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RACHEL MARTIN, HOST:

This is WEEKEND EDITION from NPR News. I'm Rachel Martin.

Today, we continue with our series on The Changing Lives of Women with a visit to Brazil. That country has seen an economic boom in the last decade that has launched some 40 million people into the middle class. And a new status symbol has emerged for some Brazilian women - the way they deliver their babies

NPR's Lourdes-Garcia Navarro reports from Sao Paulo.

LOURDES GARCIA-NAVARRO, BYLINE: The office is immaculate as you'd expect in an upscale neighborhood in Sao Paulo; all sterile white modish plastic furniture and green plants. Behind the reception desk are pictures that would look more appropriate in a pop art gallery than a private maternity clinic. Fertility treatments, specialized gynecology and, of course, obstetrics. But one thing they rarely do here is preside over a vaginal delivery.

DR. ALEXANDRE SASAOKA: (Foreign language spoken)

GARCIA-NAVARRO: Dr. Alexandre Sasaoka struggles to remember the last time he assisted at one. We do them, he says, but rarely.

And he's not alone. Some 80 to 90 percent of women in private hospitals in Brazil give birth via Caesarian. In some hospitals that number climbs to 99 percent. That contrasts with 30 percent of women in the States and one-in-four women in the U.K. And even that's high, the World Health Organization says that anything more than 15 percent of women giving birth by C-section is too many. It cites increased medical costs and neonatal complications as potential problems.

But Dr Sasaoka avows that women here want C-sections, as they are known.

SASAOKA: (Foreign language spoken)

GARCIA-NAVARRO: Women are busy, they jobs. They have jobs, so they can schedule their births. They prefer it, he says. Dr. Sasaoka says he also recommends them.

SASAOKA: (Foreign language spoken)

GARCIA-NAVARRO: There are many advantages to a natural birth, of course. After all, C-sections are a major surgery, he says, but women want it and also it allows doctors to be better organized. For example, you don't have to stop what you are doing at your clinic to assist a natural birth, he says.

There is a debate in Brazil as to why the rate here is so high. Doctors like Dr Sasaoka say it's due to the demand. But new mother Mariana, who doesn't want her last name used - for fear of offending her doctor - says often women feel bullied into it.

(SOUNDBITE OF CONVERSATIONS)

GARCIA-NAVARRO: We met at a busy restaurant. She tells me she wanted to have a vaginal delivery. But...

MARIANA: My doctor said to me, actually, he would have more control in C-section than in a natural birth.

GARCIA-NAVARRO: He also told her he would also almost certainly have to do an episiotomy, a procedure where the vaginal opening is cut to allow for delivery. She was terrified.

Did you feel pushed to have a C-section in a way? Like, I mean obviously what he was telling you was that C-sections are better.

MARIANA: Yeah, he was telling me that. Many doctors do that.

GARCIA-NAVARRO: Still she decided she was going to try and do it naturally. Then Two weeks before her due date, her blood pressure spiked. And her doctor said she needed to have a C-section after all. The next day she was in the operating room.

MARIANA: To this day, she wonders if it was really necessary. She says that's the legacy of all the intervention here.

I don't know. I think he was right. But I think the problem in Brazil is we lack the trust between doctor and patient.

GARCIA-NAVARRO: There is a two-tiered medical system in Brazil. The C-section rate in public hospitals is much lower because they're less available, the result of a government push to bring medical costs down. But in private hospitals Caesarian deliveries are the norm, and so they're also seen as status symbols. And that, say natural childbirth advocates, has to change.

While doulas are a regular presence in many maternity wards these days in the U.S., here in Brazil they're still uncommon.

(SOUNDBITE OF A CONVERSATION)

GARCIA-NAVARRO: But they are the first port of call for couples looking to have a natural birth.

Doula Mariana de Mesquita talks to a couple who say they're having trouble finding a doctor who is willing to deliver their baby vaginally. Mariana de Mesquita tells me her profession basically disappeared with the rise of C-sections. There has recently been a pushback by some Brazilian women who marched last year to change a law that would have prohibited home births assisted by doulas in Rio. But she says a lot more still needs to be done.

She says one of the most important roles she has these days is to educate.

MARIANA DE MESQUITA: (Foreign language spoken)

GARCIA-NAVARRO: Most women don't even know how long labor can last, she says. I teach them the basics; what a normal birth is like, what they can expect, the risks there are with a Cesarean delivery, she says.

MESQUITA: (Foreign language spoken)

GARCIA-NAVARRO: Basically in Brazil, she says, we copied the North American system, which is very interventionist. She adds doctors do get paid more for C-sections which is another reason for their prevalence. But she also blames women here.

MESQUITA: (Foreign language spoken)

GARCIA-NAVARRO: She says here they aren't afraid of surgery. There is a lot of plastic surgery, for example. Women put themselves at risk for very little, she says. She says people see C-sections as a sign of women's liberation here. But I see it as a sign of their submissiveness to a violent medical system.

That's nonsense, says 29 year old Pamela Bassy. She works at a store in an upscale mall and she's expecting a boy in a few months.

PAMELA BASSY: (Foreign language spoken)

GARCIA-NAVARRO: She says with a Caesarian, I can take full advantage of my maternity leave. I can work right up to the day before I have to have the baby. My family and my husband wanted me to have a vaginal birth. But in the end, she says, it's my choice.

Lourdes Garcia-Navarro NPR News, Sao Paulo.

MARTIN: You can find stories from our series The Changing Lives of Women at our website, npr.org.

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