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May 5 is International Day of the Midwife, but Ricardo Jones, a doctor and midwife, is spending it with a 14-year prison sentence for assisting with a home birth in which the baby later died of congenital pneumonia. He says the sentence is the same had he gone "into a hospital and shot a baby in the head". The case comes as health systems globally push towards unnecessary cesarean-һƷ̽�� and foster obstetric violence that disregards pregnant people's agency.

The International Confederation of Midwives established May 5 as a day for celebrating and raising awareness of the midwifery profession. They that midwives “can provide up to 90% of sexual, reproductive, maternal, newborn, and adolescent health services”. Further, various studies have demonstrated that home births with midwives see better obstetric and neonatal outcomes for low-risk pregnancies than hospital births, and spontaneous births are  times more likely at home with a midwife.

However, Jones’ sentence appears to be a deliberate attempt to delegitimise midwifery, as part of a concerted push towards profitable hospitalisations. Jones, a Brazilian gynaecologist and obstetrician, was found guilty of homicide in the first degree (intentional murder) on . He told me he was imprisoned for three weeks, before being released home while appealing the sentence.

The incident took place 15 years ago. He described helping to deliver a 39-week-old baby. “It was a very normal labour, but the baby was breathing too fast,” he said. He and his wife, a midwife nurse who received an 11-year sentence, encouraged the mother to go to hospital two hours after the birth — standard procedure — and though the mother was initially reluctant, they did so. Overnight in the hospital, the baby had a lot of problems, and she died 24 hours after birth. It is estimated that pneumonia contributes to between to 1.2 million neonatal deaths annually.

“The first doses of antibiotics the baby received occurred four and half hours after she arrived at the hospital,” Jones said, stressing that antibiotics were key to the baby having a chance of surviving. “But there were a lot of problems at the hospital.”

A year later, Jones was summoned by the medical council and prosecuted, despite having followed protocols. His medical licence was cancelled six years later. The criminal prosecution then followed and argued that he had murdered the baby because he used a humanised childbirth protocol and, according to the prosecution, his “ideology” caused the baby's death. “They basically decided that a doctor who abides by the protocols of the World Health Organisation (WHO) and ... the Ministry of Health of Brazil is a criminal,” Jones said.

Massive rise in C-һƷ̽��

Brazil has the second-highest C-section rate, at , reaching almost  of births in private clinics. The rate is in Australia and New Zealand and  in the United States, but the WHO recommends rates should be closer to . In Britain, only  of women say they would prefer a C-section, but in England,  of deliveries are by C-section — up from % just five years ago. Of current C-һƷ̽�� in Britain, 67% were elective, meaning they were planned, rather than based on an emergency or health concerns.

The huge increase in Britain corresponds to an  in maternal and neonatal deaths, and increasing numbers of women or people giving birth reporting traumatic birth experiences. In the US, maternal mortality has more than over the past century, and even after controlling for risk factors that might have made a C-section more likely, the risk of death after the procedure is  times higher than after vaginal birth.

On the other hand, it has been that pregnancy and birth care approaches that prioritise human relationships, collaborative multidisciplinary teamwork and midwife-led care are associated with safer outcomes, physiological births (spontaneous, minimal intervention) and lower health-care costs.

According to the , pregnant people are having C-һƷ̽�� that aren’t medically indicated, due to fear of labour pain, fear of pelvic floor damage and urinary incontinence, concern about impact on sexual relationships, and a belief that they are safer. Prior negative experiences with a vaginal birth, including sub-optimal care, can also be a factor, as well as the media presenting C-һƷ̽�� as controllable, convenient and modern.

In the US, a caesarean section in the hospital for someone without insurance US$8000–71,000, while a home birth and delivery with midwife is US$1500–$5000. In Canada, delivery costs  on average, and a C-section US$5,980. A meta-analysis on ResearchGate found that for-profit hospitals are more to perform C-һƷ̽�� than non-profit hospitals.

Jones stressed that while a vaginal birth can take a day, a C-section is “20 minutes and then it’s over, and ... hospitals prefer C-һƷ̽�� because they can organise staff to work at a specific time, they can schedule the day, choose if it’s before Christmas or after it”.

Doctors performing C-һƷ̽�� often get more, with one researcher that doctors will prescribe them for non-medical reasons, “selling” the caesarean to the pregnant person by saying the labour is too slow, their pelvis isn’t wide enough or the baby too large. In India, a surge in C-һƷ̽�� has been on their profitability, convenience (including a hospital preference for day surgeries over late-night births) and doctor performance targets.

Obstetric violence and dehumanising women

Prioritising profits or efficiency over women’s wellbeing goes beyond C-һƷ̽��. There is a global prevalence of for obstetric violence, with the most identified category being non-consented care (37%).

Jones said that in Brazil, common types of violence include abuse or overuse of drugs, not allowing the father or other parent to be present, use of the Kristeller manoeuvre (pressure to the top of the uterus), episiotomy (a surgical incision made in the perineum; routine ones are not recommended), excessive light or noise in hospital rooms and not allowing women or people to choose the position they give birth in. “In Brazil, 90% of births are lying down, rather than squatting or vertical,” he said.

Such violence a loss of autonomy for women and increases the risk of postpartum depression, obstetric injury and pregnancy-related morbidity and mortality.

“Women in childbirth are transformed [by many hospital systems] into children, and children have no voice, they are submissive, they just obey. Further, birth is part of a woman’s sexual life,” Jones said, arguing that women’s sexual life is controlled. “That’s why [many] doctors don’t accept women making choices [about where they’ll give birth, in what position, in what conditions, who will be present]. In a patriarchy, men won’t want women to be free. So, we control women’s sexuality and we control birth.”

There is now a to support Jones, and it goes beyond his case to demanding support for women’s autonomy and dignity.

“Something must be done to prevent other doctors in Brazil from going to prison just for protecting the wishes of their clients and women. People understand that in Brazil, there is a push to try to criminalise spontaneous birth and out-of-hospital birth,” said Jones.