Insults to women in childbirth are the ‘tip of the iceberg’ of obstetric violence in Brazil, says doctor

Verbal insults and humiliation experienced by women during childbirth are “the tip of the iceberg” of a series of interventions and procedures that are not always necessary, sometimes performed without the patient’s consent and in certain invasive cases that characterize obstetric violence in Brazil, says the physician and scholar of the theme Melania Amorim.

“Cruel” words heard by women when giving birth range from the insistence that she push when she can’t do it to “shut up or your baby will be born deaf”, “when it’s time to do it (the child) didn’t scream” or “shut up or you’ll end up killing your baby,” says the doctor, who is a professor of gynecology and obstetrics at the Federal University of Campina Grande and co-author of national guidelines related to obstetric procedures.

These types of violence, according to her, turn births, even without serious complications, into “traumatic experiences”, with physical and psychological consequences for women.

The theme of obstetric violence came to light this week on account of leaked audios and videos from the influencer Shantal Verdelho, who gave birth in September at a birth performed by physician Renato Kalil – now under investigation by the São Paulo Regional Council of Medicine.

In the birth video, the doctor appears saying “f*ck!”

The doctor argues that the video was “edited and taken out of context”.

“The full video shows that there is no irregularity or inappropriate posture during the procedure. Attacks on your reputation will be the subject of legal measures, with the analysis of the video in its entirety”, says the doctor’s note sent by his office.

In private audios that have been made public, Shantal has claimed that the videos of her birth are a “horror show”.

“He (Kalil) curses me during the entire labor. He says ‘f*ck, push, motherfucker, faggot, she doesn’t push properly. (…) There’s a video of him tearing me with his hand, it was just for me to be blown away and say ‘oh you were right, I should have had the episiotomy’.”

Episiotomy is a surgical procedure that aims to increase the vaginal opening for the baby to exit. According to the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo), “currently, there is not enough scientific evidence to define the indications for episiotomy, only that selective use continues to be the best practice to be adopted. (…) In other words, not performing episiotomy should be the first option”.

In a statement, Kalil’s staff stated that he is “one of the most recognized doctors in Brazil. Throughout his career, he has performed more than 10,000 deliveries, without any complaints or incidents. Ms. Shantal’s delivery took place without any complications. and was praised by her on her social networks for thirty days after delivery”.

After Shantal’s report, journalist Samantha Pearson gave an interview to O Globo newspaper saying that she was also insulted by the same doctor during her prenatal care. According to her, he “talked about my vagina as if I wasn’t there”, “said I had to lose weight or my husband would cheat on me”. “I felt humiliated several times.”

‘Excessive interventions’ and ‘unnecessary suffering’

In addition to the individual cases reported above, “(insults) are shocking and happen very often, but they are the tip of the iceberg” in the obstetric scenario in Brazil, says Melania Amorim.

To measure the dimension of obstetric violence in the country, she argues, it would be necessary to add “how much women felt offended and assaulted with the amount of unnecessary and harmful procedures in prenatal care, abortion, childbirth and the puerperium”.

She cites an academic review done by Latin American researchers (including Brazil) in 2019, pointing out that “lack of respect and ill-treatment” during births and abortions occurred in 43% of pregnancies observed. But there are signs that this index is greatly underestimated.

This is because another study, Born in Brazil, conducted by Fiocruz in 2011 and 2012, with 23,800 women, concluded that “among pregnant women who had a vaginal birth, there was a predominance of an extremely medicalized care model, which ignores the best available scientific evidence.”

“Most women were subjected to excessive interventions, were confined to bed and without encouragement to walk, without eating during labor, used drugs to accelerate contractions (oxytocin), underwent episiotomy, gave birth while lying down. back, often with someone squeezing your belly (Kristeller’s maneuver). These procedures, when used without clinical indication, cause unnecessary pain and suffering and are not recommended by the World Health Organization,” says the text.

The Fiocruz study continues: “Few Brazilian women had the chance to experience a childbirth without the interventions described above, only 5% of the total, a value much lower than the 40% observed in the United Kingdom. The pattern is distributed across all geographic regions and types of health services, showing that the medicalization of childbirth is a widespread practice throughout the country.”

For Amorim, this “is the current model of obstetric care, with a literally abusive need to interfere in the birth scene”.

“This misogynistic bias still permeates our gynecology and obstetrics even when it is often performed by women, because it is the current model, which sees my body and your body as defective, that will only give birth with a medical intervention. model taught in many medical schools”, he criticizes.

This perception, emphasizes Amorim, “can hurt the sensitivity of professionals, (by) recognizing themselves as perpetrators of obstetric violence, much more hurts the women who were victims”.

This violence can happen at different times during prenatal, childbirth or postpartum and is not necessarily perpetrated by doctors, but also by other health professionals or even by the health system when it does not offer the proper conditions for a birth that , in Amorim’s words, “be based on scientific evidence”.

“Unnecessary cesarean, against the woman’s will (when she is tricked or induced to choose a cesarean, for futile or misleading pretexts), is also a form of obstetric violence”, explains the doctor.

“(In these cases) there is a false dichotomy: choosing between a ‘normal’, violent birth, and a ‘clean’ cesarean is a choice that Sofia should not be forced to make. Because there is a third way, which should be the rule : evidence-based childbirth care, (term) I even prefer than humanization of childbirth care, because the meaning is less emptied than the label ‘humanized’. This includes respect for autonomy and female protagonism, including only using procedures backed by solid evidence includes the meaning of childbirth as a psychosocial event rather than a medical act. And this is entirely possible without you being forced to make a false choice.”

‘Obstetric violence is naturalized’

One of the problems, according to Amorim, is that births with interventions that are not always necessary or ineffective methods are naturalized both in the training of doctors and in the way in which human birth is portrayed in our popular culture.

“In soap operas, there’s always someone giving commands (to a woman in labor), saying ‘force, strength’, usually to a woman lying down with her legs apart. And you start to normalize that there is the pattern, it’s the way birth. Generally they are medicated births, and with a lot of violence”, he argues.

“(…) I say this very calmly because I am a doctor, but the residency basically prepares us to act in high-risk births, in complicated births. This creates a false feeling that the woman is a time bomb about to explode and that these interventions would be justified. With time this normalizes, and you start to intervene even when it is not necessary.”

According to Amorim, two very invasive –and common– procedures are the Kristeller maneuver and episiotomies performed without the woman’s consent, or manually, without anesthesia.

“The violent atrocious pressure on the fundus of the uterus, Kristeller’s maneuver, is one of the most frequent forms, and the patient does not perceive it as violence. It can go unnoticed behind procedures incorporated by medical practice, but which are not natural”, he says .

This maneuver, also called fundic pressure in the expulsion period of childbirth, is not recommended by the World Health Organization (WHO).

About forced episiotomy, there are “cases in which the woman made a birth plan saying she did not want an episiotomy, the doctor (seems to have) got very angry about it and makes a maneuver with great force and tears the woman’s perineum with I didn’t see this once or twice, there were several cases – of open perineums, without anesthesia. It shocks me because of the retaliation, revenge character. It’s like saying ‘you (woman) dared to dictate the rules, now you will see'”, says Amorim.

“And there’s the episiotomy made with stitches without anesthesia. We don’t understand that in any other circumstance of medicine – cutting and suturing (human) tissue without anesthesia. And in such an intimate and sensitive region, and in a moment as special as childbirth. “

Saying ‘does strength’ is also harmful, says doctor

Amorim argues that, during labor, “any form of pressure is harmful, it is not effective, and, therefore, should be abolished”.

“Tie the parturient woman’s legs, make her give birth in a lying position –which is only good for the doctor– and (give) the commands during the expulsive period –such as ‘push strength’, ‘grip your teeth and apply strength’-, we already have evidence that (these procedures) are not necessary, even if they are not frankly aggressive”, he argues.

“Because childbirth is a force of nature – an uncontrollable event, which has a transformative dimension, a tsunami. In an attempt to control the uncontrollable, health professionals, steeped in this sexist training model, deal with this fear of something so intense imposing strict control. This explains, but does not justify oppressing another (person), undermining their self-esteem. In various circumstances we may need intervention (in childbirth), but this intervention can almost always be agreed, except in emergencies, with the mother.”