Maternal Health in Brazil and The Myth of Choice - Guest Post by Juliana Britto

I am thrilled to share this cross-posting by fellow blogger and feminist, Juliana Britto Schwartz. She writes about all things important to women, including reproductive health, feminism, immigration, and race, on her blog as well as on Feministing.com. She has been gracious to provide a cross-post on Feminist Midwife about birth in Brazil. A quick bio about Juliana:By day, Juliana is a student at University of California, Santa Cruz, finishing up her Latin American & Latin@ Studies major. By night, she is a Latina feminist blogger at Julianabritto.com, where she writes about reproductive health justice, immigration, and feminist movements as they pertain to Latinas in Latin America and the U.S. She pulls on her own experience being half Brazilian, half white American to inform her feminism, working to bring the needs and opinions of Latinas to the feminist blogosphere. Follow her on Twitter @JulianaBrittoS....Maternal Health in Brazil and The Myth of Choice - Juliana Britto

 

Lately, there has been a lot of talk on the feminist blogosphere about the “myth of choice,” partially inspired by Planned Parenthood’s decision last January to move away from the label “pro-choice.” Bloggers like Maegan Ortiz over at VivirLatino, have pointed out that a woman’s right to choose with regards to reproductive health is totally shaped by her experience in this world. Some women suffer from many barriers to even have an opportunity to access that “choice.” In other words, what kind of choice do you have if you are pregnant, can’t afford to keep the baby, can’t afford to pay for an abortion for the trip to the nearest out-of-state clinic and do not speak the language needed to communicate your health needs to a provider?In light of these important conversations, I wanted to consider how this situation plays out similarly for Latinas in other parts of the Americas, namely, Brazil. In Brazil, as in the U.S., the concept of “choice” is used a lot when talking about women’s right to abortion, but what is rarely discussed is women’s right to safe, quality maternal health services. This is particularly true in Brazil, where we have both private and public health care, two systems that vary drastically in quality and availability. This, along with differences in care between rural and urban hospitals has a huge effect on the services that poor women are able to access (or opt out of). In particular, I find that the politics of Cesarean sections (c-sections) can teach us a lot about maternal health care in Brazil.Brazil has one of the highest c-section rates in the world, with 30% of patients in public hospitals and 70% of patients in private hospitals undergoing them (Béhague 473). Just to give you some perspective, the World Health Organization estimates that the rate of medically necessary c-sections in any given population never reaches higher than 15% (Béhague 473). Rates higher than that generally indicate overusage of the procedure. Therefore, many women in Brazil are undergoing c-sections when they actually may not need them, whereas many women who do need them are not receiving them. In her study, Béhague also noted that with a decrease in income comes a decrease in Cesarean sections, suggesting that income is a barrier to accessing crucial medical technology (474 Béhague).Some argue that the high rate of c-sections in Brazil is due to a culture that promotes the procedure. More and more women are scheduling C-sections in advance, in an effort to avoid the pain or physical changes associated with vaginal birth, and Brazilians doctors have gained attention for pressuring women into medically unnecessary C-sections (Béhague 476). Both of these situations are common–scheduling and being pressured to have a c-section–but Béhague’s research in Pelotas, Brazil also uncovered a different phenomenon: poor women seeking out medically unnecessary C-sections as a way to take control of their own birth experience. These women were responding to their situation as mostly poor women of color in public hospital settings, where they are often treated with little respect (or even suffer abuse at the hands of their doctors), receive minimal attention, and are rarely fully informed of what is happening to their bodies. In public hospitals in Brazil, women still cannot have a partner or companion with them in the delivery room, and instead are forced to go through labor with minimal attendance by medical staff. For them, getting a c-section can mean increased care and attention in an otherwise hostile care setting.That being said, while living in a small rural town in Brazil, most of the women I spoke with were well aware of the recovery time associated with c-sections. In each interview I did, the woman told me that if she could choose, she would prefer to have a vaginal birth. Yet most of them had already had c-sections. It was easy to sense the powerlessness that these women felt as they talked about the disconnect between what they wanted, and the care they actually received. Ironically, most efforts to educate women on the benefits of vaginal birth are targeted at low-income women, even when their choice in the matter is relatively limited.My friend’s story is a prime example: She went into the doctor before her due date for a check-up and was told that she needed to have a c-section in spite of the fact that she was not in labor, and the baby was not in distress. Afraid for her baby, and powerless to challenge what the doctor told her, she had the procedure. Her situation is not uncommon: Brazilian doctors rarely speak of women as active participants in their birth experiences, instead painting them as weak, and often unable to handle the pain of vaginal birth.Along with the choice to have a baby in a safe medical environment, Brazilian women still grapple with the choice to terminate an unwanted pregnancy. Abortion is illegal in Brazil except in cases of rape or risk to the mother’s life, and under any other circumstances, the procedure is punishable by 1-10 years in prison (CFEMEA report). Of course, this doesn’t mean that abortions do not happen in Brazil; in fact 1 in 5 Brazilian women will have an abortion in her lifetime. But it does mean that access to abortion is strictly shaped by class and geography: most of these clinics are located in big cities, far away from the rural area I was living in. The lower a woman’s income, the poorer quality abortion she may receive (or induce on herself). This is why black women are much more likely to die of abortion-related complications than white women, and why the state I was living in, Bahia (which has the largest population of Afro-Brazilians in the country), lists abortion as its primary cause of maternal mortality. In 2008 alone, “there were 215,000 hospitalizations in [public hospitals] for complications of abortion” (Diniz et al 97). Those women that do suffer from post-abortion complications often seek out medical care in public hospitals, where they may suffer from abuse and poor treatment at the hands of care workers who disapprove of their “choice.”To give an example of what “choice” can look like for some women in Brazil, I looked at the experience of women living in Itacaré, the town in the North of Brazil where I lived for three months (see interviews at the end of the post). Up until recently, Itacaré was a very small beach town, five hours from the nearest city, Ilhéus. It wasn’t until 1998 that a road was built cutting that drive into 1.5 hours and opening the town up to a huge flood of tourism. Itacaré is still relatively small and has limited institutional resources: there is a hospital with a maternity ward, but it is not equipped to perform c-sections. Those pregnant women who can will almost always travel outside of Itacaré to have their baby, not wanting to risk needing an emergency c-section and not having it available. This of course costs money to travel there and stay multiple days, waiting to give birth. It also means that there is an added pressure for the baby to come quickly, motivating mothers to ask for or accept c-sections instead of waiting for vaginal birth. Many of these women work full time, and undergoing a c-section can put them out of commission for months, leaving them unable to even care for themselves and their new baby for a few weeks. Other women cannot afford the travel, and simply stay in Itacaré, where they don’t have access to a potentially life-saving medical procedure.This is not a “choice.” For many women in Brazil, safe abortions or birthing services are simply not available. Where is the choice in being pressured into an invasive surgery you don’t need? Or suffering from birth complications without a c-section to save your or your baby’s life? What “choice” includes unsafe, back alley abortions to end a pregnancy that you can’t afford?And Brazil is not the only place this is happening. We see versions of this in the U.S. each day, with barriers like language, documentation status, or money preventing Latinas from making well-informed and safe choices for their reproductive health. We see it all around Latin America, with restrictive abortion laws, poor medical systems and inadequate cultural fluency all contributing to huge disparities in maternal health care.It’s time that we move away from the rhetoric of “choice.” Here in the U.S., we’ve learned that Roe v. Wade did not actually do enough. Although we may have the legal right to abortion and other maternal health care, that right is being chipped away at every day through the passage of state laws which protect the fetus as a human being and the elimination of critical federal funds to organizations like Planned Parenthood. These changes impact all women, but are particularly devastating for poor migrant women of color.Can you still be pro-choice? Yes! Be pro-choice in the legal sense, but also acknowledge what that means. Start escorting at your local abortion clinic. Become a doula, learn Spanish and be a support for women in their birth process. Donate to your local abortion fund, campaign against restrictive laws like the one in North Dakota. Stand up for a broader understanding of reproductive “choice” for all Latinas – from the right to quality, affordable and accessible health care to the right to make the best decision for one’s body detached from politics.To learn more about Brazilian women's experience with maternal health care, take a look at some of the interviews I conducted in Itacaré.Works CitedBéhague, Dominque P. "Beyond the Simple Economics of Cesarean Section Birthing: Women's Resistance to Social Inequality." Culture, Medicine and Psychiatry 26 (2002): 473-507. Print.Diniz, Simone G., Ana Flavia Pires, Lucas D'Oliveira, and Sonia Lansky. "Equity and Women’s Health Services for Contraception, Abortion and Childbirth in Brazil." Reproductive Health Matters 94.101 (2012): n. pag. Print.Downie, Andrew. "Abortions in Brazil, Though Illegal, Are Common." Time Magazine World. Time Magazine, 2 June 2010. Web. 21 Mar. 2013 <http://buff.ly/ZLDjlb>.McCallum, Cecilia. "Explaining Caesarean Section in Salvador Da Bahia, Brazil." Foundation for the Sociology of Health and Illness (2005): n. pag. Print.