How humanized birth practice became an experience connected to neoliberal philosophy

Abstract

Humanized childbirth is a practice that began to be disseminated in Brazil about 20 years ago, seeking to promote natural birth, reduce unnecessary clinical interventions, and establish a more human model of childbirth. Although humanized childbirth in Brazil is an act of rescuing women’s autonomy and an act of resistance against the technological and capitalist perspective of birth, this philosophy harbors tensions and contradictions involving women as consumers, showing connections to a neoliberal idea of consumer empowerment. Considering this scenario, the present research intends to explore how the diffusion of the humanized birth practice was co-opted by the neoliberal philosophy. Conducting a 2-year netnographic study, we observe and analyze online traits on Instagram and YouTube about humanized childbirth. We shed light on social media as an important mechanism in facilitating practice engagement and practice reproduction, by presenting a framework about the practice diffusion process.

Keywords

humanized childbirth neoliberal philosophy practice diffusion co-optation

Introduction

The practice of humanized childbirth aims to minimize unnecessary interventions and emotional or physical trauma for women by empowering them to actively participate and honoring their preferences and needs throughout pregnancy and delivery (Buckley, 2015; Davis-Floyd, 2018). Initially prevalent in wealthier nations, where women sought active births with fewer medical interventions and greater involvement in the birthing process (Dick-Read, 1933; Nelson, 1983), the practice gained global traction after the World Health Organization (WHO) released guidelines and recommendations for childbirth practices in 1996. This initiative sparked a movement advocating for a more natural and respectful birthing experience all around the world (Davis-Floyd, 1992, 2001).

In Brazil, the humanized birth practice emerged in the late 1990s in response to high rates of cesarean sections (Rodrigues, 2021) and to the technocratic approach to birth which prioritizes capitalist logic and benefits market relations at the expense of women (Diniz, 2005). The diffusion of the practice (Akaka et al., 2022) encountered challenges within the Brazilian context, particularly regarding the significant social inequality among the population, leading to disparities in the interpretation, dissemination, and implementation of humanized childbirth (Guimarães et al., 2017). In the public system, the long waits for care and the lack of beds, resources, and trained professionals often reduce the chances of a humanized birth, causing more and more women to seek private care (Giacomini and Hirsh, 2020). On the private sector, the humanized birth became a lifestyle product marketed to middle and upper class women (Irvine, 2022). Mothers, families, doctors, midwives, doulas, hospitals, and other service providers negotiate their logics (Wrede, 2001), turning childbirth into a collaborative event shaped by the interaction of various social actors (Irvine, 2022; Rutherford and Gallo-Cruz, 2008).

Despite the aim to offer a less commercial alternative to childbirth (Diniz, 2005; Irvine, 2022), the diffusion of humanized birth in Brazil has been marked by tensions and contradictions involving women as consumers (Teixerense and Santos, 2018), healthcare professionals (Giacomini and Hirsch, 2020), markets (Irvine, 2022), and cultural aspects (Rutherford and Gallo-Cruz, 2008). For Diniz (2005), the humanized birth practice has drifted from its initial intention, becoming strongly associated with a liberal tradition guided by capitalist principles. What initially emerges as a movement opposing dominant norms – in this case, the cesarean industry – is co-opted by the ideological forces of the market, generating a response contrary to what was initially expected (Thompson and Coskuner-Balli, 2007). This is because the creation of consumption cultures around certain practices extends market dynamics to spheres of life that should be preserved, especially concerning motherhood (Takševa, 2012). According to Bujold and Vallé-Ouimet (2024), the commercialization of motherhood, even when adhering to the discourse of humanized care, aligns with the medical knowledge endorsed by capitalist and patriarchal logic. This raises a critical question: how did the diffusion of humanized birth practice become co-opted?

We believe that exploring this phenomenon becomes necessary as “more attention must be devoted to empowering mothers and challenging dominant norms that ultimately don’t always serve them” (Bujold and Vallée-Ouimet, 2024). Considering the vulnerability to which women are subjected during pregnancy and postpartum (The Voice Group, 2010), it is crucial that research at the intersection of consumption and motherhood carries a critical nature, in order not to exacerbate maternal vulnerability. Given that “neoliberalism seems to be everywhere” (Peck and Tickell, 2002, p. 380), it is important to discuss issues such as empowerment and free choice, since consumers often adopt consumption practices believing it to be a conscious choice, when in fact they are being guided by market ideologies.

In this research, we rely on a theoretical framework composed of two research traditions. Firstly, we draw upon co-optation theory, used in cultural studies to explore how dominant cultural forces, such as the market and mainstream media, neutralize the actions of alternative practices and consumer movements by incorporating them (Clark, 2003; Drew and Gottschall, 2018; Thompson and Coskuner-Balli, 2007). Secondly, we draw upon research in practice diffusion, which addresses how practices are disseminated from one cultural context to another (Akaka et al., 2022), affecting the social and cultural dynamics involving consumers, communities, and organizations (Shove et al., 2012).

Co-opting motherhood

Co-optation theory explores how countercultural concepts are assimilated into dominant discourse, where capitalism incorporates the movement into a form of commercialization (Thompson and Coskuner-Balli, 2007), entailing a symbiotic relationship between countercultures and market logic (Holt, 2002). Research on co-optation describes how countercultural movements are absorbed into mainstream markets. The concept of co-optation within the context of alternative movements is examined through various lenses in the literature. Thompson and Coskuner-Balli (2007) discuss how big corporations adopt the symbols and practices of the organic food movement to promote mainstream consumerism, thus diluting the movement’s countercultural message. Drew and Gottschall (2018) further this argument by exploring the advertising industry’s appropriation of alternative movements to reinforce dominant discourses. They analyze an Australian advertisement that ostensibly promotes inclusivity but ultimately marginalizes certain groups, suggesting that such representations reinforce a national identity centered on white Anglo-Australians. This subtle form of marginalization is a form of symbolic violence that perpetuates exclusion. Rosen and Schweitzer (2018) investigate the co-optation of the concept of distributive justice through benefits-sharing agreements between communities and developers. While these agreements are designed to ensure a fair distribution of resources, they often fail to deliver on their promises, leading to superficial community involvement and serving more as public relations tools rather than genuine commitments to community empowerment.

The dynamics of consumer co-optation are intricate, illustrating the interaction between commercial mechanisms and alternative market mindsets in shaping consumer practices. Thus, practices that have been co-opted, initially perceived as revolutionary, exemplify how consumers engage in practices influenced by both commercial mechanisms and alternative market mindsets, underscoring the complex nature of consumer co-optation dynamics (Declercq, 1983). The first step in this process of co-optation is commodification (Clark, 2003), where the market acts to neutralize oppositional aspects through commercial integration (Thompson and Coskuner-Balli, 2007). The commercialization of motherhood stands as one of these movements that have been assimilated into market philosophy (Bujold and Vallé-Ouimet, 2024; Declercq, 1983; Takševa, 2012).

Criticism of the commercialization of motherhood began in the 1980s when Declercq (1983) discussed how childbirth education initiatives, led by hospitals and healthcare professionals, emerged to increase institutional profits, albeit under the guise of advocating for women’s rights. Forty years later, what we observe is a market apparatus that accompanies women from the early stages of pregnancy to the child’s early years, under the banner of the discourse that acquiring knowledge is a woman’s right (Bujold and Vallé-Ouimet, 2024). In the case of breastfeeding, planning begins during pregnancy, involving mentorship from healthcare professionals, practical classes for pre-birth training, and the acquisition of products (Avishai, 2007).

In the context of childbirth, where the intense medicalization of maternity made cesarean section a requirement for most women, previously promoted as a safe and painless alternative (Bryant et al., 2007), the natural childbirth movement emerges as a romantic discourse. It suggests that natural childbirth is safer, empowering, and capable of providing women with a subjective experience in contrast to the commercial experience of cesarean birth (Thompson, 2010). However, contemporary humanized childbirth, with preparatory classes and the acquisition of products and services, instead of empowering women, constitutes a form of oppression, requiring women to accumulate new knowledge and roles (Bujold and Vallée-Ouimet, 2024). This approach privileges consumer practices and the medical-scientific discourse that has little in common with aspects of subjectivity, naturalness, and pleasure (Avishai, 2007).

Although paradoxical, this scenario shows connections to a neoliberal idea of consumer empowerment, under which markets govern consumers’ choices through empowerment practices (Shamir, 2008; Shankar et al., 2006). For Shankar et al. (2006, p. 1041), consumer empowerment means “the power to exercise choice”. However, despite the emancipatory essence of the empowerment concept, this concept can as well be associated with the neoliberal thinking (Lincoln et al., 2002). Neoliberalism is a set of practices that generate a form of governmentality that places the market as the basis of social relations (Shamir, 2008), with a broad penetration in every aspect of modern life (Peck and Tickell, 2002). As Becker et al. (2012a) explains, under the neoliberal thinking, individuals are encouraged to choose instead of forced to agree; however, their options are guided by the market, reinforcing the idea that the diffusion process of humanized childbirth practices in Brazil underwent co-optation, succumbing to market logic.

Practice diffusion

Practices are a set of actions and statements formed by understandings, procedures, and normative orientations involved in the specific thing that must be done (Warde, 2005). According to Gram-Hanssen (2011, p. 64), “practices are coordinated entities of sayings and doings that are held together by different elements and that are also what make practices collectively shared across time and space”. In consumer research, the study of practices emerges as an alternative to individual choice models (Warde, 2014), exploring the shift from individual consumer analysis to the analysis of collective aspects of consumption (Gram-Hanssen, 2011). Studying practices through the lens of cultural consumption is vital for grasping the societal shifts and their impact on consumers, communities, and consumption patterns (Shove et al., 2012). Unveiling the study of practices requires a fundamental understanding of how they are diffused, namely, how they spread to broader audiences and become deeply rooted in society (Akaka et al., 2022).

Shove et al. (2012) posit that practices emerge, persist, and endure in a society when the connection between the meanings, materials, and competences of a practice is sustained. Thus, the way these elements are interconnected and put into practice defines the extent of the diffusion of a specific practice (Akaka et al., 2022). This implies that practices expand as those who engage in them - the practitioners - are able to distribute the meanings, materials, and competences of such practice among the social networks they circulate in, thereby contributing to its diffusion (Lave and Wenger, 1991; Lizardo, 2009; Shove et al., 2012).

Here, it is crucial to distinguish between the reproduction and diffusion of practices. Practice reproduction refers to how people enact such practice, i.e., how they experience the meanings, use the materials, and develop the necessary competences for practice enactment (Shove et al., 2012). Practice diffusion involves the process by which a practice spreads and is adopted by consumers, communities, and organizations, a process that ranges from the dissemination to the adoption of the practice, from one source context to other contexts (Akaka et al., 2022).

Although literature recognizes that the diffusion of a practice presupposes the sharing of understandings and conventions across diverse sociocultural contexts (Schatzki, 2019; Warde, 2005), the way practices are disseminated constituted a fragmented body of research until the recent publication of Akaka et al.'s work (2022). In this study, the authors explain that practice diffusion begins with its emergence in a specific cultural context, where the practice becomes adopted as it connects to other systems of practices (Akaka et al., 2022). After the initial adoption, early practitioners act as practice carriers, enabling the reproduction of the practice as new practitioners adopt and also reproduce it (Shove et al., 2012). In this scenario, Shove et al. (2012) emphasize the role of social structures and cultural norms in the diffusion of practices, recognizing that practices are situated and embodied, meaning they are shaped by the social context and the characteristics of the individuals who perform them. In a process that takes time, even decades, the practice comes to compose the system of practices of more and more people, families, communities, and cities, causing the practice to be widely embedded in society.

The diffusion of the humanized birth practice in Brazil

In Brazil, efforts since the 2000s have aimed to ensure respectful medical treatment for pregnant women. In 2003, the National Humanization Policy was implemented, aiming, among other health humanization initiatives, to ensure practices and procedures that promote healthy childbirth and prevent perinatal morbidity and mortality (Nagahama and Santiago, 2011). Recently, legislative initiatives, like Project No. 7633/14, strive to promote humanized childbirth and combat obstetric violence. Obstetric violence refers to the infringement upon a woman’s physical autonomy during childbirth, wherein the treatment she receives is inappropriate, often involving excessive medicalization and pathologization of a natural process (childbirth), which leaves the woman in a state of embodied vulnerability, resulting in physical and psychological consequences (Shabot, 2021).

The emergence of the humanized childbirth practice in Brazil aimed to extend women’s access to humane health services and encourage natural childbirth (Nagahama and Santiago, 2011). Although theoretically, humanized childbirth is not synonymous with natural birth, given the autonomy of choice sought to be preserved for women, in practice, the arrival of this practice in Brazil was understood as synonymous with natural childbirth, shaping the understanding we have today of humanized birth (Diniz, 2005). Beyond the conceptual confusion, Brazil’s status as a developing country with significant social and economic inequalities has influenced how the practice of humanized childbirth has been disseminated (Giacomini and Hirsh, 2020).

Brazil holds the second-highest rate of cesarean sections worldwide, with approximately 57.7% of births being cesarean, exceeding the WHO’s recommendation of 15%. Historically, fear of pain and the influence of a technocratic medical model made cesarean section the preferred choice for many Brazilian women until the late 1990s, when the practice of humanized childbirth began to be disseminated (Tedesco et al., 2004). Factors driving this trend included doctors scheduling cesarean deliveries for convenience higher profits, and inadequate information for mothers to feel confident in natural birth (Irvine, 2022).

The diffusion of humanized childbirth practices in Brazil was particularly welcomed by the movement advocating for women’s rights over their bodies. A group of healthcare professionals, dissatisfied with practices related to pregnancy and childbirth, created the Network for Humanization of Birth, which began to promote humanized childbirth, in an attempt to comply with WHO guidelines (Carneiro, 2011). This initiative found resonance in a movement of women who, victims of obstetric violence, sought to claim their rights regarding childbirth, questioning the normalized obstetric treatment in Brazil.

However, the inequality present in the country affects the way the practice has been disseminated and adopted. In the public sector, the dissemination of humanized childbirth is slow due to structural issues involving prenatal services, the dissemination of evidence-based clinical protocols for medical teams, investment in hospital infrastructure to promote humanized childbirth, and the training of multidisciplinary teams (Nagahama and Santiago, 2011). As a result, humanized childbirth is still not a feasible reality for all women in the lower socioeconomic strata (Giacomini and Hirsh, 2020).

In the private sector, humanized childbirth began to be disseminated with the presence of healthcare professionals who, disillusioned with the barriers to implementing humanized childbirth in the public service, began to influence private hospitals and maternity wards regarding the practice, inducing demand for humanized childbirth (Irvine, 2022). Irvine (2022) also reports that the adoption of humanized childbirth by wealthier and more influential women helped promote the practice among other women, especially with the power of social media sharing, which helped market humanized childbirth as a lifestyle product. Contradicting criticism around the role of the market in normalizing c-sections (Rocha and Ferreira, 2020), humanized birth became a commodity marketed to women as “beautiful births” in Brazil (Irvine, 2022, p. 199), generating tension between returning to a more natural perspective on birth and a highly commercialized experience.

Methodology

In this study, we employed netnography, a qualitative research technique designed for studying social media dynamics, focusing on aspects such as interaction and sociability (Kozinets, 2019). Netnography was chosen because it allowed us to explore not only the diffusion of the humanized birth practice but also the various discourses, interactions, and ideologies surrounding it. One of the researchers began data collection during her pregnancy in 2021, immersing herself in social media content related to humanized birth as part of preliminary research efforts. This exploratory phase, conducted through netnography, spanned from January 2021 to December 2022. Upon the inclusion of a second researcher, who is not a mother but had prior knowledge of the topic, a structured data collection approach for netnography was developed based on the insights gained during the initial phase.

The data collection process followed the phases outlined by Kozinets (2019): investigative and immersive. The investigative phase extended from January 2023 to August 2023. We selected Instagram due to its abundance of content related to humanized birth, including birth stories, accounts of pregnant women preparing for childbirth, and profiles of service providers specializing in humanized birth. YouTube was chosen for its capability to host video content with longer durations, allowing for a more in-depth examination of practices beyond mere description. Throughout this phase, our primary focus was on online traces, which encompass user-generated content such as photos, comments, posts, and likes on social media platforms.

To locate relevant content on Instagram, we utilized hashtags such as #humanizedbirth and #birthreport. We specifically targeted public profiles in Brazilian Portuguese that discussed the practice and personal experiences of humanized birth. The identified content deemed pertinent to our research was systematically printed using screenshots and saved in a document within the project folder on Google Drive. Additionally, comments reflecting user interactions pertaining to humanized birth were also documented. Data collection on Instagram yielded over 100 pages of collected material. In parallel, the researchers initiated data collection on YouTube using keywords such as “humanized birth” and “birth report” applying the platform’s ‘most relevant’ filter. The researchers maintained an Excel spreadsheet to record the respective links and details of the selected videos. Videos in Portuguese with over 50K views that discussed humanized birth practices were prioritized. All chosen videos were stored in the project folder on Google Drive for further analysis. Data collection on YouTube resulted in the selection of 100 videos.

In September 2023, the researchers transitioned into the data immersion phase, which . involves evaluating and filtering content from the vast array of social media flow to identify data pertinent to netnographic research, representing a contextual and reflective stage (Kozinets, 2019). On Instagram, we began following the profiles of mothers-to-be, experienced mothers, content creators, maternity influencers, and service providers involved in the humanized birth practice. These profiles were frequently encountered during the investigative phase, prompting us to explore them further. In total, 280 screenshots of Instagram posts were collected during this phase. On YouTube, we identified three distinct types of content related to humanized birth. We collected 30 videos documenting the preparation for humanized childbirth, where women share their experiences as if maintaining a digital diary. We also compiled 14 videos of professional content, featuring doctors, doulas, nurses, and other healthcare professionals discussing humanized childbirth based on their professional expertise and scientific evidence. Lastly, we gathered 24 birth story videos, wherein women provide detailed descriptions of their birth experiences. All videos were meticulously viewed in their entirety by the researchers, with each video watched at least twice. The research phase concluded in December 2023.

Both phases of data collection were conducted manually, without the use of software, enabling the researchers to delve deeper into the research context. This approach led to the creation of two immersion journals (Kozinets, 2019) comprising reports and insights derived from the researchers’ data collection experiences. We have followed Kozinets’ (2019) principles concerning online traces, which emphasize the importance of posts, comments, and online behaviors as valuable data sources for netnography. According to Kozinets (2019), online traces can provide rich insights into the thoughts, feelings, and behaviors of online communities. Both researchers maintained separate immersion journals, each spanning approximately 40 pages. They held frequent virtual meetings to share their impressions and insights throughout the research process.

In addressing ethical considerations, we adhered to the protocol outlined by Kozinets (2019) during the data collection phases. We exclusively selected public profiles, eliminating the need for permission to follow them. We excluded any images or video excerpts portraying moments of heightened privacy, even if publicly shared on social media. All quotations were translated from Portuguese to English to maintain meaning. Faces of individuals appearing in photos and videos were obscured, and only content approved by the platforms’ ethical regulations and publicly available was linked.

Data analysis included stages of content analysis and coding with hermeneutic analysis, following the part-whole process of Thompson (1997), throughout multiple readings and comparisons of the YouTube and the Instagram data. In order to organize the findings, we performed a coding process (Saldaña, 2015) to develop our analytical categories. This process evolved in several rounds of coding and frequent references to the literature as specific themes emerged. Our findings reveal the existence of a practice diffusion process that develops from the consumption journey towards the experience of birth, and that is based on neoliberal philosophy. This practice diffusion process unfolds in three distinct phases, presented in the next sections.

Findings

Our research shows that the co-optation of the diffusion process of humanized birth practice unfolded through three interdependent dynamics: (i) instructional dynamics involve consumer education, teaching individuals how to engage in the practice; (ii) consumption dynamics revolve around acquiring products and services linked to the practice; and (iii) bodily dynamics entail conforming one’s body to the demands of the practice. These dynamics work together to promote and disseminate the humanized birth practice, guiding their adoption by consumers. In this section, we describe each of these dynamics.

Instructional dynamics

When women discover pregnancy, they encounter a series of instructional dynamics aimed at preparing them for humanized childbirth. These instructional dynamics convey the meanings of humanized childbirth, which include empowering women, respecting their choices, and centering them in the birthing process. The goal of these instructional dynamics is to provide knowledge and strategies so that women are well-informed and can actively seek a humanized birth. Instructional dynamics circulate through social media, where experienced mothers, doctors, midwives, and doulas share educational content to raise awareness on the importance of having the correct information for decision making. The instructions shared on social media follow the idea that women must be empowered to take a stand against the recommendations against normal delivery, avoid c-sections, prevent obstetric violence, have their wishes respected, and become protagonists in childbirth. This argument is reinforced by the scientific discourse, used by professionals present in social media to, through their expertise and authority, guide women in the search for humanized birth. Ana Jannuzzi, who is a doctor and mother of three children, all delivered by humanized birth, shared the following quotation:

What to study? There are many subjects, but some fundamental topics are: Choosing the Maternity and the Team, Indications for C-Section, The role of the partner during childbirth, Care for a healthy pregnancy, How to identify a team that works based on evidence, How to identify prenatal care is being done properly, Labor, C-section and its stages, Postpartum recovery, Puerperium, Breastfeeding. And so on. The study list needs to be longer than the nursery list. I assure you. You won’t regret learning it. (https://www.instagram.com/drajannuzzi)

After ensuring the decision for humanized childbirth, the instructional dynamics focus on the development of the birth team, meaning the search for healthcare professionals aligned with the practice of humanized childbirth. Woman must select among the options available on the market the professionals who, together, are responsible for the humanized birth. Doctors, pediatricians, midwives, nurses, doulas, physiotherapists, and psychologists work together team to prepare women during pregnancy, labor, and birth, each playing a role, as an obstetrician explained in her Youtube channel:

The team that assists the woman to prepare her for the humanized delivery works like an orchestra: each instrument has its importance, and everyone comes together for the main show, which is the birth of the baby. It's exactly like that! Each professional has a key role in this process that involves the entire pregnancy and goes to postpartum. All come together in a synergy so that the woman is the protagonist and feels all the support and welcome in this very unique and special moment. Having a team aligned with your goals is fundamental! https://www.instagram.com/p/Cpc_d7Yrtud/

The birth stories shared on social by other women who have successfully had their desired humanized childbirth endorse the instructional dynamics, as the following quotation illustrates:

I looked for a team that believed in this method of delivery and how lucky I was! Everyone was AMAZING in this process. I had prenatal care in Sobral and Fortaleza. In Sobral I was accompanied by the obstetrician @tadeurcpfilho and in Fortaleza by @liduinarochasousa and @drmarcosalencar. From the beginning, I had already imagined that the birth would take place there because it better met our health plan and the neonatal ICU (I was afraid of needing an emergency). As I wanted a more humanized birth, I also spoke to the doula @doulakrysrodrigues_parto and obstetric nurse @ruannalorna. (my wonderful and essential girls in this dream) They accompanied me in the best way possible and gave me security and motivation in this choice. We had online and in-person meetings, I talked and clarified all doubts. (https://www.instagram.com/p/CzrQ5mMLgEU/?igsh=eDZla3V3dGE4d3F1)

Following the preparation for humanized childbirth, the birth plan is a document prepared by the woman that describes her wishes regarding the care she wants for herself and the baby. It functions as a guide on how the delivery should occur, containing specific guidelines for each stage of labor. The birth plan is a meticulously detailed instructional guide, including directives on the role of each member of the birth team, music, lighting, accepted clinical interventions, delivery positions, and pain relief methods, among other specific desires. The following quotation was transcribed from a series of Instagram stories in which a popular mother shared her experience to guide mothers-to-be in having their humanized birth:

Try to know the maternity hospital where you are going. Look for references. See recommendations from other mothers. You look for so much on the internet and in mothers' groups, look for that too. After that research, you can write your birth plan according to what works for your family. You share personal things with your team, because your team doesn't know you in depth. This is very important [...] Run away from doctors who do not accept a birth plan. Change doctors if possible. (https://www.instagram.com/drabiancamello/)

Instructional dynamics form an educational framework, guided by the market, enabling instructional practices to intersect with consumption practices, despite of the discourse around empowerment. These dynamics aim to prepare women for humanized childbirth, linking the level of birth preparation to the level of commitment to the maternal role.

Consumption dynamics

Consumption dynamics aim to equip women with essential resources, with the market serving as a supplier of the materials needed for humanized childbirth. These dynamics encompass the consumption of online courses, the hiring of healthcare professionals, and content consumption. The promotion of these resources occurs on social media, which acts as an online shop window where doctors, midwives, doulas, physiotherapists, and psychologists showcase their products and services, establishing a distinct lineage of service providers specializing in humanized birth.

The offer of pregnancy courses seek to empower women through education, focusing on the healthy development of the pregnancy and the preparation for the humanized birth. The following description was retrieved from the sales page of the course ‘Pregnancy, birth, and Puerperium Course’: “Complete course, lasting 15 hours, aimed at women who want to learn everything about normal birth, cesarean section and its indications, obstetric violence, birth plan, reimbursement by the health plan, how to alleviate the pain of labor”. (https://hotmart.com/pt-br/marketplace/produtos/curso-de-parto-dra-ana-jannuzzi/L42813609W).

On a market perspective, the humanized birth philosophy is used by health professionals as a branding strategy. For example, in her Instagram profile biography, a popular obstetrician introduces herself as “Humanized Assistance at Birth - Integrative Gynecology” (https://www.instagram.com/dra.karolsoares/). The identification with the humanized birth movement serves as a label to differentiate these service providers from the pro-cesarean doctors.

On social media, a variety of content is shared to raise awareness about humanized childbirth. Upon examining the source of these posts and videos, we notice they originate from commercial profiles where awareness-raising content is part of the service promotion strategy. The following quotation was taken from a profile claiming to advocate for “respectful births”, offering prenatal services, childbirth assistance, doula services, breastfeeding consulting, and psychological support.

Giving birth is fantastic! Bad is the system, which puts you in an unsafe situation of unnecessarily large surgeries; obstetric violence is bad, which brings fear and disgust to what is natural. Bad is the lack of adequate, responsible and diligent assistance during births and postpartum. Bad is the society that, because birth processes are so violated, believes that the problem is the woman and not the imposed system. Bad is the outdated, plastered and medicalized workforce that does not understand childbirth as a physiological process that requires patience. Bad is the lack of quality information within clinics, to clarify and encourage people to experience what the body has prepared for.

https://www.instagram.com/p/C5Bcr3KuAJd/?igsh=NTFnNGx0MGx6aWtj

In addition to the selection of professionals, the environment in which the delivery will take place also needs an infrastructure that allows it to be carried out. Social media discusses and compares the facilities of the birth centers of different hospitals and maternity services, informing the possibilities, advantages and disadvantages, physical structure, and pricing. Many videos on YouTube provide complete coverage of the hospital’s structure, showing the bedroom, delivery room, nursery, structure for exams and other facilities such as a restaurant, assistance to families and even a beauty salon. By combining state-of-the-art medical care and the structure of a hotel, the humanized birth centers become sacred places, integrating consumers and physical, visual, sacred, and branded elements (Sherry, 1998). On social media, commercial profiles of maternity hospitals share their facilities:

The Natural Childbirth Center occupies an entire floor at Hospital, with eight equipped rooms and the support of specialized professionals for a safe and humane delivery. In addition to a bathtub, stool for vertical delivery and accessories such as acrobatic fabric and fitball, the room offers resources such as music therapy, color therapy and aromatherapy, but also has the necessary equipment for an emergency cesarean section. A video system allows the baby to be introduced to the family, and after breastfeeding in the first hour, mother and baby proceed to the room. Schedule your visit to meet our maternity. (https://www.instagram.com/p/Clmc_dZKEA6/)

The scenario in which the practice of humanized childbirth spreads also feels the impact of maternity influencers, who not only share their personal experiences but also endorse brands, organizations, and professionals involved in providing humanized childbirth. However, it is important to notice that maternity influencers not only share organic content, but also exhibit paid posts on their social media. In the humanized birth market, maternity influencers use their authority and credibility to help the marketplace to obtain more proximity with women. Debora Silva, an influencer with 1.8 million followers on Instagram, shared her experience of humanized childbirth, highlighting all the service providers who were involved:

Maria Clara was born from a humanized and respectful natural birth, surrounded by love and blessings last night … thanks to my wonderful doctor @ericamantelli and her entire team, who welcomed us from the first moment and who conducted everything with mastery and love … We thank our amazing doula @cacauprado who hugged me, calmed me down, relieved my pain; our super obstetrician @sammy.sales for all the care and affection; the wonderful physio that prepared me for this moment @carlapereirafisiosexualidade; the dear @dra.sophiagaiarim who since the prenatal consultation reassured me and took great care of our princess at birth; to @rededor_oficial_star for taking care of every detail and for having us so well. We are grateful for everyone involved who made this dream come true! (https://www.instagram.com/p/CnP7fkGu6aw/)

By advertising the freedom of choice of service providers, settings, and protocols, the market generates resources so women can choose from, acting as a fundamental element of the birth experience. In the humanized birth marketplace, the humanized birth is not only an object of desire for consumers, but also a branded product that serves as a resource for marketers.

Bodily dynamics

Bodily dynamics serve as cultural scripts that consumers deploy to discipline their bodies into enacting a certain practice. Since pregnancy and childbirth actively involve the female body, women adopt a range of bodily practices involving weight maintenance, specialized prenatal exercises, maneuvers to position the baby correctly for vaginal birth, and pelvic physiotherapy to prepare the vagina and pelvic floor for labor, as described in the following quotation:

During our months of waiting, I prepared my body and mind for our big day. I continued to go to the gym from the beginning of my pregnancy, I did Pilates, I took care of my diet, I supplemented and I asked God every day for everything to work out. (https://www.instagram.com/reel/Czq8TnTr-3U/?igsh=YnB0NzhjYThtNzN6)

Bodily dynamics involve monitoring the female body throughout pregnancy, particularly regarding the baby’s position. By the end of pregnancy, the baby should be in the cephalic position, commonly known as “head down”, the optimal position for natural childbirth. Obstetricians, nurses, physiotherapists, prenatal consultants, and doulas develop strategies to help women influence the baby’s position within their bodies. The promotion of these services is often shared on social media. In the following quote, a physiotherapist explains the “spinning babies” method, a series of exercises to be performed daily from the 24th week of gestation, aiming to help the baby engage its head in the mother’s pelvis, thereby adopting the cephalic position.

These exercises are nothing more than a group of stretching exercises, of positions that the woman needs to be in, and this will help to increase the space or improve the baby's space inside the uterus, in the belly, so that he can rotate and do the movements he needs to make to be born. They can be done during pregnancy. My baby was breech, meaning he was sitting up. And then I started doing it and at the next ultrasound he was already turned around. (https://www.youtube.com/watch?v=T8nOXy_uBOk&t=256s)

The External Cephalic Version (ECV) is a maneuver that turns a baby from a breech position to a head-down position. It is performed by obstetricians in hospital settings due to the risk of inducing labor or complications that might lead to an emergency C-section. This technique nearly disappeared in the 1960s because of reported fetal complications at the time but regained popularity in the 1980s as advocacy for humanized birth began (Regalia et al., 2000). Our data show that ECV is highly encouraged by obstetricians and medical clinics in the private sector as a last resort for facilitating vaginal birth. However, there is little discussion about the risks, contraindications, or negative experiences associated with the procedure. Below is an example retrieved from the Instagram profile of an obstetric clinic specializing in humanized childbirth.

The external cephalic version consists of a maneuver, performed by manipulating the mother’s abdomen, in which the baby is rotated and repositioned. The objective is to increase the chances of the baby being in a cephalic position, that is, upside down, on the day of birth. Women most likely to opt for this maneuver are those who are well informed, encouraged to undergo the procedure, believe in its safety, and desire a vaginal birth. (https://www.instagram.com/p/Cn4YXElPIMI/)

Labor and delivery are the most demanding bodily dynamics. The birth team steps in to execute the birth plan, monitoring and guiding the woman’s performance from the first sign of labor until after the delivery. Contractions, pain, attempts at relief, and the perception of her own body are meticulously described in birth reports shared on social media, as the following quotation demonstrates.

I entered the birthland, I lived the moment with intensity, I did my best and there came a moment that I thought I would not make it, but I was next to an incredible man (my Husband […] he encouraged me not to give up. And at 18:03 my little prince came into the world, my birth was beautiful, humanized, without obstetric violence, without episiotomy (just a small laceration), with a wonderful team […] In that, the pain became the strongest experience I've ever felt in my life and, without realizing it, I was there. Right there: in Birthland, a common mental/spiritual place where you go outside and connect with your most primitive, intuitive and wild side (https://www.instagram.com/p/CS0BPBNtJTg/)

Birth reports show a strong connection to the hero’s journey: the hero is called to a challenge, faces numerous trials that test their courage, and eventually reaches the moment of trial, followed by the reward (Campbell, 2003). In the content shared on social media, women who achieved the humanized birth they desired and planned use expressions such as resilience, determination, confidence in the process, effort, and achievement to describe their birth experience. Most of these reports are accompanied by a picture of the women making a gesture of victory, as illustrated in Figure 1.

Figure 1.

The humanized birth accomplishment.

There are cases where birth plans cannot be fully realized, and a series of strategies are implemented to facilitate vaginal delivery, always guided by the birth team professionals. However, there are instances where an emergency cesarean section is necessary due to the risks of continuing with a vaginal delivery for both mother and baby. In these cases, the feelings reported in birth stories are often of frustration, inadequacy, and failure, as the following quotation illustrates.

When the doctor realized that I was at my physical and emotional limit, that this would end up affecting the baby as well, she suggested that we go for a cesarean section. I don't know how to explain what I felt at that moment, because it was a mixture of 'no, I don't want to, I've come this far, I've been in labor for hours and hours, I've dilated 10cm, I've been in the expulsive stage for three hours' and a relief, because I couldn't take it anymore, I had no more strength. [...] Then we decided to go for a cesarean section. I went crying. [...] The next day, I was a little frustrated, should I have tried harder?

(https://www.youtube.com/watch?v=44sJnDqE1yM&t=14s)

In summary, the three dynamics reveal how the humanized childbirth practice has been interpreted, adopted, and implemented in Brazil. Our data show that while social media plays a role in disseminating the practice, the market acts as a facilitator for its adoption. As more people, whether consumers or healthcare professionals, embrace humanized childbirth, the practice becomes more embedded in society, making it common, desirable, and feasible. However, this process shows a departure from the natural, anti-technocratic, and anti-capitalist principles that originally defined humanized childbirth. Today, the practice is highly monitored and controlled, requiring medical and hospital resources, and involves a significant commercial apparatus to make it possible.

The practice diffusion process cooptation framework

The interaction among the dynamics triggers three specific co-optation processes, which together account for the co-optation of humanized childbirth during its diffusion. Figure 2 illustrates our framework.

Figure 2.

The practice diffusion process cooptation framework.

The concept of humanized childbirth, originally intended to prioritize women's agency in a natural birthing process, is being reshaped by the interplay of market forces and social media. This shift transforms the meaning from empowering women to requiring them to be educated consumers. Through social media, commercial messages engage in discourse co-optation, reframing the meaning of the practice. Consumers are led to believe they're making a social contribution while being influenced by marketing. In essence, the true meaning of humanized birth is being neutralized, and social media dictates how society understands this practice.

Regarding autonomy co-optation, the market increasingly dictates how we experience even personal practices like childbirth. This blurs the line between free choice and market-driven decisions. Consumers believe they’re making autonomous choices, but the market shapes their options and influences their understanding of these practices. This phenomenon, where the market co-opts the concept of autonomy, leaves consumers reliant on commercial forces rather than empowered by them. Lastly, we understand that the co-optation of subjectivity arises when medical practices often turn bodily experiences into rigid routines dictated by medical professionals. This means that consumers’ personal experiences and preferences are overshadowed by a focus on achieving specific outcomes. The market reinforces this by promoting a narrow view of what constitutes the bodily performance, often based on standards and achievement rather than individual needs. Even though these rules might be presented as natural, they are constructed and promoted by commercial interests.

In sum, the interplay between market forces, social media, and medical practices fundamentally drives the diffusion of the humanized childbirth practice in Brazil, reshaping its concept. This commercialization not only undermines its original focus on women’s agency but also raises concerns about informed consent and individual autonomy. As the humanized birth movement strives to ensure a positive and empowering birthing experience for all women, it’s crucial to be aware of these subtle co-optation processes. By critically examining how market forces and medical practices influence our choices, we can reclaim agency and ensure that childbirth remains a deeply personal and empowering journey.

Discussion and conclusion

This paper introduces the concept of co-optation within the diffusion process of practices. We demonstrate how market forces can manipulate the spread and adoption of practices, using the case of humanized childbirth in Brazil. Originally intended to empower women and return birth to a natural process (Davis-Floyd, 1992, 2018; Friedland et al., 2014), the diffusion of humanized childbirth has been fueled by market forces. This co-optation transforms the experience into a demanding journey of preparation, education, performance, and achievement, echoing core principles of neoliberal ideology.

The humanized birth movement, intended as a natural alternative to cesarean sections (Nagahama and Santiago, 2011) boomed in Brazil due to market forces. Unlike the natural birth movement’s focus on “re-enchantment” (Rutherford and Gallo-Cruz, 2008), this approach transformed its philosophy into an achievement-focused educational project. In line with the neoliberal notion of turning life experiences into projects (Avishai, 2007), humanized childbirth sheds its natural essence, replaced by a meticulously planned endeavor centered on achieving a specific goal. While pregnancy serves as a preparatory phase, the birthing process becomes a performance, where all efforts are put to the test, culminating in a celebration of victory or a sense of failure. The pain of childbirth, once feared (Tedesco et al., 2004), is transformed into a symbol of empowerment and bodily mastery. It is due to this transformation in meaning, driven by the emphasis on control and achievement, that we argue that the diffusion process of humanized childbirth practices has been co-opted by neoliberal ideology.

Social media plays a pivotal role in this co-optation process, allowing the creation of narratives that raise awareness of the practice, influence its adoption and spread, and legitimizes practices and ideologies. Galloway (2004) argues that social media mediation introduces a new kind of power, establishing protocols and unspoken rules that govern online connections. While the discourse on humanized birth aims to empower women and make them the central figures in childbirth (Rutherford and Gallo-Cruz, 2008), social media often promotes the idea that achieving a humanized birth requires a network of professionals aligned with this philosophy. Like the creation of a service ecosystem (Akaka and Vargo, 2015), the relationship between doctor and patient expands into a network of actors, transforming childbirth into a collective performance.

Our analysis aligns with critiques of neoliberalism’s impact on consumption (Peck and Tickell, 2002; Shamir, 2008; Shankar et al., 2006), revealing two concerning trends. Firstly, humanized birth seems to favor the wealthy, exacerbating social inequalities instead of promoting equity. Future research should investigate how current practices unintentionally exclude some women and how neoliberal narratives of success and failure influence birthing experiences. Secondly, humanized birth practices can be oppressive. They can subject women’s bodies to an intense regimen based on entrepreneurial ideals of training, physical readiness, and achieving performance. Examining societal pressures on mothers to perform, dedicate themselves excessively, and achieve reinforces the need for research on how these expectations impact women’s experiences of motherhood and the social consequences of contemporary childbirth practices.

Note that our discussion is not about having or not a humanized birth but exploring its cultural and ideological dimensions of how the diffusion of this practice was co-optated by neoliberal ideals. By doing so, we contribute to consumer studies on practice diffusion and the co-optation of motherhood. Building on Akaka et al. (2022) and Irvine (2022), we highlight the understudied role of digital technologies, particularly social media, in shaping practice diffusion. Furthermore, by applying co-optation theory (Bujold and Vallé-Ouimet, 2024), we expose how market forces influence societal norms and expectations around motherhood, impacting women’s resistance and empowerment efforts (Takševa, 2012). This study’s significance lies in its demonstration of how commercial and ideological narratives can be disguised as alternative discourses, potentially manipulating consumer decision-making. By illuminating the agendas underlying the diffusion of the humanized birth practice, this research provides valuable insights for empowering women to navigate the complexities of motherhood within the broader consumer culture landscape.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Thaysa Costa do Nascimento

Author Biographies

Fernanda Bueno Cardoso Scussel is a PhD in Administration from the Federal University of Santa Catarina and works as a researcher in the area of marketing. Her research focuses on cultural studies of consumption, especially Consumer Culture Theory (CCT), a context in which she contributes with content on consumer experience. Her current interest is qualitative research, especially netnography. Given her diverse experience, she works as a mentor for graduate students at my company Pesquisa na Prática, where she develops courses on scientific writing, methods and study organization.

Thaysa Nascimento is a PhD in Administration at the Instituto COPPEAD Institute, Rio de Janeiro Federal University (UFRJ), with a bachelor’s degree in international management and Defense from the Rio de Janeiro Federal University. She is currently a Researcher with the Consumption Studies Center at COPPEAD-UFRJ. She has experience in the Administration field, particularly Marketing, in the following fields: consumption, behavior, beauty, food consumption, brands, cultural branding and blogs. Her research topics are related mainly to Culture and Consumption, particularly Consumer Culture Theory (CCT) with analyses conducted through qualitative methodology, itineraries method and nethnography. She also works as a consultant in the influencer marketing market, negotiating with influencers and brands, assisting in mapping influencers and executing content, and consequently evaluating metrics.

References

Akaka

Vargo

(2015) Extending the context of service: from encounters to ecosystems. Journal of Services Marketing 29(6/7): 453–462. DOI: 10.1108/JSM-03-2015-0126.

Akaka

Schau

Vargo

(2022) Practice diffusion. Journal of Consumer Research 48(6): 939–969. DOI: 10.1093/jcr/ucab045.

Avishai

(2007) Managing the lactating body: the breast-feeding project and privileged motherhood. Qualitative Sociology 30: 135–152. DOI: 10.1007/s11133-006-9054-5.

Becker

Ewald

Harcourt

, (2012a) 'Becker on Ewald on Foucault on Becker': American Neoliberalism and Michel Foucault's 1979 'Birth of Biopolitics' Lectures (September 5, 2012). University of Chicago Institute for Law & Economics Olin Research Paper No. 614, U of Chicago, Public Law Working Paper No. 401, Available at SSRN: https://ssrn.com/abstract=2142163 or DOI: 10.2139/ssrn.2142163.

Bryant

Porter

Tracy

, et al. (2007) Caesarean birth: consumption, safety, order, and good mothering. Social science & medicine 65(6): 1192–1201.

Buckley

(2015) Hormonal Physiology of Childbearing: Evidence And Implications for Women, Babies, and Maternity Care. Retrieved from. https://bpgmobile.rnao.ca/sites/default/files/hormonal-physiology-of-childbearing.pdf.

Bujold

Vallée-Ouimet

(2024) A call for conscious “anti-preparation” to motherhood. Aporia 16(1): 6–7.

Campbell

(2003) The Hero's Journey: Joseph Campbell on his life and work. New World Library, Vol. 7.

Carneiro

(2011) Cenas de parto e políticas do corpo= uma etnografia de práticas femininas de parto humanizado (Doctoral dissertation, [sn]).

10.

Clark

(2003) Disaggregate evidence on the persistence of consumer price inflation. In: Research Working Paper 03–11. Federal Reserve Bank of Kansas City.

11.

Davis-Floyd

(1992) Birth as an American Rite of Passage. University of California Press.

12.

Davis-Floyd

(2018) Ways of Knowing about Birth: Mothers, Midwives, Medicine, and Birth Activism. Waveland Press.

13.

Declercq

(1983) The politics of Co-optation: strategies for childbirth educators. Birth 10(3): 167–172. DOI: 10.1111/j.1523-536X.1983.tb01419.x.

14.

Dick-Read

(1933) Natural Childbirth. Heinemann.

15.

Diniz

CSG

(2005) Humanização da assistência ao parto no Brasil: os muitos sentidos de um movimento. Ciência & Saúde Coletiva 10(3): 627–637.

16.

Drew

Gottschall

(2018) Co-optation of diversity in nationalist advertising: a case study of an Australian advertisement. Continuum 32(5): 581–593.

17.

Friedland

Mohr

Roose

, et al. (2014) The institutional logics of love: measuring intimate life. Theory and Society 43(3): 333–370. DOI: 10.1007/s11186-014-9223-6.

18.

Galloway

(2004) Intimations of everyday life: ubiquitous computing and the city. Cultural Studies 18(2-3): 384–408. DOI: 10.1080/0950238042000201572.

19.

Giacomini

Hirsch

(2020) “Natural” and/or “humanized” childbirth? A reflection from the class perspective. Revista Estudos Feministas 28(1). DOI: 10.1590/1806-9584-2020v28n157704.

20.

Gram-Hanssen

(2011) Understanding change and continuity in residential energy consumption. Journal of Consumer Culture 11(1): 61–78.

21.

Guimarães

Leiróz

Dutra

VGP

, et al. (2017) Fatores associados ao tipo de parto em hospitais públicos e privados no Brasil. Revista Brasileira de Saúde Materno Infantil 17: 571–580.

22.

Holt

(2002) Why do brands cause trouble? A dialectical theory of consumer culture and branding. Journal of Consumer Research 29(1): 70–90. DOI: 10.1086/339922.

23.

Irvine

(2022) Selling beautiful births: the use of evidence by Brazil's humanised birth movement. In: Wallace

(ed), Anthropologies of Global Maternal and Reproductive Health. Springer, 199–219.

24.

Kozinets

(2019) Netnography: The Essential Guide to Qualitative Social Media Research. Sage.

25.

Lave

Wenger

(1991) Learning in doing: social, cognitive, and computational perspectives. Situated learning: Legitimate peripheral participation 10: 109–155.

26.

Lincoln

Travers

Ackers

, et al. (2002) The meaning of empowerment: the interdisciplinary etymology of a new management concept. International Journal of Management Reviews 4(3): 271–290. DOI: 10.1111/1468-2370.00087.

27.

Lizardo

(2009) Formalism, behavioral realism and the interdisciplinary challenge in sociological theory. Journal for the Theory of Social Behaviour 39(1): 39–79. DOI: 10.1111/j.1468-5914.2008.00393.x.

28.

Nagahama

EEI

Santiago

(2011) Parto humanizado e tipo de parto: avaliação da assistência oferecida pelo Sistema Único de Saúde em uma cidade do sul do Brasil. Revista Brasileira de Saúde Materno Infantil 11: 415–425.

29.

Nelson

(1983) Working-class women, middle-class women, and models of childbirth. Social Problems 30(3): 284–297. DOI: 10.2307/800354.

30.

Peck

Tickell

(2002) Neoliberalizing space. Antipode 34(3): 380–404. DOI: 10.1111/1467-8330.00247.

31.

Regalia

Kofidi

(2000) The higher-order power method revisited: convergence proofs and effective initialization. In: 2000 IEEE International Conference on Acoustics, Speech, and Signal Processing. Proceedings (Cat. No. 00CH37100). IEEE, Vol. 5, 2709–2712.

32.

Rocha

NFF

Ferreira

(2020) A escolha da via de parto e a autonomia das mulheres no Brasil: uma revisão integrativa. Saúde em Debate 44(125): 556–568. DOI: 10.1590/0103-1104202012521.

33.

Rodrigues

(2021) No Brasil das cesáreas, falta de autonomia da mulher sobre o parto é histórica. Casa de Oswaldo Cruz, Jun 6. https://coc.fiocruz.br/index.php/pt/todas-as-noticias/1967-no-brasil-das-cesareas-a-falta-de-autonomia-da-mulher-sobre-o-parto-e-historica.html#:∼:text=taxadeces%C3%A1reasdomundo&text=NoBrasil%2Caproximadamente55%25dos,apropor%C3%A7%C3%A3opulapara86%25.

34.

Rosen

Schweitzer

(2018) Benefits-sharing agreements and nonideal theory: the warning signs of agreement co-optation. Planning Theory 17(3): 396–417. DOI: 10.1177/147309521772338.

35.

Rutherford

Gallo-Cruz

(2008) Selling the ideal birth: rationalization and re-enchantment in the marketing of maternity care. In: Chambré

Goldner

(eds) Patients, Consumers and Civil Society. Emerald Group Publishing Limited, 75–98.

36.

Saldaña

(2015) The coding manual for qualitative researchers. Sage.

37.

Schatzki

(2019) Processes, life, and the practice plenum. In: Institutions and Organizations: A Process View, 79–99.

38.

Shabot

(2021) We birth with others: towards a Beauvoirian understanding of obstetric violence. European Journal of Women's Studies 28(2): 213–228.

39.

Shamir

(2008) The age of responsibilization: on market-embedded morality. Economy and Society 37(1): 1–19. DOI: 10.1080/03085140701760833.

40.

Shankar

Cherrier

Canniford

, et al. (2006) Consumer empowerment: a Foucauldian interpretation. European Journal of Marketing. DOI: 10.1108/03090560610680989.

41.

Sherry

Jr (1998) Servicescapes: The Concept of Place in Contemporary Markets. American Marketing Association.

42.

Shove

Pantzar

Watson

(2012) The Dynamics of Social Practice: Everyday Life and How it Changes. Sage.

43.

Takševa

(2012) The commercialization of motherhood and mothering in the context of globalization: anglo-American perspectives. Journal of the Motherhood Initiative for Research and Community Involvement.

44.

Tedesco

Maia

FNL

Mathias

, et al. (2004) Fatores determinantes para as expectativas de primigestas acerca da via de parto. Revista Brasileira de Ginecologia e Obstetrícia 26: 791–798.

45.

Teixeirense

MMDS

Santos

SLSD

(2018) From expectation to experience: humanizing childbirth in the Brazilian National Health System. Interface: Comunicacao, Saude, Educacao 22(65): 399–410. DOI: 10.1590/1807-57622016.0926.

46.

The Voice Group (2010) Motherhood, marketization, and consumer vulnerability. Journal of Macromarketing 30(4): 384–397. DOI: 10.1177/027614671037817.

47.

Thompson

(1997) Interpreting consumers: a hermeneutical framework for deriving marketing insights from the texts of consumers' consumption stories. Journal of Marketing Research 34(4): 438–455. DOI: 10.1177/002224379703400403.

48.

Thompson

(2010) Caesarean section at maternal request: a literature review. British Journal of Midwifery 18(8): 484–491. DOI: 10.12968/bjom.2010.18.8.49315.

49.

Thompson

Coskuner-Balli

(2007) Countervailing market responses to corporate Co-optation and the ideological recruitment of consumption communities: table 1. Journal of Consumer Research 34(2): 135–152. DOI: 10.1086/519143.

50.

Warde

(2005) Consumption and theories of practice. Journal of Consumer Culture 5(2): 131–153. DOI: 10.1177/1469540505053090.

51.

Warde

(2014) After taste: culture, consumption and theories of practice. Journal of Consumer Culture 14(3): 279–303.

52.

Wrede

(2001) Introduction to Part I. In: De Vries

(ed), Birth by Design: Pregnancy, Maternity Care and Midwifery in North America and Europe. Routledge, 3–6.