Without scientific support, the bill passed by Janaína Paschoal (PSL), which guarantees pregnant women the option of cesarean delivery in the SUS, even at the time of delivery and without clinical indication, has advanced urgently in the São Paulo Legislative Assembly and must go to a vote in plenary this Wednesday (26).
The proposal divides medical entities. Sogesp (Association of Obstetrics and Gynecology of the State of São Paulo) says the project has no scientific evidence and can stimulate indiscriminate rates of cesarean sections, which poses risks to the woman and the baby.
Cremesp (Regional Council of Medicine of the State of São Paulo) defends the Paschoal project, claiming that it opposes the "vilanization" of cesarean deliveries.
Brazil is far from reaching the recommendations of the WHO (World Health Organization), which considers that only between 10% and 15% of the countries with the highest rate of cesarean sections in the world, only losing to the Dominican Republic (56%). are indicated for medical reasons only.
Of the births made in SUS, 40% occur through cesarean sections. In the private network, the index reaches 84%.
Cremesp understands that the evaluation of perinatal care is multifactorial and should not be based on "ideal cesarean indexes", disregarding medical indications and maternal will.
According to counselor Lyane Cardoso, Cremesp considers it ethical that SUS pregnant women can choose cesarean birth, from the 39th week, and analgesia, when choosing the normal delivery. "This is respected in the private network, but not in the public one. A law that guarantees the autonomy of SUS patients is important. "
She says that since 2015, the council has received 70 complaints, of which 24 have turned into ethical processes, adverse events resulting from the delay in performing cesarean section and complications of the insistence on vaginal deliveries. "We are aware of this and we have decided to support this bill," Cardoso says.
Cremesp's arguments are very similar to those of Janaina Paschoal in defending her project. "What is happening to the poorest women in this country is unacceptable. At 40 weeks of gestation, babies are ready to be born. They send women in these conditions to return to their homes, a number of times, by bus, waiting for the baby to be born, "he says.
She says that because of delay and insistence on normal birth, babies suffer "anoxia [falta de oxigênio], becoming sealed for the rest of their lives, due to the so-called cerebral palsy. "
It occurs that there are no data on the rates of cerebral palsy in the state of São Paulo or studies that determine if this occurrence is higher or lower in public or private hospitals in São Paulo, according to Sogesp.
"There is no evidence in the medical literature that normal delivery is associated with an increased risk of cerebral palsy. On the contrary, there is evidence that the increase in cesarean rates does not change the occurrence of cerebral palsy, "says Gynecologist and USP professor Rossana Pulcineli Vieira Francisco, president of the entity.
Several studies indicate that only 10% of cases of cerebral palsy are related to events during labor. The other (90%) have genetic causes or are associated with changes during prenatal or postnatal care.
"Without concrete data, making decisions and proposing a bill on an extremely serious but infrequent and multifactorial event is very fearful and in some ways irresponsible with public health," says Francisco Rossana.
According to Simone Diniz, a physician and professor at the School of Public Health at USP, the Paschoal project raises a feminist banner, to give women greater autonomy at the time of childbirth, in the worst possible way.
"It responds to the call for a nonviolent delivery by selling more Caesarean section, which, in this context, appears as capable of giving more physical and emotional security to the woman."
For her, if women actually had access to humanized delivery and more information about the risks associated with cesarean section, prematurity, and respiratory problems, the chances of future chronic diseases would not be seen as the best option.
In the opinion of Rossana Francisco, one of the probable consequences of the bill, if it becomes state law, will be the indiscriminate increase in cesarean rates in public hospitals in São Paulo.
"This fact has also not been adequately analyzed, including planning on its impact on cesarean complications as a higher risk of bleeding and infection."
Wanted since last Friday (21), the secretary of health of the State of São Paulo, José Henrique Germann Ferreira, did not express whether the health network in São Paulo will be able to absorb an eventual increase in cesarean sections.
In a note prepared by the press office, the folder says that it follows the protocols of obstetric assistance of the Ministry of Health and the WHO (World Health Organization) that define that cesarean should be used in cases of risk to the mother, fetus or both .
"The decision on the recommended type of delivery is evaluated and defined by the medical staff on a case-by-case basis," the statement said. It also states that "state services offer humanized assistance to pregnant women assisted by SUS, so that they can choose natural and less invasive methods that offer comfort and well-being, provided there is no risk to the safety and / or health of mother and child ".
According to Rossana Francisco, the increase in cesarean sections is associated with obstetric complications that lead to hemorrhages, which are now one of the main causes of maternal mortality in the country.
For her, a bill that increases cesarean rates and thereby brings more chances of bleeding and maternal death will not collaborate to improve women's health and may even put them at greater risk.