The goal of this study was to evaluate the change in women's perceived knowledge about normal birth, cesarean, and EBP after a health education intervention. Considering that the majority of the women perceived an increase in knowledge, results show that there is room to improve knowledge about normal birth, cesarean, and EBP among pregnant Brazilian women. The results also indicate that women who joined the intervention have the perceived knowledge about the risks and benefits of normal birth and cesarean above three on a scale from 1 to 5. In spite of this, women lack knowledge about how to achieve a positive childbirth experience since the majority are not aware of intrapartum EBP, and how the practices can be a tool/pathway to have a positive childbirth experience.
The SoB intervention’s impact on women’s perceived knowledge
Most pregnant women in this study experienced an increase in perceived knowledge about normal birth, cesarean, and EBP after participating in the SoB intervention. Prior studies that evaluated the impact of a health education intervention on women's preference, knowledge, skills, and behavior found that culturally appropriate maternity care has positive effects on increasing knowledge, stronger attitude, perceived behavior control, and the use of skilled maternity care among women (10,63,64). Recent findings from the “Lancet Series of Optimizing Caesarean Section Use” also showed that non-clinical health-care interventions to reduce unnecessary C-sections are most effective when prioritizing human relationships, promoting respectful and collaborative care, and addressing women's beliefs and attitudes (58).
The SoB intervention provides women with scientific evidence-based information, becoming a viable and valid source of women’s authoritative knowledge set, as conceptualized by different authors (45,46). The intervention can potentially empower women to use their embodied knowledge as a complement to their authoritative knowledge, potentially resulting in an increase in the woman’s perception of control of childbirth and reinforcing her decision about the type of birth
Interactive activities through the intervention provide women with the chance to experience the embodied knowledge and the new set of authoritative knowledge gained through the intervention. Increasing access to knowledge and information may empower women to challenge the authoritative and technocratic medical knowledge, providing them with the sense of self-efficacy to overcome fear, increase control, and access tools to achieve a positive experience of birth and satisfaction. Increasing women’s knowledge may also create opportunities for a meaningful conversation with their health professionals that could lead to improved support for their preference for type of birth and use of evidence-based practices to achieve a positive birth experience (21,22,65–67).
Intrapartum EBP knowledge and women’s perceived control
Before the intervention, women who participated in the SoB intervention knew more about the benefits and risks of normal birth and a cesarean than they knew about EBP. Understandably, they perceived a higher increase in their knowledge about EBP after experiencing the intervention. That difference might indicate that there is a broad or popular consciousness about the benefits of normal birth and risks of cesarean within Brazilian society, even while facing the technocratic model of care. However, information regarding best practices during childbirth, women's rights, and resources to achieve a positive birth experience are not disseminated adequately. These results are consistent with the literature showing a low awareness of reproductive rights, and EBP among Brazilian women (55,68–70).
Providing access to information about EBP for women can be a strategy to achieve a positive childbirth experience. It can be a tool for women to regain control over their bodies. The Senses of Birth intervention intentionally engaged social movement organizations that defend humanized birth in every city where the intervention was assembled; the goal was to promote social mobilization and community discussion. These partnerships also prompted many women who were already interested in and engaged in social movements to visit the intervention.
Nonetheless, the results showed that even among highly engaged women, there is a clear need and opportunity to invest in and increase Brazilian women's knowledge about normal birth, cesarean, and EBP during childbirth. Previous studies identified that Brazilian women had limited access to adequate information or educational practices during prenatal care, which reinforces a vertical and medical centered model of care that does not value health education as a potential quality measure/standard (68,71).
The lower average scores on EBP knowledge before the intervention were expected when taking into account the low rates of use of best practices among Brazilian women, shown by other studies (54,55). The Birth in Brazil survey found that only 3.4% of the live births between 2011 and 2012 used practices recommended by the WHO during labor and childbirth (54), and these practices were mainly used in public hospitals (SUS) and among primiparous women (40,70).
Creating tailored health education interventions
These results indicate that the SoB intervention was more effective for low-income women, without private health insurance, with private prenatal care, in their first pregnancy and their first or second trimester at the time of the intervention. Similar findings were observed in a study that compared two different health education interventions focused on women's decision-making processes and preference for type of birth (72). The results of the current evaluation point to an important group to be prioritized to optimize the potential of the intervention: primiparous, low-income women, at the beginning of pregnancy, without private health insurance. However, in Brazil, that would not include a group of women most likely to have an unnecessary cesarean, considering the existing paradox of care. White, high-income women with more than 12 years of education, with private prenatal care, are the characteristics of Brazilian women most likely to give birth in a private hospital, therefore, exposed to higher rates of C-section (37). Therefore, there is a need to discuss how health education interventions can also be tailored to include those women who are more likely to experience a C-section in Brazil.
Different studies found that women are more likely to have a C-section if they receive private care, have limited access to midwives as primary caregivers and/or have experienced a previous cesarean (10,73,74). Those women in this study had a higher perceived knowledge about normal birth and cesarean before the intervention than their counterparts did. However, this knowledge does not seem sufficient to impact the type of birth outcome, even though higher knowledge about the risks of C-section increases the chance of women waiting for labor onset and avoiding scheduling an elective surgery (75).
In the Birth Brazil Survey, 70.8% of pregnant women surveyed stated that they prefer a vaginal birth, and a metanalysis review with 28 different Brazilian studies found an overall prevalence of 72.8% preference for a vaginal birth (38,65). However, 40% expected to have a C-section when arriving at the hospital to give birth (76). Women that expect or prefer a C-section justify it by expressing their fear of fetal distress and mortality, excessive pain, or fear of trauma to the vagina (14–16,76).
Decisions based on fear suggest a lack of knowledge or misinformation on how to have a safe birth for the mother and child, and also a society with an instilled distrust of the body's ability to undertake labor and safely deliver a child without a negative impact on a woman's sexual life. Discussing the use of EBP might be an essential aspect to achieve a positive childbirth experience, contributing to change women’s perception of fear of normal birth and believe that a cesarean is the safest type of birth. Women’s voices and values need to be incorporated into a comprehensive childbirth model to reduce unnecessary C-sections (15,77).
Although there were no significant differences between white and black women regarding increases in knowledge, white women arrived at the intervention with higher perceived knowledge, which has also been observed in other studies about women’s decision processes type of birth (72). Considering the country's social and racial inequalities with black women being more likely to have worse childbirth outcomes, led by social inequalities during pregnancy and throughout a lifetime exposure to discrimination and stress when accessing healthcare (78–81), discussing health education within racial differences is needed.
Given the opportunity and access to information through the Senses of Birth intervention, black women who participate in the intervention have the same chances to increase their knowledge about normal birth, cesarean and evidence-based practices as white women, which might increase their chances to achieve positive childbirth outcomes. Health education can be seen as one strategy to promote a positive childbirth experience. However, closing the black-white gap in birth outcomes will not happen without a multi-sectoral policy intervention that addresses health inequalities and systemic racism not only immediately before and during pregnancy, but also through the lens of a life-course approach (80,82).
The observed opportunities to increase Brazilian pregnant women’s knowledge regarding all three domains (normal birth, cesarean, and EBP) can lead to questions about the quality of information women are currently receiving during prenatal care. Findings indicate that women in both private and public health system are likely to increase their knowledge about normal birth after participating in an effective health education intervention. Meanwhile, previous non-disclosed results indicate that 16.9% of the women who had private health insurance opted for a prenatal care at the public health system, as it is part of their constitutional right. Moreover, 9.5% of women who had no private health insurance opted for a private prenatal care, likely paying out-of-pocket. Although not addressed here, the results point to the need of exploring quality of prenatal care in both systems, allowing women to have good quality information despite of where they are.
The current literature also supports the idea that women exposed to adequate prenatal care are more likely to increase awareness and knowledge regarding signs of obstetric dangers and benefits of normal birth and screening tests; however, few women have such access (83). Health education and experience give mothers a more nuanced understanding of the birth process (84). Women from different countries consider education about childbirth important and point out that it should include not only risks and benefits of the type of birth but also information about labor, delivery, and medical interventions (15,85–88).
It is recognized that implementing scientific knowledge into practice requires a system change, and evaluating translational interventions is essential to better direct policymakers and healthcare professionals' decisions (89). In particular non-clinical and multicultural interventions tailored to a local context, addressing women and health professionals' beliefs, attitudes, knowledge, and skills, as well as the limitations of the health system, are needed (58). Therefore, health education interventions that can provide information, while promoting community engagement and giving women tools for empowerment, such as the SoB intervention, are needed to change the maternal health care scenario.
A maternal health care system as proposed by WHO to achieve SDG 3 and 5 (25) can only happen if we include women’s voices and empower them to advocate for evidence-based care, regaining control over labor and childbirth. A reproductive justice model of childbirth, focusing on building a health system that supports full reproductive health and rights, has the power to engage women in their care and reduces the impact of social inequalities on adverse birth outcomes, as demonstrated in the literature for the Zika epidemic experience (90). In a country with high cesarean rates like Brazil, a culturally tailored intervention that can impact women's knowledge has the potential to contribute to a maternal health care system, which includes women's engagement and voices.
Strengths and Limitations
This is a cross-sectional study, with its intrinsic limitations that do not permit causal inferences. On the other hand, the large sample of pregnant women answering the survey allowed adequate statistical power to detect the SoB intervention's impact on perceived knowledge about normal birth, cesarean section, and EBP to achieve a good experience in childbirth.
Brazilian women with lower perceived knowledge were likely underrepresented in our sample, which was predominantly women already sensitized about childbirth. Therefore, the impact of SoB intervention could be underestimated. In addition, women describing their childbirth perceived knowledge might be influenced by intrinsic social desirability focus on positive or negative outcomes of childbirth. However, the anonymity and high perceived knowledge before the intervention likely diminish this influence over the results.
The SoB results gain relevance when international literature review shows a lack of evidence for the efficacy of non-clinical interventions to reduce unnecessary cesareans in middle and low-income countries, singularly when the interventions are focused on women (91). In contrast, single-focus interventions that target one factor to reduce unnecessary cesareans have shown small impacts or low effectiveness (58), which might be related to the multifactorial reasons related to the TMTS and TLTL scenario.