Obstetric violence within the hospital environment: experience report on inconsistencies and controversies

Objective: to report the obstetric violence experienced by undergraduate students at pre-delivery sectors and the obstetric center in a state public hospital in south-western Bahia, Brazil. Method: descriptive study, an experience report, conducted during the practices of the Curricular Supervised Internship II, by undergraduate students of Nursing at the Bahia State University (UNEB), in April and May 2015, covering the actions observed within the hospital environment that were characterized as obstetric violence. Results: situations of physical, psychological, and institutional obstetric violence were observed, reflecting on health problems for women. Conclusion: obstetric violence still occurs and it hurts women’s autonomy, especially in a veiled way, in a moment of weakness and lack of family social support. Thus, the insensitivity of professionals during childbirth care is noticed, contradicting the childbirth humanization policies. Descriptors: Violence Against Women; Women’s Health; Nursing; Humanization of Care. RESUMO Objetivo: relatar a violência obstétrica presenciada por alunos de graduação nos setores de pré-parto e centro obstétrico de um hospital público estadual no Sudoeste baiano. Método: estudo descritivo, tipo relato de experiência, realizado durante as práticas do Estágio Curricular Supervisionado II, por alunos de graduação em Enfermagem da Universidade do Estado Bahia (Uneb), em abril e maio de 2015, abordando as ações observadas no ambiente hospitalar que se caracterizavam como violência obstétrica. Resultados: observaram-se situações de violência obstétrica física, psicológica e institucional, repercutindo em agravos à saúde da mulher. Conclusão: a violência obstétrica ainda ocorre e fere a autonomia das mulheres, sobretudo de maneira velada, em um momento de fragilidade e ausência de apoio social familiar. Desse modo, nota-se a insensibilidade dos profissionais durante a assistência ao parto, contradizendo as políticas de humanização do parto. Descritores: Violência Contra a Mulher; Saúde da Mulher; Enfermagem; Humanização da Assistência. RESUMEN Objetivo: reportar la violencia obstétrica experimentada por estudiantes de pregrado en los sectores preparto y el centro de obstetricia en un hospital público del estado en el suroeste de Bahía, Brasil. Método: estudio descriptivo, un informe de experiencia, realizado durante las prácticas de la Pasantía Curricular Supervisada II, por estudiantes de pregrado de Enfermería de la Universidad del Estado de Bahía (UNEB), en abril y mayo de 2015, que cubre las acciones observadas en el ambiente hospitalario que se caracterizaron como violencia obstétrica. Resultados: situaciones de violencia obstétrica física, psicológica e institucional se observaron, repercutiendo en problemas de salud para la mujer. Conclusión: la violencia obstétrica se sigue produciendo e hiere la autonomía de las mujeres, sobre todo de una manera velada, en un momento de debilidad y falta de apoyo social de la familia. Por lo tanto, la falta de sensibilidad de los profesionales durante la atención del parto se nota, lo que contradice las políticas de humanización del parto. Descriptores: Violencia Contra la Mujer; Salud de la Mujer; Enfermería; Humanización de la Atención. Nurse. MS in Environmental and Health Sciences. Professor at the Department of Education in the Bahia State University (UNEB). Guanambi (BA), Brazil. Email: jksilva@uneb.br; Nurse. MS in Public Health. Professor at the Department of Education in the UNEB. Guanambi (BA), Brazil. Email: magnomerces@hotmail.com; Undergraduate student of Nursing at the UNEB. Guanambi (BA), Brazil. Email: joiceamorim.enfermagem@hotmail.com; Undergraduate student of Nursing at the UNEB. Guanambi (BA), Brazil. Email: kamilaguimaraesenf@hotmail.com; Undergraduate student of Nursing at the UNEB. Guanambi (BA), Brazil. Email: lidiamaria123@yahoo.com CASE REPORT ARTICLE Silva JK da, Mercês MC das, Messias JMA et al. Obstetric violence within the hospital... English/Portuguese J Nurs UFPE on line., Recife, 9(12):1345-51, Dec., 2015 1346 ISSN: 1981-8963 DOI: 10.5205/reuol.8127-71183-1-SM.0912201537 Although conception is characterized as a physiological act, sometimes the actions of health professionals, through wrong interventions and techniques, infringe women’s participation power and autonomy during pregnancy, childbirth, and puerperium, contradicting the public humanization policies and philosophies that advocate the individual’s autonomy. In this way, a woman becomes a professional intervention object and not a subject of her own actions and decisions. Thus, the primary rights guaranteed by the Ministry of Health (MoH) as a humanized, equitable, and holistic care are not always prioritized. Despite humanization is advocated as a crucial part in childbirth care, some practices cause harmful psychological and physical outcomes to a woman’s health. This scenario represents an obstetric violence, characterized by the subordination of women to professional knowledge, practices, and knowledge that seek to control experience of motherhood and it occurs when people exceed scientific evidence for childbirth care, through the abuse of technology in violation of the physiological process. It also addresses the violation of freedom of choice and disregard for human dimensions. This kind of violation against physical and emotional integrity has become the subject of great scientific discussions due to the significant occurrence in the country’s hospitals. However, there is little information available that address childbirth care, covering procedures and techniques employed during parturition and birth, which do not allow thoroughly quantifying the magnitude of this problem. We emphasize the scarcity of studies that point the prevalence and factors associated to the theme, especially with regard to robust samples and methods. A Brazilian research conducted by the Perseu Abramo Foundation, in 2012, on the scene of labor and birth, showed that 25% of the women who had vaginal delivery reported having experienced some form of obstetric torment or violence. This finding confirms the lack of specific and clear numbers, because from this perspective information was identified only through non-formal reports, due to the lack of official notifications of cases. In addition to this fact, based on research that shows a high number of caesarean sections and dystocia that took place in vaginal deliveries, it may be said that obstetric care in the country has an interventionist nature with a technocratic approach. In 2013, the approximate total number of births in Brazil was 2,904,027, out of which 1,253,726 were vaginal deliveries and 1,644,557 were caesarean sections. Although a woman has the right to choose the mode of delivery, receiving comprehensive care during childbirth and having the support of a companion of her choice, generally this scenario emerges in a controversial way, and there are recurrent cases of verbal abuse and maneuvers that result in violence against women. Among the various situations of violence, the highest incidence within the hospital environment has an obstetric nature, which is an aggression against women’s sexual, mental, and reproductive health, and it may be caused by health professionals who work in public and private sectors. These actions cause feelings of inferiority, humiliation, and abandonment at the time of need. The most common obstetric violence is psychological, sexual, institutional, and physical. Among them the most recurrent is related to psychological mistreatment by health professionals, expressed as negligent care, rough treatment, repression, roars, and intentional humiliation. Sexual violence is commonly reported and it occurs when a woman’s intimacy and modesty are not observed or if there is unnecessarily manipulation of intimate body parts, such as invasive touch tests, constant or aggressive, enema, asking a patient to take the supine position, and repetitive tests on the nipples without any information. Institutional violence is exercised by public or private hospital organizations through improper action, omission of information and care, in order to impose unjustified standards or unnecessary requirements. Basically, it occurs in case of unequal power relationships between health professional and patient. The most common examples of institutional violence that occur at the delivery room or the obstetric center are lack of encouragement for early contact between the newborn infant and the mother and lack of breastfeeding. This scenario occurs frequently, despite the MoH advises on the promotion of breast feeding and the benefits of such a practice. Many hospitals do not consider a mother’s wish to breastfeed the baby at birth, even without any clinical restriction for this. In cesarean sections this stimulus decreases, since there is an increased practice of artificial breastfeeding. Another example of this violence is provided by the absence of a companion during labor. Despite the support of Law 11,108/2005, which guarantees the presence of a companion chosen by the woman, some health centers do INTRODUCTION Silva JK da, Mercês MC das, Messias JMA et al. Obstetric violence within the hospital... English/Portuguese J Nurs UFPE on line., Recife, 9(12):1345-51, Dec., 2015 1347 ISSN: 1981-8963 DOI: 10.5205/reuol.8127-71183-1-SM.0912201537 not have a physical structure that allows implementing it, inhibiting the presence of a partner at the time of delivery. Physical violence occurs when injury, pain, or discomfort are directly caused to the woman, without recommendation based on scientific evidence to justify such a practice. The two most common examples are episiotomy and Kristeller maneuver. Episiotomy is a procedure to increase the vaginal canal during labor, a practice that should be adopted by professionals in an appropriate and judicious way, promoting protection for the woman and the child,