Many of the debates about reproductive health revolve around the autonomy of women during pregnancy and labor. This is most apparent, of course, in the discussions about pregnancy termination, but it also shows in the broader issue of obstetric violence.
Earlier this year, the Regional Council of Medicine in Rio de Janeiro, Brazil, passed resolution n. 293/2019. This rule provides that “doctors are forbidden to adhere to any documents, including the birth plan or similar, that restrict medical autonomy in adopting measures to safeguard the well-being and health of the mother and fetus”. The birth plan, for the purpose of this document, is defined as “a series of standards dictated by the pregnant woman, or made in conjunction with her doctor, commonly taken from models available on electronic websites that determine what the doctor can and cannot do.”
This definition fails to capture the essence of putting pregnant women’s desires on paper: the power of decision-making. Essentially, it functions as a two-way process. On the one hand, making a birth plans leads to women asking more questions, therefore deepening their comprehension of labor. On the other hand, healthcare providers get to know their patients better, understanding their expectations, anxieties, and priorities. In other words, the birth plan is not only important because of its actual text, but because of the self-knowledge journey it entails. For these reasons, institutions such as the United Kingdom’s National Health Service state the benefits of having a birth plan in their website, though acknowledging that it needs to be flexible enough to accommodate the unexpected.
In turn, resolution n. 293/2019 by the Regional Council of Medicine in Rio de Janeiro focuses primarily on the healthcare providers, especially doctors. In the section that explains the reasoning behind the rule, the author says that “failure to sign this document [the birth plan] can cause numerous problems for the professional, even being denounced for ‘obstetric violence,’” and goes on to qualify this particular type of violence as “another term invented to discredit doctors.” The author also states that “this scenario has become a real ordeal for doctors, who are afraid of being prosecuted if they do not follow these guidelines, many of which completely lack scientific basis and have anti-medical bias.”
The word choice of this section is quite meaningful and provides insight into how part of the medical community is seeing the growing movement for women’s autonomy during childbirth.
First, it is important to understand that the birth plan, at least in its written form, was created as a response to an increasingly medicalized childbirth environment. It may be that they cause problems for healthcare providers, but they were created to help solve problems for women, namely, escalating interventions during labor. Science has, of course, contributed to the reduction in maternal mortality, but there is a line between what is indeed recommended and/or necessary and what effectively constitutes abuse in the doctor-patient relationship, which is asymmetrical by definition.
Second, obstetric violence is not a term invented to discredit doctors; it is a real thing that happens to countless women. It is not a coincidence that so many women claim to have suffered some kind of abuse during childbirth, being made to feel disrespected, humiliated, and patronized. It is one thing to question how we – as a society – have dealt with this problem, but an entirely different thing to deny that there is a problem to start with. Of course there is.
Third, regarding the allegation that many of the birth plan guidelines lack scientific basis, it is interesting to note the example offered by the author himself: “The Kristeller maneuver is often mistakenly classified as obstetric violence and as ‘proscribed.’ There is no scientific evidence that it should not be used in necessary situations.”
The source quoted by the author, the Brazilian Federation of Genealogical and Obstetrician Societies, states that “there is no evidence of the benefit of routine use of the Kristeller maneuver… as well as there is scarce evidence that such a maneuver could cause any damage… Therefore, it should not be a routine procedure and should be discouraged. If the maneuver is necessary, in an exceptional situation, it must be performed by an experienced professional, with the consent of the parturient and duly justified in the medical record.” It should be noted that the two clinical studies used as references are from 1999 and 2009; and that the source of there being scarce evidence that the Kristeller maneuver can cause damage is a report by the Brazilian Department of Health from January 2016.
However, in a 2017 report, the same institution – Brazilian Department of Health – released new guidelines, categorically stating: “The Kristeller maneuver should not be performed in the second stage of labor.” Moreover, in 2018, the World Health Organization issued a statement saying that “the application of manual fundal pressure to facilitate childbirth during the second stage of labor is not recommended.” That is, regardless of whether the Kristeller maneuver is prohibited or not, and of whether it is acceptable or not under exceptional circumstances, it is perfectly understandable that women experience anxiety related to this procedure. This is something that needs to be heard and addressed by the healthcare provider.
Having highlighted these three points, and accepting the premise that obstetric violence is real, the question that does seem reasonable is how to fight it. The fact that the medical community is feeling sufficiently threatened to issue resolution n. 293/2019 should be a red alert, at least in Brazil. In the end, the healthcare providers are key actors that have to be engaged, besides being well positioned to help craft a systemic change. It might be time for all of us to sit down and discuss how to create a labor environment that is not imposed on women, but rather built by them as well.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.