Brazil CREMERJ: Support Respect for Patient’s Autonomy

 

 

 

 

A coalition of non-governmental organizations, representatives of social movements and women and men in favor of healthy, humanized birth choices are organizing a protest on Sunday (August 5) in Rio de Janeiro, and other Brazilian cities, against two resolutions released by the Medical Council of Rio de Janeiro (CREMERJ) published on last Thursday (July 19).

The first resolution prohibits women in hospitals and maternity wards to have any assistance from university-trained midwives, or from doulas (birth support person). Nurse midwives, under doctors’ supervision will be tolerated. Non-compliance with the resolution by hospital directors will be considered an ethical violation and be punished accordingly.

The second resolution prohibits any doctor to participate in out-of-hospital birth, directly, or previously agreeing to provide second level care for women transferred from Birth Centers or home births. Punishment can include the revocation of medical license. It also establishes a mandatory reporting to the council of any out-hospital births, and punishment for non-reporting as an ethical offence.

Cesarean section rate in private hospitals in Rio is over 85% of all births. Given the pressure in hospitals to submit to elective c-sections or to aggressively manage vaginal birth, many women are choosing midwife care, birth centers, or home births, with support of a variety of on-line networks and resources in favor of informed choice.

Alternative places and providers in childbirth are usually strongly opposed by doctors, but never to the point of their outlawing, such as in the new resolutions. Last June, women in Brazil took the streets to protest against the same CREMERJ, that time because of the council’s attempt to punish Jorge Kuhn, an obstetrician from São Paulo who declared in a famous TV show that, in selected cases, homebirth can be an acceptable option for women. His opinion was considered an ethical offence by the Rio de Janeiro Medical Council, who reported him to the São Paulo Council. The Homebirth March was organized through web-based social networks, with demonstrations in over 30 different cities across the country, to affirm women’s rights to informed choices, to their bodily integrity and to a healthy birth experience.

These two resolutions are considered by activists to be the council’s reaction to women’s March in June. Women state that CREMERJ’s two new resolutions are illegal, against the best scientific evidence concerning care during childbirth, and a violation of women’s human rights. The resolutions are also contrary to the Ministry of Health guidelines for intrapartum care and the World Health Organization recommendations. The Rio de Janeiro Medical Council is strongly against the training, and participation in childbirth care, of direct-entry midwives and doulas (professional or lay labor support, responsible for physical and emotional comfort of the mother). Midwives and doulas, as well as Birth Centers, integrates the Ministry of Health program for a more humane, safe, woman-centered model of care (Rede Cegonha), and their benefits are based on solid scientific evidence. According to the Cochrane Library, women in midwife-led care have greater chances of spontaneous vaginal deliveries, less demand for analgesia, greater sense of control during birth, and better chances to start breastfeeding. Twenty-one clinical trials with more than 15,000 women showed that those receiving continuous support in labor reported greater satisfaction with the experience of childbirth, had shorter duration of labor and lower risk of cesarean delivery, among other advantages. 

According to doctors supporting women’s groups, the resolutions are contrary to the Code of Medical Ethics, which promotes the respect for patient’s autonomy. Despite the fact that, under doctor’s supervision, the presence of nurse midwives in hospitals will not be forbidden with the new resolution, the Rio de Janeiro Nursing Council (COREN-RJ) released an official note repudiating the Medical Council’s resolutions, defending the inclusion of midwives and doulas in a women-centered model of care in any setting (both hospital and out-of-hospital births).

Brazil has occupied a leading position in the world ranking of cesarean rates for several years. C-sections accounted for more than 52% of all births in 2010, exceeding 84% within the private healthcare system, with several cities reaching an incredible 100% rate (when the maximum recommended by WHO is 10-15%). High rates of elective pre-labor c-sections before 39 weeks are associated with poorer outcomes for mothers and infants, such as the increase in prematurity, low birth weight, and maternal mortality and morbidity.

The protesters highlight the CREMERJ’s conflict of interest in the perpetuation of a violent model of childbirth, trying to usurp the power and right to choose from women, thus violating their reproductive rights. One of the protest’s slogans is “No more violent births just to sell c-sections”. Several studies showed that the alarming rates of cesarean section in Brazilian hospitals cannot be justified by women's demand, since most of them declare a preference for normal childbirth.

According to women’s groups and their allied health providers, including doctors, the Medical Council is by contrast selectively tolerant with other serious ethical violations: overestimating risks to babies to coerce women into elective c-sections; the abuse in painful, potentially harmful interventions such as liberal episiotomy, inductions and forceps (to offer cesarean as “better”, comparatively); the sadly common sexual humiliation of distressed birthing women when they ask for help (using phrase such as “when you make that baby you liked, now do not complain”); and other forms of gender-based abuses. Activists also denounce that doctors frequently violate the federal law that ensure the right to have someone of their own choice accompanying them during childbirth, making the birth experience more stressful for women.

Together with the public demonstrations, the protesters are organizing legal actions against the Council, gathering media coverage, and demanding a formal and firm reaction from the Ministry of Health and other related institutions. 

 

Facebook of the Ação contra o Cremerj (Action against Cremerj, Portuguese)

https://www.facebook.com/groups/264877886954896/