A natural path to “deliveryland”
A natural path to “deliveryland”
Casa Angela in São Paulo, the first home birthing center in Brazil, fights for natural birth in a country where the number of cesareans is extremely high.
The group of pregnant women and their partners burst out laughing when obstetric nurse Caroline Oliveira starts describing the moment during labor in which women enter “deliveryland” – the state of consciousness into which the pregnant woman about to give birth enters when her hormones take over her body, heart, and mind in preparation for the baby’s arrival. Casa Angela is a pioneer of natural births. Home birthing centers, where children are born naturally with the assistance of midwives as opposed to doctors, are not common in Brazil. Approximately 98 percent of children in the country come into the world at hospitals, through vaginal births with intervention or C-sections – ways of being born that in most cases had involved severe pain and unnecessary risks for the women.
Today, Casa Angela is a national reference for humane birth. Founded in the 1990s, it was the first home birthing center in the country. In December 2015, Casa Angela started working through the Brazilian public health system (SUS), which offers free universal access, in addition to private services for those who can and wish to pay.
A Long Drawn-out Dispute with Legislation
Casa Angela’s origins date back to the 1980s when the German midwife Angela Gehrke brought natural birth to the Monte Azul Community Association’s medical clinic, a philanthropic organization that provides health and educational assistance to a poor community in South São Paulo. In 1997, Gehrke designed a home birthing center; however, it had to close the following year due to the lack of Brazilian sanitary regulations for such installations. Gehrke did not live to see the legislation progress. She died of cancer in 2001; however, she had performed 1,500 natural births in the Monte Azul clinic.
The German doctor Anke Riedel, who had volunteered when she was young with Gehrke in São Paulo, has since 2004 been seeing to the restructuring of the birthing center, and has reached a cooperation agreement with the city government. The Casa was ready in 2008, but at first it operated without state subsidies. As such, it remained dependent upon private contributions in order to offer services to low-income pregnant women and upon payments made by women who could afford to pay for their own birth costs.
Only in December of 2015 did the city government sign an official agreement to provide services with Casa Angela. “It was a 12-year struggle,” Riedel says. She explains that before the agreement, the Casa was performing 20 births each month: ten for low-income pregnant women and ten for women who paid. Today, it’s 40 births a month covered by the SUS. It seems like a small number, but for the defenders of humane birth, Casa’s experience is considered important because it means there is official backing for the practice of natural birth.
Extreme predilection for cesareans
A militant advocate for all Brazilian social classes to have greater access to natural birth, Raquel Marques, from the NGO Artemis, sees women’s and doctors’ preferences for cesareans as a complex phenomenon, built on two factors. On one side, the economic convenience for doctors and hospitals not to have to follow the natural timeline of a vaginal birth. On the other, many women want to free themselves of a painful normal birth, provoked by routine procedures imposed by the hospitals. Since these are often followed unnecessarily, they end up being denounced as acts of obstetric violence. Raquel Marques emphasizes that in Brazil over the last decades “the idea has been built up that the cesarean birth is painless, clean, scheduled and safe.”
However, according to the UN, women have a 3.5 times higher chance of dying in a cesarean than in normal births, and in Brazil the maternal mortality rate is extremely high: 62 cases per 100,000 births. The pressure of growing advocacy, including from the World Health Organization itself, to reduce the maternal mortality in Brazil, led the Ministry of Health to adopt a series of ordinances, policies, and programs in favor of natural birth, like the Rede Cegonha (Stork Network, 2011), a strategy that, among other things, finances the construction of birthing centers linked to or separate from hospitals.
Several cities and states have approved laws that restrict the most interventionist procedures in births. In São Paulo, where there is only one other birthing center in addition to Casa Angela, there are plans for the construction of six new centers with the Rede Cegonha’s resources. Another important step was the creation, in 2005, of a degree program in Obstetrics– the first in the country to offer university training for obstetricians and midwives.
Anke Riedel says there are still important cultural, corporate and financial barriers to overcome in order to completely change the model of childbirth care in Brazil, but she sees advances in public policies. “It is unquestionable that the model of humane childbirth, which respects the rights, physiology and wishes of the woman, is better from the viewpoint of public health. But it would be good to prove through research that this model is viable and cheaper than the hospital model,” she says. This could convince the population and the administrators of the necessity of this change. Casa Angela is one of the first small yet important steps in this direction.