Institutional violence during the parturition process in Brazil : integrative review

Objective: To identify the types of institutional violence of childbirth reported by the woman, the birth companion and health professionals. Method: Integrative review that analyzed 33 articles in the LILACS, BDENF, INDEXPSI, regional SciELO, Scopus, Web Of Science and PubMed databases. Results: Women were the main violence rapporteur, with predominance of the psychological type. Precarious infrastructure and the imposition of professional decisions were identifi ed by the companion as violence. For health professionals, performing procedures without consent does not characterize violence, but guarantees childbirth security. Final considerations: The most common types of violence in Brazilian maternity hospitals are psychological, physical and structural. Most of the time, violence is reported by women, although professionals also perceive and admit its perpetuation. Descriptors: Humanizing Delivery; Labor, Obstetric; Hospitals, Maternity; Health Services; Violence. RESUMO Objetivo: Identifi car os tipos de violência institucional no parto relatados pela mulher, pelo acompanhante de parto e por profi ssionais de saúde. Método: Revisão integrativa que analisou 33 artigos nas bases LILACS, BDENF, INDEXPSI, SciELO regional, Scopus, Web Of Science e PubMed. Resultados: A mulher foi a principal relatora da violência, com predominância do tipo psicológica. A infraestrutura precária e a imposição das decisões profi ssionais foram identifi cadas pelo acompanhante como violência. Para os profi ssionais de saúde, a realização de procedimentos sem consentimento não caracteriza violência, mas garantia de segurança no parto. Considerações fi nais: Os tipos de violência mais comuns nas maternidades brasileiras são as psicológicas, as físicas e a estrutural. Na maioria das vezes, a violência é relatada pelas mulheres, embora profi ssionais também percebam e admitam sua perpetuação. Descritores: Parto Humanizado; Trabalho de Parto; Maternidades; Serviços de Saúde; Violência. RESUMEN Objetivo: Identifi car las clases de violencia institucional durante el parto reportadas por la mujer, por el acompañante del parto y por profesionales de la salud. Método: Revisión integradora que analizó 33 artículos en las bases LILACS, BDENF, INDEXPSI, SciELO regional, Scopus, Web Of Science y PubMed. Resultados: La mujer fue la principal informante de la violencia, con predominio del tipo psicológico. La infraestructura precaria y la imposición de las decisiones profesionales fueron identifi cadas por el acompañante como violencia. Para los profesionales de la salud, la realización de procedimientos sin consentimiento no caracteriza violencia, sino una garantía de seguridad en el parto. Consideraciones fi nales: Las clases de violencia más comunes en las maternidades brasileñas son las psicológicas, las físicas y las estructurales. La mayoría de las veces, son las mujeres quienes informan sobre la violencia, aunque los profesionales también perciban y admitan su perpetración. Descriptores: Parto Humanizado; Trabajo de Parto; Maternidades; Servicios de Salud; Violencia. Institutional violence during the parturition process in Brazil: integrative review Violencia institucional durante el proceso del parto en Brasil: revisión integradora Violência institucional durante o processo parturitivo no Brasil: revisão integrativa REVIEW Lihsieh Marrero E-mail: lihsiehm@gmail.com AUTOR CORRESPONDIENTE


INTRODUCTION
Mistreatment and disrespect reports to women during the parturition process in health institutions are not recent, although their elimination is a claim of social movements for human rights, which in recent years have gained visibility because of the scientific evidence on the low quality impact of care during the pregnancy-puerperal period for women and children (1)(2) .These events have promoted conceptual advances on violence in institutionalized childbirth in the legal, political, and welfare practices, shaking government agendas (3)(4) .
Despite advances, there is still no clear and comprehensive definition of institutional violence in childbirth in the national and international literature, which is currently described and recognized as maltreatment and disrespect, use of procedure, conduct and routines that are harmful or have no scientific evidence during the women care in childbirth assistance services (5)(6)(7)(8) , still frequent in many parts of the world (9)(10) .In Brazil, it is estimated that approximately 25% of the women who went through childbirth in maternities suffered some form of violence (11)(12) .
The shortage of comprehensive studies that allow generalizations and estimates of magnitude, the methodological limitations of the investigations on the theme, the multifactorial and dimensional character of the phenomenon demonstrates the knowledge gaps and the necessity to increase the discussion, including different perspectives, to reveal the institutional violence aspects of childbirth.

OBJECTIVE
Identifying, in the literature, the types of institutional violence in childbirth care in Brazilian maternity hospitals reported by the woman, the birth companion and health professionals.

METHOD
This is an integrative review of the literature, whose development followed six stages (13) .The first one consisted in choosing the theme and in the elaboration of the following research questions: what are the most frequent types of institutional violence suffered by women seeking childbirth care in Brazil?Who are the subjects who report institutional violence during childbirth in investigations on this topic in Brazil?
In the second stage, inclusion and exclusion criteria were established.Only original research publications developed in Brazilian maternity hospitals were included, which recorded the occurrence in their findings, type and who reported the institutional violence that occurred during labor pains and childbirth; available in the electronic bases chosen for the study; in Portuguese, English or Spanish languages published between 2000 and 2016.Publications classified as experience reports, case studies, editorial, review and theoretical reflection were excluded from the review.Data collection was conducted between September 2016 and February 2017, in the Electronic databases Latin American and Caribbean Literature (LILACS), Nursing Database (BDENF), Index Psi Periodicals (INDEXPSI), MEDLINE, Scientific Electronic Library Online (regional Sci-ELO) from the Health Sciences Descriptors (DeCS) selected in the Virtual Health Library (VHL): Violence Against Women (Violência Contra a Mulher), Violence (Violência, Violencia), Hospital, Maternity (Maternidade, Maternidad), Women's Health (Saúde da Mulher), Quality improvement (Qualidade da Assistência à Saúde), Parturition (Parto, Parturição), and Obstetric (Obstetrícia, Obstetricia).The keywords "Institutional Violence" (Violência Institutional) and "Disrespect" (Desrespeito, Desprecio) were used to complement the search, with later application of the "Brazil" filter (Brazil).To search the Scopus and Web Of Science databases, the Medical Subject Headings descriptors (MeSh): "Violence", "Hospitals", "Maternity", "Parturition" and "Obstetrics" were selected from the National Library of Medicine database.The keywords "Violence Against Women", "Childbirth", "Disrespect" and "Brazil" complemented the searches.In all, 878 publications were found and 33 were eligible (Figure 1).
In the third stage, the data of interest (title, authors, year, journal, language, database, area of knowledge and type of publication, objectives, type of approach and research, study site, subjects and sample, data source and analysis, type, moment and report of registered institutional violence) with the aid of a previously elaborated instrument.The data were organized in Excel ® software.
In the critical analysis, the fourth stage of the study, the "double blind" methodology was used, in which two researchers evaluate the material without one knowing the opinion of the other.In the discordant cases, a third researcher proceeded to the review.The data were analyzed considering the categories of discriminatory institutional violence based on attributes (depreciation or non-care by the professional, based on racial, social The construction of these categories considered the definitions of different authors about mistreatment, abuses and violated rights of women in health institutions during the childbirth care (6,8,14) .
In the fifth stage of the review, aimed at the discussion and interpretation of the data, the description of the typology, the moment of occurrence and by whom institutional violence at birth was reported.The summary of the evidence and the presentation of the results of the review comprised the sixth step of the methodological choice for this study.

RESULTS
The 33 articles included in this review were published between 2003 and 2016, with diffuse distribution, 66.7% had as their language of publication only Portuguese and 30,3% Portuguese and English.The highest percentage of publications occurred in journals from Collective Health area knowledge (57.6%) and in the Nursing (33.3%).
The qualitative approach was the most frequent (78.8%), and the publications with a quantitative approach were descriptive studies.Most of the studies (93.9%) were conducted in specific municipalities or in metropolitan areas, commonly in the Southeast (15-17) and South (78.7%) (18-20) regions, and two had national coverage (12,21) .The highest percentage of studies (74%) were conducted in public institutions.
Data sources for all studies were obtained from interviews and hospital records.In 69.8% of the publications, the woman was the subject of research, victim and report of institutional violence at childbirth; in 18.1%, the health professional (physician, nurses and nursing technicians) were the authors, or as witnesses of some type of violence against parturient women in their work environment; and in 3%, the companion was the research subject (Chart 1).In 9.1% of the studies, institutional violence at childbirth was reported jointly by the woman, her companion and the health professional.

Time of violence occurrence
Aguiar e Tanaka (15) 2016 Qualitative

Woman (n=12)
To analyze the collective memories in narratives of women who lived the maternal near miss.

Woman (n=603)
To analyze the factors associated with practices not recommended in obstetric care.Physical Labor Delivery Belfort et al. (23) 2016 Qualitative

Woman (n=26)
To describe obstetric care to black women in the State of Maranhão.

Woman (n=23.940)
To analyze socio-demographic inequalities in maternity hospitals care in the Southeast Brazil.

Woman (n=172)
To verify the prevalence of obstetric violence in a maternity-school.

Woman (n=11)
To verify the perception of adolescents who have recently given birth about the care received during prenatal care and childbirth.

Psychological Physical Verbal Discrimination
Labor Delivery Rodrigues et al. (26) 2015 Qualitative

Woman (n=56)
To describe and analyze the perceptions of women about obstetric care during the labor and delivery process.

Woman (n=424)
To describe the socio-demographic and obstetric profile of women in São Paulo.

Psychological Physical Delivery
To be continued Author, year and approach Subject and sample (n) of the study Objectives of the study Type of reported violence Time of violence occurrence D'Orsi et al. (21) 2014 Quantitative

Woman (n=15.688)
To identify factors associated with the satisfaction of women related to the health professionals in hospital delivery and its influence on the overall satisfaction of women.

Woman (n=6.740)
To evaluate the use of good practices and obstetric interventions.Physical Delivery Cardoso e Barbosa (27) 2012 Qualitative Woman (n=15) To learn and understand, from the perception of women, the mismatch between the desire for vaginal delivery and the outcome in cesarean section.

Psychological Structural Discrimination
Labor Delivery Santos e Pereira (28) 2012 Qualitative

Woman (n=19)
To understand the experiences of puerperal women about the care received during the parturition process in a public maternity hospital.

Woman (n=21)
To present and discuss experiences of childbirth and mistreatment experienced by users in a health service.

Psychological Physical Verbal Discrimination
Labor Delivery Freire et al. (30) 2011 Quantitative

Woman (n=12)
To describe women's decision making about the way of delivery.Psychological Labor Delivery Carvalho et al. (31) 2010 Qualitative

Healthcare professional (n=23)
To identify the use of harmful practices in a university hospital.Physical Delivery Milbrath et al. (32) 2010 Qualitative

Woman (n=6)
To know maternal care experiences during labor and delivery.

Woman (n=33)
To describe, analyze and discuss the representations of women about parturition process assistance.

Psychological Physical Delivery
Carraro et al. (19) 2006 Quanti-qualitative Woman (n=84) To assess the opinion of puerperal women about care and comfort during labor and delivery.

Woman (n=22)
To analyze expectations of pregnant women about the care they will receive during childbirth and the evaluation of care in previous births.

Woman (n=26)
To examine childbirth in a public maternity hospital based on the perspective of young women and adolescents.

Psychological Structural Physical Verbal Discrimination
Labor Delivery Teixeira e Pereira (36) 2006 Qualitative

Woman (n=10)
To analyze cultural aspects of experiences of women who had normal hospital delivery.

Woman (n=9.633)
To analyze the social inequalities of access to the delivery service.Estrutural Admission Labor Delivery Domingues et al. (38) 2004 Qualitative

Woman (n=246)
To analyze factors associated with the satisfaction of women with attention to normal childbirth in maternity.

Psychological Structural Physical Verbal
Labor Delivery The set characterization of the selected studies brings the reader closer to the reality of childbirth care in Brazilian institutions.The methodological restriction of the studies suggests the need to extend the discussion about institutional violence in childbirth, revealing its forms, aggressors and the perception of victims and witnesses.The synthesis of the analyzed data is presented in two parts for a better understanding of the results.

Institutional violence: typology and moments of occurrence in the daily life of Brazilian maternity hospitals
The selected studies show that in the Brazilian birthing scenario, institutional violence of the psychological type was the most frequent (84.8%), followed by structural (57.6%) and physical (57.6%).Verbal (30.3%) and discriminatory (27.2%) violence were reported in a lower percentage.In most of the publications, more than one type of violence was recorded, showing concomitant occurrences.Sexual violence was not recorded in any of the studies.
In 9.1% of the studies, the results showed that institutional violence began before the woman's hospitalization and lasted until delivery (93.1%).The type of institutional violence that occurs before the woman is admitted to childbirth is usually structural, reported as a pilgrimage in the search for care due to the insufficiency of the obstetric bed in the institutions (26,43) .Discriminatory violence motivated by women's social class was also described, although in a lower percentage (17.2%) (16,32,37).
The studies showed that psychological aggressions against women were predominant in labor and delivery (75.9% and 82.8%, respectively).The companion's absence (51.7%), the neglect of the parturient needs by the care team (37.9%) and the imposition of the team's decisions on care were reported as a significant percentage of the investigations (34.5%) (12,28,33) .
Author, year and approach Subject and sample (n) of the study Objectives of the study Type of reported violence

Woman (n=27)
To investigate obstetrical care on respect for human rights, cultural and social differences and good practices.

Psychological Física Delivery
Brüggemann et al. (40) 2016.Qualitative Healthcare professional (n=17) To unveil the possibilities of the companion insertion in childbirth in public or contracted institutions.

Psychological Structural
Labor Delivery De Aguiar et al. (41) 2013 Qualitative Healthcare professional (n=18) To present and discuss institutional violence from the point of view of health professionals in public maternity hospitals.

Healthcare professional (n=23)
To know the justification of professionals for the use of harmful practices at birth.

Healthcare professional (n=23)
To analyze the conceptions of professionals about obstetric assistance to adolescents.

Healthcare professional (n=35)
To understand the representations of obstetricians and nurses about teamwork in the parturient care.
Psychological Structural Physical Verbal.

Companion (n=11)
To know the relatives' perception of women victims of maternal death and their circumstances.

Companion (n=11) Woman (n=11)
To know the experience of women and their companions in the process of childbirth.

Psychological Structural Physical
Labor Delivery Reis e Patrício (45) 2005 Qualitative To analyze the application of the recommended actions for the humanized delivery in a General Hospital of Santa Catarina.

Psychological Structural Physical
Labor Delivery Lino e Diniz (46) 2015 Qualitative Woman (n=14) Healthcare professional (n=14) To describe the perceptions of health professionals and private sector users about childbirth and contributing factors.
Physical violence in labor and delivery (62.1% and 65.5%, respectively), identified by the research subject, was characterized as an obstetric practice not recommended by the scientific evidence (17,21,34,36) .
The structural violence referred during labor and delivery (55.2%) was described as physical structure inadequacy of the institutions attendance (17.2%), the imposition of institutional routines that disregard the needs and rights of parturient women (13,8%) and staff deficit (10.3%) to provide decent and quality care at childbirth (29,35,40) .The bad qualification of the care team, the conflict between professional classes and the lack of material resources to attend delivery were also pointed out as institutional violence, although in a smaller number of studies (32,42,45) .

Interpretations of women, companions and health professionals about institutional violence at childbirth
In the studies in which the women were the subjects of the research, the violence of the psychological type was the most reported (87%), the absence of the companion was the main reason for the feeling of violation.For those attended in public maternity hospitals, the obstruction of the presence of the companion of their choice during labor and delivery also generated insecurity, fear and loneliness, transforming the experience into a violent, unpleasant and suffered one (25,38,44) .
Institutional violence, in the embarrassment form, due to the lack of privacy because of the physical structure limitations of the health institution and exposure for didactic purposes, emerges among women who gave birth in public and teaching maternities (24,29,33) .It is also worth mentioning the reports of professional coercion for delivery through cesarean surgery such as psychological violence, marked by the provision of false information, threats and disqualification of women's decisions, without differences between social class or type of service provider (27,(29)(30) .
Women's reports of some form of physical violence during childbirth were identified in 74% of the studies.The obstetric practices advised to be avoided by scientific evidence (episiotomy, Kristeler and use of oocytes) were frequently (86.9%) perceived by women as aggressions.Feelings of agression were also recorded in situations where the pain relief was denied (26.1%) and the obligation to adopt the lithotomy position at delivery (17.4%).Repeated and painful touches and the precariousness of communication between professionals and users were perceived by the parturient women as institutional violence.
Structural violence was reported as an inadequate infrastructure for attending childbirth and companion receiving (52.1%) and as institutional routines (17.4%) that violate the law and violate their rights.This type of violence was common in public health care visits (18,23) .
In the small number of studies that had the companion as a rapporteur of institutional violence in childbirth, they all referred to psychological and structural violence (40,(44)(45) .In their speeches, the companions demonstrate that they understand the imposition of the professionals' decisions during childbirth as opportunistic, given the emotional fragility of the woman, and the use of the welfare of the fetus as a bargain.The precariousness infrastructure of institutions that do not guarantee women privacy, impose limits to the companion's continuous presence and the insufficiency of obstetric beds were perceived as institutional violence, as it impairs the dignified and safe care of the woman and the newborn.
The studies carried out in which the health professional was the rapporteur on institutional violence at childbirth (8), showed that violence of the psychological and structural types is perceived more frequently (71.4%), followed by physical violence (42.9%).Attitudes such as increased tone of voice and harshness, deprivation imposition (of ingestion and emotional support) to the parturient and the abandonment threat of care are part of the routine care of many institutions and, although recognized as violence, are considered necessary for the order, professional authority and the well-being of women and the concept, especially in public maternity hospitals (18,31,41,45) .
From the professionals' point of view, in public institutions the situation is aggravated by structural violence, which victimizes not only women but also health workers, since it imposes overload and accumulation of working hours, remuneration and unsatisfactory working conditions.The discontinuity between prenatal, delivery and postpartum follow-up, the access difficulty to labor services, the lack of structure to accommodate the companion in the parturition process, and the frequent unavailability of medications for proper management of pain are examples of structural institutional violence, pointed out by health professionals (19)(20)22) .
The restriction of parturient movement at birth and the procedure performances without consent or explanation, as well as the use of techniques discouraged by scientific evidence, were not perceived by the professionals as physical violence, but as a guarantee of security, supported by the professional authority, especially the physician (31,46) .

DISCUSSION
The diverse typology, moments of occurrence, interpretations and actors involved in situations of violence in institutionalized childbirth demonstrate the multidimensional and multifactorial character of the phenomenon.
The institutional routines and professional-centered care practices employed in women's care who seek for childbirth services are understood as psychological, physical and verbal aggressions (28,44) .However, professionals and managers understand these actions/attitudes as a means of guaranteeing safety and quality of care for the woman and the newborn, although they do not deny the need for care improvements, either in access, infrastructure of maternity wards or in professional qualification (41,45) .
The different interpretations about institutional violence in childbirth care restart the discussion about the inequality of power between users and health professionals (15,27,30,41) .We have observed that the interactions between providers and users of Brazilian health services, especially in public management institutions, are marked by professional authoritarianism that can be attributed, in parts, to the maintenance of social and racial hierarchies, reflected in the current professional training process.During the learning of health profession careers, students conduct their technical skills training in health services, preferably in institutions, where the majority of the users are poor and of ethnic minorities.Patients are seen as object of training, whereas abuse, such as unnecessary or unsatisfactory interventions, ill-treatment, disrespect and their consequences are not recognized as violations of rights (16) .The authoritarian and interventionist professional training brings consequences to how care is provided to the parturient, often understood by them and their companions as negligence, violence and, often, discrimination, whether in public or private institutions (12,23,28) .
The labor pain naturalization results in the denial or nonoffer of pain relief methods, neglect of demands, abandonment and disqualification of women's opinions, as well as non-sharing of information for decision making on childbirth, are subtle forms of institutional violence, camouflaged in care routines in Brazilian maternity hospitals, accepted by professionals, women and companions (30,36) .The voluntary submission of parturient women to the professional impositions on their bodies and behaviors during the institutionalized childbirth can be explained by the Governability exercise.Governability, conceptually, one of the orders of power, which structures action, leads the individuals or groups to a conduct as subjects of action, even though it does not guarantee harmony in interpersonal interactions, nor does it prevent the occurrence of violence in care practices (47) .
Ethnic-social differences as motivators of violence against women in the pregnancy-puerperal cycle goes back decades and are recognized worldwide, being a theme in negotiation forums on international politics (International Convention on the Elimination of All Forms of Discrimination against Women, 1979, International Conference on Safe Maternity, 1987, International Conference on Population and Development, 1994, World Conference on Women, 1995).Unequal access to care services and poor quality of care are also forms of institutional violence of the structural type, produced by the neglect of the state and translated as social and gender discrimination (48) .
Regarding the efforts to change, the initiatives of the Brazilian government and social movements cannot be denied towards reorienting obstetric care, fewer interventionist care practices, and enabling new professionals to attend childbirth.However, the practices review meets opposition within medical professionals resistance and their representative entities, which present as arguments the low qualification of non-medical professionals and the doubt for their technical competencies for conducting safe childbirth (6) , despite the opposite evidence (49)(50) .
The presentation of new actors as the companion of women's choice, as well as the greater need of the parturient for their autonomy and role in institutionalized childbirth has been impaired by institutional structures that are moralistic and centered on the health professional (12) , and result in subtle forms of violence during the women care in the parturition process.Although the ministerial recommendations for childbirth and childbirth care are based on the best scientific evidence and social appeal for safe and non-violent motherhood, it is necessary to restructure the network of childbirth care and professional health training, directed by the respect and rights women must have during childbirth.

Limitations of the study
The difficulty of approaching the theme is presented as a major limitation according to this study, due to its controversy, which results in a small number of publications.The level of evidence from the included publications, mostly at level 4, makes it difficult to conclude the types, timing, and actors involved in situations of institutional violence at childbirth.The disparity between investigations that had the parturient as subject, the childbirth companion and the health professional limits the understanding of the problem.

Contributions to the area of Nursing, health or public policy
The results of the study may support proposals for the reorientation of practices and policies aimed at assisting institutionalized childbirth, drawing attention to problems that have existed for decades.This is because the presentation of the problem from different perspectives is a fundamental point for reflection on reality and about what is intended for the woman's care during childbirth.The gap between policy, legislation and obstetric care needs to be reduced, and it is essential to know the problem in its multiple dimensions, scenarios, actors and factors involved, as presented in this study, for the elaboration and implementation of effective measures and actions against institutional violence in childbirth in Brazilian maternity hospitals.

FINAL CONSIDERATIONS
The analysis of the set of studies shows that psychological, physical and structural institutional violence in childbirth are the most common in Brazilian maternity hospitals, most often reported by women, although professionals also perceive and admit their perpetration.The companion was the subject of an insignificant percentage of studies, although s/he is one of the actors in the childbirth scenario with proven benefits stated by the scientific evidence, with potential for the institutional violence prevention, it demonstrates the need to deepen and expand the investigations with the purpose to increase the knowledge about the problem.
Social and political appeals, based on scientific evidence, for a safe and non-violent motherhood have grown in the country, imposing the need to discuss the different forms of institutional violence in childbirth, related factors and effective measures for their prevention.
Given the multifactorial feature of institutional violence in childbirth, different segments of society (governments, civil society, health workers' class, training institutes, and researchers) should discuss building effective policies and guidelines to address the problem.Because one of the institutional violence side of childbirth is the structural one, which evokes The State Administration to act more vigorously in its prevention, expanding access to quality childbirth services with adequate infrastructure, adequate human resources and materials; and Institutional violence during the parturition process in Brazil: integrative review Marrero L, Brüggemann OM.
public power in the creation of legal and social devices that allow women's equality and dignity living.
Researches on the subject are still timid and restricted to local studies, with no robustness to support generalizations.In addition, the studies have not explored the different perspectives of institutional violence in childbirth; as an example is the absence of studies that have as subject the companion of choice and the occurrence of institutional violence has been seen in childbirth or suffering.
In this sense, proposals for deeper, broader research and with different methods on the subject are necessary to better explore the problem, and thus enabling, to contribute to the elaboration of policies, actions and social and legal devices for the elimination of institutional violence during childbirth.

Chart 1 -
Summary of studies included in the review, published in the period 2000 to 2016 Author, year and approach Subject and sample (n) of the study Objectives of the study Type of reported violence Institutional violence during the parturition process in Brazil: integrative review Marrero L, Brüggemann OM.