Solidarity Request: Brazil: Medical Council Of Rio De Janeiro Causes National Outrage
Resolutions prohibit midwives and doulas in hospital birth and doctor support for home births.
Women’s response: “No more violent births to sell c-sections”
A coalition of non-governmental organizations, representatives of social movements and women and men in favour of healthy, humanized birth choices are organizing a protest on Sunday (August 5) in Rio de Janeiro, and other Brazilian cities, against two resolutions released by the Medical Council of Rio de Janeiro (CREMERJ) published July 19.
The first resolution prohibits women in hospitals and maternity wards to have any assistance from university-trained midwives, or from doulas (an experienced woman who offers emotional and practical support during and after childbirth). Nurse-midwives, under doctors’ supervision will be tolerated. Non-compliance with the resolution by hospital directors will be considered an ethical violation and punished accordingly.
The second resolution prohibits any doctor to participate in out-of-hospital birth, directly, or previously agreeing to provide second-level care for women transferred from Birth Centres or home births. Punishment can include their medical licence being revoked. It also establishes a mandatory reporting to the Council of any out-of-hospital births, and punishment for non-reporting as an ethical offence.
The caesarean section rate in private hospitals in Rio de Janeiro is over 85% of all births. Given the pressure in hospitals to submit to elective c-sections or to aggressively managed vaginal birth, many women are choosing midwife care, delivery in birth centres, or home births, with support of a variety of on-line networks and resources in favour of informed choice.
Alternative places and providers in childbirth are usually strongly opposed by doctors, but never to the point of calling for them to be outlawed, as in these two resolutions. Last June, women in Brazil took to the streets to protest against the same CREMERJ, that time because of the council’s attempt to punish Jorge Kuhn, an obstetrician from São Paulo who declared in a popular TV show that, in selected cases, home birth can be an acceptable option for women. His opinion was considered an ethical offence by the Rio de Janeiro Medical Council, who reported him to the São Paulo Council. The Home Birth March was organized through web-based social networks, with demonstrations in over 30 different cities across the country, to affirm women’s right to informed choice, bodily integrity and a healthy birth experience.
These two resolutions are considered by activists to be the Council’s reaction to that march. Women have responded that CREMERJ’s new resolutions are illegal, against the best scientific evidence concerning care during childbirth, and a violation of women’s human rights. They are also contrary to the Ministry of Health guidelines for intra-partum care and World Health Organization recommendations.
The Rio de Janeiro Medical Council is strongly against the training and participation in childbirth care of direct-entry midwives and doulas. Midwives and doulas, as well as Birth Centres integrate the Ministry of Health programme for a more humane, safe, woman-centered model of care (Rede Cegonha), and their benefits are based on solid scientific evidence. According to the Cochrane Library, women in midwife-led care have a greater chance of spontaneous vaginal deliveries, less demand for analgesia, a greater sense of control during birth, and better chances to start breastfeeding. Twenty-one clinical trials with more than 15,000 women showed that those receiving continuous support during labour reported greater satisfaction with the experience of childbirth, had a shorter duration of labour and lower risk of caesarean delivery, among other advantages.
According to doctors supporting women’s groups, the resolutions are contrary to the Code of Medical Ethics, which promotes respect for patient autonomy. Despite the fact that, under a doctor’s supervision, the presence of nurse-midwives in hospitals will not be forbidden under the new resolution, the Rio de Janeiro Nursing Council (COREN-RJ) released an official statement repudiating the Medical Council’s resolutions and defending the inclusion of midwives and doulas in a women-centred model of care in any setting (both hospital and out-of-hospital births).
Brazil has occupied a leading position in the world ranking of caesarean rates for several years. C-sections accounted for more than 52% of all births in 2010, exceeding 84% within the private health care system, with several cities reaching an incredible 100% rate (the maximum recommended by WHO is 10-15%). High rates of elective pre-labour c-sections before 39 weeks are associated with poorer outcomes for mothers and infants, such as an increase in prematurity, low birthweight and maternal mortality and morbidity.
The protesters highlight CREMERJ’s conflict of interest in the perpetuation of a violent model of childbirth, trying to usurp the power and right to choose from women, thus violating their reproductive rights. One of the protest’s slogans is “No more violent births just to sell c-sections”. Several studies showed that the alarming rates of caesarean section in Brazilian hospitals cannot be justified by women's demand, since most of them state a preference for normal childbirth.
According to women’s groups and their allied health providers, including doctors, the Medical Council is by contrast selectively tolerant of other serious ethical violations, such as over-estimating risks to babies in vaginal birth to pressure women into “elective” c-sections; the abuse of painful, potentially harmful interventions such as liberal episiotomy, inductions and forceps (again to offer caesareans as “better”, comparatively); the sadly common sexual humiliation of distressed birthing women when they ask for help (using phrase such as “when you made that baby you liked it, now don’t complain”); and other forms of gender-based abuses. Activists also denounce that doctors frequently violate the federal law that ensures women the right to have someone of their own choice accompany them during childbirth, making the birth experience more stressful for women.
Together with public demonstrations, the protesters are organizing legal actions against the Council, gathering media coverage, and demanding a formal and firm reaction from the Ministry of Health and other related institutions.
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Facebook of the Ação contra o Cremerj (Action against Cremerj, Portuguese)