Are Brazilian women really choosing to deliver by cesarean?

Brazil has among the highest cesarean section rates in the world, with 36% of women in the country delivering surgically. Women, especially those who deliver in private hospitals with cesarean rates in the 80-90% range, are often portrayed as actively choosing to deliver surgically. Doctors typically promote this view, also common in the popular understanding of the phenomenon, that it is women's demand for a cesarean that is behind the high rates. Academic analyses tend to present a more balanced view with doctors' motives for wanting to perform cesareans included alongside descriptions of women's motives for the procedures. What is typically missing from such analyses is a discussion of the power differences between women and doctors. Doctors clearly have more decision-making power in the hospital birthing situation, and their medical expertise and authority is often marshaled to convince a woman to "choose" a cesarean. Using data collected from a postpartum survey, participant observation in hospital obstetrics wards, and in-depth interviews, I offer evidence which refutes many of the hypotheses associated with why women might prefer to deliver by cesarean. I also show that the majority of women surveyed in two cities in Brazil, particularly first-time mothers, do not seek to deliver by cesarean. Through an analysis of conversations between doctors and women during labor and delivery, and through women's narratives of their delivery experiences, I also show some of the mechanisms that doctors use in order to induce so-called demand for surgical delivery and argue that they are very active participants in the ongoing construction of the culture of cesarean section in Brazil. (C) 2000 Elsevier Science Ltd. All rights reserved.