Obstetric Violence in Brazil as a Violation to the Right to Information

By Julia Moreira Maschio [1]

INTRODUCTION

The fight against obstetric violence is constant and is mainly based on human rights, considering that this issue is a public health problem. In this sense, it is possible to notice the efforts of the Ministry of Health to create public policies to prevent and guarantee women’s health. However, it is clear that practices such as episiotomy (cutting in the perineum region), Kristeler’s manoeuvre (tummy pushed by nurses), artificial rupture of the bag, etc., are still very present and represent a cruel daily reality with parturient. [2]

The absence of specific legislation helps in the perpetuation of these practices, in which the doctor holds power in view of his knowledge, with a violent domain, and as a consequence, there is a violation of women’s fundamental rights of freedom, autonomy and dignity, leading to a total vulnerability of the patient. [3] From this perspective, women undergo violent procedures because they end up trusting the doctor and believe that there is a real need for intervention to protect their health and that of their baby. [4]

However, when analysing the proportion recommended by the World Health Organization for caesarean deliveries per year, it is revealed that in Brazil, the percentage is 57%. This is a very high number, considering that the recommendation remains at 10% to 15%.

Performing the procedure unnecessarily ends up composing the risk factors that contribute to maternal and child mortality, as seen in (Figueiredo, 2017), “greater risk of death and hospital infection for both the baby and the mother; risk of the baby being born prematurely, as there is a possibility of error of up to one week in marking the gestational age; increased incidence of respiratory diseases in the baby; greater difficulty in breastfeeding and probability of early weaning; bonding difficulties with the mother; higher risk of infertility from the mother later on; risk of endometriosis; long-term scar sensitivity (itching, pain, and stretching sensation); increased risk of thrombosis and related diseases (including embolism); higher rate of postpartum depression; between others. [5] Thus, it can be concluded that these surgical procedures are performed indiscriminately, without scientific proof of any need, violating women’s rights, and not observing the WHO indications on the use of caesarean section only in therapeutic need.

THE CHOICE FOR BIRTH

Several factors affect the choice of the procedure at the time of birth, such as the duration of delivery, discomfort, and also medical pressure.

Normal delivery results from the natural action of the woman’s body, which expels the foetus without medical intervention. In these cases, what defines the duration of delivery is the woman’s own body, depending on the time interval between contractions; therefore, it can last up to 24 hours. In the public network, normal birth is still the most performed, in view of the recommendation of the Ministry of Health, with the implementation of public policy for humanized childbirth.

On the other hand, in caesarean delivery, the foetus is removed directly from the uterus and then a suture of the cut is performed, taking an average of 2 hours of the procedure. Therefore, in the private network, caesarean delivery is still the most chosen as it adds the convenience of surgery, such as the duration of the procedure, to the pre-existing lack of information and general medical position on it being the most beneficial to the parturient – without, however, scientific proof.

From this perspective, it is important to understand the existence of the myth of this type of childbirth. Cesarean delivery, in Brazil, is seen as the normal means of extracting the foetus, mainly due to the fear of normal childbirth, which is seen as something uncomfortable and painful. In this sense, a survey carried out by Vitória Greve in 2017 shows that “more than half of Brazilian women (70%) want a normal birth in early pregnancy, but over time they are discouraged. Fear of the pain of normal childbirth and the unpredictability of the process are the two main factors that lead women to opt for caesarean.

However, in this same research, we have that “for every 10,000 normal births, two women die. For every 10,000 C-sections, 7 die. [6]

It is also necessary to mention the socioeconomic conditions of women. According to the AMB – Medical Association of Brazil, the value of a private birth is on average R$ 15 thousand Reais. In a survey carried out by the ANS – National Health Agency, in the demonstrative table, it can be seen that normal births are rarely chosen. In this context, it is visible that to pay for caesarean delivery in private and to have a subscription to a health plan, good financial conditions are needed.

Therefore, it is evident that the socio-economic conditions of women must be observed as they impact obstetric violence, which is generally practiced due to the lack of information. This will ensure that the right to information as a fundamental right is a woman’s defence to guarantee her health.

THE RIGHT TO INFORMATION AS A GUARANTEE TO WOMEN’S HEALTH

In Brazil, the term “obstetric violence” is still very recent and has been understood as all physical, psychological, moral, and patrimonial violence against the parturient woman in three distinct moments: childbirth, postpartum, and puerperium. In a broader definition, the WHO states that “Obstetric violence is considered from verbal abuse, restricting the presence of a companion, non- consensual medical procedures, violation of privacy, refusal to administer painkillers, physical violence, among others. The statement also says that single women, teenagers, low-income women, migrants, and ethnic minorities are the most likely to suffer abuse, disrespect, and mistreatment. WHO further reveals that obstetric violence is a “violation of fundamental human rights.

In this context, according to what has been presented, it is possible to see that the choice of women for surgical intervention in childbirth comes in two moments: the fears that are dissipated by the beliefs that caesarean delivery is the most appropriate and the strong maintenance of this practice by medical institutions, considering that they are the most benefited by this choice. [7]

What should be noted is that information about both types of delivery is important, considering that, as soon as there is this information, the mother is fully able to consent and choose what will be performed to her own body. Thus, the information provided is too important for women to defend their interests against obstetric violence. [8]

It is important to emphasize that the right to information is established in the Federal Constitution of Brazil, Article 5 and Item XIV:

  • XIV – access to information is guaranteed to everyone and the confidentiality of the source is protected, when necessary for professional practice; [9]

Thus, there is the freedom to inform, as well as the right to be informed, which gives the person protection mechanisms against possible violence. Thus, the right to information is clearly an individual guarantee of each citizen.

  • About health, Law 8080/90, [10] which provides for the conditions for the protection, promotion and recovery of health, in its article 7 establishes that:

Art. 7- Public health actions and services and private services contracted or associated with the Unified Health System (SUS) are developed in accordance with the guidelines provided for in the. Art. 198 of the Federal Constitution, still obeying the following principles:

V – Right to information, to the people assisted, about their health;

VI – disclosure of information regarding the potential of health services and their use by the user;

  • Completing the above, the physician still has the duty to ensure the information, in accordance with the Code of Medical Ethics and the Resolution of the Federal Council of Medicine No. 1931/09:
  • Art. 31. Respect the right of the patient or their legal representative to freely decide on the execution of diagnostic or therapeutic practices, except in case of imminent risk of death.
  • Art. 34. Failure to inform the patient of the diagnosis, prognosis, risks and objectives of the treatment, except when direct communication may cause harm, in which case, inform their legal representative.

Thus, it is clear that the parturient, when being clarified and informed about all the risks and amenities of the modalities of childbirth, assumes the risks of childbirth. The information then becomes a defence tool for her, regarding obstetric violence, as well as for the physician, who obtains the woman’s consent about the procedure.

In this sense, says Jessica Figueiredo: “Women are victims of this system in three ways: due to their inability to implement a constitutional right to freedom of choice and to obtain the desired natural birth; because they are often deceived by doctors who use myths to convince them of the most advantageous birth for them; and for having, in the end, such a moment of bond with his or her daughter stolen, bearing fruit of physical or material, psychological or moral damage and even aesthetic damage. It is up to the law, therefore, to provide the instrument to indemnify such women in proportion to their damage and at the same time discourage doctors from continuing to perform unnecessary caesarean sections [11]

Therefore, the choice for childbirth is only possible with the information, which still corroborates with individual freedoms, also affirmed by the Federal Constitution. Thus, the search for more human, ethical, and transparent behaviour by medical institutions is constant. It is not just about prevention, but about a cultural structure within Brazil about how women should be respected, [12] about how their rights should be more visible, and how their choice concerns their bodies. Nowadays, when we talk about the woman’s power of choice regarding her birth, the right to information is human and fundamental.

CONCLUSION

This article focuses on the right to information as a tool for women’s defence against excessively suffered obstetric violence. It is concluded that at the root of the problem, we find the lack of information, both from medical institutions and from women, in which the dissipation of misleading and baseless information leads women to have no choice when giving birth. Information is, in addition to a right, a duty, which concerns the risks of each procedure, as well as a constitutional obligation to respect the right to freedom, dignity, and life.

[1] Seventh Period, Student of Law, Pontifical Catholic University, Paraná (PUC-PR), Brazil.

[2] DINIZ, Simone Grilo et al, Obstetric violence as a public health issue in Brazil: origins, definitions, typology, impacts on maternal health, and proposals for its prevention, 25, J HUM GROWTH DEV, 377-82, (2015).

[3] TEIXEIRA, Lara Azevedo et al., Obstetric violence as a violation of women’s right to health: a narrative review, 18, HEA. CARE JOU’ (2020).

[4] Wedge & Camila Carvalho Albuquerque, Obstetric violence: an analysis from the perspective of fundamental rights (2015).

[5] Jessica & Figueiredo, Women’s right to natural childbirth in Brazil: physician’s civil liability (2017).

[6] Cesar G. Victora et al., Maternal and child health in Brazil: progress and challenges, 377 LAN. (LON. ENGL’) 1863–1876 (2011).

[7] Correa & Daniela, Obstetric violence: the violation of women’s reproductive rights.

[8] Eduardo Cazelatto et al., Right to information as a form of defense of obstetric violence, 6 BJD 9523–9540 (2020).

[9] Federal Constitution of Brazil, Article 5, Item 14.

[10] Brazil, Law No. 8080/90.

[11] Figueiredo, Jessica. Women’s right to natural childbirth in Brazil: physician’s civil liability.

[12] Wedge, Camila Carvalho Albuquerque, Obstetric violence: an analysis from the perspective of fundamental rights, (2015).

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