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RIO DE JANEIRO, Jun 22 2009 (IPS) - The recent closure of a birth centre, which offered a more “human” touch with its focus on natural childbirth, in this Brazilian city revived the controversy over such practices, which have the backing of the Health Ministry but are opposed by the medical associations.
The “David Capistrano Filho” birth centre, in the bustling working-class neighbourhood of Realengo on the west side of Rio de Janeiro, was closed early this month after a health inspection reported that it lacked equipment considered necessary for attending childbirth, such as a fetal heart monitor, and that sterilisation was inadequate.
The birth centre, which opened in 2004 under the Rio de Janeiro municipal Health Secretariat, was staffed by 18 obstetric nurses “with extensive experience” – according to a statement issued by the institution – eight nursing assistants, two social workers and a nutritionist.
Birth centres attempt to provide a more home-like environment during childbirth, along with specialised “integral” care for the expectant mother throughout the pregnancy and the birth.
The idea is to “put the social dimension back into childbirth” so it is “more than just a medical event,” says Amigas do Parto (Friends of Childbirth).
The São Paulo-based NGO says birth centres offer an alternative to typical hospital births, which “imply a series of traumatic procedures,” like separation from the family, restrictions on food and drink, the routine IV drip, being strapped into an uncomfortable bed, induced births, episiotomies or unnecessary cesareans.
For five years, an average of 25 to 30 women a month gave birth in the “David Capistrano Filho” birth centre, which also provided 820 prenatal checkups a month and set up 116 educational groups for expectant mothers.
“Pregnancy is not a disease”
“Nurses are opposed to pregnancy being considered a disease,” says a communiqué issued by the Regional Nursing Council and the Federal Nursing Council during recent national demonstrations demanding the reopening of the respected Rio de Janeiro birth centre.
The nursing councils complain that this concept has prevailed in hospital births over the last half century.
Based on the idea of natural childbirth, women in birth centres are free to eat and drink what they want, walk around, take a bath, get a massage, and give birth in any position they choose: lying down, squatting or in a tub of warm water.
In addition, they have the possibility of having a loved one by their side at all times, says the web site of the Integral Health Practices Research Laboratory (LAPPIS).
Birth centres began to operate in the 1970s in Brazil, following the example of countries like Japan, the Netherlands and the United States, and sticking to World Health Organisation (WHO) guidelines. Besides the one that was closed in Rio de Janeiro – a city that was a pioneer in this area – birth centres operate in São Paulo, Belo Horizonte, Recife, Juiz de Fora and the capital, Brasilia.
But birth centres have been a focus of controversy from the start, even after the Health Ministry created a legal framework for them in 1999, with the aim of bringing down Brazil’s soaring c-section rates.
The main objection raised by medical associations like the Brazilian Federation of Associations of Gynecology and Obstetrics (FEBRASGO) is that the birth centres are run by nurses and midwives, which poses a risk of maternal-child deaths in case of complications.
FEBRASGO said in a statement that “the insistent and frequent attempts to remove childbirth from the sphere of the obstetrician/gynecologist, the health professional with the greatest knowledge and skill in the process of assisting childbirth” is “unacceptable” and “reckless,” from the point of view of maternal-infant health.
In response, nursing associations argue that the birth centres only accept healthy women with low-risk pregnancies.
They also say an ambulance is available 24/7 in case a patient has to be transferred to the nearest hospital because of complications, for an emergency c-section for example.
But Luis Fernando Moraes, president of the Rio de Janeiro Regional Medical Council (CREMERJ) refutes these arguments. In an interview with IPS, he said this is not about generating a fight between doctors and nurses, but about “fighting for safe childbirth.”
Citing statistics according to which some kind of complication arises in up to 20 percent of pregnancies, Moraes said any problem that comes up in childbirth requires “absolutely immediate intervention,” in which five minutes can mark the difference between life and death of the mother or fetus, or between a healthy baby and an infant with future health problems caused, for example, by a lack of oxygen during birth.
With respect to the supposed proximity of birth centres to maternity wards, he said that in an area of heavy traffic like Realengo, where the “David Capistrano Filho” centre is located, it can take an ambulance more than 20 minutes to reach the hospital.
He specifically referred to two cases in which babies died at the centre, in 2005 and 2008. But the nursing councils say that gives a neonatal mortality rate of just 1.1 per 1,000 live births – out of a total 1,350 births in five years at the centre – while the maternal mortality rate was zero.
Natural birth vs c-section
One of the representatives of the Federal Nursing Council (COFEN), Ivo Borges, said the closure of the Rio de Janeiro birth centre was an “arbitrary” action, taking into account the fact that the law authorises specialised nurses to assist births without complications.
Borges pointed out to IPS that “many of our ancestors were born at home, in natural childbirth.”
He said opposition to birth centres was based on “corporate interests” that defend a system characterised by a high rate of c-sections and costly instruments and medicines required in surgery.
“C-sections are the rule” in Brazil, in both public and private hospitals, said Borges. In fact, this country has one of the highest cesarean rates in the world.
Borges said 36 percent of all births are by c-section, compared to WHO recommendations of 10 to 15 percent.
But in private hospitals and clinics, the rate often soars to 80 or 90 percent.
The government’s support for birth centres has been largely focused on bringing down the rate of c-sections, which as major abdominal surgery pose a greater health risk to the mother.
Medical risks to the mother include infections, blood transfusions, hemorrhage, injured organs and anesthesia complications, and maternal mortality two to four times higher than the rate for vaginal births.
COFEN also mentioned the importance of the role played by birth centres in promoting natural childbirth.
The nursing association cited a study by the governmental Oswaldo Cruz Foundation, which found that 88 percent of the women who were treated in the Rio de Janeiro birth centre received information about the advantages of natural childbirth, compared to just 36 percent of expectant mothers in hospitals.
In addition, 72 percent of the women assisted by the birth centre were given information on the importance of breastfeeding, against 40 percent of women in hospitals.
Besides “humanising” childbirth, said Borges, birth centres help cut avoidable childbirth costs for the Brazilian National Public Health System (Sistema Único de Saúde – SUS), where a c-section costs the government 250 dollars.
But Moraes denied that medical associations like CREMERJ are opposed to the birth centres because of a hidden interest in earning higher fees for a cesarean.
In fact, he said that contrary to popular belief, doctors earn more for a normal birth than a c-section in the public hospitals, and they earn the same for either procedure in private hospitals and clinics.
Brazil’s high c-section rate is due to other factors, said the head of CREMERJ, like the convenience of being able to schedule the birth.
Others mention factors like a lack of the necessary equipment to indicate fetal distress in some public hospitals; old practices that have since been corrected, such as higher rates of government reimbursement to hospitals for c-sections than normal deliveries or the failure to reimburse hospitals for anesthesia in the case of normal births; and above all, the widespread notion that by undergoing a cesarean, a woman can avoid the pain of childbirth.
Moraes acknowledged that birth centres play an important social role in remote rural areas located far from public health clinics, where “the best available option is a trained midwife.”
But he said they are not “a solution in a big city like Rio de Janeiro.”
He maintained that the government’s support for the birth centres is an “ideological question,” and said that to improve health care, what is needed instead is a larger number of maternity ward beds in public hospitals that cater to low-income sectors.
“We must not go back to the times of our grandmothers and great-grandmothers, who gave birth assisted by midwives, and whose deliveries often led to tragedy when complications arose,” he insisted.
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