Harmful Childbirth Practices in Southern Brazil: Healthcare Workers' Reports

The WHO categorizes childbirth practices into four main groups: those that are clearly beneficial and should be encouraged, those that are clearly harmful or ineffective and should be eliminated, those with insufficient evidence and requiring cautious use, and those frequently used inappropriately. The goal of these classifications is to guide healthcare workers in their approach to childbirth, ensuring that interventions are evidence-based and tailored to individual needs. The MS has aligned with these recommendations, promoting a shift towards a more natural and less interventionist approach to normal childbirth. However, the persistence of certain practices, despite scientific evidence of their harm, suggests a disconnect between policy and practice on the ground. This study focuses on identifying and understanding the use of these harmful practices from the perspective of healthcare workers themselves.

The study's findings, presented in Table 1, reveal a concerning prevalence of practices considered harmful to normal childbirth among healthcare workers in the investigated obstetric center. A significant majority of healthcare workers reported performing routine trichotomy (69.56%) and routine episiotomy (82.60%). The lithotomy position was universally adopted by 100% of the interviewed professionals for delivery. Routine infusion of oxytocin was also reported by over 90% of the workers. In contrast, the practice of enteroclysis was largely discontinued, with only one healthcare worker (a medical resident) indicating its routine use. These results highlight a widespread reliance on interventions that are often not supported by scientific evidence and may pose risks to mothers and newborns.

The high incidence of routine episiotomy, performed in over 80% of deliveries in the study, mirrors findings from other Brazilian hospitals. In a São Paulo university hospital, episiotomy was performed in 76.2% of normal births, rising to 95.2% for first-time mothers. The primary justification cited is the prevention of perineal lacerations, pelvic floor relaxation, and fetal head trauma. However, scientific evidence does not support these benefits and, conversely, indicates potential harm. Episiotomy, when not indicated by individual circumstances, is associated with a higher risk of severe lacerations, increased need for sutures, and complications in wound healing. The high rate of episiotomy in teaching hospitals, like the one studied, may be partly attributed to its use as a training tool for medical residents. While residency programs offer increased access to healthcare professionals, they also involve trainees learning and practicing techniques, potentially leading to more interventions. However, the routine use of episiotomy is not exclusive to teaching hospitals, with studies in tertiary hospitals also showing high rates.

The lithotomy position, a supine position with legs elevated and supported, was universally adopted by all healthcare workers interviewed in the study. This means that 100% of deliveries in this unit occur in this position, indicating it is the routine practice. This finding is consistent with studies in Rio de Janeiro maternity units, where the gynecological position (lithotomy) is routinely used, with other positions like squatting or sitting utilized in less than 1% of births. However, horizontal positions for childbirth are generally discouraged. The dorsal decubitus or supine position can compromise uterine blood flow due to aortocaval compression by the uterus, potentially affecting fetal well-being. Ideally, the choice of delivery position should be based on the woman's preference, with healthcare providers encouraging her to explore various positions to find the most comfortable one. Vertical positions are often associated with less discomfort, easier pushing, and reduced pain during labor.

The findings of this study underscore a significant disparity between recommended childbirth practices and the reality experienced by healthcare workers in southern Brazil. The continued routine use of trichotomy, episiotomy, and the lithotomy position, despite a lack of scientific evidence supporting their benefits and evidence of potential harm, points to systemic issues. The prevalence of these practices may be influenced by various factors, including institutional routines, the training of healthcare professionals, and a perceived need for control over the birthing process. The role of teaching hospitals and medical residency programs in perpetuating certain practices, such as episiotomy, is a complex issue that requires further investigation. While these programs offer valuable training opportunities, they must also prioritize evidence-based care and the well-being of the mother and child. The decline in enteroclysis use is a positive indicator, suggesting that healthcare workers are becoming more receptive to evidence-based recommendations. However, the universal adoption of the lithotomy position and the high rate of oxytocin use highlight areas where significant change is still needed. Transforming these practices requires a multi-faceted approach involving continuous education, open dialogue between healthcare providers and patients, and a commitment to implementing care models that respect women's autonomy and promote natural physiological processes.