Abstract

Introduction

In all societies, childbirth has always been surrounded by cultural, social, emotional and affective values¹1. Domingues RM, Santos EM, Leal MC. Aspectos da satisfação das mulheres com a assistência ao parto: contribuição para o debate. Cad Saude Publica. 2004; 20 Suppl 1:52-62. . judicialization. Traditionally restricted to the female universe and to the home environment, since the institutionalization of health care in the middle of the twentieth century Medicine entered this field, of whose dynamics it had little knowledge and in which it made countless mistakes²2. Tornquist CS. Paradoxos da humanização em uma maternidade no Brasil. Cad Saude Publica. 2003; 19 Suppl 2:419-27. . Thus, the female body became the legal property of physicians and from a medicalized perspective it has ever since been seen as essentially defective, unpredictable, and dangerous³3. Diniz CS. Humanização da assistência ao parto no Brasil: os muitos sentidos de um movimento. Cienc Saude Colet. 2005; 10(3):627-37. . It is now subject to medical protocols and to various routine interventions, many of which are violent and of dubious efficacy⁴4. Giffin K. Violência de gênero, sexualidade e saúde. Cad Saude Publica.1994; 10 Suppl 1:146-55. . One explanation for this scenario is that childbirth care is oriented by a strong gender bias, which sees women not as subjects with rights, but as objects of action⁵5. Hotimsky SN, Rattner D, Venancio SI, Bógus CM, Miranda MM. O parto como eu vejo... ou como eu o desejo?: expectativas de gestantes, usuárias do SUS, acerca do parto e da assistência obstétrica. Cad Saude Publica. 2002; 18(5):1303-11. , a view which is further permeated by blame assignment to female sexuality.

A hospital-based, interventionist and overly medicalized delivery model is thus strengthened⁶6. Maia MB. Humanização do parto: política pública, comportamento organizacional e ethos profissional na rede hospitalar pública e privada de Belo Horizonte [dissertação]. Belo Horizonte: Pontifícia Universidade Católica de Minas Gerais; 2008. , where the risks inherent to the process of giving birth are replaced by the potential risk of certain treatments and interventions³3. Diniz CS. Humanização da assistência ao parto no Brasil: os muitos sentidos de um movimento. Cienc Saude Colet. 2005; 10(3):627-37. , reducing a social, cultural and, health event to a pathological, medical, and fragmented phenomenon²2. Tornquist CS. Paradoxos da humanização em uma maternidade no Brasil. Cad Saude Publica. 2003; 19 Suppl 2:419-27. .

Since 1970, there has been increased recognition of this scenario, and social movements started fighting for “demedicalization”, for humanization of care and for females to recover autonomy over their bodies and health³3. Diniz CS. Humanização da assistência ao parto no Brasil: os muitos sentidos de um movimento. Cienc Saude Colet. 2005; 10(3):627-37. .

In 1985, the World Health Organization (WHO) published recommendations (reviewed in 1996) for childbirth care, which summarize research evidence, guide the revision of protocols using appropriate technology, and advocate the legitimacy of delivering women’s decisions²2. Tornquist CS. Paradoxos da humanização em uma maternidade no Brasil. Cad Saude Publica. 2003; 19 Suppl 2:419-27. , ⁷7. Sadler M, Santos MJ, Ruiz-Berdún D, Rojas GL, Skoko E, Gillen P, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters. 2016; 24(47):47-55. . In Brazil, the Ministry of Health (MS) implemented health policies such as the Prenatal and Birth Humanization Program (PHPN) in 2000 and Rede Cegonha (Stork Network) in 2011, which sought to establish a new model of obstetric and neonatal care⁸8. Sena LM, Tesser CD. Violência obstétrica no Brasil e o ciberativismo de mulheres mães: relato de duas experiências. Interface (Botucatu). 2017; 21(60):209-20. . Humanization has become a strategic term for dealing with disrespectful practices of prenatal, childbirth, postpartum and abortion care: obstetric or institutional violence (OV/IV)³3. Diniz CS. Humanização da assistência ao parto no Brasil: os muitos sentidos de um movimento. Cienc Saude Colet. 2005; 10(3):627-37. .

The term obstetric violence was first adopted in Venezuela in 2017 and was defined as “the appropriation by health professionals of the body and reproductive processes of women, expressed in a dehumanizing treatment and abuse of medicalization and pathologization of natural processes,” being recognized as a form of violence against women and an alarming social, political and public problem⁹9. D’Gregorio RP. Obstetric violence: a new legal term introduced in Venezuela. Int J Gynaecol Obstet. 2010; 111(3):201-2. .

The relevance of this type of violence as a legitimate public health problem and violation of women’s human, sexual, and reproductive rights was corroborated by a recent statement by the World Health Organization (WHO)¹⁰10. Organização Mundial de Saúde. Prevenção e eliminação de abusos, desrespeito e maus-tratos durante o parto em instituições de saúde. Genebra: OMS; 2014. , and published in six languages: “Prevention and eradication of abuse, disrespect and ill-treatment during childbirth in health institutions.” It describes several OV/IV categories and examples associated with the lack of quality and of healthcare resources, as well as poor geographic, financial and cultural accessibility, which are additional forms of structural violence that predispose obstetric violence to occur within health institutions.¹⁰10. Organização Mundial de Saúde. Prevenção e eliminação de abusos, desrespeito e maus-tratos durante o parto em instituições de saúde. Genebra: OMS; 2014.

Despite efforts of the scientific community and social movements, the implementation of childbirth humanization policies poses many challenges, as in any other process of change¹¹11. Leitão FJ. Autonomia da mulher em trabalho de parto [dissertação]. Lisboa: Universidade de Lisboa; 2010. . Recently, the survey “Birth in Brazil”, the largest study on labor and childbirth ever conducted in our country, interviewed 23,894 women, evaluated 266 hospitals in 191 Brazilian towns, and found unbelievably high rates of medical procedures not even recommended three decades ago, such as episiotomy (56%), food deprivation during labor (70%), lithotomy position (92%), Kristeller maneuver (37%), and low rates of good practices, such as the presence of an accompanying person (18%) at all times¹²12. Leal MC et al. Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual. Cad Saude Publica. 2014; 30 Suppl 1:S17-32. .

The OV/IV becomes more relevant and visible when understood by different areas, the social movement being of paramount importance in this process, especially the women’s movement and the healthcare consumers’ movement¹³13. Aguiar JM, D’Oliveira AF, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica. 2013; 29(1):2287-96. . When discussing this subject, they are actively claiming their position as victims and social recognition of the violence they were subjected to¹⁴14. Pulhez MM. A violência obstétrica e as disputas em torno dos direitos sexuais e reprodutivos. In: Anais do 10o Seminário Internacional Fazendo Gênero; 2013; Florianópolis, SC. Florianópolis: Universidade Federal de Santa Catarina; 2013. , which is also shaped as institutional and gender violence¹⁵15. Palharini LA. Autonomia para quem? O discurso médico hegemônico sobre a violência obstétrica no Brasil. Cad Pagu. 2017; (49):e174907. .

Recently, some measures have been taken to prevent, to raise awareness on, and to problematize this issue. The Brazilian state of Santa Catarina passed bill no. 17,097 in 2017, which provides for the implementation of informational and protective measures for pregnant women and women in childbirth against obstetric violence¹⁶16. Santa Catarina (Estado). Lei nº 17097, de 17 de Janeiro de 2017. Dispõe sobre a implantação de medidas de informação e proteção à gestante e parturiente contra a violência obstétrica no Estado de Santa Catarina. Diário Oficial da União. 19 Jan 2017. , precisely one year after passing the Doulas Bill no. 16,869 in January 16, 2016, which urges maternity wards to allow the presence of doulas during childbirth, regardless of the presence of any other accompanying person¹⁷17. Santa Catarina (Estado). Lei n. 16869, de 15 de Janeiro de 2016. Dispõe sobre a presença de doulas durante todo o período de trabalho de parto, parto e pós-parto imediato, e estabelece outras providências. Florianópolis; 2016. .

However, some practices usually are not perceived by medical professionals as being violent, and this ends up making doctors consider many practices acceptable, endurable, or even necessary in daily care, which only contributes to a process of trivialization of institutional violence¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. . Thus, violence usually is neither due to poorly trained teams or individuals, nor is it a behavioral exception, but in most cases it happens when performing procedures that also are part of the healthcare protocol of teaching hospitals¹⁵15. Palharini LA. Autonomia para quem? O discurso médico hegemônico sobre a violência obstétrica no Brasil. Cad Pagu. 2017; (49):e174907. .

In view of the above, even evidence suggesting that the experience of disrespect and mistreatment of women during childbirth care is widely spread, there is no international consensus on how these problems can be scientifically defined and measured. As a result, their prevalence and impact on women’s health are unknown. While governmental and civil organizations around the world stress the need to address this issue, policies to promote respectful obstetrical care have not always been implemented or translated into meaningful action, and they are not specific. Therefore, the WHO recommends studies to better define, measure and understand disrespect for women during childbirth, as well as means of preventing and eliminating it¹⁰10. Organização Mundial de Saúde. Prevenção e eliminação de abusos, desrespeito e maus-tratos durante o parto em instituições de saúde. Genebra: OMS; 2014. .

Considering that most OV/IV studies are focused on the perspective of women –users of prenatal, childbirth, postpartum and abortion care services– and the relevance of the discussion being intrinsically related to the meaning perceived by them–, we suggested a study to identify the perception of physicians, who assist childbirth in a public, humanized teaching maternity ward, on this controversial and current topic, deepening the reflection through the individual and institutional dimensions, as well that of human relationships.

Methods

This is a qualitative, epistemologically based study carried out in a humanized maternity ward of a public teaching hospital in south Brazil between February-September 2016 with a sample of 23 physicians involved in childbirth care. The data was sampled by applying a questionnaire with open questions and Likert scale and analyzed by content analysis, with definition of categories by thematic approach. Descriptive statistics were applied for categorical (rate) and continuous (mean and standard deviation (SD)) variables. The project was approved by the Ethics Committee on Research on Humans under CAAE No. 42365215.3.0000.0121, and those who agreed to participate signed a term of free and informed consent.

The term institutional violence (IV) was used as a synonym for obstetric violence (OV) in order to keep both terms used in data collection, when we chose to use alternatively the term “institutional”, as used in previous studies, in order to avoid “epistemological refusal” and not to cause any uneasiness amongst those participants who did not feel comfortable with the term OV. Although they are not synonymous, OV is a form of IV, but it can take place inside or outside an “institution”¹⁹19. Sena LM. Ameaçada e sem voz, como num campo de concentração: a medicalização do parto como porta e palco para a violência obstétrica [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2016. .

Results and discussion

Profile of respondents

The 23 participants in this study are on-call physicians at the obstetrical center of a public maternity ward. Of these, 16 are specialized in gynecology and obstetrics and seven are being trained (medical residency) in this area. Age ranged from 25 to 57 years, with a mean age of 45 years (SD 7.6) for obstetricians and 26 years (SD 1.1) for resident doctors. The sample consisted mainly of women (59%, 13/23). All participants declared themselves to be Caucasian, and most were married (59% = 13/23) and had children. Only two reported having a child born by vaginal delivery.

Among the obstetricians, 60% (14/23) have been working in this field for more than 20 years. The average time working at this hospital was 16 years (SD 7.4) and 65% (15/23) currently work in other professional activities, are in the private clinic, do surgical procedures or diagnosis, and/or teach. On average, these professionals see ten pregnant women in labor per week.

This profile of the participants mirrors the medical demography in Brazil, and in relation to the variable race, it reflects the reality of the Brazilian medical population and of the southern region²⁰20. Scheffer M, Cassenote A, Guilloux AGA, Biancarelli A, Miotto BA, Mainardi GM. Demografia médica no Brasil 2018. São Paulo: Departamento de Medicina Preventiva da Faculdade de Medicina da USP, Conselho Regional de Medicina do Estado de São Paulo, Conselho Federal de Medicina; 2018. .

Dimensions of Obstetric/Institutional Violence

All participants declared that they knew the term OV/IV, which provided a basis for their perception and included definitions as follows:

Most participants (78%, 18/23) considered OV/IV bad or terrible, and rejection was essentially related to three situations: the term induces controversy, it blames the obstetrician or questions the doctors’ “kindness”, as obstetrician M16 illustrates:

In the domestic and international literatures, there are different terms to describe OV, such as institutional violence (in childbirth)¹³13. Aguiar JM, D’Oliveira AF, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica. 2013; 29(1):2287-96. , ¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. , disrespect, abuse, abuse during obstetric care¹⁰10. Organização Mundial de Saúde. Prevenção e eliminação de abusos, desrespeito e maus-tratos durante o parto em instituições de saúde. Genebra: OMS; 2014. , gender violence during childbirth and abortion²¹21. D’Oliveira AF, Diniz SG, Schraiber LB. Violence against women in health-care institutions: an emerging problem. Lancet. 2002; 359(9318):1681-5. , and violence during delivery¹⁹19. Sena LM. Ameaçada e sem voz, como num campo de concentração: a medicalização do parto como porta e palco para a violência obstétrica [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2016. . The Network for the Humanization of Delivery and Childbirth (ReHuNa-1993) chose not to speak openly about violence, favoring terms such as “humanization of childbirth” and “promotion of women’s human rights”, for fearing antagonistic reactions from medical professionals under suspicion of violence²²22. Diniz SG, Salgado HO, Andrezzo HF, Carvalho PG, Carvalho PC, Aguiar CA, et al. Abuse and disrespect in childbirth care as a public health issue in Brazil: origins,definitions, impacts on maternal health, and proposals for its prevention. J Hum Growth Dev. 2015; 25(3):377-84. . The term violence can be defined as transforming a difference into an inequality in a hierarchical power relationship, in which the other is treated as a subject of action, curtailed in or even denied their autonomy, subjectivity, and speech¹³13. Aguiar JM, D’Oliveira AF, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica. 2013; 29(1):2287-96. .

The participants’ understanding that the term induces controversy arouses curiosity and requires reflection, because we are experiencing a revolution in the way information is produced, consumed, and spread. The new media are faster than the traditional media, making some topics to be spread swiftly and become the subject of discussion²³23. Muggah R, Diniz G. Prevenindo a violência na América Latina por meio de novas tecnologias [Internet]. Rio de Janeiro: Instituto Igarapé; 2014 [citado 1 Dez 2015]. Disponível em: http://igarape.org.br/wp-content/uploads/2013/05/AE-06_Prevenindo-violencia.pdf/
http://igarape.org.br/wp-content/uploads... , as for example OV/IV, which, although being new as a phenomenon, has quickly become a public topic. We observed that most of the participants learnt about the subject through the media (91% = 21/23), their colleagues (69% = 16/23), and at their workplace (65% = 15/23).

By considering the term exaggerated and typical of “tabloid journalism”, as put by participant M8, professionals also feel affronted by the blame involving the obstetrician, generating fear, conflict and vulnerability: "This gives the impression of violence of the doctor against the patient, that all medical procedures are against the patient, are useless or are done merely for the doctor’s convenience" (M3).

The Brazilian Federation of Gynecology and Obstetrics (Febrasgo) and its affiliates are critical of the expression obstetric violence, which has outraged countless obstetricians, by impregnating aggression bordering on hysteria²⁴24. Melo VH. Violência obstétrica e contra o obstetra: a dor além do parto. Belo Horizonte: Informativo Associação Brasileira de Ginecologia e Obstetrícia de Minas Gerais (Sogimig); 2014. p.7-11. , and they suggest using the term violence during childbirth, which includes not only the poor conditions of health facilities but all the other players involved in the process as well²⁵25. Federação Brasileira das Associações de Ginecologia e Obstetrícia. Carta de Aracajú aos obstetras do Brasil. J Febrasgo [Internet]. 2015 [citado 1 Dez 2015]. Disponível em: https://amb.org.br/noticias/carta-de-aracaju-febrasgo-aos-obstetras-brasil/
https://amb.org.br/noticias/carta-de-ara... .

There is refusal to accept that violence exists, not least because it has been linked to the authoritarian doctor-patient relationship and to inadequate procedures part of the standard protocol and not to an exceptional occurrence of inappropriate behavior or lack of professional competence. Questioning the paradigm of this model and the obstetric medical culture itself causes upset¹⁵15. Palharini LA. Autonomia para quem? O discurso médico hegemônico sobre a violência obstétrica no Brasil. Cad Pagu. 2017; (49):e174907. .

It is possible that the term obstetric violence is strategic as a political banner and provides visibility to the problem; however, within a proposal of continuing education or a change of institutional culture, terms eliciting less conflict should be used. The term “obstetric violence” was coined by social movements, more precisely by the women’s movement,²¹21. D’Oliveira AF, Diniz SG, Schraiber LB. Violence against women in health-care institutions: an emerging problem. Lancet. 2002; 359(9318):1681-5. but obstetricians in general did not validate the term. However, when asked to come up with another expression, the participants in this study found it hard to produce a “name” capable of covering the subject in all its complexity, which seems to mirror the current process of constructing concepts and definitions on this topic.

The purpose of this study was to analyze OV/IV in the individual, institutional, and human relation dimensions, with the individual dimension referring to the professional’s action, practice, and individual professional conducts, the institutional dimension referring to work conditions and infrastructure, and the human relation dimension, to aspects of professional-patient interaction, as well as to the perception of women’s autonomy, shared decision, and relationship based on rapport. They permeate all possibilities of violence and enable a multidimensional analysis by alternating concepts and aspects of their practice.

We observed that these dimensions are present in the participants’ speeches, either in the institutional and individual (M11), or in the human relation (M16) dimensions:

The human dimension was the most cited dimension (47% = 11/23), followed by the individual (34% = 8/23) and institutional (26% = 6/23) dimensions. Aguiar¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. , when studying institutional violence, also reveals that the entrenchment of poor practice in obstetric care is the result of a complicated dynamic between the work conditions the professionals are exposed to, to established routines, and to a lack of understanding and respect for women’s reproductive rights.

In some situations, the individual dimension, which refers to action, seems to take precedence over the dimension of human relation, which revolves around interaction between all players. However, while the former is intended to categorize the practical action of the professional’s care, the latter aims at the relational aspects among all persons involved.

When authors refer to materialization of OV/IV as neglect, verbal abuse (intentional threats and humiliation), physical violence (including not using analgesia, and performing unnecessary and unwanted surgeries), as well as sexual abuse²²22. Diniz SG, Salgado HO, Andrezzo HF, Carvalho PG, Carvalho PC, Aguiar CA, et al. Abuse and disrespect in childbirth care as a public health issue in Brazil: origins,definitions, impacts on maternal health, and proposals for its prevention. J Hum Growth Dev. 2015; 25(3):377-84. , we see that the individual and the human relation dimensions may be intertwined.

Although this study focuses on the doctors’ perception on this topic, obstetric violence is also committed by other professionals involved in childbirth care²⁶26. Santos RC, Souza NF. Violência institucional obstétrica no Brasil: revisão sistemática. Estação Cient UNIFAP. 2015; 5(1):57-68. .

Individual Dimension: Action

In a recent systematic review, it was observed that the quality of care often depends more on the health team than on the institution itself, and that during work in a hospital setting the lead player is the physician²⁶26. Santos RC, Souza NF. Violência institucional obstétrica no Brasil: revisão sistemática. Estação Cient UNIFAP. 2015; 5(1):57-68. . This means that their individual decision with regard to their action is beyond the structural elements to which they are or are not subordinated to¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. . Thus, a change in obstetric care also depends on the willingness of health professionals to change²⁶26. Santos RC, Souza NF. Violência institucional obstétrica no Brasil: revisão sistemática. Estação Cient UNIFAP. 2015; 5(1):57-68. .

In the individual dimension, the approach is related to care itself and involves unnecessary procedures not based on the best evidence and related to antiquated and dated routines.

Although many participants have configured dated practices as OV/IV, in Brazil, obstetrics has been marginally permeated by scientific evidence, leading to persisting inappropriate technologies in childbirth care and the perpetuation of unsafe, painful, and unnecessary interventions²⁷27. Costa SI, Oselka G, Garrafa V. Iniciação a bioética. Brasília: Conselho Federal de Medicina; 1998. , ²⁸28. Diniz CS, Niy DY, Andrezzo HF, Carvalho PC, Salgado HO. A vagina-escola: seminário interdisciplinar sobre violência contra a mulher no ensino das profissões de saúde. Interface (Botucatu). 2016; 20(56):253-9.: "[OV/IV are] conducts adopted by health professionals without any scientific basis that bring more suffering to the pregnant/delivering woman" (M18).

A professional’s conduct based on value judgments is shared amongst the health team, and often OV/IV is ignored even by its own victims²⁹29. Carvalho CA. Violência obstétrica: uma análise sob o prisma dos direitos fundamentais [trabalho de conclusão de curso]. Brasília: Universidade de Brasília; 2015. and routinely tolerated by professionals. This practice is much more oriented by individual beliefs, habits, routines, and personal and institutional behaviors rather than based on best evidences⁷7. Sadler M, Santos MJ, Ruiz-Berdún D, Rojas GL, Skoko E, Gillen P, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters. 2016; 24(47):47-55. , and the novelty here is not its occurrence but rather its problematization²⁸28. Diniz CS, Niy DY, Andrezzo HF, Carvalho PC, Salgado HO. A vagina-escola: seminário interdisciplinar sobre violência contra a mulher no ensino das profissões de saúde. Interface (Botucatu). 2016; 20(56):253-9. .

The training of health professionals, in particular physicians, has a structuring role in the current design of care and in resistance to change³⁰30. Hotimsky SN. A formação em obstetrícia: competência e cuidado na atenção ao parto. Interface (Botucatu). 2008; 12(24):215. and, therefore, medical practice can be detached from ethical constraint, prioritizing competencies to the detriment of values such as care²²22. Diniz SG, Salgado HO, Andrezzo HF, Carvalho PG, Carvalho PC, Aguiar CA, et al. Abuse and disrespect in childbirth care as a public health issue in Brazil: origins,definitions, impacts on maternal health, and proposals for its prevention. J Hum Growth Dev. 2015; 25(3):377-84. .

In this study, the participants recognized neglect as a common form of OV/IV, as shown below:

Neglect is the most common form of violence reported in previous studies; it happens almost always by neglect and it can be seen in all three dimensions²⁶26. Santos RC, Souza NF. Violência institucional obstétrica no Brasil: revisão sistemática. Estação Cient UNIFAP. 2015; 5(1):57-68.: in the individual dimension, when there is indifference, disregard and trivialization of pain; in the institutional dimension, in the “hunt” for a hospital bed vacancy or for availability of analgesia; and in the human relation dimension, in the lack of information, guidance and explanations to the patient¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. .

Regarding surgical delivery, the participants reported not performing Caesarean section at the request of pregnant women admitted through the public healthcare system SUS, while performing Caesarean section without medical indication in women requesting vaginal delivery:

In the Brazilian health system, it is usual to perform Caesarean section on the grounds that it is the wish of the delivering woman; however, Hotimsky et al.⁵5. Hotimsky SN, Rattner D, Venancio SI, Bógus CM, Miranda MM. O parto como eu vejo... ou como eu o desejo?: expectativas de gestantes, usuárias do SUS, acerca do parto e da assistência obstétrica. Cad Saude Publica. 2002; 18(5):1303-11. observed that the women’s preference is not always the decisive factor in determining the type of delivery, it being primarily a medical decision. There is a disagreement between the initial expectation of women and the outcome of delivery, with a much higher rate of Caesarean section than initially wished for by women. The interventionist health model and the traumatic experience of delivery are factors that predispose to this¹⁵15. Palharini LA. Autonomia para quem? O discurso médico hegemônico sobre a violência obstétrica no Brasil. Cad Pagu. 2017; (49):e174907. .

In the public health system SUS, the possibility of a woman choosing the type of delivery is limited, and her wish is not considered an indication for a Caesarean section³¹31. Domingues RMSM, Dias MAB, Nakamura-Pereira M, Torres JA, d’Orsi E, Pereira APE, et al. Processo de decisão pelo tipo de parto. Cad Saude Publica. 2014; 30 Suppl 1:101-16. , whereas in private clinics this option is available, which is consistent with the hypothesis that the Caesarean section has become a consumer good⁵5. Hotimsky SN, Rattner D, Venancio SI, Bógus CM, Miranda MM. O parto como eu vejo... ou como eu o desejo?: expectativas de gestantes, usuárias do SUS, acerca do parto e da assistência obstétrica. Cad Saude Publica. 2002; 18(5):1303-11. .

The medical-surgical approach to childbirth tends to overestimate the risks of the physiological process, portraying Caesarean delivery as a safe, painless, modern, and ideal type of delivery. Thus, obstetrics currently perpetuates the medical preference for surgical delivery as a prophylactic measure that protects women from the intrinsic risks and the doctor from uncertain outcomes related to vaginal delivery³²32. Diniz C. Entre a técnica e os direitos humanos: possibilidades e limites da humanização da assistência ao parto [tese]. São Paulo: Universidade de São Paulo; 2001. . The higher numbers of interventions to shorten delivery time are seen by courts in a more positive light than vaginal delivery³³33. Andrezzo HF. O desafio do direito a autonomia: uma experiência de plano de parto no SUS [dissertação]. São Paulo: Universidade de São Paulo; 2016. .

In contrast, the more technologies are introduced to Medicine and the more one trusts them, the less adverse outcomes is condoned. And the less the patient’s participation in the decisions, the more favorable is the setting for the judicialization of medical practice⁶6. Maia MB. Humanização do parto: política pública, comportamento organizacional e ethos profissional na rede hospitalar pública e privada de Belo Horizonte [dissertação]. Belo Horizonte: Pontifícia Universidade Católica de Minas Gerais; 2008. , with an actual risk of professional lawsuits²⁷27. Costa SI, Oselka G, Garrafa V. Iniciação a bioética. Brasília: Conselho Federal de Medicina; 1998. . This ends up disturbing the doctors emotionally, favoring the consolidation of a “defensive Medicine” and a litigious mentality:

Institutional Dimension: Condition

The health institution supports the physicians during patient care, and it is responsible for the structural and material conditions, as well as for establishing norms, routines and protocols underlying the health service they provide.

There are several factors related to the institutional aspects leading to OV/IV, and most participants believe that working conditions often are influencing and/or predisposing factors to OV/IV. With regard to the institution where the research was carried out, most participants believe that violence seldom or rarely happens.

When questioned about the institutional situations related to OV/IV, they reported lack of privacy, of available hospital beds and of an analgesia routine as the prevailing situations during their daily work, followed by excess demand. Situations related to accompanying persons, such as not allowing replacements, and to the institution’s regulations and routines, which must be abided by without any individualization, were also linked to violence.

Previous studies corroborate aspects related herein to working conditions. Violence in maternity wards regarding infrastructure, and material and human resources, is also a reflection of the system’s fragility, which exposes its professionals to poor conditions - such as lack of resources, low pay and excess care demand - as well as restricting access to services offered, incurring, among others, in a “hunt” for hospital vacancies in the public hospital network¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. .

The following account describes a doctor’s view about the types of OV/IV in the institutional dimension experienced in their daily life: "To work without having enough hospital beds available, overburdened nurses, citizens dissatisfied with the public health system, and a culture in which 'the doctor is to be blamed for everything'” (M11).

Since 2007, Brazilian legislation (Law No. 11.634) provides for the right of the pregnant woman to be informed about the institution where she will receive childbirth care under the SUS system. However, the chronic shortage of hospital beds and the phenomenon of vacancy “hunt” still represent a serious public health problem, and a repeal of pregnant women’s rights, therefore, a form of violence³⁴34. Rodrigues DP, Alves VH, Penna LH, Pereira AV, Branco MB, Silva LA. A peregrinação no período reprodutivo: uma violência no campo obstétrico. Esc Anna Nery. 2015; 19(4):614-20. .

Since the humanization program, the concept of ambience is highlighted, the treatment given to the physical space being understood as a social, professional and interpersonal space. It is related not only to the structure, but also to comfort, privacy and the attitude of the professionals in that ambience³⁵35. Wunderlich BL. Protagonismo da mulher em trabalho de parto em uma maternidade pública no sul do Brasil [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2016. . The respondents recognized that ambience-related factors influence OV/IV in the institutions: "[An example of OV/IV is] the inability of the institution to provide a physical ambience and a prepared staff to provide care of the delivering mothers" (M8).

The management of labor pain is another challenge for those who provide care and experience childbirth. According to the Ministry of Health, adequate pain control during labor is a woman’s right, guaranteed by the law (Ordinances no. 2,815 and 572, of 1998 and 2000, respectively)³⁵35. Wunderlich BL. Protagonismo da mulher em trabalho de parto em uma maternidade pública no sul do Brasil [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2016. , and the pregnant woman’s request for labor analgesia implies sufficient indication for providing it³⁶36. Brasil. Ministerio da Saúde. Conitec. Relatório de recomendação. Diretriz nacional de assistência ao parto normal. Brasília: Ministério da Saúde; 2016. . This procedure is listed in SUS’ reimbursement table, and to deny it is recognized as a form of OV/IV as per a recent law of the state of Santa Catarina (Law no. 17,097 of 2017)¹⁶16. Santa Catarina (Estado). Lei nº 17097, de 17 de Janeiro de 2017. Dispõe sobre a implantação de medidas de informação e proteção à gestante e parturiente contra a violência obstétrica no Estado de Santa Catarina. Diário Oficial da União. 19 Jan 2017. .

The non-availability of routine analgesia during childbirth care, the denial of providing it, even where indicated and requested by the obstetricians, and the refusal of anesthesiologists to perform the procedure, was mentioned by most participants as an issue related to OV/IV: "Any anesthesiologist who refuses to perform labor analgesia to avoid “having” to be available in case of an emergency procedure" (M16).

In this struggle, the anesthesiologists’ justification for refusing to perform labor analgesia is based on Resolution 1363/93 of the Federal Medical Council (CFM), which considers “an act against medical ethics to perform simultaneous anesthesia on different patients by the same professional, even if in the same surgical environment”³⁷37. Conselho Federal de Medicina. Resolução CFM nº 1.802, de 4 de Outubro de 2006. Dispõe sobre a prática do ato anestésico. Brasília: CFM; 2006. . This poses an institutional challenge, both in defining responsibilities and solving this issue and in respecting the medical act without disregarding the suffering of the other. When childbirth pain must be endured, without any possibility of acknowledgement and negotiation, it points towards trivialization of OV/IV²2. Tornquist CS. Paradoxos da humanização em uma maternidade no Brasil. Cad Saude Publica. 2003; 19 Suppl 2:419-27. .

It is crucial to reflect about institutional issues that predispose to violence, since issues of management and health services beyond the individual medical practice have to be addressed, as one enables the other³³33. Andrezzo HF. O desafio do direito a autonomia: uma experiência de plano de parto no SUS [dissertação]. São Paulo: Universidade de São Paulo; 2016. . It is true that there are inadequate working conditions that predispose to OV/IV, representing work endangerment, as put by the participants of this study.

The Human Relation Dimension: Interaction

The human relation involves all aspects of the doctor-patient interaction, permeating communication and shared decision, regard for women’s autonomy and agency, and empathy between the parties involved in the interaction established. A professional’s performance is not only based on material conditions or on their technical-scientific knowledge, but also on relational tools, the fruit of interactive and communicational ethics³⁸38. Schraiber LB. No encontro da técnica com a ética: o exercício de julgar e decidir no cotidiano do trabalho em medicina. Interface (Botucatu). 1997; 1(1):123-40. .

To Aguiar¹³13. Aguiar JM, D’Oliveira AF, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica. 2013; 29(1):2287-96. , the most difficult forms of violence to perceive are precisely those in the field of relations. The construction of the relationship between two individuals only has materiality in the act, and it offers a path to better care, with more understanding and open-mindedness, when establishing an active, two-way partnership marked by transparency and being consummated under the auspices of autonomy³⁹39. Gotardo GI, Silva IA. Refletindo sobre a prática obstétrica à luz de um modelo de relacionamento humano. Cienc Cuid Saude. 2007; 6(2):245-51. .

All participants agreed that the woman has the right to question, choose or give her opinion on the procedures and conducts suggested by the care team, being clearly established that the attitude of informing and clarifying is recommended and well accepted by them, who consider this act as an ethical duty in their professional practice.

The medical act does not imply an unlimited power over the patient’s life or health; therefore, all clarifications in this relation are considered unconditional and mandatory, being the duty to inform a prerequisite to consent²⁷27. Costa SI, Oselka G, Garrafa V. Iniciação a bioética. Brasília: Conselho Federal de Medicina; 1998. .

However, when questions, refusals and challenge of the doctor’s authority, of the prescribed conduct or of the institution’s routines arise, there are disturbances in the understanding of the limits of women’s autonomy. In these situations, it is difficult for the professional to respect autonomy⁴⁰40. Sens MM, Stamm AMNF. Percepção dos médicos sobre a violência obstétrica na sutil dimensão da relação humana e médico-paciente. Interface (Botucatu). Forthcoming 2019; 23:e180487. .

From the answers of some of the participants in this research, it is clear that the woman’s autonomy has limits and that this limit is reached when in the professional’s understanding there is risk to the mother’s and/or unborn child’s health. The medicalized model prevailing in healthcare units is based on the assumption that the doctor has all knowledge and, consequently, the woman, after being informed, should abide by their technical-scientific authority¹⁸18. Aguiar JM. Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero [tese]. São Paulo: Universidade de São Paulo; 2010. . Medical authority comes up in the participants’ speech at various instances, and the asymmetry in the doctor-patient relationship becomes clearer when it comes to decision-making where there is disagreement of opinion.

Several studies on health care in maternity wards show that obedience is a quality expected of the patient²⁶26. Santos RC, Souza NF. Violência institucional obstétrica no Brasil: revisão sistemática. Estação Cient UNIFAP. 2015; 5(1):57-68. , and that non-obedience is perceived by professionals as disrespect, ignorance or aggression¹³13. Aguiar JM, D’Oliveira AF, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica. 2013; 29(1):2287-96. . A review on this topic pointed out that the model of women’s care is hierarchical and institutionally reinforced by the doctor’s ascendance over the patient, being a reflection of the way each professional thinks and acts²⁶26. Santos RC, Souza NF. Violência institucional obstétrica no Brasil: revisão sistemática. Estação Cient UNIFAP. 2015; 5(1):57-68. . The arbitrary use that many health professionals make of their authority and knowledge in controlling the bodies and the sexuality of their female patients is one of the major sources of institutional violence to which women are subjected to in health care units¹³13. Aguiar JM, D’Oliveira AF, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica. 2013; 29(1):2287-96. .

Final considerations

Obstetric and/or institutional violence is a phenomenon known and acknowledged by professionals who participated in this research; however, it is still in the process of construction regarding definition, categorization and naming, and it is understandable that controversial aspects and disagreement will arise amongst all key players.

The term displeases professionals, who criticize the way obstetricians are blamed and the role of the media in contributing to the controversy about this topic.

When analyzing violence in the individual, institutional, and human relation dimensions, with their respective impacts on action, condition and interaction, it was possible to cover all forms of expressing OV/IV. This proposal of categorization allows a multidimensional analysis of the topic, as well as an interaction between concept and practice, clarifying agents and predisposing conditions.

In the individual dimension, where professional action is the relevant factor, a dated practice and not based on evidence, as well as neglect and conducts influenced by the prevailing judicialization of Medicine, were issues related to OV/IV. In the institutional dimension, the conditions made available may predispose and influence the occurrence of violence, with lack of hospital vacancies, of analgesia and of privacy, as well as others factors related to the ambience and the institution’s routines being prevalent. In the human relation dimension, women’s autonomy emerges as an unquestionable ethical right, whose limit is set by the professional; and when there is disagreement of opinions in the decision-making process, the asymmetry in the relationship becomes evident.

Despite important advances in the construction, problematization and greater awareness of this topic, a deeper discussion and its better characterization are still crucial, in order to provide a mechanism of listening and understanding among the various players involved in the OV/IV phenomenon.

Acknowledgements

We are grateful to the Federal University of Santa Catarina, the Teaching Hospital Polydoro Ernani de São Thiago and to all the professionals who voluntarily took part in this study.

References

Publication Dates

History