In the Crossing of Politics With Science: Medical Arguments on the High Rate of Cesarean Sections in Rio de Janeiro, Brazil

Abstract

Brazil is the second country with the highest rate of cesarean sections in the world. Most of these procedures are without medical reasons, representing risks for the mother and baby. Obstetric doctors are appointed as the main responsible for this index. The reasons given are for financial reasons or for the convenience of predictable and planned births, and in these cases, cesarean sections are performed without sufficient clarification to pregnant women about their risks and their real need. In this context, there is a constant conflict between doctors and social movement activists in favor of the humanization of childbirth. The purpose of this paper is to analyze from an anthropological point of view the arguments that doctors use to defend themselves against these accusations. Through participant observation at scientific events and meetings of representatives of medical entities, it was found that obstetricians argue that they are based on “medical evidence” and accuse humanized childbirth activists of being based on “ideology”. These arguments reflect the current political context in Brazil marked by intolerance and the advance of neoconservatism.

1. Introduction

This study is anchored in the field of Anthropology of Biomedicine, which addresses an area of anthropological investigation focused on the influence of sociocultural aspects in the biomedical theories and practices. In this view, it is important to recognize that medicine is a cultural system as subject to anthropological analysis as any other context [1, 2]. Likewise, studies in unusual fields like Bruno Latour and Steve Woolgar’s [3] in laboratory helped to put under perspective the production of scientific facts as topics of investigation in the social sciences.

In this line of reasoning, diagnostic and therapeutic interventions bring to the light political, economic and commercial issues in their ethical, clinical and philosophical dimensions. Such questions have lived up debates in Sociology of Science and Anthropology of Biomedicine with questionings like: What are the meanings and effects of these interventions on intimacy? How is the health/illness process reconfigured in the daily life of the individuals in face of such interventions? How do health professionals remodel their practices and their relations with sick individuals in front of these new technological and scientific resources? Which is the accessibility and the ethical and cultural consequences of the intense development of these scientific technologies for the societies and the individuals? From the point of view of the Foucauldian notions of biopolitics and biopower, the debates show that the biotechnologies constantly use hegemony, inequality, and subordination to create social consumption in order to control both individuals and collectives. It is with this view that this study approaches the positioning of entities representing the physicians of Rio de Janeiro, Brazil on the excessive number of cesarean sections in the country, in counterpoint to the position of activists for humanized childbirth. The goal is to understand how the physicians conduct their discourses and practices concerning the contemporary issues on childbirth medicalization, specifically the C-section.

In Brazil, the rate of C-sections is considered way above any existing parameter. The World Health Organization (WHO) recommends a rate of 15% of C-sections in the country, although a slight increase can be presently observed in part of the developed countries [4]. In the United States, for instance, there was an increase from 20.7% in 1996 to 31.1% in 2006 [4]. In Brazil, current data indicate a rate of 53% of C-sections on the total labors in the country, existing a distinction between the rate for those conducted in the public sector (46%) when compared to those accomplished in the private health sector (88%), being considered that there is a “cesarean epidemic” in the country [5, 6].

The WHO recognizes that there is an “actual cesarean culture in the country, even when considering that local particularities make the definition of a unified goal difficult [4]. Thus, the organization advocates for the need to reduce C-sections in the country, claiming that this procedure “can cause significant, sometimes permanent complications, as well as sequelae or death” in mothers and babies.

Several works try to identify the causes of these high rates and the focus is always on the physicians. A great number of inquiries accuse them of carrying through procedures like C-sections because they are better remunerated [7]. Others point equally to the preference of physicians for carrying through procedures in schedules and days marked according to their own comfort [8, 9].

These arguments have been used also by the feminist activists for humanized childbirth to accuse the doctors of carrying through an excessive medicalization of labor in which the cesarean is the major representative. They also emphasize that the doctors do not privilege the autonomy of the women, do not appreciate their experience and do not respect all their citizenship rights related with the choice of their way of labor [10]. The activists claim that the doctors must respect the female physiology of the childbirth, not interfering unnecessarily, recognizing the social and cultural processes of labor and birth, providing emotional support to the woman and her family, facilitating the mother–child bond, and assuring her autonomy when choosing the way and the place where the childbirth will be carried through: at the hospital or at home. In the same way, they claim that the doctors must inform the woman on all the procedures [11, 12, 13].

There are several works dedicated to study the point of view of women on the cesarean childbirth [14, 15]. However, the medical reasons are little studied. Thus, this study will focus on the medical perspective. The universe of the study that will be presented here regards to the medical representatives of Federal Council of Medicine of Rio de Janeiro [16].

In Brazil, the agencies that inspect, regulate, and promote the doctors activities are the Federal and the Regional Councils. The Federal Council of Medicine é based in the Brasília, F.D. and has jurisdiction over the whole Brazilian territory. However, in each region, it works in partnership with the Regional Councils of Medicine (RCM). There are several RCMs in the country, as it is the case of Rio de Janeiro, the CREMERJ. The CREMERJ exists for 60 years and is formed by 42 council members who represent the several medical specialties.

The RCMs watch for the ethical principles of the profession in all Brazilian regions. They are autarchies with autonomy in their administration, keeping their own view, values, and financial management. For such, they make available information, documents, resolutions, and publications. In order to accomplish their activities, all doctors must be registered at the RCM of their state, being them, therefore, crucial for the exercise of the activity. Trying to enclose all professionals and specialties, the RCMs are subdivided to address each sector of medicine. They are the Chambers and Commissions, aimed to the medical specialties and other activities of the doctors, like clinic manager or health entrepreneur. Everything is inspected by the Council.

The regional councils are places of the medical elite with a political and scientificist aura. They assume the mission of appreciating the profession and they have the power to entitle or exclude doctors carrying through an ethical analysis of medicine. This leads us to the power of the medical class as already mentioned by Freidson: “The origin of the control of Medicine on its own work is, therefore, of a clear political character, involving the aid of the State in the establishment and preservation of the preeminence of the profession” ([17], p43).

Despite the advances, there still are huge gaps related to the strongly corporatist character of the profession. In this sense, the debate promoted by CREMERJ concerning the c-sections is exemplary. In this case, there is a straight confrontation with feminist militants who, to a large extent, are represented by the classic “enemies” of the profession, midwives and nurses. Not less relevant is the character of gender that historically crosses the childbirth medicalization, as the feminist militants are females and the medical representatives of CREMERJ are mostly males [18].

One of the tasks of CREMERJ is to develop events and debate meetings aimed to promote good medical practices. For this research, it was accomplished a participant observation of the “Symposium Childbirth and Abortion” (29 and 30 March, 2019), promoted by the entity between 29 and 30 of March [19]. It was also made the documental analysis of news published in its website, of documents produced by it and statements of its members to the media.

It is worth highlighting that the debate on C-section versus normal childbirth is quite polarized in the country. It has opposing political partisan contours: the ultraconservative right and the progressive left. It should be made here a brief retrospect of the current Brazilian context that livens up this debate.

2. The political context in Brazil and the political-ideological polarizations around the cesarean and the humanized childbirth

Brazil suffered a coup in 2016 that removed the first female president elected of the country, Dilma Rousseff, under the accusation of corruption. This event was followed by neoliberal transformations that increasingly decreased the accountability of the State in the addressing of social problems. Consequently, there was a reduction of investments in the public sector and the wellbeing of the population was delegated to private organizations. Unemployment and poverty increased enormously, social rights historically acquired were lost and unions and social movements have demobilized.

The media, strongly aligned with the interests of the elites, demonized the left movements and parties, which had progressive agendas and advocated for human rights. In this way, the country has been crossing a period in which intolerances result in aversion to the differences, to the minorities and that are manifested in hostile discourses. Souza [20] tries to interpret this phenomenon to the light of the values crucial to the democratic regime:

This way takes us to think on the discursivation of antagonistic relations in the present Brazilian society, on the dichotomist and hierarchized way of materializing the force relations underlying these discursive practices. To put in question the hatred discourse concerns, overall, to the limits of the rights of liberty of speech; to the way how the relation I/other is engendered; to the way how the freedom and equality values circulate in our society. It concerns, therefore, to think on dignity and human rights. ([20], p930)

In this context, the progressive agendas are accused of being “ideological”, as they are often associated with totalitarian states, intense critics of capitalism. In these “intolerances”, we observe that the expression “ideology” is loaded with derogatory meanings.

Also, the neoconservative agendas based on religious values oppose to the rights to gender equality, to sexual diversity and to reproductive rights. This way, the debate around normal or cesarean childbirth became an expression of ideological differences between liberals and conservatives. In 2018, in the electoral period that elected the candidate Jair Bolsonaro, identified as extreme-rightist, there were many controversies around this issue, as his speeches indicated that he would put at risk any agenda related with reproductive rights in counterpoint to the speeches of former-president Luis Inácio da Silva (Lula) and former-president Dilma Roussef, from leftist parties.

It should be highlighted that the coup that removed President Dilma Rousseff was strongly supported by the medical entities, among them the CREMERJ, which claimed the doctors to be involved in the pro-impeachment movement under the slogan “corruption is bad for health”. One of accusations to the government of the female President was her arbitrary attitudes regarding decisions in the health fields without inviting the doctors to the debate [21].

Jair Bolsonaro and his family have openly advocated for the limitation of abortion and criticized the movements for childbirth humanizing. The current board of CREMERJ openly advocates for the same positions: against the abortion and questions the advocacy for the reduction of cesareans. The fact is that the current board is openly rightist and conservative, like the counselor representing the obstetricians and one of the major representatives of the Symposium. He assumed in an interview to BBC News Brazil that the new board “was openly elected with a more conservative agenda”. According to him, “most of the people are from the right. Then, ideologically, we are closer to Bolsonaro”, claims the gynecologist, adding having voted and made campaign for Bolsonaro [22].

The counselor has assumed his views in several articles published in the media and in the CREMERJ bulletin, in which he questions the scientific validity, the financing and the “conflict of ideological interests” that permeate the debates on abortion and C-sections [22, 23, 24]. On the other hand, he accuses the activists of competing with the doctors: “nurses and doulas want this field of work”, illustrating the historical competitions of gender and professional categories around the medicalizing of childbirth.

The CREMERJ representatives question the benefits of the normal labor and the World Health Organization international goals to decrease C-sections. According to them, an “excessive autonomy of the woman” and non-doctors in the follow up of the childbirth would be harmful to the baby, as the scientific medical knowledge is what must prevail in this event.

In counterpoint, the activists who fight for the childbirth humanizing recognize the C-section relevance, but they argue that when it is not well used, it puts mothers and babies at risk, killing or resulting in sequelae. For instance, Talíria Petrone, the left member of the House of Representatives who participated in the event analyzed in this work, says: “I don’t see that it’s something ideological, from the left or from the right. It’s a matter of rights. We cannot leave the context where we are. There is a polarization in which there is a political line that denies and excludes rights; and another one that defends rights historically acquired”, says the activist, who claims to personally advocate the conquests of the left governments, especially those from the Workers Party (PT) and the former-president Lula.

One of the criticisms of the feminist activists for the humanizing childbirth to the doctors, especially to the representatives of CREMERJ, is based on their closeness to Jair Bolsonaro’s family. During the last presidential elections, for instance, the vice-president of the entity took a picture with one of Bolsonaro’s sons mimicking a “gun”, and that was emblematic of his presidential campaign. The picture circulated widely in the social networks and was quite criticized on the Internet and representatives of human rights movements; a female doctor shared the idea of adhesion to the guns, and consequently the discourse of hatred and violence that accompanies it. The reply of CREMERJ board when asked on this fact is that “people have the right to vote on those they want”. “The democratic” position is highlighted by the board of the entity in many events, like the one that will be analyzed next. It is worth highlighting that the current president consistently emphasizes that this is the first non-partisan” and “non-ideological” management “of CREMERJ, in a clear reference to previous boards that “showed a trend to the left”.

2.1 The abortion symposium

The symposium Childbirth and Abortion was a privileged space of observation to know the medical arguments in favor of C-section and for the refusal of the accusation to the category for its high rates in the country.

The first day of the event was exclusively dedicated to the subject of Childbirth, while the second focused on the subject Abortion. There were around 40 people in the audience, most of them female obstetricians and young residents in obstetrics. Most of the speakers were male and their conferences approached mainly technical issues on childbirth and legal resolutions. Concerning the female speakers, one was a pediatrician and spoke about the advocacy of cesareans for the sake of the newborn wellbeing, and a female resident in obstetrics reported an aggression that she suffered in a shift. The other women were an attorney general who addressed “obstetric violence” and two federal representatives who debated on cesarean and humanized childbirth.

The female federal representatives invited by CREMERJ are from opposing political parties, one from the left and the other from the right. This choice of CREMERJ was explained by its directors as on purpose in order to show the “opening of the entity to the democratic debates”.

The representative from the right, Janaína Paschoal, is known for her ultraconservative positions and speeches, in full agreement with President Jair Bolsonaro. Her conference was entitled: “The obstinacy for the normal childbirth leads women to death”. Her argument was that women with low purchasing power and who wish to have a cesarean are not able to have it in the public sector. According to her, poor women need to comply with what is offered in “public health”, motivated by the “mantra of the epidemic of cesarean”. According to the federal representative, these women also have the right to what we call in Brazil as “cesarean upon request”, that is, the woman being able to choose previously her way of childbirth, in this case the cesarean, and denying this right to the women is violence: “these are almost torture-like situations”, and many of them and/or the babies end up dying. The federal representative assumed that she was based on accounts she had access to as a lawyer during the presidential campaign of Jair Bolsonaro, as well as in conversations with the Obstetrician Counselor of CREMERJ, openly adept of Bolsonaro.

On the other hand, the leftist representative Talíria Petrone, militant of the issues related to tackling violence against woman and for reproductive rights, spoke on “Normal childbirth as a social conquest and women’s freedom”. Her speech was clearly against the cesarean, accusing its trivialization when childbirth is approached as a good. According to her, the medical knowledge cannot intervene with the choices of the woman in relation to her body and denying information to her is the most serious element that we have in the health scopes.

The debate that followed was intense, with aggressive reactions from the audience to the leftist representative, being often necessary the intervention of the organizers to calm down the people. These two antagonistic and polarized positions reflect the existing conflicts in Brazil on the excessive childbirth medicalization and the humanized childbirth. In this context, it has been significant the position of the medical entity of Rio de Janeiro, CREMERJ, which has been making a strong opposition to the activists for the humanized childbirth with the argument that they are not based on “scientific evidence”, but rather on “ideologies”. The symposium was especially marked by this conflict.

2.2 Scientific evidence x ideologies: categories in dispute

The main argument of CREMERJ doctors in the symposium in favor of the cesarean concerns the evolutive process. In this sense, the obstetrician counselor speech was the highlight of the event. It was based on an article authored by him and colleagues published in 2011 in the Arch Gynecol Obstet under the title “The history of vaginal birth” [25]. One of the images presented in the Symposium is from the abovementioned paper and compares the pelvis of female primates and modern western woman. The abstract of the paper illustrates the authors’ position:

Vaginal delivery, as known today, is a still unfinished product, originated hundreds of million years ago, much before mammals evolved on land. In this article, we will discuss the way in which our direct ancestors were born over the eons until the present day, focusing on the factors that presented substantial changes in how birth occurred, in relation to our earlier ancestors. The history begins with the first amniotes around 300 million years ago and ends with the appearance of the first Homo sapiens around 160,000 years ago. ([25], p1)

It follows the paper’s argument showing that the evolution of species gave origin to a narrowing of the birth canal in women in the post-industrial era. This way, modern women may face more difficulties in childbirth and the use of more efficient procedures to give birth, i.e., a cesarean, is justified. The rationale that the maternal pelvic dimensions are subject to the powerful competitive demands of reproduction and locomotion is widely accepted in the biomedical literature. According to this reasoning, the two-legged phenomenon associated to the erect position and, later, to the alimentary changes, caused evolutive transformations that modified the dimensions of the females pelvis [26, 27, 28].

The evolutionist ideas have been accepted by the scientific community since the 1940s, receiving criticisms more in the field of human sciences than in the biological sciences. This way, this argument is strongly used as undisputed scientific evidence, justifying the increasing childbirth medicalization.

The speech of the obstetrician counselor during the event follows in defense of the cesarean, highlighting “scientific evidence”:

It is a duty of the obstetrician to be updated on the best medical evidence. Episiotomy is recommended in selected cases. The C-section has several relative and absolute indications and a Guideline from 2019 of the American College of Obstetricians and Gynecologists (ACOG) showed that, in the current level of knowledge, it cannot be said that there is a safer childbirth. There is no scientific evidence that the vaginal childbirth is better that the cesarian in situations when there is no indication for it: over 39 weeks.

The symposium continued with the entity’s representatives accusing the advocates of humanized childbirth of following an “ideological” trend and that it does not fulfill the scientific canons. These arguments, especially the most emphatic views of counselor were applauded by most of the public.

The fact is that in the opposition evidence x ideology related with the indication of C-sections or not specifically addressed in this symposium, it can be observed that the evidence can be aimed and used in accordance with non-scientific interests. Let us consider the speech of the two federal representatives: Janaína Paschoal advocates for the incentive to cesareans under the rationale that women depending on the public health network want to have it and they cannot because of a “stubbornness for the normal childbirth”. Her speech was challenged by one female doctor in the audience only, an activist of humanized childbirth, with the argument that if women had as much difficulty to have cesareans, there would not be as many unnecessary C-sections in the country. This, as well as any reference on the high rates of this procedure in the country, did not have any reaction from the pro-cesarean audience.

On the other hand, the speech of the leftist representative, grounded on the advocacy of the humanized childbirth, condemning the excessive medicalization of childbirth, raised violent reactions. One particular aspect mentioned by her – “Women know how to give birth and children know how to be born”, which insinuates that the doctor would be a mere supporting actor in the birth process, resulted in intense and aggressive reactions both from the audience and from the speeches that followed, accusing it of being an “ideological position”. Other speakers reassumed this issue bringing “scientific evidence” of how the doctors are necessary in childbirth, given the modifications that the female physiology has been suffering with the evolutive process and the fact that childbirth is an unexpected event. A female doctor, member of CREMERJ council, emphasized that a safe childbirth can only be the one attended by doctors, when is an integrated and up-to-date team, as well as available material and human resources. In turn, the childbirth “adventure” (referring to the humanized labor) would be the one when the parents are suspicious due to so many disagreeing information, with rejected and questioned protocols and medical recommendations in “an alternative and ideological” environment.

Since childbirth passed from the hands of midwives to the doctors’, it was redefined by biomedicine as a medicalizing event with the promise from the obstetric science to foresee and minimize its risks. Although a large body of feminist literature has criticized the biomedical field with the argument that this weakens the women in labor and makes a pathological event of a normal one, the biomedical language of risk within a “technical-scientific” model emphasizing the specialist and based on evidence knowledge, predictability and control are dominant. To minimize the risk, the childbirth must, therefore, be managed by specialists, constantly monitored and subject to a series of investigations to investigate disfunctions and anomalies [29].

In turn, for the activists, the humanized childbirth is resistance to this model. In its conception, the woman’s body cannot be object of a medical technology. It is about an alternative approach for the birth in which the woman in labor is the center of the process. This contrasts strongly with a technocratic model of childbirth in which the woman in labor and her body are predominantly presented as objects of the medical specialist. However, the humanized labor activists try to be substantiated in scientific evidence as a way to legitimize their discourse in favor of the change in practices [30]. But this approach coexists with the discourse of the biomedical risk, as the humanized childbirth assumes equally medicalized and surveillance technologies [31].

On the other hand, the literature has shown that the biomedical argument of “risk” for the raised incidence of C-sections in Brazil does not agree with the reality of its clientele: middle-class women, with better prenatal assistance, good health, and nutrition. Thus, it is evident that other medical reasons besides the scientific ones act in this context. Besides the factors already described in this study, like medical comfort and remuneration, other authors equally point the fear of lawsuits in case of problems in the childbirth with the mother and the baby, reduction of the stress for having to wait long hours for the normal childbirth, what would increase the “risk” and, overall, the total control on the process:

It is unquestionable that the doctors have to deal with an ambiguity: they manage a physiological process that in most cases, as they recognize, would end well, regardless of their presence. The resource to the risk concept justifies the presence of the doctor in the assistance to the childbirth, but it also conditions their behavior, favoring the intervention. ([32], p434)

This is in opposition to Freidson [17], who says that the medical practice is made of uncertainties. In fact, everything indicates that the doctors wish to control their diagnostic practices and therapeutical procedures. Aiming to reduce its uncertainties, the Evidence-based Medicine medical movement was inaugurated in Canada in 1980. In this sense, evidence would be scientific proofs based on experimentation. This way, the doctors must be guided in their daily practice for the use of the best updated evidence for decision making in their practice [33].

For Uchôa and Camargo [34], Evidence-based Medicine is liable to criticism. Using Fleck’s study [35] as a starting point that reports how the facts are collectively constructed in accordance with a thought style, the authors claim:

We have chosen the hypothesis that the supposed adhesion to the transmutation of the “art” dimension of the medical practice – recognition and appreciation of the doctor’s individual experience – to the scientific one (formal logical validation to the medical knowledge) does not happen as a “natural” result of the cumulative and linear technoscientific progress, but as an option of the category for, at the same time, diminishing the degree of uncertainty of their choices and reaffirming their autonomy and social status. We start from the assumption that the decisions and judgments of the doctors in interaction with the other “social worlds” which determine, support, and develop their “thought style” also determine what is considered as valid knowledge: the scientific fact. ([34], p2241)

Thus, according to the authors, evidence would be, for the doctors, another way of normatization of health, becoming sick, and living experiences.

Other fields of knowledge have also been dedicated to claim that science is not neutral nor exempt of values and that it presents judgments of political, economic, and even moral order. As Kuhn said [36]: “Science is a historical phenomenon and it can only be understood in its historical dimension”. According to the author, a philosopher of science, it must be considered the historical, sociological, and psychological aspects in the analysis of the scientific practice, and even a certain subjectivity and “irrationality”, which ultimately have a decisive role in the imposing of certain theories in the detriment of others.

That is, science is only science when surrounded by the border of uncertainty, doubt. Despite being cumulative, the scientific knowledge is always provisional and relative. Nonetheless, the scientist’s common sense is peculiar, distinct from the ordinary person’s, but equally influenced by ideological factors. In our context, we can exemplify by relativizing the term “humanizing”.

“Humanization” is a term used for many decades by exponents of obstetrics in Brazil and the international scope. For them, interventions like narcosis and forceps “have humanized the assistance to childbirths” [37, 38], that is, the increasing medicalization of the childbirth assumes here a humanizing function.

On the other hand, as already mentioned, in the current Brazil the word “ideology” became an accusation category related with totalitarian regimes. This is what we observed when the obstetricians of the mentioned event referred to the ideas advocating normal labor as “ideological”, when medicine only works with evidence. This makes a strong reference to the common sense in which the term is used as a set of ideas or world views of a certain group guided by social actions of political matrix.

This way, we observe that “scientific evidence” and “ideologies” are categories in dispute by activists for the humanized childbirth and obstetricians in search of legitimacy of their discourses and practices. In this sense, this paper assumes that the issues linked with medicalization of the childbirth, having the cesarean as the main protagonist, bring to the surface scientific and political issues. Thus, we can say that the arguments of CREMERJ doctors in relation to C-sections are also permeated by ideologies.

3. Conclusions

Entities like CREMERJ mirror quite well the thought of the medical category, as well as have the power to influence it. When doctors use their power and establish conditions and limits for their practices and teaching, we are in face of ideologization of practices and knowledge. Even with the pretext of fighting ideologies where they must not intervene, these doctors end up acting and thinking under ideological premises, becoming themselves the target of what they fight.

The scientific work is limited by the scientists’ non-scientific ideologies. On behalf of the religion that he/she may profess or beliefs, a scientist can curtail in research, suppressing research topics and problems that oppose his/her religious beliefs. Or, on behalf of a certain political-partisan option, even a social scientist can make harmful corrections of interpretation so that it does not collide with his/her non-scientific ideas. This does not imply that these influences can affect the technical and formal rigor of the scientific research in itself, because the interference happens previously, in the choice of topics and in the definition of investigation problems.

From the anthropological point of view, the data here presented searched for an exercise of understanding the positions of doctors in face of the accusation of being the major accountable ones for the “C-sections epidemic” in Brazil. In their defense, they are grounded on “scientific evidence” supporting that the childbirth is a totally liable to medicalization and that the interference of non-medical professionals, midwives and obstetric nurses, and their techniques, are grounded on “ideologies”. However, as it was demonstrated in this work, we can observe that the excessive medicalization of childbirth goes beyond scientific reasons, also based on “ideologies” of a strong conservative nature and lined up with the current civil rights denial policy. This way, we can conclude that science is not neutral nor immune to sociopolitical contexts.

The activists from the humanized childbirth movement, in turn, argue that the C-section is a saving surgery in case of risk for the mother or baby. However, there are also scientific evidence suggesting that the pre-scheduled C-section, when not indicated by clinical reasons, causes three times more maternal deaths than the normal childbirth [39], besides increasing the risk of prematurity and neonatal death [40]. The fact that a great number of C-sections is accomplished in low-risk women and with a higher purchasing power strengthens the idea of the humanized childbirth activists that non-clinical factors influence this choice [41, 42]. These activists base themselves on clinical and epidemiological literature to claim that the relation of maternal deaths following C-sections in low- and middle-income counties like Brazil are 100 times higher than in high-income countries, with up to one third of all babies dying, according to data based on 12 million pregnancies [43]. That is, activists for the humanized childbirth consistently search for scientific arguments to legitimize their certainties. Therefore, even though the “ideology” is undisputed, in the fights for the humanized childbirth the activists use scientific arguments to accuse the doctors of ideological practices in relation to their “preferences” for the cesarean.

Here we observe that the “scientific evidence” becomes an argument of defense and that “ideology” is a category of accusation between the two poles.

The goal of this paper is not to advocate nor to accuse one or the other pole, but rather to evidence interpretations of the common sense both on the part of doctors and activists. Neither is the goal to question the scientific arguments defended by both poles, but rather to assume that one of the functions of social scientists is to diagnose the socially problematic consequences of the scientific development itself. In an exercise of relativization of both poles, one of the major conclusions that this study assumes is that, for the doctors, the preference for the cesarean does not have as a major factor the economic aspects and the comfort of the scheduled procedures, but rather the premise of the total control of the event of the childbirth, thus decreasing the uncertainties related to the unpredictability e of the events that surround it. This premise comes endorsed by the scientificity concerning the difficulty of modern women to give birth in a spontaneous way. The activists for the humanized childbirth, in turn, advocate for an absolute autonomy of the women on their childbirth, even being able, through a document called “childbirth plan”, to decide all the procedures that will involve the event, including the accomplishment or not of episiotomy, anesthesia, position of the childbirth, and home childbirth. It can be inferred that some excesses in front of childbirth plans restraining any type of medicalization can make it difficult to make necessary decisions in the defense of the life of the mother and the baby in face of unexpected risks during the childbirth.

Thus, the great challenge is the need of a greater closeness between doctors and activists for the humanized childbirth, without prejudices and rejection from both parts, so that to guarantee the quality of the obstetric assistance. For the childbirth humanizing, an improvement of the relations between health professionals and users of the services is necessary. It is equally necessary significant transformations in the training of new obstetricians in relation to the appreciation of new knowledge and practices; acquisition of a more dialogic and horizontal position of the team with the patients; rediscussion of the excessively biological model of medicine; and adoption of bigger political accountability of the managers, aiming at the improvement of less invasive techniques.

Acknowledgments

I thank Marina Fagundes Gueiros and Ananyr Fajardo for the final version of the text in English.