title: Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods.
abstract: OBJECTIVE
  To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.
  
  
  METHODS
  Population based birth cohort study, using ethnographic and epidemiological methods.
  
  
  METHODS
  Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.
  
  
  METHODS
  5304 women who gave birth in any of the city's hospitals in 1993.
  
  
  METHODS
  Birth by caesarean section or vaginal delivery.
  
  
  RESULTS
  In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.
  
  
  CONCLUSIONS
  Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.
authors.affiliation: Department of Social Medicine, Federal University of Pelotas, CP 464-96001-970, Pelotas, Rio Grande do Sul, Brazil.
authors.forename: Dominique P
authors.initials: DP
authors.lastname: Béhague
authors.forename: Cesar G
authors.initials: CG
authors.lastname: Victora
authors.forename: Fernando C
authors.initials: FC
authors.lastname: Barros
mesh_terms: D000328:Adult; D000884:Anthropology, Cultural; D001294:Attitude to Health; D001938:Brazil; D002585:Cesarean Section / Q000523:psychology / Q000706:statistics & numerical data*; D015331:Cohort Studies; D003657:Decision Making; D005260:Female; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006801:Humans; D007751:Labor, Induced; D016015:Logistic Models; D010342:Patient Acceptance of Health Care / Q000208:ethnology; D017060:Patient Satisfaction / Q000208:ethnology*; D011247:Pregnancy; D011256:Pregnancy Outcome; D012959:Socioeconomic Factors