Rio de Janeiro (AFP) - New regulations aimed at rolling back Brazil's obsession with Cesarean sections took effect Monday, with the government hoping it can steer the country from its status as a world leader in C-section births. 
 
 The rules and a campaign called "Childbirth is normal!" address what Health Minister Arthur Chioro has dubbed an "epidemic" of Cesareans, currently accounting for more than half of births in this nation of 200 million. 
 
 About 84 percent of Brazilian mothers on private health care undergo the operation, in which the baby is delivered through a small incision in the mother's abdomen -- often for no other reason than the convenience of being able to choose the date. 
 
 In public hospitals, that figure is approximately 40 percent. 
 
 This still tops the 32 percent rate in the United States and is massively higher than World Health Organisation recommendations of 10 to 15 percent. 
 
 Brazil's new rules require doctors and hospitals to share information with patients, notably the number of Cesareans they have already carried out. 
 
 When they fail to give requested information, the health insurance companies face fines of up to about $8,000. 
 
 Making patients better informed will help diminish the rush for C-sections, health officials say. 
 
 "Childbirth is one of the most important moments in the life of a woman and her family," said Jose Carlos de Souza Abrahao, director of ANS, a specialized health ministry agency. 
 
 "By informing her of the risks that could come with an unnecessary surgical procedure, she will be more sure in her decision regarding the delivery, choosing what's best for her health and for her baby's health." 
 
 - Mothers mean money - 
 
 Mass Cesareans are Brazil's "international shame," pediatrician Luciana Herrero told AFP. 
 
 Ignorance and desire for convenience drive Brazilian mothers-to-be to the operating table, said the author of the just published book "Diario de Bordo do Parto," or "Guide to Childbirth." 
 
 But Herrero echoed many in Brazil, saying that "encouragement" by doctors and hospitals is also to blame. 
 
 Even when fees for a Cesarean and normal birth don't vary, the surgical option is still more profitable for hospitals because it can be scheduled to the minute and has little of the unpredictability -- and possibly long working hours -- of natural labor. 
 
 Rosana Clein, a 37-year-old marketing manager in Rio, wanted to have her son naturally three months ago. At the last minute, due to pain, she had Tom delivered by Cesarean. 
 
 Even well before, though, when she was insisting on keeping things natural, she felt pressured. 
 
 "I tried to find a doctor who was supposed to do a natural birth like this, but in Brazil it's not so easy. They try to convince you the best way is to do a Cesarean. They say you're going to have a lot of pain the natural way," she told AFP. 
 
 "For the doctor, it's really easier to have the Cesarean. You can book it and you have your agenda. It's not a question of saying, 'Go to the hospital now in the middle of the night.'" 
 
 - Changing the culture - 
 
 Cesareans may be convenient but they can also be dangerous for the mother and potentially pose grave future health consequences for the baby, ranging from an increased risk of obesity to chronic illness. 
 
 Herrero applauded government attempts to make women better informed. 
 
 "Knowledge is power," she said. 
 
 "Seven out of 10 Brazilian women begin their pregnancy intending to have a normal delivery, but barely half of them do so. 
 
 "I wonder how many of these women changed their mind during their pregnancy, how many had a real medical reason justifying surgery, and how many were persuaded unnecessarily to have the Cesarean?" 
 
 But the latest government effort is still insufficient. 
 
 "I believe the solution must include other sectors of society and be discussed openly with all involved... so that together we can put births in Brazil onto a new path," said Herrero. 
 
 Clein said that after speaking with many other expectant and new mothers over the last year, she feels change is already happening. 
 
 "There are a lot of women trying now to have the natural way. They're talking a lot about it, that it's good for the baby, just in the same way that they say breastfeeding is good for the baby." ||||| C-Sections Deliver Cachet For Wealthy Brazilian Women 
 
 Enlarge this image toggle caption Felipe Dana/AP Felipe Dana/AP 
 
 The office is immaculate, as you would expect in an upscale neighborhood in Sao Paulo — all sterile, white, modish plastic furniture and green plants. Behind the reception desk are pictures that would look more appropriate in a pop art gallery than a private maternity clinic. 
 
 The list of services at the clinic in Brazil's largest city is long: fertility treatments, specialized gynecology and, of course, obstetrics. But one thing they rarely do here is preside over a vaginal delivery. 
 
 Dr. Alexandre Sasaoka struggles to remember the last time he assisted at one. We do them, he says, but rarely. 
 
 Enlarge this image toggle caption Felipe Dana/AP Felipe Dana/AP 
 
 And he's not alone. 
 
 Brazil has one of the world's highest rates of cesarean deliveries: Some 80 to 90 percent of women in private hospitals in the country give birth via cesarean section. In some hospitals that number climbs to 99 percent. 
 
 Much Higher Than The U.S. 
 
 That contrasts with 30 percent of women in the United States and 1 in 4 women in Britain. 
 
 And even that is high: The World Health Organization says more than 15 percent of women giving birth by C-section is too many. It cites increased medical costs and neonatal complications as potential problems. 
 
 But Brazil's economic boom of the past decade has dragged some 40 million people into the middle class. The emphasis on status begins at birth — and cesarean deliveries are the Louis Vuitton of the maternity world. 
 
 Women in Brazil want C-sections, says Sasaoka. They like them because they prefer being able to schedule their delivery and better organize their busy lives. 
 
 Sasaoka says he also recommends them. 
 
 He says he doesn't think they are necessarily better, but that a woman needs to consider more than just the medical aspect of birth, such as the impact on her and her family. 
 
 Of course, he says, there are many advantages to a natural birth; C-sections are a major surgery, after all. But he says women ask for C-sections, and they also allow doctors to be better organized. 
 
 For example, he says, doctors don't have to interrupt what they are doing with other patients to assist a natural birth. 
 
 Pressure From Doctors 
 
 
 
 There is a debate in Brazil as to why the rate here is so high. Doctors like Sasaoka say it's due to the demand. 
 
 But new mother Mariana — who doesn't want her last name used for fear of offending her doctor — says often women feel bullied into it. 
 
 She says she wanted to have a vaginal delivery. 
 
 "My doctor said to me he'd have more control in a C-section than in a natural birth," she says. 
 
 He also told her he would also almost certainly have to do an episiotomy — a procedure where the vaginal opening gets cut to allow for delivery. She was terrified. She says her doctor kept telling her that C-sections were better, and that she felt pressure to have one. 
 
 Still, Mariana decided to try to give birth naturally. Then two weeks before her due date, her blood pressure spiked. And her doctor said she needed to have a C-section after all. The next day she was in the operating room. 
 
 To this day she wonders if it was really necessary. She says that's the legacy of all the intervention here. 
 
 "I don't know. I think he was right," she says. "But the problem in Brazil is we lack the trust between doctor and patient." 
 
 Brazil has a two-tiered medical system. The C-section rate in public hospitals is much lower, the result of a government push to reduce medical costs associated with C-sections. 
 
 But in private hospitals, cesarean deliveries are seen as status symbols. 
 
 And that, say natural childbirth advocates, has to change. 
 
 While doulas — or birth coaches — are a regular presence in many maternity wards these days in the U.S., they are still uncommon in Brazil. 
 
 But they are the first port of call for couples looking to have a natural birth. 
 
 Doula Mariana de Mesquita talks to a couple who say they are having trouble finding a doctor who is willing to deliver their baby vaginally. 
 
 She says her profession basically disappeared with the rise of C-sections. And she says one of the most important roles she has these days is education. 
 
 "Most women don't even know how long labor can last, the basics," de Mesquita says. "So I teach them what a normal birth is like, what they can expect." 
 
 Sign Of Liberation Or Submissiveness? 
 
 Brazil essentially copied the North American obstetric model, which is very interventionist, she says. 
 
 De Mesquita adds that doctors do get paid more for C-sections, which is another reason for their prevalence. 
 
 But she also blames women here. 
 
 She says Brazilian women aren't afraid of surgery. There is a lot of plastic surgery, for example. 
 
 "Women put themselves at risk for very little," de Mesquita says. 
 
 She says people in Brazil see C-sections as a sign of women's liberation, but she sees them as "a sign of their submissiveness to a violent medical system." 
 
 That's nonsense, says 29-year-old Pamela Bassy. She works at a store in an upscale mall, and she's expecting a son in a few months. 
 
 With a cesarean, she says, she can take full advantage of her maternity leave, working right up to the day before she gives birth. 
 
 "My family and my husband wanted me to have a vaginal birth," she adds. "But in the end, it's my choice." ||||| The hospital has threatened to perform cesarean surgery on Jennifer Goodall "with or without [her] consent." (Hospital via Shutterstock) 
 
 In an action that appears to be increasingly commonplace, a Florida hospital has threatened to force a pregnant patient to undergo cesarean surgery against her will, or to report her to child welfare authorities for attempting to exercise her right to make the medical decisions she deems best for herself and her family. 
 
 Jennifer Goodall of Coral Gables was informed in a July 10 letter from the chief financial officer of Bayfront Health Port Charlotte that because she decided to attempt vaginal delivery before agreeing to cesarean surgery in her fourth pregnancy, her prenatal care providers intended to report her to the Department of Children and Family Services, seek a court order to perform surgery, and perform cesarean surgery on her “with or without [her] consent” if she came to the hospital. 
 
 A complaint on behalf of Goodall was filed in federal court last week by National Advocates for Pregnant Women (NAPW) and Florida attorney Patricia E. Kahn, seeking a temporary restraining order to prevent the hospital from carrying out its threats. Federal District Judge John E. Steele denied the request, stating in part that Goodall has no “right to compel a physician or medical facility to perform a medical procedure in the manner she wishes against their best medical judgment.” 
 
 Goodall is now 41 weeks pregnant and has told her lawyers she is terrified to enter a hospital. Given this and the weight of medical evidence in Goodall’s favor regarding the safety of the delivery she wanted to have, it is unclear whether the hospital or the courts are considering “best medical judgment” and in whose interest they are acting. 
 
 Goodall delivered her three other children via c-section and now desires to undergo what is commonly known as vaginal birth after cesarean (VBAC). In decades past, VBAC was a common choice for women who had previously had c-sections, rising from roughly 5 percent of all deliveries after a cesarean in 1985 to roughly 28 percent by 1996. The rate of VBAC deliveries started to fall in the late ’90s, according to the American Congress of Obstetricians and Gynecologists, reaching 8.5 percent in 2006 due in part to “restrictions that some hospitals and insurers placed” on the procedure. In tandem with what some have noted as pressure on women to undergo cesareans, the rate of cesarean delivery overall in the United States simultaneously increased dramatically over the past four decades, from 5 percent to over 31 percent in 2007. 
 
 Medical and public health bodies have long criticized the high rate of cesarean sections in the United States. The World Health Organization points out that at the current rate of 30 percent of all deliveries, cesarean sections in the United States far exceed what should normally be between 5 to 10 percent of all deliveries. ACOG agrees. “The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” ACOG President Richard N. Waldman said in a statement. “[ACOG’s] VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.” 
 
 “The risks associated with a vaginal delivery are lower than the risks associated with a C-section overall, as long as you can deliver the baby at a facility equipped to handle a C-section in case of emergency,” Roger W. Harms, an obstetrician at the Mayo Clinic in Rochester, Minnesota, and medical editor-in-chief of MayoClinic.com, said in a statement. And the recovery time is faster. Undergoing a cesarean surgery for the fourth time carries a 1 in 8 chance of major complications. In short, VBAC deliveries are safer for both the pregnant person and the fetus and lead to fewer complications. 
 
 These facts did not escape Goodall, who said in a statement released by NAPW: 
 
 My decision to allow labor to proceed before consenting to a surgical intervention is based on years of research, careful consideration of the risks to me and my baby, and my family’s needs. All I want is to be able to go to the hospital when I’m in labor and have my medical decisions respected – and my decision is to proceed with a trial of labor and not have cesarean surgery unless some medical complication arises that makes cesarean surgery necessary for my or my baby’s health. Instead of respecting my wishes like they would for any other patient, my health care providers have made me fear for my safety and custody of my children. The people who are supposed to be caring for me and my baby have put me into an even more dangerous situation. I know I’m not the only one to go through this; I’m speaking out because pregnant women deserve better. 
 
 “I would definitely consent to surgery if there were any indication during labor that it is necessary,” Goodall added. “I am trying to make the decision that will be safest for both me and my baby, and give me the greatest chance at being able to heal quickly after my child is born so I can care for my newborn and my three other children.” 
 
 NAPW staff attorney Farah Diaz-Tello expressed disappointment in Judge Steele’s ruling. “The process of labor and delivery isn’t a procedure; our client is the one trying to avoid a compelled medical procedure. Deciding whether and when to consent to surgery is a constitutionally protected right,” she said in a statement. Diaz-Tello explained that every appellate court to rule on this issue on a full record has held that pregnant women retain their constitutional rights, including rights to medical decision-making and bodily integrity. “No woman should fear that because she’s pregnant, she can be threatened, coerced, or deprived of her constitutional rights,” she said. 
 
 But this is exactly what happened to Rinat Dray in Staten Island and to at least six other women in Florida, according to NAPW. “Florida is particularly bad for people giving birth,” Diaz-Tello told RH Reality Check in an email. “We know of at least a half dozen other women who have had court orders or threats of legal action this against them, but the certainty with which hospitals have made these threats makes us think there are more we don’t know of.” 
 
 According to declarations of medical experts filed with the lawsuit, the hospital’s actions violate medical ethics. In a statement to NAPW, Mary Faith Marshall, director of the Center for Biomedical Ethics & Humanities at the University of Virginia School of Medicine, called the hospital’s actions “troubling.” 
 
 “Given the clear statements from ACOG’s Committee on Ethics and other professional groups that coerced or court-ordered medical procedures are not ethically justified, it is stunning that a hospital would threaten such an action,” she said. 
 
 Diaz-Tello acknowledged the hospital’s concerns about malpractice liability, but noted that there is no legal or ethical authority that supports managing liability concerns by forcibly performing unwanted surgery. “The Florida Supreme Court has said health care providers are protected from liability when they respect and follow the decisions of a competent and informed patient to delay or refuse a proposed treatment, even when there are risks involved,” she said in the NAPW statement. “Ms. Goodall has explicitly and carefully documented her informed decision to proceed with a trial of labor; there is no justification for forcing her, or any person, to have unwanted surgery to protect a hospital’s bottom line.” ||||| If you have experienced a cesarean delivery, you are not alone. In November 2005, the Centers for Disease Control and Prevention reported the national cesarean birth rate was the highest ever at 29.1%–more than a quarter of all deliveries. 
 
 If you desire to try a vaginal delivery after having had a cesarean, you should be encouraged by knowing that 90% of women who have undergone cesarean deliveries are candidates for VBAC. Statistically, the highest rate of VBAC involves women who have experienced both vaginal and cesarean births and given the choice, have decided to deliver vaginally. 
 
 In most published studies, 60-80%–roughly 3 to 4 out of 5–women who have previously undergone cesarean birth can successfully give birth vaginally. After reading the following information and discussing the possibility with your health care provider, you should be able to make an informed decision about the option of VBAC. 
 
 VBAC and the Risk of Uterine Rupture: 
 
 The greatest concern for women who have had a previous cesarean is the risk of uterine rupture during a vaginal birth. According to the American College of Obstetricians and Gynecologists (ACOG), if you had a previous cesarean with a low transverse incision, the risk of uterine rupture in a vaginal delivery is .2 to 1.5%, which is approximately 1 chance in 5001. 
 
 Some studies have documented increased rates of uterine rupture in women who undergo labor induction or augmentation. You should discuss the possible complications associated with induction with your health care provider. Recently, ACOG stated that VBAC is safer than a repeat cesarean, and VBAC with more than one previous cesarean does not pose any increased risk.2 
 
 If you were given the following reasons for a previous cesarean and are considering a repeat cesarean, you might consider discussing the following with your health care provider: 
 
 Dystocia: Dystocia refers to a long and difficult labor due to slow cervical dilation, a small pelvis, or a big baby. Many women who are given this reason for previous cesareans, deliver vaginally the next time around and tend to give birth to a larger baby than their first! ACOG states that the effects [or difficulties] of labor with a baby more than 8 ¾ lbs have not been substantiated. 
 
 There is not evidence that a large baby requires a cesarean. The pelvis and the baby’s head are not rigid structures and both mold and change shape to allow birth. During labor there are certain techniques that a woman can use to help open up the pelvis, thus allowing the birth of a large baby. For example, squatting increases the outlet of the pelvis by 10%. 
 
 Genital Herpes: For many years, because of the risk of passing herpes to the baby during delivery, women with a history of herpes almost always delivered by cesarean. Physicians would examine cultures in the last weeks of pregnancy and if they found active virus, would schedule a cesarean. Today, ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable. 
 
 Fetal Distress: If the life of the baby is at risk from fetal distress or other complication, there is little doubt that most mothers will consider a cesarean delivery. According to the Centers for Disease Control and Prevention, 9% of cesarean deliveries in 1991 were due to fetal distress. Fetal heart rate monitoring to detect fetal distress can be a routine part of the VBAC procedure. 
 
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 What criteria must I meet to be considered for VBAC? 
 
 No more than 2 low transverse cesarean deliveries. 
 
 No additional uterine scars, anomalies or previous ruptures. 
 
 Your health care provider should be prepared to monitor labor and perform or refer for a cesarean if necessary . 
 
 Your birth location should have personnel available on weekends and evenings in case a cesarean is necessary. 
 
 What other criteria would make me a good candidate for a VBAC? 
 
 If the original reason for a cesarean delivery is not repeated with this pregnancy 
 
 You have no major medical problems 
 
 The baby is a normal size 
 
 The baby is head-down 
 
 In what situations would VBAC not be recommended? 
 
 If you are pregnant with twins 
 
 If you have diabetes 
 
 If you have high-blood pressure 
 
 Comparing a Repeat Cesarean to a VBAC: 
 
 Repeat Cesarean VBAC Usual risks of a surgical procedure Less than 1% chance of uterine rupture. If uterine rupture occurs you have risks of blood loss, hysterectomy, damage to bladder, infection, & blood clots Hospital stay of approximately 4 days Hospital stay of approximately 2 days Development of an infection in the uterus, bladder, or skin incision Risk of infection doubles if vaginal delivery is attempted but results in cesarean Injury to the bladder, bowel, or adjacent organs Possibility of tearing or episiotomy Development of blood clots in the legs or pelvis after the operation On-going pain & discomfort around incision Temporary pain and discomfort around vagina Small chance that the baby will have respiratory problems3 The baby’s lungs will clear as baby passes through birth canal If you plan for many more children, take into account that the more surgeries a woman has had the greater the risk of surgical complications. A fourth or fifth cesarean has more risk than the first or second. 
 
 1. ACOG Practice Bulletin, No. 5, July 1999 
 
 2. ACOG, Midwifery Today, Winter No 36, page 47. 
 
 3. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42. 
 
 International Cesarean Awareness Network, http://www.ican-online.org/
– In 2013, 32.7% of all babies delivered in America were born by cesarean section. If that sounds high, well, check out Brazil's stats. The BBC reports that at private hospitals, 85% of women deliver by cesarean; in public hospitals, it's about half that (45%). In 2013 NPR reported the figure for some private hospitals is 99%; one doctor NPR spoke with could hardly recall the last time he handled a vaginal delivery. The World Health Organization recommends a 10% to 15% rate. In an effort to get closer to that figure, Brazil is now making it a little more, well, laborious to have a cesarean. New rules were introduced yesterday, reports AFP, and going forward, there's more paperwork. After women are told about the risks (now required), they'll have to sign a consent form; a doctor will have to fill out a form that asks for the justification of the procedure. But forms may not solve what some women say is the real issue: a lack of beds. Those who want to deliver in a private hospital report that the beds are often completely preassigned to women who've booked a cesarean, forcing them to, in some instances, go to hospital after hospital while in labor. AFP reports doctors play a role, too, with some saying doctors encourage women to take the scheduled route, which helps quash middle-of-the-night working hours. As one pediatrician puts it, mass cesareans are the country's "international shame."