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Why Most Brazilian Women Get C-Sections
April 14, 2014 8:46 AM   Subscribe


 
The real kicker is that the medical professionals and institutions who push unnecessary interventions make it difficult for women to trust when necessary interventions are recommended.
posted by The Underpants Monster at 8:54 AM on April 14 [3 favorites]


unnecessary interventions make it difficult for women to trust when necessary interventions are recommended.

As I've mentioned before in these threads, if you don't 100% love and trust your obstetrician to work WITH YOU, get one you do IMMEDIATELY.
posted by mikelieman at 8:57 AM on April 14


A lot of women simply don't have the time, ability, or resources to shop around and ultimately find an OB that they love.

These issues are systemic, and not the result of women having low standards with regards to their health care provider.
posted by MisantropicPainforest at 8:59 AM on April 14 [59 favorites]


Well, the system is always going to be gamed for profit, which this article shows the extremes of, so we're sadly stuck with caveat emptor until the day the US healthcare industry is remade from the ground up.
posted by mikelieman at 9:02 AM on April 14


mikekelieman: this is also in Brazil - while I'm not sure what the particulars of their healthcare system are, I don't think It's appropriate to apply assumptions or standards around US healthcare on them.
posted by divabat at 9:06 AM on April 14 [10 favorites]


Per TFA:

But a 2001 study of Brazilian women published in the British Medical Journal concluded that the country’s rise in C-sections was driven primarily by unwanted procedures rather than personal preference. And some women elect to go under the knife only after hearing about the rough treatment of mothers who choose the alternative.

"Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can't walk, can't take a bath, can't hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies," Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation, told the AP. "What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women."


(emphasis added)

So, yes, a systemic, not individual, problem.

And not a whole lot different from what many women in the US experience, as well. The recent intervention of the March of Dimes has improved things (since it wasn't just c-sections, but early c-sections, i.e., doctor-pushed premature births that were having a bad effect on health and mortality).

Women in the US have been threatened with jail, the loss of their kid to CPS, and other punishments for refusing c-sections, despite repeated court cases finding that women do actually have the right to decide what procedures they will consent to during birth.
posted by emjaybee at 9:07 AM on April 14 [10 favorites]


I wonder if, in Brazil, there's also a pay scale issue where doctors are paid more for the (fast, convenient, scheduled) surgical intervention and less for the (slow, inconvenient, unplanned) non-surgical route.
posted by jeather at 9:07 AM on April 14




Well, the system is always going to be gamed for profit,

This happens on a daily basis with medicaid patients in non-profit US hospitals.
posted by MisantropicPainforest at 9:10 AM on April 14


"It’s impolite for doctors to leave cases for the doctors on the next shift–there’s a sense that you need to either accelerate it or do a C-section."

So it's the medical equivalent of "why doesn't anyone ever make a fresh pot of coffee before second shift gets here," except with unnecessary surgery. When my friend was in labor and trying to wait for her midwife to arrive, the OB on duty at the hospital kept making passive aggressive comments about getting the C-section, she should probably get it, it would be best to get it, etc. We started dreading his visits. When my friend was finally dilated to start pushing, the baby came out in ten minutes. Thanks for your completely incorrect input, random doctor on duty!
posted by a fiendish thingy at 9:10 AM on April 14 [2 favorites]


Can confirm the "many parts of the world" bit.
posted by 3mendo at 9:12 AM on April 14


This is why, if I ever have a kid, I'll be getting a doula. And I know I am extremely privileged to consider that a financial possibility.
posted by showbiz_liz at 9:16 AM on April 14 [1 favorite]


You'd think that after hundreds of thousands of years of evolution, childbirth would be relatively painless. So there must be some evolutionary advantage traded for the pain. My theory is that the pain is a bonding mechanism. The mother has a memorable investment in the child, and if birth were painless and quick, the mother might be less attached. So with the modern reliance on anesthetics and C-sections, we may be doing our mother and child relationship a disservice in more ways than one.
posted by weapons-grade pandemonium at 9:21 AM on April 14


Well, this is completely horrifying. Rude people keep asking me when I'm going to have children, and the answer is "it's none of your business" but the other answer is "Are you kidding me? I'm fucking terrified!". I'm a woman in a very happy, well-established marriage and my husband and I love kids and we want kids and I'm absolutely fucking scared out of my God damn mind. I'm scared of the cost of hospital visits and lack of childcare and missing work and being blamed for prioritizing my children over work if I have to take care of them and I'm scared of a lack of money and I'm terrified of doctors who either don't know or don't care what's best for me and I'm scared of being blamed for not finding the right doctor if things go badly. Seriously, why is it that all over the world things are just so fucking bad for women? Why are things just so awful and why are there so many doctors we can't trust?

The reason you GO to a doctor is because you have to trust him or her to know more than you do because they have training and experience you don't so you aren't really in a position to evaluate their advice (it's like getting overcharged by a mechanic only, you know, a doctor). All this is so terrible and so scary and I hate that, as far as I can tell, there's virtually no place in the world where I can go as a woman and really trust the medical advice I get. I'd love to have doctors I can trust and in whom I have complete faith but I seriously have no way to make that happen, and that's not even counting issues like insurance and, you know, needing to have a job.
posted by Mrs. Pterodactyl at 9:22 AM on April 14 [27 favorites]


“When women are in labor, some doctors say, ‘When you were doing it, you didn't complain, but now that you're here, you cry.’”

!!!!!

So doctors prefer the c-section because it means they won't get sued, but no one gets sued for shouting this at women in labor? What?
posted by a fiendish thingy at 9:24 AM on April 14 [2 favorites]


Well >weapons-grade pandemonium, if there ever was a competition for barely logically coherent and hilariously pseudo-scientific theory, yours would be up at the top.

Actually, check this out: http://bahfest.com/

You might win.

Actually if you don't want to enter with that, can I?
posted by jjmoney at 9:25 AM on April 14 [9 favorites]


weapons-grade pandemonium, the tradeoff is that we get huge brains while still walking upright.
posted by The Gaffer at 9:25 AM on April 14 [45 favorites]


I was at a presentation last week given by an architect who specializes in health care design, and he mentioned - off the cuff as if it were just an odd quirk - research showing that there were more c-sections done in a certain US hospital when the maternity unit was busy: in order to lighten their work load the maternity staff was off-loading patients onto the surgical unit.
posted by Flashman at 9:26 AM on April 14


So there must be some evolutionary advantage traded for the pain.

I don't think that follows. Our big head size is the change that introduced the pain, right? The big head size is adaptive because it lets us build toasters. But having less pain during childbirth would itself have to confer an advantage for that newly-introduced pain to go away.
posted by gurple at 9:26 AM on April 14 [6 favorites]


There need not be an evolutionary ADVANTAGE to any given trait, just a lack of DISadvantage. You might also come up with some convoluted reason why having the breathing tube and the eating tube be the same tube makes a ton of sense, but it would be incorrect, because the actual reason is "eh, it doesn't kill MOST people and evolution is not a clean process"
posted by showbiz_liz at 9:32 AM on April 14 [15 favorites]


The mother has a memorable investment in the child, and if birth were painless and quick, the mother might be less attached.

This demonstrates a really poor understanding of what evolution is and how it actually works, but more than that, I think it seems kind of misogynistic to imply that women need to be in a great deal of pain in order to be good mothers.

Also, yeah, this is really not what evolution is. Evolution isn't some sentient optimizing force that wants us to be happy.
posted by Mrs. Pterodactyl at 9:37 AM on April 14 [29 favorites]


[Might be a decent idea to saunter back in the general direction of the actual link at this point and leave the evolutionary theory basics to some self-directed googling or whatever.]
posted by cortex at 9:39 AM on April 14 [3 favorites]


My kid was born C-section. I worry about a lot of things, with her, because I'm a worrier, and one of the things that I worry about is that she missed the microbiome transfer that babies get from their mothers in the birth canal (though I realize it's more complicated than that).

The idea of changing the way babies are born for an entire population without a blazingly good reason, when we don't yet understand all the implications of that massive change, is really disturbing to me.

The Back to Sleep campaign in the 80s and 90s disturbs me for the same reason: really, we're going to mess with all that sleep and all that brain development, for a whole population, because of this one thing we know about that area, that a vanishingly small number of kids won't die because we do it. Don't get me wrong, I'm glad those few kids are alive, I just worry about the potential unknown affects on the hundreds of millions of kids who would have been just fine without the change.
posted by gurple at 9:50 AM on April 14


That was quite harrowing reading. That the WHO recommended c-sections make up only 15% of births, but in Brazil it's 82%, is staggering.

"There are countries where birth is industrialized and dominated by men, and there's very little input from women.”

I'd suggest it's the majority of them.
posted by billiebee at 9:52 AM on April 14 [2 favorites]


That the WHO recommended c-sections make up only 15% of births

I am very into reducing the number of C-sections, but I think it's important to point out that the WHO has stepped back from the 15% number because they didn't have a lot of evidence supporting it. It's clear that anything north of 30% is probably too high (we can tell that from maternal mortality and morbidity statistics, if nothing else) but the sweet spot isn't really known.
posted by KathrynT at 10:00 AM on April 14 [2 favorites]


the WHO recommended c-sections make up only 15% of births

That struck me as an odd statement. Presumably it means something like "the WHO recommended that C-sections are only used in specific circumstances, which just happen to constitute 15% of births"? Does anyone know what those circumstances are?
posted by metaBugs at 10:03 AM on April 14


The high rate of c-sections in Brazil has been looked at in medical circles for some time, with much head scratching done over its causes and what should be done to improve the numbers. As often as not it is used to show "hey, the US isn't that bad!" At the other extreme, many poor countries, especially in sub-Saharan Africa have rates in the single digits, with Chad coming in at 0.4% (source) Unfortunatels a high rate of maternal and infant mortality accompanies these very low c-section rates.

Concern over medicalization of pregnancy and childbirth is nothing new. When James Young Simpson began using ether and chloroform during deliveries he was strongly criticized by both the medical establishment and clegy, often using Genesis 3:16 as justification for not relieving the pain of labor and delivery. Supposedly it was not until Queen Victoria insisted on anesthesia during the birth of Prince Leopold ("We are having this baby and we are having the chloroform!") that it became more acceptable. More on Simpson and OB anesthesia here.
posted by TedW at 10:06 AM on April 14 [5 favorites]


metaBugs, it's not really like that. the recommendation was based on a belief that maternal and infant morbidity and mortality were lowest when C-sections occurred in about 15% of births, but a closer examination found that conclusion wasn't based on rigorous research. It's hard to do the research rigorously because cohort studies are rife with so many confounding variables, and blind studies are both ethically impossible and also practically impossible. Basically, we need more observation over both population and time to come up with a more reliable number.
posted by KathrynT at 10:08 AM on April 14 [3 favorites]


KathrynT, that still sounds odd to me. I can't wrap my head around making a statement that's more focused on how many patients than on which patients; it just doesn't seem like useful information. It does sound like it'd be nightmarishly difficult to do good studies though, so I can easily believe that the data just isn't there.
posted by metaBugs at 10:19 AM on April 14


that still sounds odd to me. I can't wrap my head around making a statement that's more focused on how many patients than on which patients; it just doesn't seem like useful information.

It's not "do it to this many people," it's "we find that the best outcomes occurred in situations where it was done to this many people." Which makes perfect sense to me, because some women would die without them and some women are more hurt than helped by them, so some percentage more then 0% and less than 100% is clearly optimal.
posted by showbiz_liz at 10:22 AM on April 14


I can't wrap my head around making a statement that's more focused on how many patients than on which patients

Well, the thing is -- there are some situations that clearly, obviously require a C-section. Transverse breech, complete previa, placental abruption, situations like that where without surgery, the risks to mother and baby are extreme. Then there are situations where statistically a section is overwhelmingly safer but where women nonetheless deliver vaginally all the time -- stuff like toxemia (pre-eclampsia) and gestatational diabetes, or frank breech, or twin births. (The risk/reward ratios are different for all of those, obviously.) Then there are situations where a section MIGHT be better or might not -- big baby, long labor, tired mom -- and the problem is that while the best outcome is a vaginal birth, the second best outcome is a C-section on a well-rested mother, and the distant third best is a crash section on an exhausted mom with a baby in distress, which provides a strong incentive towards making the C-section call earlier. I believe, though I can't cite you a source, that this last situation describes the majority of C-sections in this country, and it's the hardest one to draw rules about because you can't split the timeline and follow the identical case in two different scenarios. So you HAVE to study the issue in the aggregate.
posted by KathrynT at 10:34 AM on April 14 [7 favorites]


What a horrifying thing do to put a pregnant and in labor woman. Reading some of the comments the doctor's made to the women made me think of My OB Said What!?!. It amazes me that people who are working in an OB profession have such callous attitudes towards women.
posted by Suffocating Kitty at 10:35 AM on April 14


Oh, it's not just OBs. There are horrible people in every field but I think doctors get get away with it because a lot of folks can't call them on their shit, either because of a power differential or the urgency of the situation. The doctor examining our newborn adopted son reassured my wife that maybe someday she's have a child of her own. ("I do have a child of my own. You're holding him." was her IMO light-on-the-stabbing response)

I can certainly see the idea that a male-driven process would result in more c-sections; personally I'm amazed anyone opts for anything else, based on my dude-centric view of the process. I'd be drugged up and begging to have someone make an alternate exit.
posted by phearlez at 10:45 AM on April 14 [3 favorites]


Oh, and when you study the issue in the aggregate, you that, for example, the maternal mortality rates in California tripled in a decade, during a time period when C-sections went from 22% of all births to 35% of all births. (That paper also discusses several other possible factors, and makes really interesting reading.)
posted by KathrynT at 10:45 AM on April 14 [1 favorite]


Huh. Interesting, thanks!
posted by metaBugs at 10:47 AM on April 14


Oh, it's not just OBs.

The crux of this issue is that OBs are pathologists, and pregnancy and births are not illnesses.
posted by MisantropicPainforest at 10:48 AM on April 14 [2 favorites]


I can certainly see the idea that a male-driven process would result in more c-sections; personally I'm amazed anyone opts for anything else, based on my dude-centric view of the process.

Well, as much as squooshing a human out of your vag sounds unpleasant, so does having somebody slice through your abdominal wall and into your internal organs, leaving you to heal a pretty serious wound while also being responsible for a newborn.
posted by showbiz_liz at 10:48 AM on April 14 [5 favorites]


personally I'm amazed anyone opts for anything else,

well, here's one reason why not to: statistically, it is much easier to recover from a vaginal birth than from a C-section. There are outliers on either side and a lot of overlap, from women who needed significant reconstruction after vaginal births to women who needed only ibuprofen for the pain after a C-section and were up and running around within a day or so, but overall -- populations again -- vaginal delivery involves fewer complications and a shorter recovery time.
posted by KathrynT at 10:49 AM on April 14 [2 favorites]


I recently overheard a conversation between two women who were planning to have C sections to avoid birth impacts to their vaginas. It was a momentary view into what is for me a foreign world.

Voluntary cosmetic C sections are one thing; involuntary (or as the less bad of two crappy options) is much worse.
posted by Dip Flash at 10:56 AM on April 14


research showing that there were more c-sections done in a certain US hospital when the maternity unit was busy: in order to lighten their work load the maternity staff was off-loading patients onto the surgical unit.

It doesn't work like that. OB nurses don't make the call on whether it's a vaginal or c/s birth, it's the doctor and/or midwife. Additionally, c/s patients stay on the OB floor and are cared for by OB nurses and usually (not always, but usually), there is an entire seperate operating room on the OB floor used for c/s patients.
posted by hollygoheavy at 11:01 AM on April 14 [1 favorite]


this is also in Brazil - while I'm not sure what the particulars of their healthcare system are

From the article:
Brazil has a free, public healthcare system, but many of its wealthier residents–about a quarter of the population–use a private insurance scheme that functions much like the U.S. medical system.

With the higher price of the private system comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.
Emphasis mine. Not the only factor, clearly, but the bifurcated system certainly isn't helping. The article notes that 82% of births in private hospitals were via C-section, while that number was "roughly half" in public hospitals.
posted by Panjandrum at 11:03 AM on April 14


I'm no doctor, but with Mrs w0mbat it looked to me like the epidural stopped her delivery from progressing normally (she was doing fine up to that point), which is why a c section was later required. Also the digging around in her spine with a needle to do the epidural seems to have fucked up her back permanently. I suspect that left to her own devices we would have got a baby the normal way, and it would have been worth it for her to not have to go through c-section recovery and to not have back pain now, over a year later.
posted by w0mbat at 11:06 AM on April 14


research showing that there were more c-sections done in a certain US hospital when the maternity unit was busy: in order to lighten their work load the maternity staff was off-loading patients onto the surgical unit.

It doesn't work like that. OB nurses don't make the call on whether it's a vaginal or c/s birth, it's the doctor and/or midwife. Additionally, c/s patients stay on the OB floor and are cared for by OB nurses and usually (not always, but usually), there is an entire seperate operating room on the OB floor used for c/s patients.


One, nurses don't make the call but they certainly have power over a prostrated patient who is experiencing severe pain. Two, c sections are not done on different floors/rooms/wards in every US hospital.

source: partner is L&D nurse.
posted by MisantropicPainforest at 11:06 AM on April 14


I just figured having the C-section option made it easier for the doctor to change the delivery time than his tee-off time at the golf course.
posted by George_Spiggott at 11:23 AM on April 14


Well, OBs also see birth injuries, stillbirths, 4th degree tears, newborns who need resuscitation, shoulder dystocias, cord prolapses...

Anyway, maybe we could focus this on the article instead of general birth-in-the-us stuff.
posted by the young rope-rider at 11:44 AM on April 14 [6 favorites]


It's not "do it to this many people," it's "we find that the best outcomes occurred in situations where it was done to this many people." Which makes perfect sense

But the number for, say, African-American women who haven't given birth and who have high blood pressure is different than the number for Hispanic women who are obese and have successfully had two vaginal births.

Older first-time mother. Twins. Midline defects.

There's not one type of woman + fetus combination that has x chance of needing a c-section. There are a bunch of risk factors that vary widely among different groups.
posted by the young rope-rider at 11:52 AM on April 14 [1 favorite]


São Paulo experience: My wife gave birth to Yuri in a bathtub, in the only hospital we found that had the facilities and allowed her plan (no interventions, no IV, no anaesthesia, etc). Everything went perfectly, I was in the bathtub with her during the whole process and if we had complications of any kind there was medical help available. To do this we had to pay for our own OB nurse and doula as the "natural" course of things in the hospital would have been a c-section. All the other babies born on same day in that same hospital were via c-sections. To get to this point we went through 7 different doctors... some said they "don't do natural births" others that she was "too old" (39) to try it. One thing that totally helped was seeing a presentation by the creator of the Active Childbirth movement Janet Balaskas, who explained what a positive difference having a natural birth makes.

So many friends said they would "try" having natural birth and ended up having c-sections we now have learned that the only way to avoid them is to arrive in the hospital with your own team and a printed plan detailing exactly what one allows.

Private health plans in Brazil pay doctors more for c-sections than for assisting natural birth, so it is inevitably easier for them to schedule several c-sections instead of waiting an indeterminate number of hours for a mother in labor to take the natural time needed. Most people in Brazil cannot afford this option and end up having c-sections.

I am happy to see this being discussed more and hopeful that this terrible statistic changes in the future. Films like "O Renascimento do Parto" are important and useful in helping to change the current situation.
posted by ig at 11:55 AM on April 14 [8 favorites]


I can certainly see the idea that a male-driven process would result in more c-sections; personally I'm amazed anyone opts for anything else, based on my dude-centric view of the process.

I bet you there's money involved somehow too. Taking the profit motive out of healthcare would immediately improve health outcomes for the whole population.

And speaking of the dude perspective, the whole idea is inconceivable to me. It's a weird thing, I spent six months in the hospital recovering from a near fatal motorcycle accident, and was pretty cavalier about it, but when I recently went to visit a friend in the hospital shortly after she gave birth, I practically passed out - and this is after the deed was already done, and she was recovering. It's like the creature-bursting scene from Alien, except it happens regularly to your neighbors and acquaintances. And while she was cheerfully pregnant I had to constantly fight to suppress unwanted thoughts every time I saw her: "don't you know what awaits you??!!". Then you add the whole other dimension of the doctors who might not even have your best interests at heart, and you wonder how any births happen at all. Society should be doing everything possible to make the process easier, and also richly rewarding women for giving birth, I say.

If men had to give birth, I think we'd have offloaded that process into other hosts or lab vats by now - none of that pregnancy and birth business. You donate the egg and sperm and the lab takes care of the rest and nine months later you pick up your baby. I remain convinced that this is the future anyhow - two, three hundred years from now natural birth will be seen as too stressful for most.

I wonder if the ACA will change the C-section stats at all in the U.S., or if that's not a factor.
posted by VikingSword at 12:00 PM on April 14


I remain convinced that this is the future anyhow - two, three hundred years from now natural birth will be seen as too stressful for most.

You know, one time I said this to my mom, and she said she'd never have chosen to miss being pregnant. Of course many women have terrible pregnancies, but I think a not-insignificant number of women enjoy it.
posted by showbiz_liz at 12:08 PM on April 14 [3 favorites]


So there must be some evolutionary advantage traded for the pain. My theory is that the pain is a bonding mechanism. The mother has a memorable investment in the child, and if birth were painless and quick, the mother might be less attached.

What we do have, interestingly enough, is a phenomena experienced by many women (including myself) where you honestly can't remember the pain afterwards. I don't remember labour hurting at all (though I do remember screaming, as one does).

This article completely horrified me in every way.
posted by jokeefe at 1:39 PM on April 14


Lest you're tempted to read this as somehow an issue of an underdeveloped nation, Italy is another poster-child for excessive C-sections: though I don't have the comparable percentage for private clinic C-section births (which the article has at 82% in Brazil), the overall national percentage in Italy was 38% in 2008, with some regions above 60% - and it's surely risen since then...
posted by progosk at 12:17 AM on April 15


I can't resist commenting on the evolutionary thing: the pay-off for the HIGH RISK OF DEATH relative to other mammals for humans giving birth (not just pain!) is that we get big brains in big heads, and pelvises with minimally sized openings that can actually support our weight while walking upright. Pain makes bonding harder, not easier.

More importantly, it does not seem hard to me at all to explain high C-section rates without malice or greed or laziness: C-Sections put doctors in control of the process. Vaginal deliveries put no one in control of the process.

Would you rather take a ride on a boat with a motor and a rudder, or just drift down the river? What if you're the boat pilot, responsible for getting your passengers safely to their destination? Rudder, or no rudder? And if you'd seen data that showed that even though on a clear day the "drifting" is perfectly safe and more pleasant and you can catch a line at the other end and tow yourselves to shore, you've also seen data that shows that any kind of turbulance at all means the risks of death or permanent disability go way up, and especially especially if you've actually been on some of those drifting boats and actually seen some of those people die, sometimes because of sandbars no one could have known about?

Humans like to be in control of our situations, of our life-and-death risks! Doctors especially, and scared pregnant women, would like to know that someone is at the wheel.
posted by OnceUponATime at 9:16 AM on April 15 [1 favorite]


It's also notable that the C-section is a balance between the well-being of the mother and the baby. If you completely ignore the effects to the mother, a C-section for a healthy, term baby is probably safer for the baby in most cases. Of course, ignoring the effects to the mother is a serious devaluation of her as a person with her own interests and rights.

I can't help but point out that abortion is mostly illegal in Brazil.

Women are seriously devalued relative to fetuses in both cases.
posted by the young rope-rider at 9:19 AM on April 15 [1 favorite]


C-Sections put doctors in control of the process. Vaginal deliveries put no one in control of the process

I'm not sure I agree with that. With a vaginal birth a woman is in control (ideally) of whether she wants to squat, lie down, be in water, be in her partner's arms etc. With a c-section she is on a hospital bed and with a screen covering what's happening, with medical staff doing their thing, and generally having no input into the process. I think I'd rather have the natural process (where possible) where at least I felt my body had done this incredible thing it was designed to do, however painfully, than hand over all control to doctors and turn it into a surgical procedure.
posted by billiebee at 11:33 AM on April 15 [3 favorites]


The description in TFA and in other articles I've googled since reading it sounds like what's going on in other countries but taken to a whole other realm of extremes, and done more overtly. For instance, in the U.S. you can hire a doula to advocate for you but not openly bribe the doctor for better treatment.
posted by The Underpants Monster at 12:57 PM on April 15


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