The New Latin Labor.(cesarean sections)(Statistical Data Included)

Nuevo Leon is Mexico's richest state. Picturesque mountains rise over its industrial parks, BMWs cruise its five-lane highways and automatic- teller machines offer the country's highest daily withdrawal limit. And Nuevo Leon holds another nationwide distinction: king of the cesarean section. Half of all the state's babies are born surgically. In private hospitals, the proportion is 73 percent--the highest in the country and nearly five times the international norm. Women want the operation to avoid the pains of all-night labors, and overworked doctors are happy to oblige with a half-hour insurance-paid procedure before breakfast. "I told the doctor I didn't want a natural birth. I didn't want a long labor," says Paulina Estrada, a mother of two in Monterrey, the state's capital. "In fact, I hardly know anyone who has had a natural birth."

Monterrey may be C-section central, but it is hardly the exception. Across Mexico--and much of Latin America--the number of cesareans is on the rise. In Mexico, the rate in public hospitals jumped from 23.5 percent in 1991 to 31.4 percent in 1999. In private hospitals, where two fifths of babies are born, the rate soared to 52.8 percent in 1999. Chic among the rich, the C-section is also trickling down to the middle and lower classes in Brazil, Argentina, Chile and Colombia. There are several explanations: better early detection of pregnancy complications, fear of malpractice suits for not having performed the surgery in deliveries that ended tragically, the idea among women that a C-section is somehow more civilized than a natural birth and the desire of doctors to maintain a large number of patients without the telephone's ringing at 3 every morning. "Any doctor who says he doesn't do unnecessary cesareans is lying," says Mauro Munoz, a 49-year-old Monterrey gynecologist, who delivers at least three babies a week--65 percent of them by surgery, he estimates. "And they also lie about the number they are doing."

Why do the numbers matter? The C-section is an important procedure in protecting the lives of mothers and their babies, but it also carries higher risks than a vaginal delivery: infections and hemorrhaging in mothers, and respiratory distress syndrome in babies. In 1985 the World Health Organization established 15 percent as the ideal C-section rate, and several countries, including the United States, launched campaigns to reduce the number of surgeries. (After a steady drop, the U.S. rate has risen slightly in the last two years--to about 22 percent--because doctors have grown more reluctant to allow women who have had C- sections in the past to deliver naturally.) But in Latin America, the number of elective C-sections grew steadily throughout the 1990s. A recent study in the British Medical Journal concluded that 850,000 C- sections are needlessly performed throughout the region each year. Yet the real problem is the distribution of C-sections along class lines. While urban, well-to-do women chose surgery--unworried about increasing their risk of delivery complications--many poor, rural women who need the operation don't get it. "There are still lots of women dying at childbirth because they didn't have access to C-sections," says Arachu Castro, a professor at Harvard Medical School who has studied the rates in Mexico. "That is the big irony."

At one extreme is Monterrey, a city of 1.1 million, where C-sections are scheduled like hair appointments. Like her friends, 31-year-old Estrada wanted one when she got pregnant for the first time in 1997. Her mother, who had four natural births, warned her that vaginal deliveries do damage "down there." The C-section has since become something of a tradition in Estrada's family. Last summer she had her second, and her two sisters had their first. Estrada's doctor, 45-year- old Manuel Garcia, contends that after a vaginal delivery, "the sexual satisfaction is not the same." Even so, he says he favors natural births. His hospital, San Jose, has a C-section rate of 77 percent, but Garcia says he has found a way to keep his surgery rate under 35 percent and still deliver 15 babies a month. Heinduces labor in nearly all of his patients who want natur-al births, two each Wednesday and Saturday. "If I have 20 patients who need babies delivered and I'm trying to schedule office visits, I have to be honest with myself."

Viviane ...