A 2004 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2004;12(23):100–110 0968-8080/04 $ – see front matter www.rhm-elsevier.com PII: S 096 8-80 80 (0 4)2311 2-3 www.rhmjournal.org.uk

‘‘The Cut Above’’ and ‘‘the Cut Below’’: The Abuse of Caesareans and in Sa˜oPaulo,Brazil Simone G Diniz,a Alessandra S Chachamb

a Research Director, Coletivo Feminista Sexualidade e Sau´ de, Sa˜o Paulo, Brazil. E-mail: [email protected] b Associate Professor, Department of Social Sciences, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil

Abstract: In the last 50 years, a rapid increase in the use of technology to start, augment, accelerate, regulate and monitor the process of has frequently led to the of inadequate, unnecessary and sometimes dangerous interventions. Although research has shown that the least amount of interference compatible with safety is the paradigm to follow, vaginal birth is still being treated as if it carries a high risk to women’s health and sexual life in Brazil. This paper describes the impact of the intervention model on women’s birth experience, and discusses how the organisation of public and private maternity services in Brazil influences the quality of obstetric care. Brazil is known for high rates of unnecessary (‘‘the cut above’’), performed in over two-thirds of in the private sector, where 30% of women give birth. The 94.2% rate of episiotomy (‘‘the cut below’’) in women who give birth vaginally, affecting the 70% of poor women using the public sector most, receives less attention. A change in the understanding of women’s bodies is required before a change in the procedures themselves can be expected. Since 1993, inspired by campaigns against female genital mutilation, a national movement of providers, feminists and consumer groups has been promoting evidence-based care and humanisation of in Brazil, to reduce unnecessary surgical procedures. A 2004 Reproductive Health Matters. All rights reserved.

Keywords: evidence-based medicine, caesarean section, episiotomy, medicalisation of childbirth, humanisation of childbirth, Brazil

‘‘If I were a I would have started, I don’t health. In this process, both in developed and know, an armed insurrection, because there is too developing countries, the search for ways to much violence... She goes to the maternity improve the quality of assistance at birthing hospital, and either they cut her belly, unneces- has frequently led to its medicalisation and an sarily most of the time, or her . Anyway uncritical adoption of inadequate, unnecessary someone is going to assault her with a knife.’’ and sometimes dangerous interventions, with- (A. Atallah, Brazilian Cochrane Centre)1 out proper evaluation of their effectiveness or safety.2,3 N the last 50 years, there has been a rapid However, by the end of the century, an in- increase in the use of technologies whose ternational movement had grown that cam- Ipurpose is to start, augment, accelerate, reg- paigned for medical care based on empirical ulate and monitor the process of birth, all with evidence of safety and effectiveness of medical the aim of making it ‘‘more normal’’ and to procedures in all specialities, evidence-based improve the outcome for women and ’ medicine (EBM). In the case of and

100 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 assistance at birth, practices are used in the some kind of private health insurance, and the course of a process that is usually though not poorer 70% who depend on the Brazilian Public always normal. Scientific evaluation has shown Health System (Sistema U´ nico de Sau´de, SUS). that minimal intervention – the least amount of According to the Brazilian Constitution (1988) interference compatible with safety – is the para- access to health care is a universal right and it is digm to follow for a normal birth. Thus, during a duty of the state to provide it. Both in the delivery and birth there must be a valid reason public and the private sectors, good and bad to intervene in a natural process, which is to do standards of care can be found, but substandard entirely with complications in the woman or care is prevalent. Health Ministry data show that the .2–4 in 2002 only 5% of pregnant women enrolled in The incorporation of these changes in antenatal care programmes had received the American countries has been very slow and has standard antenatal care services.11 met great resistance,5 including from teaching Private health services and private health in- institutions. In most medical schools in Brazil, surance are favoured by anyone who can afford providers are still taught the intervention model. them. Within the diversity of health plans and Surgical ability and sophisticated pathology insurance available, there is normally a group of assistance are highly valued, while comparative- specified health care providers and hospitals that ly little attention is paid to women-centred care women must use. The most expensive health for normal deliveries, and good communication insurance gives women the right to choose and interaction with all birthing women.6,7 which doctor will assist her during birth, usually This paper describes and discusses the impact the same one she sees for antenatal care. This on women’s health and sexuality of the inter- continuity of care is highly valued but it is vention model on women’s birth experience in generally not available for women who use the Brazil, drawing on information from qualitative SUS. They will see a doctor for antenatal care at and quantitative studies in the published lite- the health centre and will be attended by any rature. Quotes from interviews with doctors, doctor who happens to be on duty in the hospital nurses and patients collected in the course of when they arrive, whom they have most likely our own studies in this area are also presented. never before met. Since doctors do not necessar- These illustrate how the organisation of mater- ily introduce themselves in these circumstances, nity services in the public and private sectors women often do not even learn the names of influences the quality of obstetric care, leading those who assisted them.6 to high rates of unnecessary caesarean section and episiotomy. The obstetric pilgrimage Women who use the SUS for antenatal care Giving birth in Brazil frequently cannot secure a place in advance In Brazil, 96.5% of births take place in hospitals.8 where they can deliver. The guidelines for ante- This does not indicate that Brazilian women re- natal care instruct public health providers to ceive good assistance, however. According to the give women a referral letter to a hospital by the Brazilian Ministry of Health, the maternal mortal- end of pregnancy, to help them to secure a bed ity ratio in 2002 was 74.8 deaths per 100,000 live when in labour. Providers joke that this is an births,9 while the UNDP Development Report 2003 alvara´ de vire-se (license to look after yourself) gives a (contested in Brazil) estimate of 260 per because often it does not secure anything.12 100,000.10 Most maternal deaths were in women Frequently, their first choice of hospital is full who had had antenatal care. Hypertensive disor- and women have to go looking for a bed on ders in pregnancy and haemorrhage are the most their own, sometimes to more than one hospital. commoncausesofdeath,followedbycomplica- A study in the city of Sa˜o Paulo in 2002 found tions of unsafe .6 that among low-income women, 76% had had Inequality is a significant characteristic of to go to more than one hospital during labour health care in Brazil, with social, economic and to find a bed – 61% went to two institutions and regional parameters. Brazilian women can be 15% to three or more.13 For women with high- divided into the more affluent 30%, who have risk , this ‘‘pilgrimage’’ to find a

101 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 bed can be lethal; in Sa˜o Paulo, 55% of mater- The conveyor-belt approach: risking nal deaths occurred during or shortly after a women’s safety and bodily integrity 14 woman’s search for a bed. A third problem is that the shortage of beds is Several public initiatives have taken up this used to justify interventions not based on evi- problem in the last decade. In 2000 the Ministry dence. Thus, many doctors think that labour of Health launched the Programme for Human- should be induced to free up beds, especially in isation of Childbirth and gave health authorities public hospitals. in several cities incentives to find solutions to this problem. In Belo Horizonte, the third largest ‘‘Leaving women for too long in a bed during city in Brazil, since 2002 each of the nine health labour is a waste of space and limits the number districts has its own reference hospital. Women of cases we can attend to. That is the reason why from that district go directly there and if the they have to induce all deliveries.’’ (Medical hospital is full, the hospital has to find a bed resident, Sa˜o Paulo)7 elsewhere and take the woman there. Anecdotal evidence indicates that most women, but not all, ‘‘I compare this to a construction site: you now find a place or are taken to another hospi- cannot stop. You cannot go by the book, nor wait for nature to act. I put everybody on pitocin.’’ tal. However, women now complain that their 6 choice is limited as they have to go to the local (Obstetrician-gynaecologist, Rio de Janeiro) ˆ hospital whether they like it or not (Dr Sonia Apart from the medical risks, induction and ac- Lansky, Maternal Mortality Committee, Belo celeration of labour are considered very painful Horizonte, personal communication, 2003). by women. Some providers believe that increas- For women who depend on the SUS, access to ing the pain is accepted by women since it makes a bed in any maternity ward presents several labour shorter.6,7,16 In Rio Grande do Sul, older problems. One problem is when to go to the women argued that induction and increased hospital to ensure access to a bed. Because there pain from pitocin often helped in obtaining a is no consensus as to when labour begins, some caesarean section, as ‘‘proof’’ that labour would hospitals accept women at the very beginning of not succeed.17 These interventions, the so-called labour, which tends to promote more in- ‘‘conveyor-belt ’’,18 are part of routine terventions, while others refuse women until care in Brazil. they are close to delivering, which gives them 7 Many interventions to expedite labour and little time to find a bed. birth have unintended effects. Often these new A second problem is that the epidemic of problems are resolved with further interven- caesareans contributes to the shortage of beds. tions. This chain of events has been called the An uncomplicated vaginal delivery means a ‘‘cascade of intervention’’ and includes using hospital stay of 24 hours, against 72 hours for various medications to induce labour, artificially an uncomplicated caesarean. Furthermore, rupturing the membranes before or during la- availability of beds depends on the number of bour, using back-lying positions for labour or beds needed for post-delivery and neonatal birth, episiotomy and so on.19 Other obsolete care, especially for high-risk pregnancies. In interventions, although proscribed by medical ˜ Sao Paulo, due to the caesarean epidemic, a textbooks as very risky, such as the Kristeller significant number of neonatal intensive care manoeuvre (fundal pressure, i.e. a doctor or beds are needed for babies with iatrogenic pre- nurse push on the to speed delivery), maturity, a common complication of elective are still frequently used.6,7,16 Providers recog- caesarean.* When those neonatal beds are full, nise that women reject it: hospitals will not admit more women but will refer them on. ‘‘About Kristeller, personally I don’t like it... women also don’t like it, and sometimes the situation in the delivery room becomes very *A study of trends in low birthweight (LBW) in Sa˜o Paulo aggressive.’’16 compared birth cohorts in 1979 and 1994 and found an increase in the rate of LBW in higher income women, Clearing the ward is also used by providers to probably associated with elective caesarean section.15 control their workload and have enough time to

102 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 sleep before their next shift. Leaving the deformed head because of the forceps. She said I ward full for the next shift is considered bad was irresponsible even to think about a vaginal practice, so doctors consider it their duty to birth.’’ 22 ‘‘clean’’ the ward using induction or caesarean It is time to recognise the painful, harmful and section.6,7,16 unscientific practices in maternity care as a ‘‘If you feel that the patient is taking too much public health and human rights problem. time, you have to have resolution... I would be ashamed to hand over a full shift like that.’’ 6 In Sa˜o Paulo, some university hospitals use Caesarean section: ‘‘the cut above’’ routine forceps deliveries for all primiparae, Caesarean section is performed in over two- with the aim of speeding up labour or for thirds of births in the private health sector in training purposes, regardless of clinical indica- Brazil where, theoretically, women have more tion (Dr Jorge Kuhn, Professor of Obstetrics, choices. Several studies that have sought to Universidade Federal de Sa˜o Paulo, personal understand whether and why Brazilian women communication, December 2003). A recent prefer caesareans to vaginal birth show that study reports that delivery with forceps is asso- most women declared a preference for a vaginal ciated with a ten-fold increased risk of perineal birth over a surgical one. However, through injury compared to non-instrumental deliver- processes such as over-estimating fetal risk or ies.20 Perineal injuries are associated with anal interpreting maternal pain as a demand for and , poor sexual function, caesarean, as well as their own schedules and post-partum pain and more difficult breastfeed- convenience, doctors decide to do caesareans ing and bonding.21 despite women’s wishes, especially in the pri- Training of new providers in episiotomy and vate sector. Another factor which seems to pro- forceps delivery can be done using prosthetic mote professional belief in the superiority of models rather than women’s bodies. Activists caesareans is concern to preserve the woman’s argue that learning clinical judgement, correct genitals.23–28 indications and respect for women’s right to A typical arrangement in the private sector in bodily integrity are the skills providers need to Sa˜o Paulo is to schedule all women around 38 learn in the delivery room. weeks of pregnancy for a collective caesarean day, the so-called ‘‘surgical day’’.29 In the private ‘‘Residents enter a hospital and start to hunt for sector, there is virtually no control over pathologies. When a woman in labour shows up caesarean rates, which are as high as 80–90% with no complications they do not know what to of all births.25 In Sa˜o Paulo State, 59 private do. Surgical knowledge is easier... The more hospitals have caesarean rates over 80%. For passive the patient, the easier for medical 7 women with more than 11 years of schooling in practice.’’ (Medical professor, Sa˜o Paulo) Sa˜o Paulo (who are more likely to have a higher In 2003, Globo TV Network, a major Brazilian income level and use private services), the channel, in a programme about pregnancy chances of having a caesarean are over 85%. (Gra´vidas), presented the ‘‘natural childbirth’’ The Sa˜o Paulo Medical Council sampled 99 of one private patient as follows: the woman public and private hospitals and found a was in a horizontal position, under epidural caesarean rate greater than 35 per 100 births anaesthesia. She had an episiotomy and a Kris- for 82% of the hospitals, greater than 50 per 100 teller manoeuvre. Seeing this, it is not surprising births in 63% and greater than 70 per 100 births in 36% (24% of the public hospitals and 40% of that many women dread vaginal birth. In the 30 words of this middle-class pregnant woman on the private ones). an electronic forum: A government initiative limiting reimburse- ment of childbirth costs to a 30% caesarean ‘‘My friend visited her cousin and baby, and told rate in the public sector since 1998 has had an me crying that her chest and abdomen were full impact on the official rates in SUS services. of bruises, she’d had an episiotomy bigger than However, in a multicentre study by the Health the Rio-Nitero´i Bridge, and the baby had a Ministry in 2001 in five states, comparing

103 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 type of birth data in the national live-birth vered. Women attended by private doctors who registration system (SINASC) with figures pre- have painful procedures such as induction, epi- sented by the hospitals, the number of vaginal siotomy and Kristeller are given an epidural. For births in public hospitals was 49.3%. Initiatives women using the SUS, however, episiotomy and to reduce the caesarean rate seemed to be repair of perineal tears are done with local better accepted by public health policymakers anaesthesia. The amount of pain women expe- than by hospital directors and obstetricians. It rience during perineal suturing is very poorly also appeared that the figures were frequently studied, although anecdotal evidence suggests massaged by registering some caesareans as that the procedure can be associated with con- vaginal deliveries in order to meet the official siderable pain.33 target.31 ‘‘... the patient had a . During stitching, she cried from the first to the last Episiotomy: ‘‘the cut below’’ stitch.’’ 34 ‘‘I know I shouldn’t perform episiotomy as a In a study conducted in Latin America between routine, I know all the evidence. But when I see 1995 and 1998, nine out of ten primiparous the baby’s head on the ... my hand goes women who gave birth vaginally in a hospital by itself.’’ 7 had an episiotomy. In Brazil, the rate was 94.2%. This proportion was similar in public and private Episiotomy has been routinely used since the hospitals, primary care and referral hospitals, middle of the 20th century, in the belief that and whether attended by doctors or midwives. it facilitates birth and preserves women’s geni- Thus, the unnecessary and routine use of episi- tal integrity. Since the mid-1980s there has otomy in Latin America has been wasting been enough scientific evidence to recommend around US $134 million annually on the proce- abolishing episiotomy as a routine procedure, dure alone, without counting the additional however. Its use is now advised in a maximum costs of resulting complications.35 of 15–30% of cases or less,34 where there is There are no official data in the SUS system, evidence of fetal or maternal distress, or to but episiotomy is included in the birth assist- achieve adequate progress when the perineum ance package, as part of standard care. As is responsible for lack of progress.2 Routine one of the most used obstetrics handbook in episiotomy is not justified: it has no benefit Brazil stresses: for mother or infant, increases the need for suturing of the perineum and the risk of com- ‘‘Passage of the fetus through the vulva and plications at seven days post-partum, and pro- perineum is rarely possible without damaging duces unnecessary pain and discomfort. For the integrity of maternal tissues, with possible example, a rigid perineum is frequently a con- multiple lacerations and rupture, leading to sequence of a previous episiotomy.21 irreversible looseness of the ... Episiotomy is therefore almost always unavoid- ‘‘Where do you think surgeons of any speciality able in the primiparous woman, and in the do their first stitch? Here, it is always an multiparous one in whom it has been done episiotomy.’’ (Doctor, Sa˜o Paulo)7 before.’’ 36 ‘‘It is difficult to observe episiotomy training without feeling sorry for the woman. The woman is lying there having contractions, and they have Sexuality and childbirth care to try numerous times with the needle until they In Brazil, one of the main arguments used in find the right spot for the anaesthesia. Then after favour of both routine episiotomy and caesar- the birth, there is a very long wait before they do eans is that vaginal birth makes the vaginal the suture, and some hardly know how to handle muscles flaccid, compromising women’s sexual the surgical materials or tie the stitch.’’ (Doctor, attractiveness. However, according to scientific Rio de Janeiro)6 evidence, routine damage vaginal The extent of pain women experience in - structures rather than protect them. Women birth in Brazil is a marker of where they deli- whose infants were delivered over an intact

104 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 perineum reported the best outcomes overall, urinary incontinence.38,39 Yet this orientation is whereas perineal trauma and the use of obste- generally absent in antenatal and post-natal tric instrumentation were factors related to the care and in gynaecological care in general in frequency or severity of post-partum dyspar- Brazil. The assessment, management and pre- eunia, indicating that it is important to mini- vention of pelvic floor dysfunction, including its mise the extent of perineal damage during sexual dimensions, remain a neglected part of childbirth.40 the education and training of many health care Vaginal birth is being treated as if it carries a professionals. Inaccurate knowledge, myths and high risk to women’s health and sexual life. misconceptions of the incidence, cause and Considering that there is no risk-free human treatment of pelvic floor dysfunction abound.40 experience, it is necessary to assess how much Many women, even health care providers, do damage arises from the natural process of birth not know how to identify, contract and relax the and how much is the result of unnecessary or pelvic muscles. If this information is not part of harmful interventions. The large majority of routine care, pregnant women have to press to women can have a safe and satisfying vaginal receive it.41 birth, with vaginal tonus better after delivery In Brazil, notions of active–masculine and than before if they receive assistance based both passive–feminine42 reinforce the medical con- on scientific evidence and on their sexual and struction of the as a passive , reproductive rights. This synergy is not only either tight or flabby (as experienced by the possible but also necessary. phallus during intercourse), in opposition to The post-partum period is an opportunity for the understanding of the vagina and vulva as women to do pelvic floor exercises to maintain active, muscular and , able to relax vaginal tonus and receive advice on preventing and contract. THOMAS HOEPKER / MAGNUM PHOTOS Dancer at the Amazona Fish Festival, Brazil, 2001

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Dissection of the vulva suggests that current we call ‘vulval stroke’, you know, as happens anatomical descriptions of female human when someone has a stroke and their mouth and urethral and genital are inaccurate, face become asymmetrical?’’ (Maternity director, underestimating the extension of the clitoral Sa˜o Paulo)7 and vulvar structures.43 Many of these struc- tures can be damaged by interventions in deliv- Women accept routine episiotomy in Brazil, be- ery, not only the ability to contract and relax the cause most believe that it is medically necessary muscles but also the blood vessels, and to protect themselves and their baby. Since 44 erectile tissue. Frequently the iatrogenic con- episiotomy is the decision of the doctor, women sequences and sexual sequelae of these inter- assume the doctor is doing the right thing. If ventions are confused with vaginal birth itself. women believe they will have sexual problems Some women have been led to believe that and a flabby vagina after a vaginal birth and natural birth is like , a horrible form of that episiotomy is a solution, they will agree to sexual victimisation, and that caesarean section it. In a study in Uruguay, when asked if they is the way to prevent it. believed that episiotomy was necessary, 11% thought it was not, 13% had no opinion and ‘‘I would not have a normal birth, in no way. I 76% believed its use was justified.32 would hate to have my legs open and my sexuality invaded and destroyed.’’ 45 ‘‘If I were to give birth now everything would Doctors do not perform routine episiotomies be different... the most important, no episio- because they are indifferent to women’s suffer- tomy. It wouldn’t matter if I had some tearing, I ing, or because they always ignore the evidence. would not feel so uncomfortable when I was Rather it is a matter of beliefs. If they believe sitting down later – or now that I am 50, for the vulva and vagina are passive, it is difficult . More than ever, when oes- even for them to understand that these tissues trogen is decreasing, it hurts very much during are able to distend for birth and contract after- penetration. I have talked to many women doc- tors like me, and many other women who feel wards. Thus, through episiotomy, physicians de- 47 construct and reconstruct the vagina, in the same.’’ 46 accordance with cultural beliefs. The image In electronic forums where Brazilian women that medical discourse suggests is that, after speak in favour of alternatives in childbirth, the passage of the baby, the partner’s many have said they had sought a caesarean would be too small to stimulate or be stimulated 7 to avoid episiotomy, especially after a previous by the now-stretched vagina. Thus, delivery is traumatic procedure in which they sustained perceived as rape, with the baby causing defin- long-lasting damage.48 itive damage to women’s sexual function, and women needing to be returned to their ‘‘virginal 21 state’’. Humanising childbirth in Brazil Professionals we have interviewed often men- tion the ponto do marido (husband’s stitch), In the Brazilian case, unnecessary caesarean intended to make the vaginal opening even section and episiotomy are also a problem tighter after delivery. Frequent complications relatedtosocialclassandrace.Whiteand are vulval and vaginal pain, scarring problems middle class women attending private sector and deformities that need further surgical cor- services are more likely to get ‘‘the cut above’’ rection.7 Long-term consequences for sexual (caesarean), while black and poor woman using relations of episiotomy need further study. SUS (70% of Brazilian women) are more likely to get ‘‘the cut below’’ (episiotomy). As black ‘‘... we have colleagues who cripple women. Some women have different characteristics in relation episiotomies we call ‘lateral right hemi-bum- to wound healing, with a tendency to have more ectomy’, because of the huge sutures, going into problems with scarring and keloid formation,49 the patient’s fanny, making it look like she has they may be more exposed to complications three bums. Not to mention those episiotomies from episiotomy repair . Not rarely, it that make the vulva and vagina crooked, which is necessary to seek the services of a plastic

106 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 surgeon to correct the deviation and retractions Rehuna is campaigning for the right of SUS of the vaginal after episiotomy.50 and private patients to companionship and social The expression ‘‘humanisation of childbirth’’ support during labour, a simple, cheap, effective in Brazil means respect for and promotion of and satisfying way to make birth a better experi- women’s and children’s right to evidence-based ence for women.2–5,54,55 In June 2003, Rehuna care, including safety, effectiveness and satis- launched a Campaign against Routine Episiot- faction. When women have access to good omy. The first event was in Sa˜o Paulo, with repre- information, they understand that episiotomy sentatives from the College of Public Health, is not always necessary. To get the care they Federation of Brazilian Societies of want, some Brazilian women are now changing and Obstetrics (FEBRASGO), National Association doctors during pregnancy, with the help of a of Obstetric Nurses (ABENFO), policymakers, very promising resource for change – electronic feminist NGOs, organised consumers, Medical support groups and sites, for and by consumers Council, Brazilian Cochrane Centre and National who want evidence-based, humanised care. Network on Health and Reproductive Rights, Women who chose caesarean because they did among others. not know that an episiotomy-free birth was Inspired by the movement against female possible have set up a website to educate the genital mutilation in non-western societies, rou- public.48 tine episiotomy has been considered by many as Since 1993, there has been a National Network a form of genital mutilation,56,57 and gender for the Humanisation of Childbirth (Rehuna) violence committed by institutions and profes- that includes progressive providers, policymak- sionals.58 Some are proposing changes in the ers, feminists, alternative healers, midwives terminology, calling unnecessary episiotomies and organised health service users’ groups. ‘‘iatrogenic genital lesion’’, ‘‘iatrogenic sexual The latter have several electronic lists, forums, damage’’ or ‘‘iatrogenic sexual wound’’.51 The sites and blogs, including the very active high numbers of episiotomies has been consid- Amigas do Parto (Friends of Childbirth).51 Bra- ered as an archetypal case of violation of human zilian feminists have been part of Rehuna rights in relation to health.59 since its foundation, defending the vision of The Campaign was an opportunity to combine a ‘‘voluntary, pleasurable, safe and socially the evidence-based and women’s reproductive supported motherhood’’.29 rights perspectives, through a partnership with Since the mid-1990s several governmental the Latin American Centre for Perinatology (CLAP) initiatives, many of them in partnership with and the Latin American Centre for Women’s Rights NGOs, have supported proposals to change (CLADEM). We are at present looking for the childbirth assistance in Brazil, especially focus- support of health authorities to follow the recom- ing on the reduction of caesarean rates. These mendations we have put forward, including for include the establishment by the Ministry of the training of providers, the introduction of in- Health of the Dr Galba de Arau´jo Award in formed consent for episiotomy in SUS services, and 1998 for the most humanised maternity hospi- monitoring of progress.51 tals, a programme for training obstetric nurses The prevention of unnecessary caesareans and the Prenatal and Birth Humanisation and episiotomies and the promotion of normal Programme (PHPN) in 2000. In 2001, the Min- vaginal delivery with an intact perineum de- istry of Health distributed a Portuguese version mand profound transformations in obstetric of the WHO manual for vaginal birth assistance care. A change in gender stereotypes and better to doctors and nurses all over the country.52 At understanding of women’s bodies is required regional level, in various states, services with a before a change in the procedures themselves humanised approach were created, both in the can be expected. That includes women’s right private and public sectors. There is a very prom- to evidence-based information, privacy, free- ising programme for establishing Normal Birth dom to choose position in labour and birth, Centres, with very successful experiences in the right to have a companion at birth and several parts of the country, but in others it social support during labour, adequate pain has met with strong resistance from more con- control and prevention of iatrogenic pain, and servative sectors.53 promotion of pelvic exercises for a ‘‘powerful’’

107 SG Diniz, AS Chacham / Reproductive Health Matters 2004;12(23):100–110 vagina. Although the focus of Rehuna’s cam- Acknowledgements paign is the abolition of routine episiotomies, Quotes and text were translated from Portuguese the broader aim is to contribute to changes by Alessandra Chacham. This paper reports part in reproductive and sexual health care provi- of the research by Simone Diniz on ‘‘Expectations sion, promoting women’s genital integrity, sat- and satisfaction of users and providers in the hu- isfaction and safety both in reproductive and manisation of childbirth’’, supported by the Sa˜o sexual life. PauloResearchFoundation(FAPESP/Cemicamp).

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Re´ sume´ Resumen Ces 50 dernie`res anne´es, l’accroissement rapide En los u´ltimos 50 an˜os, un aumento ra´pido en de l’utilisation de la technologie pour de´clencher, el uso de la tecnologı´a para iniciar, aumentar, acce´le´rer, re´guler et surveiller l’accouchement acelerar, regular y vigilar el proceso de parto a souvent abouti a` des interventions errone´es, llevo´ a menudo a la adopcio´n de intervenciones inutiles et parfois dangereuses. Bien que la inadecuadas, innecesarias y a veces peligrosas. recherche ait montre´ que le moins d’interfe´rence Si bien se ha mostrado que la menor interferencia compatible avec la se´curite´ e´tait le principe a` que sea compatible con la seguridad es el paradigma suivre, au Bre´sil, l’accouchement par voie vaginale a seguir, en Brasil todavı´a se trata el parto vaginal est encore traite´ comme s’il comportait un risque como si presentara un alto riesgo para la salud y e´leve´ pour la sante´ et la vie sexuelle des femmes. Cet vida sexual de las mujeres. Este artı´culo describe el article de´crit l’impact du mode`le d’intervention sur impacto del modelo intervencionista sobre la l’expe´rience qu’ont les femmes de l’accouchement experiencia de parto de las mujeres, y muestra et montre comment l’organisation des services como la organizacio´n de servicios de maternidad publics et prive´sdematernite´ influence la qualite´ pu´blicos y privados en Brasil impacta la calidad de des soins obste´triques au Bre´sil. Le Bre´sil est connu la atencio´n obste´trica. Brasil es conocido por sus pour ses taux e´leve´sdece´sariennes pratique´es sur altas tasas de cesa´reas innecesarias, practicadas en plus des deux tiers des naissances dans le secteur dos tercios de los partos en el sector privado, prive´,ou` 30% des femmes accouchent. Le taux donde dan a luz 30% de las mujeres. Llama de 94,2% d’e´pisiotomie chez les femmes qui menos la atencio´n la tasa de 94.2% de episiotomı´as accouchent par voie vaginale, touchant 70% en mujeres que tienen un parto vaginal, afectando des femmes pauvres qui utilisent principalement a un 70% de las mujeres pobres que usan ma´sel le secteur public, rec¸oit moins d’attention. Un sector pu´blico. Se requiere un cambio en la changement dans la manie`re dont le corps comprensio´n del cuerpo de la mujer antes de que des femmes est compris devra pre´ce´der tout se pueda esperar un cambio en las intervenciones. changement des proce´dures elles-meˆmes. Depuis Desde 1993, inspirado por las campan˜as en contra 1993, inspire´ par des campagnes contre la de la mutilacio´n genital femenina, un movimiento mutilation sexuelle fe´minine, un mouvement de proveedores, feministas y grupos de consumidores national de prestataires de services, de fe´ministes promueve la atencio´nbasadaenhechosyla et de groupes de consommateurs pre´conise des humanizacio´n del parto en Brasil, con el fin de soins fonde´s sur les recherches disponibles et reducir las intervenciones quiru´rgicas innecesarias. l’humanisation de l’accouchement au Bre´sil, pour re´duire les proce´dures chirurgicales inutiles.

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