Perceptions of the Brazilian obstetrics physicians about the term obstetric violence: a cross-sectional study

SUMMARY

INTRODUCTION:

We observe a growing global discussion about the practices considered “obstetric violence” against women during pregnancy and childbirth. Otherwise, the indiscriminate subjective and lay interpretation of the term “obstetric violence” can lead to a misunderstanding among medical professionals.

OBJECTIVE:

This study aimed to describe the obstetrician's perceptions about the term “obstetric violence” and the medical groups affected negatively by the topic.

METHODS:

A cross-sectional study applied to Brazilian obstetrics physicians regarding their perceptions of “obstetric violence.”

RESULTS:

From January to April 2022, we sent about 14,000 direct mail nationwide. A total of 506 participants responded. We observed that 374 (73.9%) participants consider the term obstetric violence nocive or harmful to professional practice. Furthermore, after Poisson regression, we described that the respondents who graduated before 2000 and from a private institution were significant and independent groups for the full or partial agreement that the term is nocive for the obstetricians in Brazil.

CONCLUSION:

We observed that almost three in four obstetrician participants consider the term “obstetric violence” nocive or harmful to professional practice, particularly in those who graduated before 2000 and from a private institution. The findings are relevant to propose further debates and strategies to mitigate the possible harms caused to the obstetrician team by the indiscriminate use of the term obstetric violence.

KEYWORDS:
Gender-based violence; Physician-patient relations; Professional–-patient relations; Obstetrics; Pregnancy; Parturition

INTRODUCTION

We observe a growing global discussion about the practices considered “obstetric violence” against women during pregnancy and childbirth¹. Any interactions that offend the dignity and autonomy of pregnant women to achieve a desired or imagined result by obstetricians and staff can lead to a rupture in the doctor–-patient relationship and can be considered “obstetric violence².” The World Health Organization is concerned with the issues involving disrespect and abuse during childbirth, prioritizing evaluation, prevention, and elimination of these practices³. There are many efforts to recognize and change this condition, avoiding medical hospital cultures that can perpetuate practices and behaviors harmful to human beings⁴. In contrast, the indiscriminate use of subjective and lay interpretation of the term “obstetric violence” can lead to a misunderstanding that negatively affects the doctor–-patient relationship.

The Spanish Society of Gynecology and Obstetrics recently issued an official web communication on the subject: “We find the term ‘obstetric violence’ inappropriate, biased and unfair because of its malicious legal meaning, as an intention to cause harm, to injure, use force or threat, criminally liable, which we must reject completely.” Furthermore, we consider that the widespread use of the term “obstetric violence” can compromise the behavior of the professional team involved in the care of pregnant women. Therefore, the topic is very relevant to be studied to understand the interpretation and attitudes of the professionals involved in obstetric care. The study can guide future interventions to minimize the effects of compromise in the doctor–-patient relationship in obstetrics care. The need for good care and compliance with good practices in obstetrics care is undeniable. However, we hypothesize that obstetricians disagree with using the generalized form of the term “obstetric violence” as it has usually been propagated.

OBJECTIVE

The aim of this study was to describe the perceptions of the obstetrics medical professional on the term “obstetric violence.” From the obstetrician's point of view, to describe whether the term “obstetric violence” in Brazil may be nocive to the doctor–-patient relation. To estimate the percentage of Brazilian obstetricians who agree and those who disagree with the term “obstetric violence” besides the medical groups more affected.

METHODS

We developed a cross-sectional study at the Faculty of Medicine of Educational Foundation of Assis Municipality, São Paulo, Brazil. The recruitment period was from January to April 2022. We collected data from an anonymous web-based questionnaire sent by email to Brazilian obstetricians and gynecologists. According to the latest publication in 2018 by the Federal Medicine Council, there are more than 30,000 gynecologists in Brazil. In addition, we obtained direct mail contact from about 14,000 obstetricians and gynecologists provided by the Brazilian Federation of Ob/Gyn societies and the Regional Councils of Medicine from each state nationwide. For this estimated population, using a 5% sampling error, 95% confidence level, and more heterogeneous population distribution (50/50), the estimated sample size was 380 respondents.

Inclusion criteria were as follows: physicians registered with the Regional Councils of Medicine of Brazil who work in obstetrics. Exclusion criteria included responses to questionnaires with inconsistent answers or missing data. Study variables included the sociodemographic profile; whether or not to agree with the term obstetric violence; whether the regulation of laws or regulations on obstetric violence is beneficial or harmful for the doctor–-patient relation; and working or not in obstetrics for the last 5 years. Therefore, participation in this research does not violate legal and ethical standards. Data were collected using an online email questionnaire sent to Brazilian physicians working in obstetrics nationwide. The invitation letter was sent through direct mail, endorsed, and posted by The Obstetrics and Gynecology Society of Sao Paulo State (SOGESP) to all the physicians included in the association. The research obtained the official authorization from the Ethics Committee Institution under number 51946721.3.0000.8547. The participants who agreed obtained access after agreeing to the informed consent form. The questionnaire contains sociodemographic profile (age, sex, state location), professional profile (year of graduation, the period in professional activity, graduation from a public or private medical school, the highest graduation, if worked as an obstetrician in the last 5 years, work institution public or not, hospital or not), and the guiding questions of the research objectives, as published in the supplementary file. According to the Likert scale, the number and percentage of physicians who agree or disagree with the term “obstetric violence” (disagree entirely, partially, neither disagree nor agree, partially agree, or totally agree). The number and percentage of physicians agree with the possibility that the term “obstetric violence” harms the obstetrician's practice of medicine. Data collected were analyzed according to the outcomes using statistical methods to determine the proposed objectives. The sample characteristics were presented in number and percentage rates. Then, the bivariate associations were estimated between each independent variable with the outcome of full or partial agreement about the assertion that the term obstetric violence may be harmful/nocive to professional practice. The dependent variables that showed bivariate association with p≤0.20 were taken to a multiple regression model with Poisson response. The associations were considered statistically significant in the final model if p≤0.05. The analysis was done using the SPSS v21 software (IBM, New York).

RESULTS

From January to April 2022, we sent approximately 14,000 direct mail nationwide with the invitation, consent form, and questionnaire for the obstetrician physicians in Brazil. A total of 510 participants responded, and 4 questionnaires were excluded due to inconsistent data on the association between age and the year of graduation. Thus, 506 participants were included (Table 1).

Table 1
Participant characteristics (n=506).

Variable		n	%
Gender
	Female	293	57.9
	Male	213	42.1
Median age in years (min–max)		47 (25–100)
	18–29	39	7.7
	30–59	348	68.8
	60–69	73	14.4
	70 +	49	9.1
Graduation conclusion year
	1950–1959	3	0.6
	1960–1969	10	2
	1970–1979	50	9.9
	1980–1989	86	17
	1990–1999	106	20.9
	2000–2009	100	19.7
	2010–2019	144	28.5
	2020–2022	7	1.4
Graduation conclusion period
	Before 2000	255.0	50.4
	After 2000	251.0	49.6
Graduation institution
	Public	290	57.3
	Private	216	42.7
Highest academic degree
	Medical graduation	13	2.6
	Specialization course	43	8.5
	Residence	310	61.3
	Master's degree	67	13.2
	Doctoral degree	57	11.3
	Postdoctoral or highest	16	3.2
Private office working
	No	180	35.4
	Yes	326	64.6
Private hospital working
	No	231	45.5
	Yes	275	54.5
Public office working
	No	408	80.6
	Yes	98	19.4
Public hospital working
	No	185	36.6
	Yes	321	63.4
Preceptor working
	No	393	77.6
	Yes	113	22.4
Public–-private hospital
	No	399	78.8
	Yes	107	21.2
Primary healthcare office
	No	425	84.0
	Yes	81	16.0
Number of institutions areworking
	1	114	22.5
	2	176	34.8
	3	88	17.4
	≥4	128	25.3
Primary Brazilian geographical region
	South	89	17.5
	Southeast	332	65.5
	North	18	3.6
	Northeast	36	7.2
	Midwest	31	6.2
Working in obstetrics in the last 5 years
	No	31	6.1
	Yes	475	93.9
The context: it seems inappropriate, tendentiously, and unfair to use “obstetric violence”
	Fully disagree	122	24.1
	Partially disagree	30	6.0
	Neutral	5	1.0
	Partially agree	69	13.6
	Fully agree	280	55.3
Please give your opinion: “Using the term obstetric violence may be nocive for the professional practice, from the point of view of the self-judged qualified worker that ever practiced considered violent acts during your lifespan”
	Fully disagree	115	22.7
	Partially disagree	12	2,4
	Neutral	5	1.0
	Partially agree	49	9.7
	Fully agree	325	64.2
Is the “obstetric violence” media placement beneficial or malefic for the medical–-patient relationship?
	Absolutely malefic	351	69.9
	Relatively malefic	3	0.6
	Indifferent	51	10.2
	Absolutely beneficial	90	17.9
	Other responses	7	1.4
	I prefer not to respond	4

• n: number of participants.

The number of participants who agreed that the term “obstetric violence” may be nocive for the professional practice was 374 (73.9%). In addition, 349 participants (68.9%) agreed that the term “obstetric violence” seems inappropriate, tendentious, and unfair. Moreover, 354 (70.5%) considered that the media placement of the term “obstetric violence” may be malefic to the doctor–-patient relation. Finally, 127 (25.1%) respondents disagreed that the “obstetric violence” term may be nocive.

We performed the bivariate association to investigate the population-stratified-dependent variables and the prevalence of agreement that the term use is nocive for professional practice.

The bivariate association for the prevalence of participants in full or partial agreement that the term “obstetric violence” may be nocive to the doctor–-patient relation demonstrates that male participants, graduation before the year 2000, and graduation from a private institution were significant statistically (p<0.20). Thus, we performed the Poisson regression to obtain the independent variables (Table 2).

Table 2
Poisson regression to explain the prevalence of full or partial agreement about the harmful or nocive consideration of the term violence obstetric for the professional practice.

Variable	β	95%CI		PR	95%CI		p
(Intercept)	-0.332	-0.545	-0.119	0.72	0.58	0.89	0.002
Male gender	0.174	-0.045	0.394	1.19	0.96	1.48	0.119
Graduation after 2000	-0.361	-0.585	-0.136	0.70	0.56	0.87	0.002
Private medical school	0.241	0.037	0.444	1.27	1.04	1.56	0.020

• β: beta coefficient; 95%CI: 95% confidence interval; PR: predictive risk. p<0.05.

After a Poisson regression, those respondents who graduated from private medical institutions remain statistically significant (β: 0.241; p: 0.020) to the full or partial agreement concerning the sentence that obstetric violence may be nocive to the professional practice. The respondents who graduated after 2000 had a significant negative β-coefficient (β: −0.361; p: 0.002); thus, we considered that graduation before 2000 was statistically significant.

DISCUSSION

We observed that almost three in four obstetrician respondents consider the term obstetric violence nocive or harmful to the professional practice in Brazil. Moreover, more than 70% responded that the media placement of obstetric violence is malefic to the medical–-patient relationship. Besides, the context seems inappropriate, tendentious, and unfair for more than 70%. The Spanish Gynecology and Obstetrics Society recently published a bulletin entitled “comunicado SEGO: “violencia obstétrica”” on their website (www.sego.es), positioning the same perception against the indiscriminate use of the term obstetric violence by the institution⁵–⁷.

Furthermore, after Poisson regression, we described that the respondents who graduated before 2000 and graduated from a private medicine institution were significant and independent groups for the full or partial agreement that the term is nocive for the obstetricians in Brazil. However, we did not find similarities in the current literature to provide discussion concerning the graduation period and institution type.

The primary limitation is due to the cross-sectional study design, with no evidence of a temporal relationship between exposure and outcome. Second, the cross-sectional study may be prone to nonresponse bias when those who consent to participate in the study differ from those who do not, resulting in a sample not representative of the population. Third, we used a nonvalidated questionnaire. We did not find similar studies and valid questionnaires about the topic in the current literature.

Considering our objectives, limitations, analyses, and the lack of similar studies in the literature, we provide a relevant inference that the perception of the majority of obstetricians in Brazil concerning the term obstetric violence may be nocive and may cause damage to the professional behavior and doctor–-patient relationship.

Our study evaluated a nationwide proportion of obstetricians, and we consider the results consistent with validating externally, significantly nationwide in Brazil.

CONCLUSION

We described that more than 70% of Brazilian obstetricians in the survey considered the term obstetric violence harmful to professional practice. Physicians who graduated before 2000 and from a private medicine institution were the most influential groups following the perception that the term may be nocive for the doctor–-patient relation. Besides, the topic is considered very controversial. Nevertheless, it is evident that the abuse and disrespect during obstetric or female care need to be recognized and dealt with firmly. Therefore, the results of our study are relevant to propose further debates and strategies to mitigate the possible harms caused by the indiscriminate use of the term obstetric violence in Brazil.

• Funding: none.

ACKNOWLEDGMENTS

The authors thank Miss Cristiane Muniz from the Obstetrics and Gynecology Society of Sao Paulo State; Prof. Dr. Luiz Fernando Ferrari Neto from SINDHOSP; and Prof. Dr. Hélio Nunes for the statistical analysis.

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Publication Dates

• Publication in this collection
  03 Mar 2023
• Date of issue
  2023

History

• Received
  15 Sept 2022
• Accepted
  12 Oct 2022