Who is afraid of obstetric violence?

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Introduction
The care of pregnant women and the process of care during labor and birth should be guided by quality and humanized principles, and it is the duty of healthcare services and healthcare professionals to welcome women and newborns with dignity, focusing on the rights of the individual. 1 Although this statement seems logical and direct, there is solid and growing evidence of the occurrence of disrespectful and violent practices experienced by women in obstetric care facilities, particularly during childbirth, which is a matter with no major differences in the literature. [2][3][4] This violation of rights has received several denominations such as disrespect, mistreatment or obstetric violence. It is worth mentioning that the choice of words used to express an idea, even if not conscious, is not random. In this way, it is necessary to understand what obstetric violence means -since this expression is what we understand as appropriate -and to contextualize it historically in order to understand the rhetorical resistance to the use of the term.
Obstetric violence is any action or omission directed at women during prenatal care, childbirth or the puerperium, which causes unnecessary pain, harm or suffering to the woman, practiced without her explicit consent or in disrespect to her autonomy. 5 In this perspective, it consists of the appropriation of body and reproductive processes of women by healthcare professionals (medical and non-medical), through dehumanized treatment, mistreatment, abuse of medicalization without the explicit consent of women and the pathologizing of natural processes, causing loss of autonomy and ability to freely decide on their bodies and sexuality, having a negative impact on their quality of life. 6 Obstetric violence is characterized by acts such as: verbal abuse with shouting, procedures without consent or information; denying access to analgesia; impediment to the presence of a birth companion of the laboring woman's choice (which is guaranteed by law); denying the right to privacy during labor, psychological violence (aggressive, discriminatory, authoritarian or rude treatment); performing cesarean section or episiotomy without consent; use of oxytocin without medical indication in order to accelerate labor; Kristeller's maneuver; prohibition of access to food or hydration and restriction of freedom of movement, forcing women to stay in bed. [2][3][4] This violation of rights in obstetric practice occurs both in the public and in the private sector during care related to pregnancy and birth, situated within a multifactorial context of institutional and gender violence. 5 Despite being a relatively new term, obstetric violence is an old problem. 3,7 The intensification of the debate, however, coincides with the emergence of a new legal construction that includes elements of quality in obstetric care and mistreatment of women during childbirth. 4,8 The concept of obstetric violence emerged in Latin America and Spain in the 2000s from activist movements for the humanization of childbirth. These demands were in line with a central agenda for feminist movements, which have long criticized medicalized models of labor and birth care, denouncing them as a serious violation of women's autonomy. 9,10 As a legal framework, the term appeared in Venezuela in 2007, followed by Argentina in 2009 and Mexico in 2014, with agents of obstetric violence subject to criminal liability in those countries. [11][12][13] In Brazil, like other countries, the expression took shape and body at the heart of feminist movements and by the humanization of childbirth. 10,14 Although there is no specific federal law, there is generic state legislation in the legal system regarding obstetric violence. 15 Several states and municipalities have been enacting laws that typify obstetric violence. The state of Santa Catarina sanctioned the Law Nº 17,097, of January 2017 and, in Pernambuco, there is the Law Nº 16499, of December 2018, defining obstetric violence as "any act practiced by health professionals, which implies negligence in care, verbal, physical, psychological or sexual discrimination or violence against pregnant women, laboring women and women who have recently given birth". 16,17 Despite the social and legal recognition of the term, there are many challenges to its use. The World Health Organization (WHO), although recognizing the issue as a health problem that violates women's rights to respectful care, resists the use of the term obstetric violence. In place, the WHO adopts the terms "abuse, disrespect and mistreatment during childbirth in facilities". 18 This resistance is contradictory in the face of the organization's own concept of violence. WHO defines violence as any action that has the intentional use of physical force or power, real or threatening, against oneself, against another or against a group, which results or may result in any psychological damage, disability, injury or death. 19 As for intentionality, it should be noted that it refers to the intention to use the force or inherent power and not necessarily to cause the damage itself. 20 The use of the term "power" demands an understanding of the establishment of hierarchical rela-Who is afraid of obstetric violence? tionships, including negligence or acts of omission, withdrawal of the other's autonomy, in addition to the most obvious violent acts. 21 In this way, care acts during childbirth/puerperium that start from a power relationship between health systems, healthcare professionals and patients, during which procedures are imposed on women, injuring them in their exercise of autonomy and assuming the risk of physical, emotional or psychological trauma fulfill all the criteria to be named by the term "violence".
In addition to the term violence, its qualification "obstetric" is also the target of resistance. Some professionals, with the support and approval of some medical councils and societies, claim that the use of the term would be violence against obstetricians. 7,8,22,23 In line with this perspective, the Ministry of Health recently tried to remove the term "obstetric violence" from public documents. 19 The controversy is unreasonable, since the adjective "obstetric" is not exclusive to the medical doctor. Violence can result from systemic failures in different levels of care in health systems, 2,4,24 so that the expression cannot be understood as a synonym for "violence committed by the obstetrician". Recognizing, therefore, obstetric violence as a reality, does not mean blaming any specific professional category.
Here, it is worth rescuing a principle idea of Discourse Analysis, according to the French school: Silence is contingent on the enunciation. This means that the words we choose not to use say more about the ideological north of our discourse than those we choose to verbalize. 25 It turns out that health professionals' discursive practices are shaped in a social environment and in health systems whose political and economic foundations foster the development of power relationships. 3,4 This violence is, therefore, not only direct, but structural, and reflects the patriarchalism that prevails in our society and also in healthcare practices. 26 In this way, even professionals who propose to be caregivers, are inserted in a care context that not only naturalizes, but constructs a discursive rhetoric without scientific basis to not recognize as violent practices that actually are.
Obstetrics was built as a specialty in a context in which all of medicine was quite interventionist and doctor-centered. Add to that the mistaken idea of perennial pathologizing of the female body, considered defective in several aspects, which implied constant need of corrections. It is in this context that the standardization of obstetric surgical practices gained strength in obstetric practice, such as the use of prophylactic forceps in primiparous women and the use of systematic episiotomy. 27 Medicine, however, has been evolving guided by principles of bioethics and, in this context, it is important to recognize that the principles of autonomy, beneficence and non-maleficence have been demanding the revision of countless practices which are historically ingrained,however, without any support in scientific evidence. 28 It is worth remembering that some obstetric practices are not violent in themselves, but are understood in this manner only when used inadvertently, by imposition or in disagreement with scientific evidence. Confronting obstetric violence, therefore, mainly benefits women, but it also brings advantages to healthcare professionals involved in care, as ethical and evidence-based professional practices demand an adequate structure, harmonious and non-hierarchical work relationships.
Thus, narcissistic resistance to the use of the term "obstetric violence" does not protect medical professionals from legal repercussions arising from possible failures. On the contrary, insofar as it perpetuates a problematic structure, it favors the occurrence of failures and ethical lapses. Its recognition, however, not as mistreatment, but as violence as it is, requires structural changes and its contextualization in obstetric care situates the scenarios of this reconstruction. As long as we do not recognize that the current model of childbirth care, which is excessively technocratic, abusive and permeated by unnecessary interventions, generates violence against women, it is difficult to modify practices to avoid violence. As much concerned as medical councils are at avoiding hurting doctors' susceptibility, it is important to recognize that it hurts any one of us to admit that we are, or were once, violent, but it hurts much more the violence against women itself. Only through acknowledgement and acceptance can the redeeming process of deconstruction and transformation begin.
There is no reason to fear the term "obstetric violence", what we need is to make every effort to eradicate it. If the term causes discomfort to the medical community, it also provides space for us to debate the necessary changes. The result of obstetric violence is a brutal attack on women and all of our empathy and solidarity are with them.