By Catarina Barata, Dulce Morgado Neves and Mário JDS Santos
In Portugal, as in many other countries, the COVID-19 pandemic exposed the highly medicalized, interventionist, and disrespectful manner in which facility-based births were happening before the outbreak. In line with nationwide containment measures adopted to prevent the spread of the disease – particularly within healthcare institutions – several measures and procedures were readily implemented in maternal and newborn care. These measures focused exclusively on controlling and minimizing risk of contagion at all costs, to the detriment of evidence-based, adequate quality obstetric care. For example, in its first guideline on pregnancy, childbirth, and COVID-19, the governmental Directorate-General of Health (Direção Geral da Saúde – DGS) recommended against contact between mother and child, breastfeeding, and the presence of a birth companion to women who tested positive for the disease. However disproportionate and lacking in scientific support, these measures were not only widely implemented, but most institutions applied even stricter internal policies regardless of a patient’s COVID-19 status.
After the implementation of these measures, which directly impacted women’s perinatal experiences and those of their families, self-organized groups of citizens joined civil society organizations in voicing concerns over the multiple limitations on women’s rights in obstetric care services, such as birth companion prohibition, as well as in devising strategies to demand the reinstatement of those rights. As social scientists and childbirth rights activists, we witnessed with concern the increasing discomfort among pregnant women, families and practicing doulas, made visible through their testimonies and cries for help both on birth-related pages on social media and the multiple communication channels of the NGO we collaborate with, the Portuguese Association for Women’s Rights in Pregnancy and Childbirth – APDMGP. This article draws on information that circulated in the milieu of childbirth activism during the pandemic.
In Portugal, the publicly financed National Health Service (Serviço Nacional de Saúde – SNS) provides the bulk of care, and only a minority of the population can afford private services. As healthcare resources in general were directed to the pandemic response, the services in both state-owned and private sectors were reorganized into COVID-19 services and COVID-19 free services, implying the physical reallocation of services and the cancelation of routine and non-urgent diagnostic and treatment procedures in all medical specialties. Prenatal care of low-risk pregnancies is provided by family doctors and nurses at primary care centers in the public sector and by OB-GYNs in the private sector. High-risk pregnancies are referred to the hospital and supervised by an OB-GYN in the public sector. Diagnostic procedures take place at the hospital or at private clinics, paid by the state or insurance companies.
In the attempt to reduce women’s visits to health facilities, DGS advised physicians to resort to teleconsultations whenever possible. Portuguese women reported having prenatal appointments, routine exams and ultrasounds cancelled, including those considered essential to optimal prenatal care. In the beginning of the pandemic, health professionals denounced lack of access to appropriate personal protective equipment (PPE), which possibly also motivated their cancelation of appointments and conditioned the quality of interactions between patients and carers.
The most widely voiced complaint by women in Facebook groups and through activist organizations was the overall suspension of the right to a companion of choice. Companions ceased to be allowed at prenatal appointments, during labor and birth, and postpartum, regardless of their or their partner’s COVID-19 diagnosis. This meant that women had to go through all these perinatal experiences on their own. The other parent, family members, or friends were prevented from being directly involved. Women had to endure their hospital stay alone, despite the availability of PPE, overruling the World Health Organization’s recommendations. In cases of complications during pregnancy or after birth, the hospital stay could last for several days or weeks.
Moreover, many women reported being coerced into labor inductions. Healthy pregnant women with no clinical complications were routinely tested for COVID-19 at around 39 weeks of gestation. In most hospitals, if a woman tested negative, she would be strongly advised to have an induction of labor in the following days. This led to an increase of routine labor inductions without clinical reason. On the other hand, some hospitals imposed C-sections on women who tested positive, ostensibly to protect staff. Altogether, this has led to a rise in the number of caesarean sections before the onset of labor.
Women who tested positive were also prevented from skin-to-skin contact with their newborns and from breastfeeding while in the hospital. Test results might take up to 24 hours, and women who were tested upon admittance for labor but delivered before the result was known were generally not allowed to have direct contact with their newborn. In fact, women have reported discriminatory attitudes by health personnel in face of the slightest suspicion they might be COVID-19 positive.
These limitations reconfigured the perceived risk associated with hospital birth, and many families chose a home birth to escape the constraints imposed by health institutions. These were women who would otherwise not have considered giving birth at home. Homebirth in Portugal is only available as part of the private provision of care, paid out-of-pocket, and it is thus something that only a minority can afford, yet many women had difficulties finding midwives to assist them, as demand suddenly surpassed supply. In most cases, this meant resigning to a hospital birth under these hostile conditions. In some rare but meaningful cases, women decided for a planned, unassisted home birth.
Literature suggests that the most distinctive characteristic of childbirth activism is the mobilization of evidence-based, scientific arguments in activist campaigns. And in fact, in Portugal, childbirth organizations and users’ groups reacted to the COVID-19 pandemic management in the maternity care system by seeking to disseminate international guidelines and evidence that contradicted the highly restrictive measures adopted by national authorities.
In addition to providing direct support to women, the Portuguese Association for Women’s Rights in Pregnancy and Childbirth played an active role in contesting the measures adopted at facilities, by issuing statements, establishing direct contacts with regulatory institutions and hospitals, and reporting disrespectful care through the media. The association confronted the position of the Directorate-General of Health (DGS) with the WHO recommendations, sent letters to health facilities questioning when they would revise their policies regarding the presence of companions, and issued a complaint to the Health Regulatory Entity (Entidade Reguladora da Saúde – ERS). The feminist organization “A Coletiva” issued a document analyzing how the implemented measures violated personal rights consecrated in the Portuguese constitution. That information served as the basis for a successful visual campaign disseminated through social media. Also, in a more peer-to-peer approach, self-organized communities of women shared experiences, information, and contestation tools on Facebook and other social media. They debated strategies to empower women in their relationship with health institutions, in efforts to try to ensure the most positive birth experience possible despite the restrictions imposed by the response to the pandemic.
These actions had led to changes, albeit limited ones. Activists’ demands for the reinstatement of women’s rights in obstetric care services contributed to slight (but important) reviews of DGS’ guidelines about maternal and neonatal assistance. The Health Regulatory Entity officially urged health institutions to comply with the law. Some hospitals began to allow the presence of one birth companion, although with restrictions. Far from being widespread, these improvements depend on restrictive protocols defined by the health institutions, presuppose COVID-19 negative testing and in some institutions only allow companion presence during birth and/or immediately after birth.
Looking beyond the need to adapt the response of maternal health services to the pandemic, it becomes clear how the implemented measures mainly acted as a magnifying lens for the prevalence of disrespectful and non-evidence-based care in health institutions. Under the guise of preventive measures, health institutions invested in already existing practices that tend to objectify women and to limit their capabilities and agency in childbirth. The mindset that pervades obstetric care in Portugal – as in other countries – is the reflection of a worldview that underplays a woman’s role in her own birth and undervalues woman-centered care.
The COVID-19 pandemic showed the extent to which the achievements of childbirth rights over the years are fragile and easily overridden. The political and institutional response to this health crisis displayed the readiness of the established, ruling powers to consider personal rights and self-determination as secondary, which is both revelatory and unsettling. In the face of the perception of a major threat to human life and to society, a sacrificial approach was enforced, in which women’s rights were traded away for the sake of protecting workers and women from spreading the virus. In obstetric care, this paved the way for a widespread acceptance of this dismissal of women’s rights and evidence-based obstetric practices. All of these measures and their consequences arguably had great impact on women’s and families’ childbirth experiences, as well as on newborns, in ways that we may not fully understand for years to come.
Catarina Barata is a PhD candidate in Anthropology at the Institute of Social Sciences of the University of Lisbon (ICS-UL, Portugal) doing research on obstetric violence (OV), focusing on perceptions, discourses and representations related to experiences of OV, women’s reproductive rights activism, and the transformative power of the arts. Research funded by FCT/MCTES, the Portuguese Foundation for Science and Technology (grant number SFRH/BD/128600/2017).
Dulce Morgado Neves (PhD, 2013) is an integrated researcher at the Centre for Research and Studies in Sociology of Iscte – University Institute of Lisbon (CIES-Iscte) and her main research interests are related to childbirth, gender, parenting and social movements. Currently she is a co-coordinator of nascer.pt – the Laboratory of Social Studies on Childbirth and she develops research on childbirth activism in Europe.
Mário JDS Santos is a specialist in the social studies on childbirth. He holds a PhD in Sociology, a MSc in Health, Medicine and Society, and a Nursing degree. He is an assistant researcher at the Centre for Research and Studies in Sociology of Iscte – University Institute of Lisbon (CIES-Iscte), and a collaborator at the Interdisciplinary Centre for the Social Sciences of NOVA University of Lisbon (CICS.NOVA).