Objectives To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment. Design Population based birth cohort study, using ethnographic and epidemiological methods. Setting Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed. Participants 5304 women who gave birth in any of the city's hospitals in 1993. Main outcome measures Birth by caesarean section or vaginal delivery. Results In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education. Conclusions Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

Pacifiers may be an effective weaning mechanism used by mothers who have explicit or implicit difficulties in breastfeeding, but they are much less likely to affect infants whose mothers are confident about nursing. Breastfeeding promotion campaigns aimed specifically at reducing pacifier use will fail unless they also help women face the challenges of nursing and address their anxieties. The combination of epidemiologic and ethnographic methods was essential for understanding the complex relations between pacifier use and breastfeeding.

This paper describes the main methodological aspects of a cohort study, with emphasis on its recent phases, which may be relevant to investigators planning to carry out similar studies. In 1993, a population based study was launched in Pelotas, Southern Brazil. All 5,249 newborns delivered in the city's hospitals were enrolled, and subsamples were visited at the ages of one, three and six months and of one and four years. In 2004-5 it was possible to trace 87.5% of the cohort at the age of 10-12 years. Sub-studies are addressing issues related to oral health, psychological development and mental health, body composition, and ethnography. Birth cohort studies are essential for investigating the early determinants of adult disease and nutritional status, yet few such studies are available from low and middle-income countries where these determinants may differ from those documented in more developed settings. Resumo

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Based on an ethnography of the international Safe Motherhood Initiative (SMI), this article charts the rise of evidence-based advocacy (EBA), a term global-level maternal health advocates have used to indicate the use of scientific evidence to bolster the SMI's authority in the global health arena. EBA represents a shift in the SMI's priorities and tactics over the past two decades, from a call to promote poor women's health on the grounds of feminism and social justice (entailing broad-scale action) to the enumeration of much more narrowly defined practices to avert maternal deaths whose outcomes and cost effectiveness can be measured and evaluated. Though linked to the growth of an audit- and business-oriented ethos, we draw from anthropological theory of global forms to argue that EBA—or “playing the numbers game”—profoundly affects nearly every facet of evidence production, bringing about ambivalent reactions and a contested technocratic narrowing of the SMI's policy agenda.

BackgroundLittle is known about the impact of life-threatening obstetric complications (‘near miss’) on women’s mental health in low- and middle-income countries.AimsTo examine the relationships between near miss and postpartum psychological distress in the Republic of Benin.MethodOne-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities.ResultsIn total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth.ConclusionsA live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

This paper explores the social and institutional processes that constrain and enable obstetric patients in Benin to critically evaluate quality of healthcare and to stimulate positive changes in the health system. Based on qualitative data collected as part of a hospital auditing system, the paper analyses semi-structured patient feedback interviews and their function as a primary mechanism through which critical patient evaluation can develop constructively. Using a Bourdieuan framework, we explore the dynamic social conditions that give rise to transformative agency and institutional change. Our results show that hospitals are often permeated with the habitus of employment, kinship and reproductive social fields, through which a number of social, economic and healthcare conflicts, power struggles and blame-inducing interactions emerge. These conflicts generally serve to keep patients quiescent and passive when it comes to developing critical statements of quality of care. In a subset of cases, however, these conflicts are transformed by patients and their family members into opportunities for modifying the values and practices of each habitus in new and creative ways. The active negotiation of social conflict and blame enabled a minority of patients actively to divert blame from themselves and to develop and maintain critical healthcare evaluations.

Given the growing recognition of the importance of the life course approach for the determination of chronic diseases, birth cohort studies are becoming increasingly important. This paper describes the methods used in the 1982 1983, 1984, 1986, 1995, 1997, 2000, and 2001 em 1983, 1984, 1986, 1995, 1997, 2000