Brazil’s Debate Over ‘Obstetric Violence’ Shines Light On Abuse During Childbirth

The term “obstetric violence” has been used in Brazil for years to describe a type of abuse of women that occurs during childbirth and was first officially recognized in the country about a decade ago. But recently, the term itself has been under threat.

In an official order published in May, the Brazilian Ministry of Health advised that the term should be avoided and, if possible, banned from government public policy documents.

“The term ‘obstetric violence’ adds no value, and, therefore, strategies have been put in place to ban its use, focusing on ethics and the provision of qualified health care,” the ministry said.

Given that “neither health care practitioners nor other professionals intend to cause damage or harm” to pregnant women, the May directive said, people shouldn’t talk about practices of violence. The ministry said it was working to “evaluate care for labor and delivery.”

After backlash from medical specialists, activists, and human and women’s rights groups, the ministry slightly altered its position. It said that it would recognize the term “obstetric violence” when it was used by women, but that it wouldn’t change its policy about government documents.

Read on to learn what obstetric violence is, how it happens and what can be done to fight it.

The World Health Organization and the International Federation of Gynecology and Obstetrics recognize that abuse, mistreatment and disrespect suffered by a woman during pregnancy, childbirth or the postpartum period is a problem. Some countries, like Brazil, refer to this as “obstetric violence,” while others see that term as more contentious and controversial.

Such violence may be carried out by a variety of professionals dedicated to women’s care, said Ana Lúcia Keunecke, an attorney and member of the Network for the Humanization of Delivery and Birth.

“It’s not just doctors. It could be nurses or even the hospital receptionist,” she said. “Any action that interferes with a woman’s autonomy or causes her to lose her ability to make decisions about her own physiological processes is recognized as obstetric violence.”

Doctors say childbirth should be safe and that decisions around childbirth should be made based on scientific evidence, input from a multidisciplinary team, and the pregnant woman’s choice. Any action that compromises one of those elements could be considered obstetric violence.

“Damage to a woman’s autonomy is obstetric violence, damaging scientific evidence is obstetric violence, and having an incomplete team is obstetric violence,” said obstetrician Braulio Zorzella. 

Obstetric violence can be physical, verbal or psychological and can occur to greater or lesser degrees.

A guide published by NUDEM, a group that promotes women’s rights and is affiliated with the public defender’s office of São Paulo, offers examples that show the range of possible abuse:

• Denying the right to a companion. Since 2005, women in Brazil have had the legal right to have a companion during childbirth, regardless of the type of procedure.

• Undertaking interventions on a woman’s body without explanation or consent. This includes removing pubic hair and performing an episiotomy indiscriminately or without medical recommendation.

• Making embarrassing, offending, insulting or humiliating comments to the woman. These could refer to her skin color, race, ethnicity, age, education, family or marital status, sexual orientation or number of children.

• Not providing proper hydration or nutrition during labor.

• Not allowing the woman to get up or move around during labor, or forcing her to remain in one position.

• Applying pressure to the abdomen to push out the baby, which is known as the Kristeller maneuver.

• Scheduling a cesarean section without proper medical recommendation and without the woman’s consent. 

• Providing any aspect of health care without taking into consideration the pregnant woman’s needs and questions.

This should not be taken to suggest that all interventions are obstetric violence. “If the professional has explained things ahead of time and made it clear while it was being done that it was the last resort, it is not necessarily violence,” Keunecke said.

Many health professionals in Brazil struggle with problematic working conditions that can end up leading to obstetric violence, according to Zorzella. 

“The fact that a doctor can be on a shift with 10 births taking place at the same time, for example,” he said. “This is a form of violence against them that can often result in obstetric violence against women.”

“If a doctor is working in a hospital that is understaffed, that is already a strike against” their ability to treat patients appropriately, Zorzella said. “If he or she is dealing with obsolete protocols and is forced to observe those protocols or face reprimand, that is going to cascade into obstetric violence, and this happens a great deal in Brazil ― lack of structure and outdated protocols.”

Keunecke agreed that working conditions for health professionals in Brazil are often difficult, and she highlighted the importance of a multidisciplinary team during childbirth “so that the doctor is there just for the actual birth, and doulas, midwives, and nurses can handle other phases of the process.”

Zorzella said another issue comes up when doctors are hired by health insurance companies and paid a flat rate for childbirth, which doesn’t take into consideration the amount of time spent or the type of procedure needed.

“They earn the same amount whether they perform a scheduled cesarean section or if they spend 18 hours with a laboring woman without knowing when the birth will take place,” he said. “That’s a form of workplace violence against them that frequently cascades into obstetric violence against the woman, because the doctor then goes ahead and schedules a cesarean section. I’m not saying they’re right when doing this, but I do want to point out their challenges.”

And some medical professionals in Brazil, Zorzella noted, may not be “up to date” on best practices in childbirth and what actually constitutes obstetric violence. 

For example, he said, they may routinely perform an episiotomy ― a surgical incision of the muscle tissue between the vagina and anus ― even where it’s no longer recommended.

“This is a procedure that was invented in the 18th century to prevent lacerations that occurred due to the Kristeller maneuver, which is the act of pushing on the abdomen, placing a great deal of pressure on the woman’s perineum,” Zorzella said. “That’s how such tearing can happen.”

But “nowadays, doctors are not aware of where it came from,” he added. “They learn that they must do it and they do it.”

After the baby is born, the episiotomy incision has to be sewn back up. In Brazil, that procedure typically includes a so-called “husband stitch” ― an additional stitch that closes up the vagina more than necessary but enhances a man’s pleasure during sex. That’s obstetric violence too.

Obstetric violence is likely an underreported phenomenon in Brazil. Research coordinated in 2014 by Fiocruz, a public health research institution in Rio de Janeiro, found that 1 in every 4 Brazilian women have suffered such violence, but the actual number is thought to be higher.

“Many remain silent, like women who are victims of sexual violence,” Zorzella said. “They hesitate to speak up, they are afraid of the system, and for every three who don’t report it, there are certainly more women who suffer without knowing that it was violence because they think it is normal.”

Women in Brazil who believe they have been victims of such violence have a few resources, such as filing a claim with the Health Ministry or the hospital’s ombudsman office. Beyond these administrative measures, which offer no compensation for the woman, it is also possible to seek an attorney and claim damages. 

Creating a birth plan ahead of time is one tool women can use to fight back against obstetric violence, experts say, and it’s recommended by the WHO. A simple document can outline a pregnant woman’s wishes, preferences and decisions related to childbirth. Though there is obviously much about childbirth that is unforeseeable, this birth plan can then serve as a kind of guide for her medical team, as well as aid any possible legal actions if there are violations.

“The best path is information, prenatal care and a multidisciplinary team in which each member has a role to play and respects a woman’s individuality,” Keunecke said.