ATTITUDES TOWARD PREGNANCY AND BIRTH
While attitudes are changing, you'll find that the Brazilian system tends to treat pregnancy as a disease. You're considered frail and unfit for even daily activities like walking or carrying groceries. Women milk it, obviously, because the benefits of being treated like a porcelain queen from the time your belly starts showing are really, really nice. Seats on the bus, cutting in line...I'm surprised there's not a market for pregnant despaschantes! Imagine how much they could get done! The C-section rate is super high in the private sector, which is where you'll be going as an expat unless you have some great desire to see the inside of a public hospital up close and personal. Bring your own soap, if you do, and towels and bed linens and the like...because it's highly possible they won't have any of that available. And if you want to watch television? You'll need to bring that too...
According to this and other sources, Brazil's private care c-section rate is 80% (or greater) while in the public sector it's 29%. The World Health Organization recommends a 15% rate...and in other developed countries, the rate is much, much lower.
Midwife care, natural birthing methods and anything that doesn't include a scalpel and medication is still really, really OUT THERE for Brazilians. Our preference for a natural, unmedicated if possible, birth is making its way through my social networks at lightning speed. Someone actually asked me, at a wedding, where I was clad in a full-length formal and sparkly jewelry, if I could demonstrate a squat. Apparently, only the indigenous give birth NOT on their backs and they just "had" to see if I was serious.
You might have a hard time finding a doctor who will allow you to have a natural birth, especially if you choose one who accepts local insurance. Even if the doctor says they are pro-natural, the internets and social networks are full of women complaining that their doctors lied to them. Suddenly a C-section is urgently necessary, or the woman is given a full three hours and not a second more in which to labor before the doctor decides it's been too long...See this article, in Portuguese, for a few horror stories.
Most Brazilians I encounter find it baffling that anyone would want a vaginal birth, and incomprehensible that it might be done without an epidural. Scheduled surgeries are the norm for almost all women birthing outside the free public healthcare system.
Moral? If you don't want to know the hour and date of your child's birth months in advance, you'll have to interview your doctor. You'll want to ask some other people who have used him or her, get statistics, get a feel for whether they're on board with your philosophy. And you'll need to be prepared, mentally, physically and possibly linguistically, for the kind of birth you want (emergencies obviously excepted), because you might not have the support network you'd have in other places. Also, make sure your doctor knows whether or not you want strangers attending your birth; the few women I know who have had natural births here mentioned that a good part of the hospital came in to watch because THEY'D NEVER SEEN a natural birth before. If you don't want to be gossip fodder around the hospital water cooler, you'll need to be firm about this ahead of time.
I know my doctor isn't the most natural-friendly on the continuum scale, but I've been really happy with how she's handled my special needs, what with the PCOS and the rheumatoid arthritis, so I'm willing to take my chances. My doctor knows my desires and wishes and also that I'm very prepared; I'm going to be clear in my birth plan that moaning, groaning and even the occasional scream do NOT mean that I'm done and it's time to go in with knives blazing! We're also limiting the possibility of an unnecessary c-section through sheer stubbornness. I'm preparing myself to do a majority of the laboring at home. The longer we can delay going to the hospital, the better our chances of having a non-intrusive, intervention-free labor. Since the doctor and her team will be with us for the whole birth from the moment we arrive at the hospital, we don't want their schedules to affect our labor timeline. The best way to do that, according to everyone we've talked to, is NOT to show up too early.
THE FINANCIAL SIDE OF THINGS
A lot of doctors won't accept insurance. They just can't make enough with the pittances the insurance companies offer. So be prepared to shell out anything from about R$250 to R$500 for a doctor's visit. You will get your money's worth, though. It's rare that my scheduled consultations last less than an hour and they frequently go closer to two hours. Your doctor and their team will also want to be paid their fees separately; when my husband had his surgery, we paid each doctor individually and were reimbursed by our insurance company. Most of the bills were paid within 2 to 8 CENTS of the original bill, and only the anesthesiologist actually cost us money, as the insurance had a much lower fee threshold for this professional. Your OB's fee can run as high as R$9000 or more, depending on who you choose; this fee covers the birth, regardless of whether you arrive at the hospital with the baby crowning or if you have the most difficult labor in the world. DailyRioLife (no longer an active blog) has a post here with somewhat outdated but useful information on the cost of the whole birth experience at a private hospital and without local insurance.
We have Brazilian insurance and it covers almost all of the tests that my doctor wanted to run, as well as a good portion of my doctor's fees. She asked for ultrasounds and pretty extensive blood workups at least every two months, which I found a little excessive.
I was okay with that many ultrasounds, provided I didn't have to pay for it (I see it as getting both value for our health insurance package and helping out the Brazilian economy) but if you're paying out of pocket, or need to be reimbursed after the fact, it can get quite pricey. I'm not sure what the average cost of tests is today, but I heard one expat say something about R$1400 for a full workup of blood and urine tests.
Obviously, not all those tests are necessary. If you go to your doctor with a list of what health care in your country considers standard, you can probably convince them to require fewer tests. My doctor highly recommended that I go to the lab where one of the doctors on her birthing team worked...I felt as if the number of ultrasounds was kind of linked to that. Like so many things in Brazil, medical care has its share of beneficial relationships and back-patting and jeitinho. If you choose to do a procedure that your doctor doesn't approve of, you just might find that the next doctor down the line isn't willing to assist you if they have any personal or professional connection with your original OB. (Heard this happened to a lady who wanted to try breech turning to avoid a C-section.)
If you want to know the sex before it's visible on an ultrasound, you can pay for a blood test; they'll start testing at week 8, I believe. Insurance won't cover that one. It's worth checking around at different labs if you decide to do it, as prices can swing quite a lot, between R$300 and R$500.
This website, in Portuguese, has information on costs and what-to-do's in various insured and non-insured situations.
Info on natural birth and links to various Portuguese-language sites. Another website with similar content here.
ISHTAR has regular meetings in Rio on natural birthing, breastfeeding, etc. They've been recommended but I haven't had a chance to attend any meetings yet.
The expat community usually has at least a few midwives and doulas floating around, so if you have something specific you're looking for or want to find someone who can answer your questions personally in English (or French or German or whatever), recommend doctors, etc...ask around! You might be surprised at the wealth of resources available.