Por que 90%?: uma análise das taxas de cesárea em serviços hospitalares privados do município de São Paulo
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As taxas de cesárea têm apresentado elevação progressiva nos últimos vinte anos em diversos países, inclusive no Brasil. Esse estudo objetivou analisar os fatores associados à escolha pela cesárea no sistema privado de saúde brasileiro. Esta análise foi feita por meio de entrevistas com 250 mulheres após o parto e com 122 médicos que prestaram assistência a essas pacientes. Os resultados demonstraram associação significativa entre a realização de cesáreas, maior nível de escolaridade, renda superior a 10 salários mínimos e emprego entre as mulheres, que foram submetidas a essa cirurgia em 88% dos partos realizados. O principal fator envolvido na decisão pela cesariana para as pacientes foi a praticidade em agendar o parto. Para os médicos, os principais fatores associados à realização da cirurgia foram a insegurança materna pelo parto vaginal, a solicitação de cesárea pela gestante, a forma de remuneração pelo procedimento e a formação médica atual. Concluímos, a partir da percepção de dois agentes dessa cadeia de assistência, que as taxas de cesárea atingem cifras ao redor de 90% em decorrência da forma de organização da prática obstétrica inserida no modelo privado de saúde brasileiro, das características sócio-culturais das mulheres assistidas por esse sistema de saúde e da formação dos profissionais de medicina.The rates of cesarean section have shown a progressive growth in the last twenty years in several countries, including Brazil. Such fact, considered a public health problem, has raised questions about the factors involved in deciding the type of delivery. This study aimed to analyze the factors associated with the choice for cesarean sections in the Brazilian private health system, which has the highest rates in the world for this procedure. It was assumed that the way the obstetric practice is organized in this private health insurance system, which involves socio-cultural and economic factors of both pregnant women and doctors, would favor this situation. This analysis was carried out through interviews with 250 women who had given birth and with 171 doctors who had provided care to these patients. Results have shown a meaningful association between cesarean sections and a higher level of education, income greater than 10 minimum wages and employment among the women who were subjected to surgical procedures in 88% of the deliveries made. These patients showed high negotiation power with doctors, with whom they develop a close doctor-patient relationship: 80% of them considered they were participants in the decision making regarding the type of delivery and above 95% of satisfaction with the delivery made was found. Among the factors involved in the decision for a cesarean section by the patients, the possibility to schedule the delivery was the most relevant one. It was found that a considerable number of women changed their minds as to the type of delivery desired during the pregnancy, particularly among those who wanted normal delivery at the beginning and finally chose a cesarean section at the end of the gestation. For the doctors, main factors associated with the surgery were maternal insecurity regarding vaginal delivery, request for caesarean section made by pregnant women, form of remuneration for this kind of procedure and current medical training. When women doctors were asked what kind of delivery they would like to have if they were pregnant, 40% said they would choose the cesarean section. In spite of this preference, the cesarean section rate found among women doctors and doctors’ wives was lower when compared to the rate of this procedure among interviewed patients. We have noticed that a cesarean section is perceived as a safe means of birth both by the patients and the doctors. We have concluded, from the perception of two players within this health care chain, that the cesarean section rates reach figures around 90% due to the organization way of the obstetric practice inserted in the Brazilian private health care model, the socio-cultural characteristics of women assisted by this health system and the educational background of physicians.