The increasing rates of cesarean delivery (C-sections) in high-income and medium-income countries are a global concern (1,2). The high rates contrast with the worrisome low rates in low-income countries, stressing the gaps of access to adequate quality maternal care and the over-medicalization of childbirth (2,3). United Nations (UN) Sustainable Development Goals (SDG) call for a new era of accountability, challenging the health systems to identify and eliminate the preventable maternal morbidity and mortality associated with inadequate access to services, or the delivery of services that are “too little, too late” (TLTL) (1,4,5). The SDGs also question the opposite extreme reality of the over-medicalization of regular antenatal, intrapartum, and postnatal care, referred to as “too much, too soon” (TMTS) (1,4,5).
The SDG #3 - to reduce maternal mortality to at least 12 per 1,000 live births, and the SDG #5 - gender equality—ensuring access to reproductive health and reproductive rights (6) can be approached through the lens of the new World Health Organization (WHO) recommendations for intrapartum care (7). WHO presents a comprehensive document that creates a platform for pregnant women with respectful, individualized, woman-centered, and effective clinical and non-clinical practices to optimize birth outcomes for the woman and her baby (5,7). The protocol reinforces that evidence-based practices can be effective strategies for both scenarios—TMTS and TLTL—to ensure women’s reproductive rights (1).
Data from 137 countries revealed that every year in the world there is a need for 0.8–3.2 million C-sections in low-income countries and an excess of 4.0–6.2 million C-sections performed in middle and high-income countries (8,9). In Latin America, the average C-section rate is 33 cesareans per 100 live births, 49% of those considered elective (9,10). Brazilian C-section rates have been increasing since the year 2001, and by 2009 exceeded the number of vaginal deliveries, reaching 57% in 2014 (11–13), up to 47.2% of those were classified as unnecessary (8).
Since 1985, WHO recommends that C-section rates should be between 10 to 15% (14). Medically indicated cesareans are useful to save maternal and infant lives. However, several studies have shown that C-section rates higher than 15% are associated with an increase in maternal mortality and morbidity, including a higher chance of a more prolonged hospital stay, hysterectomy caused by postpartum hemorrhage, postnatal treatment with antibiotics and cardiac arrest for women, and increased risk of neonatal intensive care admission for babies, among others (10,14–18).
Reasons behind the higher rates are multifactorial, including socio-inequalities, cultural preferences, clinical recommendations not based on the best scientific evidence, underuse of evidence-based practices, practice of defensive medicine, lack of midwife availability/support, value/cost of procedures, increased use of technology, and increased medicalization of childbirth (19–24).
Countries with alarming cesarean rates such as Brazil, Dominican Republic, Egypt, Taiwan, China, India, and Iran have similar non-clinical factors identified as contributors to the high rates (25–30). Researchers found that social and cultural beliefs of women, families and communities in those countries result in a viewpoint that a cesarean is a safer delivery mode for mother and child when compared to a vaginal birth. More specifically, common perceptions in these countries include: women are not physically and mentally prepared for a vaginal childbirth, vaginal birth can impact a woman’s future sexual life, medical interventions are regular unavoidable procedural practices in vaginal birth, and the process of birth is unimportant (21,31–33).
The Brazilian maternity health care system is mostly interventionist, an example of a “too much, too soon” approach where labor and childbirth is considered a medical event instead of a normal physiologic process with its own social and cultural context (34,35). Brazil’s C-section rate was 55.7% in 2017 (36). Fifty-eight percent of births in Brazil happen in the private sector, among which 83% of the deliveries are cesareans, while in the public sector the C-section rate is 40% (37,38). Additional reasons for the high rates of cesarean in Brazil might be related to the model of care and physicians’ beliefs and behavior. Studies show that, frequently, the relationship between women and obstetricians is asymmetrical and physician centered, with no place for women’s choices and preferences (27,39,40).
The technocratic model of childbirth is the hegemonic model around the world, centered on the physician’s knowledge, hospital procedures and a high technological system (41–43). On the other hand, the humanistic model emphasizes the connection between mind and body, focusing on a soft approach, balancing between the need of the institution and individual/tailored continuum of care (41,42). In Brazil, the humanistic model is advocated for by community-based movements since the beginning of the 1990s (43), and concepts of the model have been incorporated into public policies as the most recent “Stork Network”, a strategy that aims to implement a network of care to assure women the right to reproductive planning and humanized care during pregnancy, childbirth and the postnatal, as well as guaranteeing children the right to a safe birth and healthy growth and development (44). However, the changes were not sufficient to oppose a TMTS system, with practices strongly anchored by a medical authoritative knowledge.
Authoritative knowledge is a set of scientific-based information, more commonly available for physicians and other health care professionals, and embodied knowledge is based on the individual perception/intuition and practical experience (45,46). Knowledge is a distinct domain of control, and control is often linked to a broad notion of a “good” birth (22). Women’s perceptions of birth and decisions for type of birth are a combination of embodied knowledge and authoritative knowledge since the technocratic and the humanistic models coexist in most maternal care models around the world (33,41,46). Women might exercise control of the body during childbirth with use of evidence-based practices such as pain management (non-pharmacological methods), feeling supported or cared for (one-to-one support/companionship), and active informed consent including respect of her wishes by the health professional attending the childbirth (birth plan) (22).
Although using EBPs during labor and childbirth are recommended to improve birth outcomes (47–52), they are still underused practices (35,53–56), while the poor maternal mortality and morbidity rates show that their implementation still needs to be reinforced (57–59). EBPs during labor and childbirth, also known as best practices, can be effective strategies for both scenarios TMTS and TLTL, and to ensure women’s reproductive rights (1).
Considering the urgent need to reduce unnecessary cesareans in Brazil and the multi-factorial reasons for the increasing rates, a health education and health promotion intervention named Senses of Birth (SoB) was implemented in three different states of Brazil between 2015 and 2017 (60). SoB aimed to contribute to the reduction of unnecessary C-sections and iatrogenic prematurity in Brazil (60) by addressing cultural preferences shaped by generations of women that suffered a negative experience in childbirth. (60). SoB is an interactive exhibition where visitors (women, men, children, adolescents) are invited to walk through the pregnancy and childbirth process, first as a pregnant woman and later as the newborn (60). During the experience the visitor is engaged in themes related to normal birth, risks of cesarean, best practices during childbirth, obstetric violence, the Ministry of Health (MS) and World Health Organization (WHO) recommendations, and the Brazilian humanization movement (60).
This study evaluates the impact of the SoB intervention on pregnant women, with regard to their perceived knowledge about normal birth, cesarean, and their use of evidence-based practices (EBP) during labor and childbirth.