Women's movement defends birth centres in Brazil

Brazil has a public health system (SUS) that provides health care for all. The rate of institutional births is over 98%.¹ Access to appropriate obstetric care for pregnant women is a key part of a comprehensive health system aimed at reducing maternal and neonatal mortality and morbidity. However, care for normal birth of healthy women and babies – the vast majority of cases – can safely be provided by a skilled attendant at the level of care that women prefer, in hospitals, birth centres or at home.²

In the last two decades, efforts to evaluate the use of technology at birth resulted in a profound change in the understanding of the safety and effectiveness of obstetric care.² Unfortunately, hospitals in Brazil, like in other Latin American countries, resist change to provide women-centred, evidence-based, humanised care. According to national data for 2006, in the SUS services, 84.6% of women having their first vaginal birth were subjected to episiotomies and only 9.6% had a companion of their choice with them (despite a national law that all women should have this right).¹

Over-intervention makes the experience of vaginal birth more painful and stressful, and increases potential harm for women and their babies. Many women “choose” a caesarean section (c-section) to escape the suffering associated with the over-interventionist model of care for vaginal birth.³ In the private sector, a doctor-centered “routine c-section” model of care was adopted, although research consistently shows that most women want a normal birth.⁴ In the absence of any regulation or systematic monitoring of outcomes, over 80% of women in the private sector have c-sections.¹ An editorial in an obstetrics journal declared: “There is no doubt that, even when unnecessary or carrying additional risks for the mother or the baby, elective c-sections are much safer for the obstetrician.”⁵ In Brazil, several networks of consumers were organised to denounce these distortions and demand the provision of evidence-based, informed options for birth.

The now several decades-old movement for humanised care led to the creation of midwife-led birth centres in the late 1990s, whose aim was to reduce both over-intervention in vaginal birth and astronomic c-section rates. The few public birth centres in operation, in São Paulo, Minas Gerais and Rio de Janeiro, have excellent outcomes,⁶ but face aggressive resistance from the medical establishment, as well as opposition both to out-of-hospital birth and autonomous delivery practice by nurse-midwives. Doctors were prohibited, by their Medical Councils, to collaborate with such birth centres.⁷

On 5 June 2009, as part of the State Medical Council (CREMERJ) campaign against birth centres, the government of Rio de Janeiro closed the David Capistrano Centre in Realengo, a very successful birth centre and the only one in operation in Rio, for “failing to provide medical care”.⁷

Reactions were immediate. Women's networks started several demonstrations against the closure. In a few days, an on-line petition organised by the consumer's group Parto do Princípio had more than 10,000 signatures from Brazil and abroad. With the support of many consumers' groups, nurse-midwives and other professional associations, the Network for the Humanisation of Childbirth, the Feminist Health Network, and the Health Ministry, the birth centre re-opened on 16 June. On 25 June, hundreds of women, their families, activists, health providers and policy-makers marched on Copacabana beach (Rio de Janeiro) to celebrate this provisional victory.

One of the best outcomes was widespread media visibility, with discussion of why doctors resist scientific evidence when it threatens their privileges, women's right to make free decisions about their reproductive lives, and ways to promote better, healthier birth experiences for women in Brazil.

Figure 1 Bus stop, Salvador da Bahia, Brazil, 2005