The Rebirth of Maternal Health: Strengthening Midwifery Programs to Reduce the Prevalence of Caesarean Sections in Brazil

Abstract

For the past three decades, Brazil has made rapid strides to improve maternal health as outlined by the Millennium Declaration. Although changes in the organization of the health system have enabled greater access to care, the country continues to face major challenges in reducing unfavorable childbirth practices. The Brazilian model of care defines childbirth as a medical event, where physicians attend births in hospitals, using technological interventions to treat women. As a result, rates of caesarean sections have increased dramatically, which have had a negative health effect on maternal and infant outcomes. The increase in surgical deliveries points to the importance of identifying factors associated with the choice of delivery. In general, the decision to perform a caesarean section is strongly influenced by nonmedical factors. To understand the context in which mothers were having caesarean sections, interviews were conducted with actors involved in the chain of delivery care. Relevant stakeholders included patients, healthcare professionals and researchers. Ethnographic research was useful in identifying aspects of the Brazilian medical culture, where healthcare providers were motivated to perform caesarean sections. Archival research, hospital observations and literature reviews were also utilized to study the political response to unfavorable trends in maternal health. With particular focus on the relationship between the patient and healthcare provider, there have been efforts to integrate midwifery into healthcare models. The most recent initiative has been the establishment of a direct-entry midwifery program at the University of São Paulo. In countries that have achieved dramatic improvements in maternal health, professionally trained midwives have been a key to success. Midwives ensure that women receive a continuum of skilled care during pregnancy without overt reliance on technological interventions. In Brazil, they may also play an essential role in achieving the Millennium Development Goals and reducing the prevalence of surgical deliveries. When they are properly trained and supported, midwives can offer the most cost-effective and high-quality form of maternal health care. However, speaking with graduates from the only midwifery program in São Paulo reveals the realities of introducing midwives into the healthcare system. As a relatively new occupation in the field of maternal health, the profession of midwifery garners little acceptance and limited career opportunities in spite of legal recognition. Without proper action from political leaders and policymakers, the shortage of these valuable health workers can postpone efforts to improve maternal health and worsen conditions for mothers and infants.