Carla’s childbirth experience

The contact with Carla came about after she was admitted to the CP one afternoon, with dilation of 5 cm, to give birth to her first child. With her consent, the decision was made to spend the night there to watch the birth. She was alone, since her sister-in-law and niece who accompanied her on admission had left, and Carla was awaiting the arrival of two friends. She had changed clothes and was wearing a smock that she had been given in the CP.

Carla was working as a manicurist and hair-braider, which provided her with an income of approximately one monthly minimum wage. She is a tall, black, strong-willed woman. She had certain particularities that made her stand out among the women in pre-natal: Carla was 36 years old at the time, which was well above the average, especially for a first-timer, and she was living alone, unlike the other women present. She no longer had any ties to the baby’s father, of whom she made only negative comments, and she did not get on with her mother either - which was uncommon in that context. On that day, she had not notified either of them that she had been admitted to the CP.

Her friends arrived a little later and meanwhile I kept her company. Agitated, Carla complained that there was no TV in the room and asked to walk in the garden. She spoke animatedly on the cell phone and seemed to be tolerating the contractions without great difficulty, merely holding herself up and remaining quiet whenever she felt them come on: nothing that would affect her good mood.

A little later on, Carla returned to the room and the nurse who coordinated the CP began to create an ambiance by introducing an aromatizer and turning off the brighter lights. From then on, the room was in semi-darkness and there was soft music playing in the background.

Carla’s friends arrived soon after. They had never visited the CP or participated in the workshops and were not really aware of the institution’s proposal. After a few hours, one of the friends asked me if the nurse could provide a little “help”, referring to the routine procedures and drugs given during “normal” deliveries in maternities.

From time to time a couple of night nurses came in to examine Carla, listen to the fetus’ heartbeat, evaluate the dynamic of the contractions and perform the touch test. In one of these examinations, they got the impression there was meconium in the amniotic fluid - that is, the first contents of the baby’s intestine, but which is not yet feces (^{DINIZ; Ana Cristina DUARTE, 2004}).²¹ Talking to Carla, they explained that given the context, there were two possibilities: transfer to the maternity of choice or take synthetic oxytocin to try to accelerate her labor. The parturient was no longer in good spirits and at each contraction seemed to feel a lot of pain, but she remained resolute and said she wanted to stay. “I’ll go until the end, I’m not giving up”.

Carla received an intravenous oxytocin solution for approximately 1 hour 30 minutes. After a while, she became very annoyed at the pain the contractions were causing. With her strong personality, she seemed to be more dominant than her friends, who were also showing signs of frayed nerves. At a certain moment, Carla said she no longer wanted the synthetic hormone since she could not stand the pain anymore. The nurses insisted that she keep it on, but she threatened to rip it off with her own hands. The nurses, who remained calm and unaffected by the agitation that took hold of the atmosphere, ended up granting her request.

One of the nurses suggested that Carla perform some walking and squatting exercises to help the baby’s descent, which she did for a short while only, after claiming the exercises intensified the pain. Carla preferred to remain in bed in a prone position which, according to the nurses, reduces the rhythm of the labor. Between contractions, Carla began to have regrets and apologize. “I’d like a natural birth, but I can’t manage it. Sorry, I’m ashamed... you treat me so well, I think it’s great here, but I can’t manage it. I don’t want to scream and make a big scene, I’m so embarrassed...”, she said, while occasionally trying to muffle her screams with a piece of cloth.

Outside the room, one of the nurses went through Carla’s medical records looking for information on her background that might explain her irascibility and irritation, deemed by the team to be clearly disproportional. “Sooner or later her resistance will drop”, they said, believing that the outlook for normal birth was positive.

Then came the moment that Carla’s water broke spontaneously and the appearance and odor of the liquid discounted the nurses’ suspicion about the presence of meconium. However, her labor continued to progress slowly, especially from Carla’s perspective, who was showing clear signs of impatience and intolerance of pain.

Carla became increasingly upset, saying that she wanted to be transferred to the maternity of choice to undergo a C-section. The nurses told her that the transfer could not be made without a clinical justification - which was absent since the liquid was clear and had a normal odor - and even if she went to the maternity, this would not mean she’d be submitted to a C-section since the decision to perform the surgical procedure was not up to her, but the doctors.

Carla, in a great deal of pain, ripped the towel holder off the wall and began to punch the walls in reaction to her contractions. It was then she started calling her friends on her cell phone to ask for help, in the early hours of the morning, Between calls, Carla put on her own clothes again, saying she wanted to leave and go to a private hospital to have a C-section. At this stage, she had dilated to 9 cm: “I’ll pay whatever it costs to have a C-section now! I’ll pay with my credit card and work after to pay it off. I’m not afraid of work!”. At a certain moment, she yelled: “If they [the nurses] respect that the birth be the way I want it, then they must respect that I want to go and have a C-section. I can’t stand any more pain!”

Carla’s companions oscillated between empathizing with their friend’s pain - and pressuring me to intercede with the nurses - and rebuking her. One of them lowered her voice to tell me: “She’s like this here because she feels as if she’s at home. I doubt she’d behave like this in a public hospital... I never thought Carla would make a scene like this!”. Carla’s attitude was seen by her friends as an unexpected show of weakness, which became evident in a conversation between her and one of her companions: “A woman the size of you, people will laugh when they find out what happened!”, to which Carla responded, between contractions: “Ah, I’m not falling for that! Better to be alive and weak than strong and dead!”.

After receiving a call from Carla, one friend, who is a nursing technician and lives in the surrounding area, went with her mother to the CP. Carla insisted that her friend take her out of the CP and bring her to a private hospital to have a C-section, but her friend said she could not take responsibility for her. In a conversation, in the corridor outside the room, the friend’s mother, who gave birth to twins when she was young, asked: “What? She didn’t know she’d feel pain when having a baby?”.

Carla’s companions even rang her brother, who is in the army, to see if he could come there to deter her (or contain her?) but, according to them, he was in “service” in the barracks and could not leave. Early in the morning, the day-nurse team arrived and decided to transfer Carla to the maternity of choice. Around noon, having been fully “accommodated” in the maternity, as one of the nurses from the CP told me, Carla gave birth to a baby weighing approximately 4kg, in a “normal” delivery.

Carla’s experience seems to reveal the expectations that the CP professionals, her friends and she herself had regarding what should happen there, an event in which Carla would ideally figure as the main protagonist and with a well-defined role. Preparation for the birth in that institution had provided her with a series of instructions and corporal techniques, a “training in levelheadedness” which, as Marcel ^{Mauss highlighted (1974}), ultimately constitutes something inseparable from the technique itself. It was expected that she would react as per the script, in which the parturient, by incorporating the techniques learned - and, in this sense, controlling her emotions -, is meant to be capable of directing and guiding the development of the birthing process in the predicted manner and towards the desired outcome. It presumes an implicit acceptance of a certain level of control in relation to pain and emotions making a “natural” birth possible and achievable in normal situations where the techniques have been taught and assimilated. In Carla’s case, unlike an abstract parturient whose limits for controlling pain and emotions are presumed, her “lack of control” in fact indicates a capacity for control on a level that differs from that expected. It was acknowledged that Carla would feel pain, but not that she would lose control, which in contemporary western society constitutes a reason to feel ashamed and a sign of immaturity and/or inferiority, as stated by Norbert ^{Elias (1994}) when analyzing the nexus of what he called “the civilizing process”.

The ideal of the self-regulating individual, who maintains strict control of bodily impulses and emotions, that is, the idealization of balanced emotions, is implicit. Hence the playful comment by her friend reminding her that she would be the butt of her friends’ joke, and also the embarrassment and numerous apologies from Carla and the feeling of failure. All of this suggests the existence, in that context, of a birthing model that approves or rewards women who experience it as a rite of passage in which self-control is associated with personal development or self-betterment, as seems to occur with the middle-class women (Olívia ^{HIRSCH, 2019}; ^{CARNEIRO, 2011}, among others).

A study by ^{Corossacz (2009}) in two public hospitals indicates the existence of an acute perception of difference regarding low-income women, as suggested by the interview the author carried out with a doctor, identified as M in the transcription below:

M: Our reasoning is more objective. Our class thinks like this: it’s better to have two children eating first-grade meat than six children eating second-grade meat. [...] They are not as concerned as we are [...]

V: In what way do you see them as being unconcerned?

M: You see a woman with five, six kids; she isn’t bothered [...] She is fulfilling a quasi biological function, and this [poor] woman’s expression of pain is different from that which we see elsewhere [private hospital], from an economist or an anthropologist. When you have a baby, you’ll have a different reaction.

V: How do they react to pain?

M: Either she is extremely resigned to the pain because her mother suffered, her sister suffered, or she is hysterical and wants to throw herself on the ground. Even when you suffer, you can do it with elegance, with manners and common sense; it’s a question of education and attitude. A woman from a higher social class might not be able to stand the pain as she is not used to it, but she behaves a lot better. (^{COROSSACZ, 2009}, p. 243)

If class difference is therefore evident - expressed in the use of “us”, on one side, and “them”, on the other -, it is also a culturally different manner of dealing with emotions and pain: this woman is unbalanced, oscillating from one extreme to the other - from resignation to hysteria -, that is, she represents a “problem”, as do her unplanned children.

Regarding the inability to control pain and emotions in a social context in which self-control is highly valued, there is another aspect that arises from Carla’s childbirth experience, namely, the possibility for the parturient to interfere in the course the childbirth takes, whereby her wishes are respected, which broadly speaking corresponds to the definition of “humanized” birth (cf. ^{CARNEIRO, 2014}). Starting from this premise, Carla certainly did not experience this, despite receiving care in a unit considered to be a “humanization” model.

As shown, Carla took on-board the childbirth proposal and the team consulted her on the execution of procedures, giving her the option to choose between staying there or being transferred to the maternity. Up until that moment, the nurses collaborated with her decisions on the direction of the labor. However, once Carla gave up on that proposal and began to want a C-section, the professionals no longer accepted her choices, refusing any possibility of negotiation.

As demonstrated throughout the article, this is an important difference between women from different social classes since the decision on the course of the birthing is not presented in the same manner, namely, as irrevocable, in the other context investigated. As Carla’s case suggests, for women admitted to the public system, this choice is not theirs but the medical team’s. In that context, the parturients who do not follow the desired behavioral and self-control norms and ask for a C-section, as Carla did, generally know beforehand that their request will most likely be denied, given that, as a rule, the public system health professional makes the decisions about the course of the labor and delivery, rejecting dialogue with the parturient.

In research conducted by Alessandra ^{Chacham (2004}), in which women from different social segments participated, a small part of the interviewees, from both groups, reported that they had sought C-sections during their pregnancies. However, while practically all the middle-class women had their wishes respected, the same did not happen for the women from low-income backgrounds, which led the author to state:

For [middle class women] it is easier to obtain a cesarean when they wish one. In the case of poor and working class women delivering in public hospitals, even when they want a cesarean they do not get one unless a doctor decides they need them. Most of the time they do not know who is going to assist their birth or they even have the chance to express their wishes. (^{CHACHAM, 2004}, p. 09)

^{Daneluci (2016}), who carried out research in a teaching-maternity-hospital recognized as a “center of reference for women’s health” with a focus on “humanized” birth, came to similar conclusions when stating that in the study context,

it is not they [the parturients] who decide and determine what is necessary nor do they participate in this decision: they are there in body, but without the right to make themselves heard. It is as if they have no knowledge or control over their bodies and it is up to the doctor and to biology to decipher and decide (^{DANELUCI, 2016}, p. 174).

It is worth adding that in public maternities and hospitals the definition for surgical birth cannot be exclusively attributed to a question of “necessity”, that is, to a clinical recommendation. In some situations, the C-section can be performed as a means of fulfilling a tacit agreement between doctors, providing for the “pre-delivery” to be “clear” before a change in shifts, so that all parturients who are in labor should give birth, in order for the incoming professional to be unencumbered by those women who were admitted earlier, as shown in a study by Marcos Augusto ^{Dias (2006}).

The fact that the Brazilian public health system provides care to women from almost exclusively low-income classes should not be ignored, bearing in mind that, as Luc ^{Boltanski (1979}) stated, “the patient-doctor relationship is a class relation and the doctor adopts different behavior depending on the patient’s social class” (p. 39). The experience of Elena, described below, seems to corroborate this affirmation.

Elena’s childbirth experience

Elena initially planned to have a C-section but changed her mind when she discovered the “natural” and “humanized” birth proposal in her birth preparation and yoga classes in a private institution in an affluent area of city. She swapped doctors during her pregnancy and even hired a team recognized by this group as “humanized”.

When she learned about the “natural” and “humanized” birth proposal, at the start of her pregnancy, Elena imagined that during labor she would feel pains similar to menstrual cramps, which would intensify at the end when the baby was ready to be born. She would be squatting or in water, “like they said” - referring to the accounts she heard from other women in the group which served as an inspiration to her - and her baby would be born in “really peaceful” environment.

It was a Friday and Elena, who was 37 weeks and 5 days along in her pregnancy, had not gone to work since she had made some purchases and there were people coming from the shop to assemble furniture in the baby’s room. She went to bed late, at about 11 at night and, around midnight, she went to the toilet whereupon she noticed a liquid that was not urine running down her legs. She quickly realized her water had broken and called her husband. They rang the obstetric nurse, her doctor’s assistant,²² as previously arranged.

She was told to monitor the intervals of the contractions and, when they were regular and approximately 5 minutes apart, call back. The nurse also told her to try to relax and go to sleep, adding that she would probably go into labor in the morning. Her husband followed the instructions and Elena, who was tossing and turning, started to watch TV. At 5 in the morning, she woke him up, as she was tired of being alone and, shortly after, rang the nurse again: “Look, it [the contraction] is already strong. I think there is a sequence so you can come and accompany me”, she said on the phone. “I thought I would already be able to go the hospital in the morning”, she commented during the interview.

When the nurse arrived at Elena’s house, she examined her and merely said “there was a way to go”, adding that it was better to stay there and “work”. Elena began to do exercises, put a hot compress on her back, and also tried to relax in the shower but the pain she was feeling at that point was “horrible”: “A pain that seemed to be ripping through my back. My intestines hurt, my abdomen, down below; nothing was having any effect”.

Time passed by and, in the early afternoon, Elena started to say she wanted to go to the hospital to take an anesthetic. The nurse examined her again and tried to dissuade her, saying that it was still better to stay at home. “At that time, my husband later told me, I was dilated to 1 cm and she didn’t tell me so as not to upset me further. I thought I was dilated to 5 cm and that it was time to go to the hospital”. After much insistence, Elena went to the maternity, accompanied by her husband and the obstetric nurse. Wary of causing a scene in the reception, she waited in the car until her admission process was completed.

In contrast to her nervousness and anxiety, the doctor arrived to the maternity “totally calm”, about 2 hours later. After another examination, Elena was told she was dilated to 6 cm. She was then transferred to the delivery room where, at her request, she received epidural anesthesia. Despite the “acute” pain, Elena was satisfied, relaxed and managed to sleep. “I was completely relaxed because I didn’t feel it anymore.” The doctor said the effect of the anesthetic would wear off after 2 hours and, according to Elena, that is exactly what happened.

When she again began to feel the pain of the contractions, the doctor repeated the manual examination and told her she was dilated to 9 cm. Elena was sure: “I want more anesthetic”, she stated. The obstetric nurse explained that during labor a lower dosage would have to be applied so that she could feel the contractions and expend the force necessary to give birth in the birthing period. “Said and done”, Elena commented, and even under anesthetic she managed to change positions and feel the contractions.

Dilated to 10 cm, the parturient tried several times, without success, to push the baby out. The team then got together briefly before telling her the fetus was probably not in the correct position, which was impeding the descent. For this reason, they told her it would be necessary to perform certain maneuvers to facilitate the birth. Elena agreed initially. “But then I felt terrible pain because she [the doctor] stuck her hand inside me and turned it”. In one of these maneuvers, she reflexively pushed the obstetric nurse with her foot. At this point she categorically stated: “Listen, I want have a C-section. I wanted the birth to be truly normal, not with these maneuvers. I don’t want to go through this”.

Within 15 minutes, Elena was transferred to the surgical center. She was given a higher dose of anesthesia and the baby was born shortly after, at 22h45min. He was brought to the nursery, accompanied by the father. Elena, who despite not feeling pain, had been distressed during the birth when she felt her skin being cut and the handling of the baby inside her body, asked the anesthetist to give her another shot to “knock her out”. “I want to sleep and wake up once I’ve been sewn up and everything”. She was back to herself about an hour later.

Despite supporting and routinely practicing “natural” birth,²³ that is, ideally without medical or pharmaceutical intervention, the “humanized” team that cared for Elena ended up acting in a manner that respected her wishes. The parturient, as was evident, directly intervened in the course of the birth experience, which would probably have taken a different course if it had depended exclusively on the team responsible for her care.

Elena’s experience seems to reflect an important precept of “humanization”, namely: that “the birth is the woman’s” not the doctor’s. This precept overrides demedicalization, as show by certain interviewees from the middle-class group - even though almost all of them initially wanted to have a childbirth experience simultaneously “humanized” and free of interventions, that is, “natural”, to reproduce the term used by them.

Natural childbirth is one without any intervention, whether synthetic oxytocin or anesthesia, for example. It is a totally physiological birth. It is a humanized birth where the woman’s protagonism is respected, where all the decisions or interventions are informed and consented to by the woman. A birth may be humanized even with the use of anesthesia, if that decision comes from the woman. In that case, it would be a humanized birth but not a natural one. The contrary may also occur: a woman may have a natural birth and be disrespected in the care she receives or suffer some type of obstetric violence, which may not necessarily mean an intervention. (Vanessa)

I think the humanized birth is the one where your wishes are respected. So if you want a C-section, you can have one. If your wish is respected and you feel happy with it, I think you’ve had a humanized birth, you know what I mean? But if you take into account that the humanized birth entails the minimum of interventions possible, it’s another concept. It can be, though I think it would be more of a natural birth concept. A natural birth is the one with the least possible intervention. And I would define the humanized version as the birth where your wishes are respected. I think the ideal would be a natural and humanized birth. (Alice)

As the testimony shows, the categories of “natural” childbirth and “humanized” childbirth are clearly defined here, although they were used interchangeably in the discourse of the middle-class interviewees. As such, the “humanized” birth, which often encompasses the “natural” birth, namely, demedicalization, is not limited to it, whereby a delivery with inventions or even surgery could be considered “humanized”, provided it meets the demands of a parturient who is informed of its risks and benefits. In other words, the idea of “humanization”, according to this reading, places emphasis on the rights of the woman regarding her body and the delivery. On the other hand, it is interesting to note that neither is “natural” childbirth necessarily “humanized”, since the absence of intervention does not mean that the parturient’s choices are respected. This is a relevant distinction when analyzing the topic at hand, the relation between childbirth and class in the “humanization” proposals, or in other words, how the “humanization” of the delivery is configured according to the parturient’s social class.

Unlike what happened to Elena, Carla’s request to have a C-section, which she expressed several times, was ignored by the team. It is true that the CP is limited in terms of infrastructure and because the professionals working there (obstetric nurses) are not trained in performing surgical deliveries of the type she was requesting. Neither are the nurses qualified to administer anesthetics, which Carla would possibly have accepted if it was offered - which is also the case in maternities and public hospitals. As shown by the study “Being born in Brazil: National Inquiry into Delivery and Childbirth”, the application of anesthesia in the public health system occurs in only 27.1% of deliveries, a rate that falls to 21.5% when the patient’s level of formal education drops (apud Maria do Carmo ^{LEAL et al., 2014}),²⁴ where there is practically no provision for it. In addition, Carla’s transfer to the maternity, where theoretically she could have had a C-section, was flatly rejected by the team, under the claim that there would need to be a clinical justification for it, which did not exist: it “only” involved the patient’s wish. In effect, the transfer took place the following day and only then because there was a shift change, despite Carla requesting it throughout the previous night.

As demonstrated, Carla’s choice to have a medicalized delivery or be transferred to the maternity, changing her initial intention to give birth in the CP, was not respected. In fact, once admitted to the CP and going into labor, the parturient was given no opportunity to interfere in the decisions relating to medicalization, which were based on strictly clinical criteria and taken unilaterally by the team, which clashes somewhat with the concept of “humanization”, that is, respecting the choices and rights of the parturient. In this sense, the woman’s freedom to choose is quite restricted compared to the other group, being limited to aspects involving birthing position, movement, the use of non-pharmacological means to alleviate pain, mood music etc. To sum up, it does not go beyond the range of possibilities presented by the team and is considered to favor “natural” birth, therefore not including decisions relating to medical or pharmacological procedures, which remain exclusively in the hands of the health professionals. Camila ^{Amaral (2016}), who performed research in the CP a few years after the research analyzed here, states that this information began to be transmitted to women during the childbirth preparation workshops - which did not take place at the time the investigation that resulted in this article was undertaken.²⁵ As such, it may not be claimed that the nurses who were caring for Carla during her labor were unprepared, since they approached it in the manner they were trained. What appears to have been added to the training or preparation for birth in the version accompanied by Amaral (2016) is a more explicit questioning of what could be viewed as a conflict between the woman’s wishes and necessity, an issue that seems to be exemplified in Carla’s childbirth experience.

In this context, it is comprehensible that the professionals in the CP would avoid using the expression “humanized” childbirth, preferring the term “natural” birth. It is not that there is no chance to have a “humanized” delivery there, but it entails a commitment to the demedicalization proposal that was not always observed among women from the low-income classes studied.²⁶ As stressed by ^{Carneiro (2017}), who carried out ethnography in a public normal birthing center in the peripheral region of the Federal District,

childbirth as event comprises numerous semantics and [that] the particularities experienced by women who are young, poor, single, black and residents of rural areas may create another assumption of care, beyond the physiology or absence of technical and pharmacological interventions (p. 397).