**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.

#### *Current Topics in Caesarean Section*

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 [22–24]. 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 *In the Crossing of Politics With Science: Medical Arguments on the High Rate of Cesarean... DOI: http://dx.doi.org/10.5772/intechopen.97635*

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 [26–28].

#### *In the Crossing of Politics With Science: Medical Arguments on the High Rate of Cesarean... DOI: http://dx.doi.org/10.5772/intechopen.97635*

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 procesarean 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)*

#### *In the Crossing of Politics With Science: Medical Arguments on the High Rate of Cesarean... DOI: http://dx.doi.org/10.5772/intechopen.97635*

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.
