Brazil Takes Unnatural Course in Delivery Room : Health: One-third of all births in the nation are by Cesarean. Doctors and patients like it, but critics call it an epidemic.

There are hospitals in Brazil where a normal delivery is anything but routine. Many obstetricians, particularly those in Brazil’s major cities, have such a strong preference for delivering babies by Cesarean section that their patients have a vaginal birth only by a fluke.

Brazil has the highest rate of Cesareans of any Latin American country, and probably one of the highest in the world, although precise figures are not available for all countries.

According to surveys by the World Health Organization and the Brazilian Pediatrics Assn., one-third of all births in this nation of 150 million people are by Cesarean. The World Health Organization considers a rate of up to 15% to 20% to be medically acceptable.

In some areas of the Brazilian health system, Cesarean rates are even higher. In hospitals affiliated with the public health-insurance system, the rate is double the national average--or 66%. The priciest private maternity hospitals report that 80% or more of their births are by Cesarean.

“We have a Cesarean epidemic,” said Navantino Alves Filho, a pediatrician who has campaigned to reduce the number.

The practice evolved over the past two decades because many Brazilian doctors like it, many Brazilian women agree with them, and the public-health system encourages it even for women who would prefer to have a vaginal delivery.

In the United States, a Cesarean section--withdrawing a baby from a mother’s uterus through an incision in the abdomen--is usually performed only when a pregnancy has problems: when the fetus is in a breech position with its feet down, for example, or when a difficult labor drags on to the point of posing a risk for the baby and mother. The rate in the United States is 23.8 per 100 deliveries and has been fairly level since 1986, according to a report issued in July by the National Center for Health Statistics.

In Brazil, by contrast, the Cesarean is regarded as a standard form of delivery. Many are performed on women with routine pregnancies who set a date with their doctors and give birth without ever going into labor.

“The Cesarean is the best delivery procedure for Brazil’s sociocultural environment,” says Carlos Antonio Barbosa Montenegro, director of one of the chief maternity teaching hospitals in Rio.

Brazilian hospitals ordinarily do not have regular round-the-clock staffs of residents and nurses ready to watch over a labor until the doctor arrives for the final stages.

Instead, the routine is for private doctors to bring their own teams.

“It’s often impossible to get my team together when a woman goes suddenly into labor,” says Montenegro, who also has a private practice. “The anesthesiologist has a second job, the nurse is visiting her mother out of town . . . “

In Rio especially, Montenegro notes, “it is simply impossible for me to agree to a single unscheduled delivery.” Well-to-do doctors “live in terror,” he says, because of Rio’s perennial crime wave, which recently has included a spate of kidnapings for ransom of upper-middle-class Brazilians. “I can’t go out at night safely. I can’t park my car on the street at night in front of the hospital without having it stolen,” he explains.

Convenience is a factor as well, physicians say.

A doctor “books a Cesarean for Friday morning, then calmly takes his weekend at the beach,” says Jose de Souza Costa, president of the Brazilian Federation of Obstetricians and Gynecologists. In private clinics, a doctor will order frequent sonograms to get a precise record of fetal progress, then schedule the delivery when the pregnancy has reached 39 weeks, one week before the natural term.

The government health system also encourages Cesareans by not paying for anesthetic for an ordinary vaginal delivery. A woman who is covered by the national health plan enters the hospital knowing that if she needs pain relief during labor, she must pay for it herself. Until recently, the national health system also reimbursed physicians at much higher rates for a Cesarean than for a vaginal birth.

Montenegro points out that although there is a considerable risk of infection in the mother if a Cesarean is performed during labor, the risk is negligible if the surgery is performed before labor begins.

Nevertheless, one pediatrician says, risks do exist. A baby born by Cesarean is seven times more likely to become ill, often with respiratory difficulties, in the nursery, the pediatrics association has found.

As a result of campaigns by the World Health Organization and the Brazilian Pediatrics Assn., the preference for Cesareans is slowly changing.

The Health Ministry is reviewing its policies to eliminate incentives that favor Cesareans. The obstetricians’ federation has asked the government to open schools to train nurse-midwives, who would attend the early hours of a labor or even complete deliveries in areas where no doctors are available.