Disrespect and abuse in childbirth in Brazil: social activism, public policies and providers’ training

Figures & data

Table 1. Political initiatives of the social movements, Brazil, 1993–2018

Year	Organisation	Action	Effect
1997 + 1998	ReHuNa^a	Petitions endorsed by 315 participants of the 5th Brazilian Congress of Public Health (1997) and by 285 participants of the 4th Brazilian Congress of Epidemiology (1998) demanding a public policy on humanisation of childbirth (1997) and training of professionals on humanisation of care (1998). The Brazilian Association of Public Health endorsed them and presented these demands to MofH	Creation in 1998 of the Galba de Araúdo Award, the first accreditation to promote humanised, woman-friendly, evidence-based maternal care; In 1998 the MofH published an edict acknowledging payment for births attended by obstetric nurses; In 1999, the MofH started courses of specialisation in Obstetric Nursing, contracting federal universities; In 2000, the MofH launched the Program for Humanization of Prenatal and Birth Care
1998–1999	ReHuNa	Alliance with state representative of São Paulo State	São Paulo State Law 10,241 that guarantees patients’ rights, among them a companion during prenatal care and birth
2002	ReHuNa	Alliance with state representative of Santa Catarina State	Santa Catarina State Law N° 12,133/2002 that guarantees companions to women during labour and birth
2003	ReHuNa	That Santa Catarina State representative was elected to the Senate and proposed the same law project	Federal Law N° 11,108/2005, guaranteeing a companion during labour, birth and in the postpartum period. Other states also edited their laws during this period
2006	Parto do Princípio	Demand in the Public Prosecutor Office against the excess of C-sections in Brazil. There were public audiences in 2007, 2014 and 2015	Normative Resolution N° 368/2015 of the Regulatory Agency of the Supplementary Sector (ANS), defining: women with health insurance should receive their prenatal care records; their birth record should have a partograph; and hospitals and obstetricians in the private sector should publicise their C-section rates. In 2016 ANS launched the programme Adequate Birth, designed to reduce C-section rates in the private sector
2010	Parto do Princípio	Denounced to Public Prosecutor violation of Federal Law N° 11,108/05	In some States, maternity hospitals had to commit to complying with the law
2011	Parto do Princípio	Participated in municipal, state and national women’s policy conferences	Four motions related to childbirth assistance approved, one for eradication of institutional violence in obstetric care
2012	Parto do Princípio	Prepared a dossier on obstetric violence presented to the Joint Parliamentary Committee of Inquiry on violence against women	Denunciations and claims were included in the Joint Committee’s final report, to contribute to governmental actions addressing violence against women
2013	Activists + Casa da Borboleta	After prohibiting women breastfeeding in public sites in the city of São Paulo, they organised a mamaço, a collective action of women breastfeeding in public sites. Alliance with state and municipal legislators	São Paulo city Municipal Law N° 16,161/2015 and São Paulo state Law N° 16,047/2015, that proposes a fine for establishments that hinder breastfeeding
2014	Artemis Women's Network	Alliance with Federal Representative: organised a seminar in the Federal House of Representatives, “Faces of Violence against Women” and proposed Law Project N° 7,633, that guarantees humanised care in childbirth and defines obstetric violence	The project is still under discussion
2014	ReHuNa + ADDF^b	Alliance with Federal District Representative: law project guaranteeing humanised care, doulas, companions, and defining obstetric violence	Became Federal District Law 5,534/2015
2014	Parto do Princípio	In Pará state, training on obstetric violence for women’s rights NGOs, Human Rights Defense Center’s prosecutors, Order of Attorneys of Brazil section and health professionals	Sensitisation of diverse actors on obstetric violence and violence against women; legal actions were taken against hospitals that did not respect the legislation regarding companionship
Since 2014	Activists, mostly doulas	Alliances with local and state politicians proposing laws that guarantee doulas during labour and birth	There are about 60 state and municipal laws guaranteeing doula care for childbearing women
Since 2014	Parto do Princípio	Was elected to participate in the National Council of Women’s Rights	Sensitisation on obstetric violence and change in the Call 180 – Women’s Hotline for Gender-based Violence, to receive reports on obstetric violence, mainly in childbirth and abortion care

^aReHuNa: The Brazilian Network for the Humanization of Childbirth.

^bADDF: Doulas Association of the Federal District.

Table 2. Meetings organised by social movements for diffusion of information, Brazil, 1993–2018

Year	Organisation	Event
Since 1992	Instituto de Ioga e Terapias Aurora	Empowering women to fight the system and find alternatives; Yearly Meetings on Conscious Pregnancy and Natural Birth – Rio de Janeiro
1996, 1999	GENP^a/ ReHuNa	I and II Seminars on Childbirth in São Paulo State; biannual bulletins on evidence-based childbirth practices
1997	Grupo Curumim	Seminar, Campaign “Humanized birth, think about it!”
1999	GENP + ReHuNa	Campaign for the companion of choice during labour and birth
2000, 2005, 2010, 2016	ReHuNa and partners	International Conferences on Humanisation of Childbirth: I – Fortaleza; II – Rio de Janeiro; III and IV – Federal District
2002, 2004	State University of Rio de Janeiro and partners	I and II Congresses on Ecological Childbirth – Rio de Janeiro Meeting of doulas and companionship movements
2003	ReHuNa	Campaign to abolish routine episiotomy, with policy makers and training institutions
Since 2009	Parto do Princípio and partners	Yearly exhibition of photos of normal births during International Week for Respecting Childbirth, coordinated with European Network of Childbirth Associations (ENCA)
2011 to 2014	ReHuNa	2 Seminars on Humanised Care, several Workshops on Soft Technologies for Birth (doulas, ambience and companion), in the Federal District and nationally
2012	Group of bloggers	Connected via social media, filmed the documentary “Obstetric Violence – the voice of Brazilian Women”. Launched on November 25th for the “16 days of activism to end violence against women”. Best film award in the Fazendo Gênero Congress on Gender in 2013. Raised awareness on this issue
2013	Activists	Filmed the documentary “Birth reborn”, a harsh critique of Brazilian obstetric care, was exhibited for several months at cinemas, reaching an audience that would not be sensitised by the movement otherwise
2013	Artemis	Elaborated folder explaining the meaning of Obstetric Violence
2014	Parto do Princípio	Publication of two booklets (on obstetric violence and episiotomy), used in awareness-raising activities with health professionals, activists and women
Since 2014	Activists	Yearly Siaparto – International Symposium on Childbirth Care, foremost specialists on evidence-based, rights-based childbirth care, including both normalcy and complications
Since 2014	Artemis	Courses for Public Defenders, health professionals and women about Obstetric Violence. Distribution of material that explains what obstetric violence is about
Since 2015	Santa Catarina State House of representatives	Yearly National Congresses on Humanisation of Childbirth, to contribute to elaboration of laws
2017	Unicef + ReHuNa	Campaign Quem espera, Espera!^b (“One who is expecting should be patient”), to reduce iatrogenic pre-term births

^aStudy Group on Childbirth (Grupo de Estudos sobre Nascimento e Parto).

^b http://www.quemesperaespera.org.br/.

Table 3. Ministry of Health policies related to humanisation of childbirth, Brazil, 1993–2018

Year	Policy/Edicts^a	Content
1995	Safe Motherhood Program	Partnership with PAHO, UNICEF and Febrasgo to reduce aggressive management of labour and birth
1998	2815	Authorises payment of delivery care by obstetric nurse in Universal Health System (SUS) to reduce aggressive management of labour and birth
1998	2816	Defines limit of 40% C-section rate for reimbursement to hospitals (progressive reduction till 30% in 2000) in SUS
1998	2883	Institutes Prize Professor Galba de Araujo for public maternities with good practices, one for each region; acknowledgement for humanised, evidence-based obstetric and neonatal care
1998	3016	Institutes programme to organise state references for high-risk pregnancies in SUS, reducing aggressive management
1998	3477	Creates high-risk pregnancy programme in SUS
1999	985	Creates Birth Centers programme in SUS to reduce aggressive management. Updated in 2013 and 2015
2000	466	Creates Pact for the Reduction of C-section Rate in SUS
2000	569, 570, 571, 572	Creates Program for Humanization of Prenatal Care and Childbirth (PHPN) in SUS: perspective of citizenship, rights to prenatal and hospital childbirth care, financial incentives to municipal health secretariats to provide care, support to purchase equipment, adequacy of ambience, organisation of call centres for referrals and other structural developments
2005	1067	Institutes National Policy for Obstetric and Neonatal Care
2009		Program to Reduce Infant and Maternal Mortalities in the Legal Amazon and the Northeast in SUS. Program to Qualify Maternities
2011	1459	Institutes the Stork Network in SUS, a programme to induce change in the models of care and management of health services and health systems. Emphasis on birth centres and obstetric nurses delivering care. Created committees of specialists, of social mobilisation, of campaign for normal birth to support the MofH action. Created Perinatal Forums, a monthly meeting with managers, providers, social movements representatives in the states and capitals to discuss and support the local policies and actions
2014–2017	Vaginal birth and C-section guidelines	Based in the NICE protocols and using Adapt methodology, guidelines were elaborated with the participation of experts, professional corporations and social movements
2018	Careful birth	Programme launched on March 8th, similar to the Adequate Birth program of ANS

^aNumbers refer to edicts of that year.

Table 4. Campaigns, seminars and training organised by the Ministry of Health, Brazil, 1993–2018

Year	Partners	Event
1999	Federal Universities	Specialisation in Obstetric Nursing for Nurses (previously, only MDs were supposed to be authorised to assist births
Since 2000	Programme “Working with traditional midwives”	Includes publications and training of traditional midwives
2002	University of Campinas	Seminar “C-section: evaluation and proposal for action”
2004–2006	National and international organisations	30 Seminars “Humanized and Evidence Based Obstetric and Neonatal Care”. All states and FD
2003–2005	Doulas program	Training of community voluntary doulas in 10 states
2006 + 2008	Campaigns in the media	2006: to publicise law about companion of choice at birth. 2008: about normal birth
Since 2009	ALSO	Training on Advanced Life Support in Obstetrics in several states, to reduce inappropriate clinical management
Since 2009	Hospital Sofia Feldman	Training of health managers and health professionals on new model of care and of management. Visit to model collaborative centre
Since 2013	Federal Universities	Specialisation in Obstetric Nursing, Residences in Obstetric Nursing, Upgrading for obstetric nurses out of practice
Since 2017	Federal University of Minas Gerais	Project Apice ON – Upgrading and Innovation in Teaching and Care – Obstetrics and Neonatology. 96 Teaching Hospitals