SAO PAULO, Brazil — The rate in the United States for elective Caesarean sections is 32.9 percent. Brazil, meanwhile, has one of the highest rates of these operations in the world; C-sections account for 55.5 percent of all deliveries in Brazil, spiking to 84 percent in private hospitals, according to the Public Health Ministry.

Why? These operations have long been a status symbol among the country’s elite, a way for some of the country’s wealthier women to avoid the unpredictability of natural childbirth.

Now the phenomenon is inspiring a new industry of party planners, makeup artists and caterers, focused on turning these highly orchestrated operations into wedding-like spectacles, produced for an audience.

The presidential room of the Sao Luiz hospital in Sao Paulo rents for about $500 a day. (Pétala Lopes/For The Washington Post)
The presidential room of the Sao Luiz hospital in Sao Paulo rents for about $500 a day. (Pétala Lopes/For The Washington Post)

The main event: The birth itself, viewed by family and friends from a gallery built for the purpose.

At the Sao Luiz private hospital in Sao Paulo, a mother-to-be can get her hair and makeup done in her hospital room. For 2,000 reais per day — about $500 — her family can rent out the presidential suite, with a living room and bathroom for guests, a balcony and minibar. Mothers can request their favorite flowers and magazines, and even change the furniture if it clashes with their planned decorations. A 22-story maternity ward now under construction will include a wine cellar and ballroom.

Family members wait at Sao Luiz. (Pétala Lopes/For The Washington Post)
Family members wait at Sao Luiz. (Pétala Lopes/For The Washington Post)

“It’s cultural,” said Marcia da Costa, the hospital’s director. “Brazilians want to plan for everything. They don’t want to hit traffic on the way to the hospital. They want to get their nails done, get a wax, to plan it like an event.”

The controversy of C-sections

Still, da Costa and other health professionals are ambivalent. The World Health Organization has long campaigned to reduce elective C-sections, which are nearly twice as deadly for mothers than natural births and require longer recovery times for mothers and babies.

In Brazil, public health officials and some of the country’s top doctors have worked to cure the upper class of its penchant for the procedure.

Costs vary, but C-sections are generally more expensive than natural childbirths. While the risk of maternal death in well-equipped private hospitals is low, hemorrhage and infection are more likely in an elective Caesarean than in a natural birth. For babies, C-sections have been linked to higher rates of respiratory distress, diabetes and high blood pressure.

The WHO estimates that about 10 percent of births require a C-section.

“Here we had the opposite statistics,” said Rodrigo Aguiar, a director at Brazil’s National ­Supplementary Health Agency, which regulates private hospitals.

The numbers were even more pronounced during the holiday months, he said, when women and doctors called for elective C-sections before the baby was ready to be born. This led to higher rates of respiratory problems for infants and prolonged hospital stays for both mothers and babies.

A room is prepared for a C-section celebration at Albert Einstein Maternity Hospital. (Pétala Lopes/For The Washington Post)
A room is prepared for a C-section celebration at Albert Einstein Maternity Hospital. (Pétala Lopes/For The Washington Post)

“We saw that we had to reevaluate these percentages and make sure that birth decisions were being geared toward the health of the mother and the child, and not for convenience,” Aguiar said.

Brazil’s Health Ministry has taken steps to reduce what it calls the Caesarean “epidemic.” In 2016, the government banned medically unnecessary C-sections before 39 weeks.

Brazilian women historically have had good reason to fear natural birth. The country’s overwhelmed public health system meant that doctors and nurses lacked the resources to closely monitor women through hours of labor. C-sections allowed the staff to closely monitor mothers for a shorter amount of time.

A luxury room at Einstein. (Pétala Lopes/For The Washington Post)
A luxury room at Einstein. (Pétala Lopes/For The Washington Post)

At private hospitals, the procedure has gained favor both among mothers — who want their personal doctors, not the on-call staff at the hospital, to deliver their babies — and among doctors juggling busy schedules.

Olímpio de Moraes Filho, a member of the Brazilian Federation of Obstetrics and Gynecology, says Caesarean sections fit some lifestyles.

“C-sections today are much safer than they were 30 years ago,” he said. “Things are changing. Women are in the job market. Couples are trying to schedule a moment when the family can get together.”

A scene at the hospital

At the Albert Einstein Maternity Hospital in Sao Paulo, the party starts before the baby is born. A frosted window looking into the operating room turns transparent for the surgery, allowing guests to see the moment of the birth.

As Mariana Casmalla, a 28-year-old dental surgeon, was wheeled to her operating room, 15 of her closest family members and friends trailed behind. They gathered around the window, ears pressed to the wall, listening for the baby’s first wail.

Families prepare to view Casmalla’s delivery at the hospital. Pictured are paternal grandmother Marisol Casmalla, 54, and great-grandmother Nadir Pereira da Silva, 78. (Pétala Lopes/For The Washington Post)
Families prepare to view Casmalla’s delivery at the hospital. Pictured are paternal grandmother Marisol Casmalla, 54, and great-grandmother Nadir Pereira da Silva, 78. (Pétala Lopes/For The Washington Post)

When the doctor pulled Lorena from the incision in Casmalla’s abdomen, the window turned transparent. Casmalla gave the audience a thumbs-up.

“She’s here!,” said Casmalla’s mother-in-law, Marisol, tearing up. Relatives watching on FaceTime asked for closer looks.

Paula Ascar Baracat is co-founder of Estudio Matre, a ­party-planning service that specializes in maternity wards. She says new mothers increasingly prefer receiving guests at the hospital, rather than at home.

Bruna Viera, 32, left, receives family members after delivering her son by C-section. (Pétala Lopes/For The Washington Post)
Bruna Viera, 32, left, receives family members after delivering her son by C-section. (Pétala Lopes/For The Washington Post)

“The mom has just given birth, she is learning to breast-feed, she doesn’t want to entertain at home,” Baracat said. “So while she’s getting ready for the birth, we are getting ready to host.”

Baracat’s clients spend upward of $10,000 for services that include floral arrangements, guest books, monogrammed sheets, personalized water bottles, and silver-plated favors for guests.

The push for natural births

Women who have natural births often seek these services, too. Nina Materna, another ­party-planning service, has three hotlines that women can call as they go into labor. The company promises to have fully sterilized decorations up within eight hours. But C-sections allow mothers another level of planning.

Nina Materna has three hotlines that women can call as they go into labor. (Pétala Lopes/For The Washington Post)
Nina Materna has three hotlines that women can call as they go into labor. (Pétala Lopes/For The Washington Post)

In 2015, Linus Pauling Fascina, director of the maternity ward at Einstein, called together doctors, doulas, midwives, feminist activists and government officials to discuss ways to increase the rate of natural births in Brazil’s private hospitals.

The group launched the Appropriate Birth Project, a partnership with 35 hospitals to prioritize natural deliveries among the country’s elite.

One of their first steps was to bring the luxury and family experience associated with Caesareans to natural childbirth.

Nina Materna advertises its party-planning services at a trade show for baby products. (Pétala Lopes/For The Washington Post)
Nina Materna advertises its party-planning services at a trade show for baby products. (Pétala Lopes/For The Washington Post)

Einstein hospital opened five new natural-birth centers with private showers and tubs. At Sao Luiz, women giving birth naturally can choose the color of the lighting of their in-room whirlpool bathtubs. Fairy lights on the ceiling can turn blue or red, depending on the mood of the patient. All rooms are equipped with MP3 players that patients can load with personalized playlists.

Results came quickly. In four years, the rate of natural births at Einstein rose from 18 percent to nearly 50 percent. The program has expanded to more than 200 hospitals.

“The changes have to be concurrent for everyone: women, their families, their workplace, doctors, nurses,” Fascina said. “When the husband comes in and says, ‘I’m working, I need to know the date of the birth’ — it’s about learning to plan for the unplannable.”

For Bruna Viera, 32, a natural birth was always out of the question.

“It doesn’t fit with our lifestyle,” she said. “I’m a doctor, and my husband is, too. We have a very planned life and had to take vacation for the baby to be born.”

Viera spent weeks planning the drinks and decorations for her maternity room at Sao Luiz. By the time baby Arthur made his debut last month, her hospital room was decorated with blue and white balloons, the fridge was stocked with rum barrel-aged beer, and the table of her luxury suite was lined with succulent plants — parting gifts for the 80 guests she expected that weekend.

Fernando Tagliarine, 32, holds newborn son, Arthur. (Pétala Lopes/For The Washington Post)
Fernando Tagliarine, 32, holds newborn son, Arthur. (Pétala Lopes/For The Washington Post)

“I love it,” she said. “You feel the tenderness people have for you. Many moms suffer from postpartum depression and feel isolated. Your hormones are raging. But to be surrounded by the people you love, people who saw you grow up, is extraordinary.”

As a half-dozen of her mother’s friends cooed at the baby, her husband popped open a bottle of wine.

Grandmother Lucimeire Viera swayed baby Arthur in her arms while holding a glass of merlot.

“You see, darling,” she explained to the baby. “Life’s a party.”

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