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One morning, in the gravel ambulance pull-up area just outside a public maternity hospital in Salvador da Bahia, Brazil, a middle-aged woman struck up a conversation with me. She was waiting for visiting hours so she could see her daughter and newborn grandchild. She complained that the doctors had forced her daughter to go through “normal birth” (vaginal delivery) when she should have been given a cesarean section. She herself had been subjected to similar treatment in her last birth, which she said almost killed her. Another woman she knew almost lost her baby when doctors “kept waiting and waiting” for labor to progress. The way she was dressed, and the fact that her daughter had given birth at a public hospital, signaled to me that she and her family were poor. Like most of those at the hospital that day and every day during my research, she was Afro-Brazilian. I heard similar complaints repeatedly over the course of my fieldwork in Brazil: “normal” birth was being imposed on women, even those who really should have C-sections.
Although few ever named it directly, such commentary was clearly directed at the Rede Cegonha (Stork Network) program, a national initiative to improve care for mothers and babies in the country’s universal public health system. Launched in early 2011, Rede Cegonha aims to increase access to health services and bolster the links between prenatal, birth, and postpartum care. At the foundation of this program is the paradigm of “humanized birth”—the promotion of evidence-based, low-intervention birth care that empowers women and their families. Rede Cegonha thus aimed to combat not just maternal and neonatal mortality, but also the over-medicalization of childbirth.
Image description: The occupants of an operating room are wearing blue scrubs and stand around a figure on an operating table. No faces are visible and the image is blurry, with the exception of surgical tools in the foreground. Piron Guillaume on Unsplash
The program’s goal of reducing “unnecessary” medical interventions in birth, however, was often interpreted by the working-class Afro-Brazilian women and their families I met in the northeastern city of Salvador, Bahia as a sign of the state’s disregard for their lives. Their rejection of low-intervention obstetric care must be understood within the context of longstanding social exclusions in Brazilian health care.
Between 2012 and 2017, I conducted 24 months of multi-sited ethnographic field research on the implementation of Rede Cegonha in Salvador. “Following the policy” from the national Ministry of Health to local health secretariats, maternity care clinics, and communities in Salvador, I conducted participant observation and interviewed over 70 policymakers, government bureaucrats, health care professionals, birth activists, women, and women’s family members.
Over half of all babies in Brazil—around 52 percent—are born via cesarean section. When it is clinically justified, C-section can save lives. However, when it is done for other than medical reasons, this major surgery poses risks that can outweigh its potential benefits. Furthermore, humanized birth advocates argue, cesareans are often imposed on women who do not want them, constituting a form of obstetric violence. Yet despite a series of government and grassroots initiatives to promote vaginal delivery since the 1990s, Brazil’s C-section rate has only continued to increase.
In its explicit embrace of humanized birth, Rede Cegonha seeks to change the dominant, overly “medicalized” model of birth care in hospitals, where even normal, physiological birth is treated as if it were an illness and subjected to a series of clinical interventions. In alignment with World Health Organization recommendations, Rede Cegonha promotes birth care that uses the fewest interventions possible to achieve the best outcomes.
While the goal of reducing unnecessary medical intervention in birth is an admirable one, Rede Cegonha’s boas práticas are disconcerting to many of those the program is designed to benefit.
Medical interventions in birth, however, are unevenly distributed. Black Brazilian women, who are the majority in Salvador, have less access to prenatal and birth care and die of obstetric causes at up to seven times the rate of white women. Black women are also less likely to get pain relief in labor, have a family member accompanying them in labor, or have elective cesarean sections. Given this context, it is perhaps unsurprising that many of my Bahian interlocutors were uneasy with government attempts to reduce medical intervention in birth, seeing these as the latest iteration of a longstanding denial of adequate care to poor and Black Brazilians like themselves.
One of Rede Cegonha’s main goals was the implementation of what are referred to as “good practices” (boas práticas) in childbirth: physical movement to encourage labor progression, vertical or semi-vertical birthing positions, and the use of non-pharmacological pain relief methods such as breathing techniques and lumbar massage, among others. To encourage the adoption of boas práticas, the Ministry of Health distributed special equipment to birth centers and hospitals, such as the so-called cavalinho (“rocking horse”), which allows women to rock back and forth in a seated position to help alleviate lumbar pressure and position the hips in a way that facilitates the baby’s descent through the birth canal. While innovative in their low-tech approach, the boas práticas aren’t always appreciated by the women they are supposed to benefit. On another occasion, another woman told me that her daughter was made to try all manner of strange positions and “procedures,” including sitting on a cavalinho. She expressed that it was almost as if the health care professionals attending her were inventing ways of prolonging her suffering.
On several other occasions during my fieldwork, I witnessed the tensions that arose in labor and delivery units when the care provided failed to align with the expectations of patients and their family members. Rather than convey “humanized” care, boas práticas signaled the opposite: this government-run hospital treated its patients with disdain and disrespect, “making up” ways to prolong women’s suffering when what was really needed was medical intervention—specifically, surgical delivery. In all of these cases, being made to wait for adequate care was a key feature of women’s narratives about their own and their loved ones’ birth experiences.
While the goal of reducing unnecessary medical intervention in birth is an admirable one, Rede Cegonha’s boas práticas are disconcerting to many of those the program is designed to benefit. The program’s insistence on reducing medical intervention in birth is viewed with suspicion by Brazil’s socially marginalized, whose primary experiences with public health care are ones in which waiting for care poses risks to their wellbeing and reveals the state’s disregard for their lives. To them, the kind of birth care Rede Cegonha promotes, where waiting and observing are central to “good practices,” is experienced as the opposite of care. If the objective is to make “good” birth a possibility for all Brazilian women, then maternal and infant health policies must make a more robust attempt to address the systematic exclusions of racially and economically marginalized Brazilians from the promise of “health for all.”
Eliza Williamson is a postdoctoral teaching fellow in Latin American Studies at Washington University in St. Louis. Her current book project addresses health policy to “humanize” childbirth in Brazil’s public health system, and her second research project focuses on parents and children affected by the Zika virus epidemic in Bahia.
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Cite as: Williamson, K. Eliza. 2020. “’Good Practices,’ Humanized Birth, and Waiting for Care in Brazil.” Anthropology News website, November 19, 2020. DOI: 10.14506/AN.1544