Date of Award




Document Type


Degree Name

Doctor of Public Health (DrPH)


Department of Health Policy, Management and Behavior

Content Description

1 online resource (xv, 170 pages) : illustrations (some color)

Dissertation/Thesis Chair

Benjamim A Shaw

Committee Members

Sonia Lansky, Patricia Strach, Christine Bozlak


Childbirth, Evidence-based Medicine, Health Education, Maternal Health, Normal Birth, Women’s Knowledge, Prenatal care, Maternal health services, Health education of women

Subject Categories

Health and Physical Education | Public Health


Background: Senses of Birth (SoB) is a health education intervention in Brazil that addresses reproductive rights, the benefits and risks of normal birth and cesarean, and use of evidence-based practices (EBP) during labor and childbirth, aiming to reduce unnecessary cesareans in the country. This mixed-method study had three objectives: 1) evaluate the impact of the SoB intervention on pregnant women’s perceived knowledge about normal birth, cesarean, and use of EBP in childbirth; 2) identify socio-demographic factors, obstetric characteristics, and aspects of women’s perceived knowledge that influence women’s use of EBP; and 3) analyze the outcomes, barriers and facilitators/strategies to use EBP described by women and understand their correlation with socio-demographic factors, obstetric characteristics, and women’s perceived knowledge. Method: 1,287 pregnant women answered a post-test survey, immediately after their visit to the exhibition, between March 2015 and March 2016, in four different cities. 555 women answered an online follow-up survey after giving birth. Quantitative analyses were performed, including T-tests, ANOVA, logistic and linear regression. A qualitative analysis using discourse analysis was also performed. To further understand women’s use of EBP experience, a triangulation of methods was used. Results: The mean score (MS) of perceived knowledge after the intervention was higher than the mean score before experiencing the SoB for all three knowledge domains: Normal Birth (MS Before= 3.71 x MS After= 4.49), Cesarean (MS Before= 3.54 x MS After= 4.26) and EBPs (MS Before= 3.14 x MS After= 4.14). The results suggest that the SoB intervention was more effective for low income women (B = 0.206; p < 0.001 for EBP), women without private health insurance (OR 2.47, 95% CI: 1.49- 4.09 for normal birth), women with private prenatal care (OR 2.42, 95% CI: 1.59- 3.66 for normal birth), women experiencing their first pregnancy (OR 1.92, 95% CI: 1.31-2.82 for EBP; OR 1.37, 95% CI: 1.03-1.84 for normal birth; OR 1.37, 95% CI: 1.03-1.84 for cesarean), and women in their first or second trimester at the time of the intervention (OR 1.64, 95% CI: 1.13-2.39 for EBP; OR 1.48, 95% CI: 1.11-1.97 for normal birth; OR 1.85, 95% CI: 1.40-2.41 for cesarean). In this study, the majority of women used intrapartum EBPs, with the exception of the doula support (26%). Using the intrapartum EBPs was associated with high mean score of knowledge before the intervention; giving birth in a public hospital (p ≤ 0.05), and having a vaginal birth (p ≤ 0.05). Some practices were also associated with socioeconomic characteristics: women among the lower-income range (2 to < 5 MW) were less likely to use a birth plan (35.1%, p ≤ 0.05) and have midwife care (40.1%, p ≤ 0.01) compared to women with more than 10 MW; being a black woman was correlated with not using a birth plan (59.3%, p ≤ 0.01), and not having doula support (56.7%, p ≤ 0.01); and women who had more than 13 years of formal education were associated with use of a birth plan (83.3%, p ≤ 0.01), freedom of mobility during labor (84.3%, p ≤ 0.05) and freedom of choice of position at delivery (83.3%, p ≤ 0.01). Midwife care (95.9%, p ≤ 0.05) and doula support (97.9%, p ≤ 0.05) were also associated with women who believed they were able to have a normal birth after participating in the SoB intervention. Women who answered the open-ended questions on the follow-up survey and were included into the qualitative analysis perceived an increase in knowledge for EBP Knowledge domain after participating in the SoB intervention. Positive outcomes were described related to the use of EBPs, such as satisfaction and respect of their choices, while negative outcomes were referred by women who did not use the practices. Barriers identified by women mainly referred to low quality of care, especially no woman-centered care to support and incentivize/promote the use of EBPs, while facilitators reported reinforced the need to implement EBPs protocols at hospitals but also the importance of individualized care and respect, reinforcing the “acolhimento” practices. Conclusion: The study showed opportunities to increase knowledge among Brazilian pregnant women for the three knowledge domains, and a need to focus the discussion on how to achieve a positive experience of birth using EBP. This study corroborates previous findings that Brazilian women have restricted access to intrapartum EBPs, and although recent policies have improved the offers, there are still systemic barriers that make it difficult for women to achieve a positive childbirth experience. Increased perceptions of knowledge about normal birth, cesarean and EBP gave the women a chance to critically reflect upon the maternal care scenario in Brazil and advocate for their choices, desires, and rights. Nonetheless, it is clear that health education is an essential element to increase the use of WHO and MS recommended practices. However, it cannot be used isolated from systemic changes that overcome barriers identified by women, including co-responsibility with the changes by hospitals/institutions and health professionals. The intervention gains relevance considering the lack of evidence of the efficacy of non-clinical interventions to reduce unnecessary cesareans in middle and low-income countries prioritizing women. Therefore, this study can guide policy decisions and program implementation to improve maternal health care by explicitly considering women's voices and experiences. As long as we continue to value only authoritative knowledge and not involve the women in their own health care decisions, the health system will continue to be organized outside of their priorities.