the structure of the health system. She says that the payment for obstetric care is too low, which results in the closure of delivery units because they are not profitable, and that the human resources to care for them are scarce. It's not uncommon to see 15 women in labor and a single gynecologist attending to her, she says. That leads many professionals to start making decisions "that could wait."

"A gynecologist who comes to a shift at seven o'clock at night to see 15 patients in labor begins to make preventive decisions of certain patients to whom he sees certain risks." He passes them to cesarean section "because he can't be very aware of them." Castañeda points out that behind the increase in cesarean sections is the growing concern of doctors about the risk of being sued without a natural birth goes wrong.

Camilo Arenas, a physician and health administration expert, says the gap between the WHO recommendation and the number of C-sections also reflects the system's economic incentives. Remember that a study by the Ministry of Health on a group of women with a lower risk of cesarean section concluded that the financial factor in health institutions is significant when choosing cesarean sections. "In situations where there is a greater discrepancy in the perception of cost between a cesarean section and other types of delivery, it is possible that the choice of cesarean section may be promoted in cases that clinically may not be necessary," he explains.

The system can pay a hospital and doctor more for a C-section than for a vaginal delivery, because the fees are tied to the complexity of the procedure, its duration and the likelihood of complications, Arenas says. Another incentive for doctors to prefer C-sections is time and comfort, quality of life. "Childbirth is at any time of the day or night; The caesarean section is scheduled," he adds.

Castañeda says that when a patient goes into labor "it is impossible for a gynecologist to sit next to her, because she must perform other activities such as consultations, surgeries or review of other patients." Therefore, although he accepts that it is not ideal, these situations lead doctors "sometimes" to make decisions that "are not adjusted to the evidence, doing more cesarean sections of the account," he acknowledges.

However, studies say that more than money or time, the factor that most encourages cesarean sections is the request of mothers to perform it. Dr. Ruiz says that some request it because of the fear of pain associated with vaginal delivery, possible complications, fears of deformation of the body and vagina or simply the desire to have greater control over the time of delivery. "There are thousands of fears that exist," says Ruiz.

The patient has the right to make a decision about the type of birth she wants to have, which was reinforced with the Humanized Childbirth Law of 2022, which makes explicit the right to request a cesarean section "in a free and informed manner." Precisely, experts agree that the mother's decision-making must be informed and her autonomy must be respected, without this exempting medical professionals from responsibility who must prioritize the safest and most appropriate method.

"If they come asking me for a cesarean section, I answer that we have the whole pregnancy to talk and I give them the reasons, to see if I can change their minds," says Dr. Ruiz. "Mind you, I can't force anyone to do something they don't want to. If after hearing all the arguments for and against all birth routes, the decision is the cesarean section, I have to respect it."

Now Alzate chose a C-section because she wants to have her tubes tied at once, even though her doctor told her that a vaginal delivery was possible after the C-section she had in her first pregnancy. "This time I chose. The problem is when they choose for you," he says.

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