Approximately 18% of women who delivered babies in the city of Pelotas during 2015 were victims of at least one type of disrespectful or abusive treatment during the process of childbirth. This result is similar to the findings of a previous study conducted in Kenya [23], in which 20% of women reported experiencing some type of mistreatment or abuse by healthcare professionals during labor. In a study of eight institutions in a rural area in Tanzania, Kruk et al. [21] also reported a prevalence of approximately 20%, which was slightly lower than another study conducted in the same country [18]. In the latter study, there was no significant difference in abuse when compared between human immunodeficiency virus (HIV)-positive and -negative women. These findings are in contrast with those from a study conducted in Nigeria, where Okafor et al. [19] reported that 98% of women experienced some form of disrespectful or abusive treatment among the 460 puerperal women interviewed at a child immunization clinic. The almost universal prevalence reported by that study could be explained by a detailed evaluation of the different types of disrespect and abuse, for example, episiotomy, augmentation of labor, shaving of pubic hair, sterilization, cesarean delivery and blood transfusion and aspects relating to the payment of hospital fees. The specific form of disrespectful or abusive treatment that contributed most to the observed high levels of prevalence was non-consent care, at a prevalence of 55% [19].
Some studies have reported disrespectful or abusive treatment during childbirth in Latin America. In Venezuela, a hospital study using a self-applied confidential questionnaire showed that 49.4% of women giving birth reported having experienced some form of inhumane treatment from healthcare professionals [24]. In a survey across three Mexican hospitals, 11% of mothers reported some form of mistreatment by healthcare professionals during the process of childbirth [29]. In Brazil, a study conducted in both public and private hospitals across 25 states showed that 25% of women reported having experienced some type of obstetric violence [15]. The wide range of prevalence evident in these studies, from 11% to 98%, may be related to different definitions of obstetric violence, but nevertheless there is no question that the problem is a common one.
Our present results showed that younger age, family income, type of hospitalization system for childbirth and type of childbirth were associated with the incidence of abuse or disrespect during the process of childbirth.
Several studies have been published regarding the relationship between disrespect or abuse during childbirth and a range of associated factors; however, these previous studies yielded inconsistent results. Abuya et al. [23] found no association of any type between disrespect/abuse and maternal age, educational level, marital status and the presence of family/friends, but did show an association between parity and socioeconomic status and between detention for lack of payment and bribery requests, factors that were not included in our present analyses. In another study, Terán and colleagues [24] failed to find an association between dehumanizing treatment and educational level, but did identify a positive association with extreme age groups (adolescents and older women). These authors also showed an association between non-consented procedures with educational level and the type of childbirth. Kruk et al. further demonstrated that disrespect or abuse were associated with higher educational level, higher parity, poverty, cesarean section and depression; however, these authors failed to find an association with age, marital status and health facility factors. In another study, Okafor and colleagues [19] found no association between disrespectful or abusive care during childbirth and any other factor analyzed (maternal age, tribe, marital status, educational status and parity).
A study referred to as ‘Birth in Brazil’ (Nascer no Brasil), a nationally representative population-based study in which a total of 15,688 women were interviewed by telephone during the postpartum period, showed a higher chance of verbal, psychological or physical violence among women who went into labor (odds ratio [OR]: 1.79; 95% CI: 1.28–2.52), and a lower chance among those whose childbirth was privately financed (OR: 0.41; 95% CI: 0.30–0.56) and those who were accompanied by a family member throughout the childbirth process. There was no association between violence and skin color, socioeconomic position, educational level, maternal age or the type of delivery (categorized into vaginal and cesarean section only) [14].
In the Brazilian private or supplementary healthcare network, 90% of childbirths occur by means of cesarean section; of these, 78% occur without the pregnant women having gone into labor [22]. Considering that there is a greater likelihood of abuse and disrespect among women who go into labor, it might be expected that there would be a lower occurrence among those hospitalized in the private system.
Despite international recommendations suggesting that the proportion of cesarean sections should not exceed 15% [30], the levels of surgical deliveries in Brazil have reached epidemic levels and account for 55% of childbirths [22]. This reflects an over-medicalization of birth which has unfortunately accompanied public health achievements such as increased access to prenatal care and a higher proportion of childbirths in healthcare institutions [2].
The greater occurrence of violence among women who went into labor, along with the medicalization of childbirth, may be indicative of a lack of training among medical professionals in carrying out vaginal deliveries. In general terms, Brazil has adopted a highly medicalized model for obstetric care, which uses high levels of technology and little participation from the women who receive this care. During the process of childbirth, the doctor is an authority figure who holds knowledge and power, and is the protagonist of the process. In this, the woman in labor acts merely as an assistant who must obey all medical instructions and accept the procedures that are often imposed on her. In this context, disrespect and/or abuse would consist of the abusive use of power when the authority of a doctor, also represented by the team of other professionals that act under his/her orders, is directly or indirectly challenged by “disobedience”, resistance or questioning [13, 31, 32]. It is also important to consider the fact that disrespect and abuse of women during the process of childbirth is permeated by issues of medicalization relating to their bodies and gender, and reflects the depreciation of their sex and the normalization of violence against women [20, 33].
Women within the Brazilian civil society have become mobilized to fight for dignified and respectful care during pregnancy and childbirth. The movement referred to as “Delivery through Principles – Women’s Network for Active Maternity” (Parto do Princípio – Mulheres em Rede pela Maternidade Ativa), acts to promote women’s autonomy and defend their sexual and reproductive rights, especially regarding awareness during maternity, and has denounced institutional violence during pregnancy and childbirth care to policy makers [34]. However, despite these initiatives, and the implementation of public policies such as the Program for Humanization of Labor and Childbirth, disrespectful treatment and abuse of women during childbirth still occur frequently.
In 2014, the magnitude and severity of this issue at a global level led the WHO to publish a statement [1] proposing actions to eliminate this form of violence. This statement proposed to provide greater support for research and actions, to develop programs to improve the quality of maternal healthcare, to emphasize the right for women to receive dignified and respectful care during pregnancy and childbirth and to monitor data relating to this issue and to involve all stakeholders in a concerted effort to improve the quality of care and eliminate disrespectful practices.
One possible limitation of the present study may lie in the under-reporting of disrespectful or abusive treatment, which may have reduced the magnitude of our estimates and diluted the associations observed. To minimize information bias and to avoid embarrassment and the fear of possible retaliation by the hospital or healthcare professionals, information relating to disrespect and abuse during childbirth were obtained during the three-month follow-up period. It is also important to consider the influence of women’s perceptions on their reports. For example, women who had received lower levels of education and were in lower socioeconomic positions may have tended not to notice abuse because they may have considered this to be part of the normal process. On the other hand, women who presented with higher educational levels and, probably, higher levels of information relating to their rights, may have noticed more subtle forms of violence. Another important limitation is the fact that there was no individualized information on which professionals perpetrated the abuse, or whether they were doctors or nurses. Therefore, in our discussion, we considered doctors to be hierarchically superior and responsible for the team and for the decisions made during the process of childbirth.
Considering that pregnant women are in a situation of great vulnerability, and that the agents of violence against them are the ones that should be providing comprehensive care, the proportion of women who experience disrespect and abuse during the process of childbirth is absurd and unacceptable. It seems that the subjective “judgment” of permitting professionals to adopt unacceptable behavior is more tolerated in healthcare services, particularly public services. It is therefore fundamental to recognize, within the healthcare model, that obstetric care has become too medicalized and that the ethical background of the professionals involved needs to be reviewed.
