Sunday, August 23, 2015

Birth in Northeast Brazil: Part 3

Birthing in Brazil Series

Part 3: Obstetric violence in NE Brazil
Everywhere you turn here in  the rural Northeast of Brazil you face obstetric violence in one form or another. You usually have three options when it comes to labor and birth, and their are serious problems with all three.  Here are your main options as a mother in Brazil:

1) Birth in a public hospital. Here is what you have to look forward to: Rundown facilities with a lack of supplies. You may have to share your room, and your labor space. There may be no bed for you. No bed for the baby. No basic care items for the baby. The doctor may not be in town and you may have to rush to another hospital in another town. Your companion may be forced to wait elsewhere. If a doctor is around he (or she) will most likely use verbal abuse to keep you quiet and complacent. If you get a bed, you may be forced to lay down on the bed for the whole labor and even be strapped or tied down. Episiotomies are common. So is the Kristeller maneuver. So is the doctor sitting on your belly forcing the baby down. If you need an emergency c-section it may be not started quickly enough to save the baby and the mother.  There is a great likelihood that you will not receive a lifesaving procedure such as pitocin after birth or a blood transfusion for hemorrhaging (a common complication after the Kristeller maneuver, episiotomies, and c-sections).  You will not get the attention needed for a pregnant woman in labor and your likelihood of morbidity and mortality is high.  

2) Birth in a private hospital, with a private doctor. Here is what you have to look forward to: A beautiful well equipped pristine setting with a 75-100% c-section rate.  When you meet with your doctor before birth she will do her best to convince you that a c-section is best. If you don’t agree she will coerce you, rationalize with you, and even lie to you to get you to do a c-section, or just refuse to deliver your baby. At best, if you try to birth normally in a private hospital without a supportive doctor you will be ridiculed by the staff, ignored, stared at, called crazy by the other mothers and medical professionals, and in the end you will most likely have a c-section.  At worst, you will experience the Kristeller maneuver, an episiotomy, unnecessary pitocin, overdoses of pain medication, and an epidural (whether you want it/need it or not). Or you can just give in and schedule your c-section, where there is a high likelihood that your baby will be born premature and you will have other complications due to an unnecessary major abdominal surgery. Regardless of if you have a c-section or normal birth, your baby will be taken away to the nursery, “made presentable,”  and given formula making nursing difficult, if not impossible.

3) Often misunderstood or unheard of, humanized birth. I’ll explain this more in another part of our series.

A little more about obstetric violence (or obstetric abuse): “Obstetric violence takes two forms: physical, manifested in invasive practices, unnecessary use of medicines and disregard for the time required or eventualities of labor; and psychological, meaning dehumanizing or rude treatment and discrimination or humiliation when a woman seeks advice or medical attention”  (Obstetric Violence -

The types of obstetric violence that occur in NE brazil include:
During pregnancy:
  • Denying prenatal services to a woman or imposes difficulties in treatment
  • Health officials neglecting to provide high quality treatment for a pregnant woman;
  • A cesarean section is scheduled without recommendation based on scientific evidence. This can include social coercion and intimidation by the medical professional (ex. no one has babies vaginally anymore, it’s barbaric, it will ruin your sex life, you can’t handle the pain), medical coercion from a medical professional (you are too small, you are too big, your baby is too big, your baby is too small, ), and even complete lies (doctors lie about babies being breach, the umbilical cord is too short, the umbilical cord is too long, the cord is wrapped around the baby’s neck and the baby will suffocate [nuchal cord], the baby is overdue [at 40 wks], the baby does not have enough amniotic fluid, the baby has too much amniotic fluid, hemorrhoids, the baby doesn’t want to come, a part of the baby’s body is stuck in the mother’s ribs [seriously..]).
During labor:
  • The hospital will turn away a woman in labor.
  • There is a lack of or withheld essential life-saving and important care equipment.
  • A woman in labor is left alone and not allowed her partner or other companion.
  • Procedures on the woman’s body that interfere in the process of childbirth, cause pain or physical injury (be that to be slight or grave). Examples: administering serum with oxytocin in order to accelerate the childbirth (for to the doctor’s convenience, with no medical necessity), successive manual examinations by different people on the woman’s cervix (introducing higher likelihood of infection); no food provided for the woman in labour; episiotomy (surgical incision used to enlarge the vaginal opening); immobilization (arms and legs), etc.;  the Kristeller maneuver (applying pressure to get the baby to move down the birth canal), sitting on the mother’s belling and attempting to push the baby down the birth canal
  • Verbal abuse during labor (shouting at the woman to keep quiet, telling her that if she yells too loud she’ll harm her baby, saying overly sexualized comments such as “you didn’t complain when you were making the baby, so stop complaining now”)
  • Performance of cesarean surgery without clinical indication or the woman’s consent
  • Denying or delaying a cesarean surgery when medically necessary
Directly after birth:
  • Delay or prevention of the woman’s contact with the baby just after the birth

  • Preventing or hampering of breastfeeding (preventing it during the first hour after the child’s birth, separating the baby from the mother, leaving the baby in the nursery where baby bottles and pacifiers are used, etc.)
  • Denying or not providing life-saving procedures when necessary (such as blood transfusions, intravenous liquids, pitocin to shrink the uterus back down when needed, suturing as needed)
  • Overuse of medical interventions (prolonged intravenous liquids, over-dosage of pitocin, overdose or incorrect dosage of pain and other medications)

 Sometimes the abuse is “minor” but often it is extreme and leads to poor maternal and infant outcomes after birth.

In part 4 of the series, I will talk about humanized birth and what a difference it can make!


"Obstetric Violence: do you know what it is? - Defensoria." 2014. 26 Aug. 2015 <>

"Obstetric violence | May 28." 2015. 26 Aug. 2015 <>

Tuesday, August 04, 2015

Birthing in (Northeast) Brazil: Part 2, Julia's Story

Birthing in Brazil Series
Part 2: Julia’s Story

I want to tell a little story today. When people read the statistics about the increasing c-section rate in Brazil, they usually ask me, why? Is it really that women are scared of childbirth?  Is it that doctors really don’t do normal birth?  It just doesn’t make sense to people from our culture why someone would choose major abdominal surgery over a “natural process.”

Well, to help you understand a bit better let me tell you the story of Julia.*
36 years ago, Julia’s mother gave birth to Julia via a planned c-section. Julia’s mother lived in the rural interior of Brazil. Her town had a public hospital, but it was not guaranteed there would be a doctor or medical supplies necessary. Julia’s father was a fairly successful local business owner and loved his wife dearly. He knew many women died in labor and even lost his mother after the birth of his sister. Instead of relying on the local (often uneducated) midwives he decided to take his wife to an obstetrician. The obstetrician was from out of town and could not guarantee he would be around when the time came for her to give birth. He was young and recently had been trained to do birth by c-section. He personally saw lives saved from the procedure, especially when compared to unattended births or births by untrained midwives. He recommended scheduling a cesarean birth for when he would be in town  to guarantee the safety of the mother and the baby.  

Julia was born healthy and happy. Three years later her brother joined her in the world in the same manner.
Julia’s mother accredited her children’s survival, and her own, to childbirth by c-section. She saw many of her friends and relatives die in childbirth or shortly after. During the late 60’s to early 80’s the infant mortality rate within the first year was 200-300 infant deaths per 100,000 live births. ("BRAZIL: No More Angel Babies on the Alto | Center for Latin ..." 2013. 4 Aug. 2015 <>) While many of those deaths were due to malnutrition and illness within the first year, folk superstitions often blamed the violence of childbirth.  For Julia’s mother the c-section was a miracle! She tells her friends and family and those who can afford it start to have planned c-sections also.

36 years later, Julia is even more well off than her mother and father. With time Julia marries and gets pregnant. All of her friends and family have had scheduled c-sections. Her mother had a c-section. Her doctor recommends a scheduled c-section. Normal childbirth doesn’t even seem like an option. She doesn't know anyone in her social circle that has done it. It seems primitive and risky. Even though she lives close to a “good public hospital,” she has heard horror stories of violence in labor and maternal and infant deaths at that hospital.  Even if she mentions normal birth, her doctor laughs it off and tells her that she won’t be able to handle the pain of childbirth, he says you are too petite for normal labor and your baby is already very large. She wants the best for her baby so at her first prenatal appointment she schedules the date of her baby's birth.

Does Julia really have any other good options?  Why would she even consider vaginal birth as a healthy option?

*Julia is a character made up from three stories of three different friends here in Brazil, but her story (and her mother’s) is very common and is very similar to the story of most of the women who schedule a c-section in their first doctor’s appointment.

I hope this story helps outsiders to see a little more about why women here in the interior would choose c-sections. Next week I'll get into more about obstetric violence in the public (and private) sector!