We at IPOV Respectful Care are delighted to learn of the enactment of Portuguese Law No. 33/2025 , which, for the first time, defines obstetric violence within a national legal framework in a European country.

We consider this development a significant milestone. Before this, only three regional laws had addressed obstetric violence in Europe — those enacted by the autonomous communities of Catalonia (the first in Europe, in 2020), Valencia, and the Basque Country. The adoption of a national law — long awaited and widely debated — represents a pivotal step, not only for Portugal but also for fostering political dialogue on this issue across Europe.

This law marks a vital step towards recognising obstetric violence as a distinct form of violence — one that requires targeted responses, including concrete legislative measures, to prevent and address it effectively.

Its approval is in line with recent recommendations to EU Member States by both the European Commission (see report) and the European Parliament (see publication), which urge governments to review and adapt their legal frameworks to address obstetric violence.

This legislative achievement lays the groundwork for continued progress in recognising and preventing this form of gender-based violence.

We encourage all stakeholders and individuals interested in respectful, evidence-based maternity care to share their views and contribute to this important conversation.

Legislative Content of Law 33/2025 (Diário da República)

Law No. 33/2025 introduces, for the first time in Portugal, a clear legal framework defining obstetric violence, alongside robust preventive measures including education, professional training, transparency in childbirth care, and sanctions against disrespectful and harmful practices.

Law No. 33/2025, enacted on March 31, 2025, in Portugal, aims to advance women’s reproductive rights and protect pregnant individuals from obstetric violence. According to its official text published in Diário da República, the law explicitly defines “obstetric violence” as any physical or verbal act by healthcare professionals on women’s bodies or reproductive autonomy involving dehumanizing treatment, excessive medical intervention, or unnecessary pathologization of natural childbirth processes, thus violating established maternity protection frameworks.

The law outlines several concrete measures designed to eradicate these harmful practices. All medical or nursing interventions during childbirth must be carefully documented with clear clinical justifications adhering to technical guidelines. Routine episiotomies and other repeated, unjustified medical procedures are explicitly prohibited, with specific penalties including fines, funding cuts for hospitals that fail to adhere to World Health Organization (WHO) guidelines or recommendations from Portugal’s Directorate-General of Health (DGS), and disciplinary procedures against healthcare professionals involved.

Additionally, the law mandates informational obligations: healthcare centers providing childbirth services must prominently display notices informing pregnant individuals of their rights throughout preconception, pregnancy, childbirth, and postpartum periods. These notices also indicate relevant authorities to contact for reporting instances of obstetric violence.

Furthermore, the law establishes a Multidisciplinary Commission on Pregnancy and Birth Rights, tasked with promoting public awareness campaigns to humanize maternity care, eliminate obstetric violence practices, and produce an annual report providing official data on patient satisfaction and adherence to birth plans.

References:

• Diário da República (official text of Law 33/2025): https://files.diariodarepublica.pt
• SIC Notícias (on the Multidisciplinary Commission and further information): https://sicnoticias.pt

The Emergence of Obstetric Violence in the Portuguese Legal Framework: Potential and Limitations of Law No. 33/2025

By Ana Bela Gil, Master’s student in Public Policy at ISCTE – University Institute of Lisbon

On March 31, 2025, Law No. 33/2025 was published in the Diário da República, making Portugal the first country in the European Union to include the term obstetric violence in its legal framework (Silvia et al., 2024; IPOV, 2025). This law amends Law No. 15/2014 with the objective of promoting rights across all phases of the reproductive process (preconception, medically assisted reproduction, pregnancy, childbirth, birth, and postpartum), establishing specific measures against obstetric violence and creating the Multidisciplinary Commission for Rights in Pregnancy and Childbirth.

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Legal Definition

The law defines obstetric violence as:

“The physical and verbal actions exerted by healthcare professionals on the body and reproductive procedures of women or other pregnant individuals, expressed through dehumanizing treatment, abuse of medicalization, or pathologization of natural processes, in violation of the protection framework established by Law No. 15/2014.”

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Legal Mechanisms Against Obstetric Violence

Training, Awareness, and Information

• The Ministry of Education must include obstetric violence as a topic in sexual education curricula.
• Healthcare training programs must address obstetric violence and promote the humanization of childbirth.
• Healthcare facilities are required to display informational posters on obstetric violence and how to file complaints.
• The Multidisciplinary Commission for Rights in Pregnancy and Childbirth will be responsible for:
  • Conducting awareness campaigns
  • Producing an annual report including:
    • Official data on satisfaction with childbirth and postpartum care
    • Compliance rates with birth plans

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Medical Practices

• All medical and nursing procedures must be recorded and justified.
• Any procedures that deviate from the birth plan must also be documented and justified.

Penalized practices include:

• Routine episiotomies
• Other repetitive and unjustified procedures that go against birth plans

These actions may lead to:

• Reduced funding for the hospitals involved
• Disciplinary investigations of the responsible professionals

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Critiques of the Legal Definition

While the law is an important step forward, it has notable conceptual limitations:

Focus on the Interpersonal Dimension

By emphasizing only individual professional conduct, the law fails to address obstetric violence as a structural or institutional issue, overlooking elements such as:

• Unequal access to healthcare services
• The impact of maternity unit closures and other health system constraints (SIC Notícias, 2023; OVO, 2023; APDMGP, 2023)
• Staff shortages and systemic overload in the public health system

Neglect of Structural Violence

Obstetric violence is a form of gender-based violence, rooted in:

• Control over women’s bodies and autonomy
• Excessive medicalization, dehumanization, and the failure to deliver woman-centered care (Simões, 2016; IPPF, 2022; United Nations, 2019)

No Explicit Mention of Informed Consent

Despite being enshrined in Law No. 15/2014, informed consent is not explicitly referenced in Law No. 33/2025—this is a serious omission, as informed consent is central to humanized and dignified maternal healthcare.

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Reactions to the Law

The public response to Law No. 33/2025 reveals deep polarization over the concept of obstetric violence in Portuguese society.

Civil Society

• Several feminist organizations and groups advocating for childbirth rights celebrated the law as a landmark achievement.
• However, the Observatório da Violência Obstétrica (OVO) expressed concern about the limited scope and insufficient measures included in the law.

Portuguese Medical Association (Ordem dos Médicos)

• Called for the immediate repeal of the law.
• Argued that:
  • Medical professionals were not consulted during the legislative process
  • The law constitutes an attack on healthcare professionals
  • The concept of obstetric violence is inappropriate and not applicable to the Portuguese context

Nursing Professionals

• The Portuguese Association of Obstetric Nurses (APEO) supported the law, affirming that it upholds women’s autonomy without threatening the healthcare workforce.
• The Portuguese Order of Nurses acknowledged the importance of the law’s aims, but also raised concerns about:
  • Its technical and conceptual weaknesses
  • Risks to the practical effectiveness of the law and to the legal safety of professionals
  • The lack of consultation during its drafting

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Joint Petition to Revoke the Law

On April 10, 2025, the Portuguese Medical Association and the Portuguese Order of Nurses issued a joint public petition to revoke the law, arguing that the use of the term obstetric violence is controversial and inappropriate.

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Conclusions

The legal recognition of obstetric violence in Portugal marks an unprecedented development in European policy, but it does not yet reflect a broad social or institutional consensus.

Law No. 33/2025 was passed without consulting key healthcare stakeholders, fueling defensiveness and resistance among professionals.

Despite its limited scope and conceptual shortcomings, this law represents a symbolic and political milestone in the struggle to uphold the rights of women and pregnant individuals throughout the reproductive process.

The effective implementation and social legitimacy of this law will require:

• The construction of interdisciplinary dialogue
• A participatory review process
• A commitment to addressing both the interpersonal and systemic dimensions of obstetric violence

Nascer.pt’s Statement on Portugal’s New Law Recognizing Obstetric Violence

An in-depth reflection on Law 33/2025 and the challenges ahead for respectful maternity care

From IPOV Respectful Care, we share and celebrate the thoughtful analysis by our Portuguese colleagues at nascer.pt on the recent incorporation of the term obstetric violence into Portugal’s legal framework. With the publication of Law no. 33/2025 on March 31, Portugal becomes the first country in the European Union to legally recognize this form of violence.

This legislation marks a significant step forward by defining obstetric violence as physical or verbal acts by health professionals that involve dehumanized treatment, abuse of medical interventions, or the pathologization of physiological processes—violating the rights of women and other birthing people during preconception, assisted reproduction, pregnancy, childbirth, and the postpartum period.

Beyond this definition, the law establishes concrete measures for prevention, awareness, and oversight, including:

• Mandatory training for health professionals on respectful maternity care.
• Integration of the topic into sexual education curricula.
• Display of informational posters in healthcare facilities.
• Creation of a Multidisciplinary Commission for Rights in Pregnancy and Birth.
• Regulation of routine episiotomies and unjustified deviations from birth plans.
• Requirement to record and justify all medical interventions not aligned with the birth plan.

However, as highlighted in the analysis by nascer.pt the law also shows significant limitations:

• Its definition of obstetric violence focuses solely on interpersonal dynamics, failing to address the institutional and structural dimensions of this issue—such as lack of access to care, hospital closures, and protocol-driven overmedicalization.
• Although informed consent is recognized in previous laws, it is not explicitly included in this new legislation, despite being a cornerstone of dignified, person-centered care.
• The legislative process excluded meaningful participation from healthcare professionals, sparking backlash from medical associations such as the Portuguese Medical Council and Nursing Council, both of which have requested the law’s revocation.

OVO Portugal on Law 33/2025: A Critical Step Towards Ending Obstetric Violence

As IPOV RespectfulCare, an initiative committed to defending human rights in childbirth care, we present a rigorous, science-based analysis of the statement issued by the Portuguese Observatory on Obstetric Violence (OVO) regarding Law 33/2025, recently enacted in Portugal. Below, we break down the key issues raised by OVO, contextualizing them within scientific evidence and international human rights standards.

1. Incomplete Definition of Obstetric Violence (Article 2)

OVO points out that the law’s definition is overly narrow, focusing solely on physical and verbal acts while omitting critical aspects such as:

• Psychological and emotional violence, which is well-documented in scientific literature as a cause of perinatal trauma, anxiety disorders, and postpartum depression (WHO, 2014; Bohren et al., 2015).
• Structural abuse of power, rooted in historical and institutional asymmetries, as outlined in WHO’s gender-sensitive approaches to health systems.
• Lack of free, informed consent, violating foundational bioethical principles and the right to bodily and reproductive autonomy (Beauchamp & Childress, 2001).
• Inequitable access to healthcare, linking to broader social determinants of maternal health and the right to non-discriminatory care (UN Committee on ESCR, General Comment No. 14).

OVO rightly criticizes the law’s tendency to individualize what is in fact a systemic, institutional and collective phenomenon, placing the burden of prevention and reporting on the woman alone.

2. Failure to Classify Obstetric Violence as Gender-Based Violence (Article 3)

The law does not categorize obstetric violence as a form of gender-based violence, despite the fact that:

• It is recognized internationally as such by the UN Special Rapporteur on Violence Against Women (A/HRC/20/16, 2012).
• It operates within structural inequalities and gendered power dynamics.
• This omission prevents its integration into equality policies, including those under the responsibility of the Ministry of Education—essential for driving cultural change.

3. Inadequate Professional Training (Article 4)

OVO calls for enhancements in health professional training, including:

• Gender, ethics, and informed consent, forming the basis of human rights-centered care (FIGO, 2021).
• Empathy and communication skills, essential tools for improving birth experiences.
• Engagement with feminist organizations and civil society, in line with community-based health approaches (Alma-Ata Declaration, 1978).

4. Limitations in the Implementation of Birth Plans (Article 5)

Although the law affirms the right to submit a birth plan, OVO reports its undermining in practice:

• Institutional pre-approval requirements limit its use as a true empowerment tool.
• Women are often asked to adopt the hospital’s standard protocols under the guise of a “birth plan,” violating the right to self-determination and meaningful choice.

5. Overfocus on Episiotomy (Article 8)

While episiotomy is mentioned, OVO warns of a narrow and potentially counterproductive focus:

• Other harmful practices—such as Kristeller maneuver, unconsented administration of oxytocin, or restriction of movement and autonomy—are not addressed.
• This narrow approach may fuel defensive medicine, potentially leading to non-medically indicated cesarean sections, a trend observed in settings with high litigation fear (Chadwick, 2017).

6. Positive Recognition: Multidisciplinary Committee and Data Transparency

OVO welcomes the law’s provision for:

• A multidisciplinary commission on pregnancy and childbirth rights, and recommends the inclusion of both healthcare professionals and civil society representatives.
• The mandatory collection of data from public and private institutions, supporting transparency and accountability.

7. Additional Concerns Raised by OV

Key structural and systemic issues highlighted by OVO include:

• Focusing exclusively on obstetricians, ignoring other professionals present during childbirth, such as midwives and nurses.
• Failure to recognize home birth as a legitimate setting, despite its safety for low-risk pregnancies in regulated environments (Lancet Midwifery Series, 2014).
• Chronic staffing shortages in the public health system, which have led to an increase in cesarean rates due to lack of professional support, as evidenced by public data from the Transparency Portal, Pordata, and CPDO.
• The importance of institutional (not only individual) accountability, to shift the culture toward systemic respect for rights.
• The need for prompt reparations for women and girls harmed by obstetric violence.
• The risk of under-protecting professionals, which may increase litigation and thus defensive medicine (e.g. scheduled cesareans without clinical indication).

8. Constitutional Framework and Legal Implications

OVO stresses that the lack of access to sexual and reproductive healthcare should itself be considered a form of obstetric violence, as it represents a clear violation of Article 64 of the Portuguese Constitution, which guarantees the right to health.

9. Overall Assessment and Role of OVO

OVO acknowledges that Law 33/2025 is a small but important first step toward eliminating obstetric violence. However:

• Its implementation is dependent on the approval of the next state budget, delaying urgent measures.
• It requires structural improvements, including legal reforms, comprehensive training, community participation, and investment in the public healthcare system.

OVO Portugal reaffirms its willingness to contribute to working groups and the newly established commission, offering its technical expertise and social advocacy in the defense of women’s sexual and reproductive health rights.

Episiotomy and Obstetric Practices in Portugal – Insights from a 2022 Lancet Study

Portugal’s High Rate of Obstetric Interventions

Portugal has historically exhibited a very high rate of obstetric interventions during childbirth, especially when compared to other European countries. A multicenter study published in The Lancet Regional Health – Europe in 2022 (covering 21,027 women who gave birth in 12 European countries during the first year of the COVID-19 pandemic) highlighted that women in Portugal were more frequently subjected to certain non-recommended childbirth practices than women in the other surveyed countries​ (rr.pt). In particular, two interventions stood out for their excessive use in Portugal: episiotomy and the Kristeller maneuver (external fundal pressure on the uterus). Both of these practices are not recommended by the World Health Organization (WHO) in routine births due to their potential harms and lack of clear benefit in uncomplicated deliveries​ (rr.pt) (pmc.ncbi.nlm.nih.gov). This over-medicalization of childbirth in Portugal has prompted concern and critique from a feminist perspective, as it directly impacts women’s bodily autonomy and birth experiences.

Episiotomy Rates in Portugal vs. Europe

An episiotomy is a surgical cut made in the perineum (the tissue between the vagina and anus) during the second stage of labor. While intended historically to enlarge the vaginal opening and prevent severe tears, routine episiotomy is now widely discouraged in modern obstetric care. The 2022 Lancet study revealed a strikingly high episiotomy rate among Portuguese women. About 40.7% of Portuguese mothers who had a spontaneous vaginal birth underwent an episiotomy, more than double the average episiotomy rate (20.1%) across the 12 European countries in the study​ (rr.pt). This means a Portuguese woman giving birth vaginally was roughly twice as likely to have her perineum cut as the average European participant. For context, some countries like Sweden reported episiotomy rates as low as ~6%, whereas others, such as Romania, reported rates up to 66% in similar births​ (thelancet.com). Portugal’s rate was among the highest in Europe, identifying Portugal as one of the most intervention-intensive (highly “medicalized”) childbirth settings in the region.

Such high usage of episiotomy in Portugal is not a new phenomenon – it has been a longstanding practice. Even before the pandemic, Portugal’s episiotomy rates were extremely elevated, often exceeding 70% of births in recent years​ (rr.pt). For example, around 2010 the national episiotomy rate was about 72.9% of all deliveries. This included episiotomies in roughly two-thirds of unassisted vaginal births and over 94% of instrument-assisted births (those involving forceps or vacuum extraction)​ (pmc.ncbi.nlm.nih.gov). Although reforms over the last decade have gradually reduced these figures (episiotomy rates have been declining, especially in spontaneous deliveries​ (pmc.ncbi.nlm.nih.gov), they remained very high through the late 2010s. (In 2019, national data still indicated an episiotomy rate above 70%​ (rr.pt)). For perspective, the WHO recommends an episiotomy rate of no more than about 10% – advising that episiotomies should be reserved for specific medical indications rather than done routinely​ (rr.pt). Thus, Portugal’s routine use of episiotomy has far exceeded international guidelines and evidence-based practice standards. Feminist health advocates argue that this routine cutting of women’s bodies without clear necessity represents an infringement on women’s rights and is reflective of outdated, paternalistic medical attitudes toward childbirth.

The Kristeller Maneuver: A Harmful Practice Still in Use

The other intervention highlighted is the Kristeller maneuver, an obstetric technique in which external pressure is applied to the mother’s abdomen (fundus of the uterus) to help push the baby out. This maneuver is widely considered outdated and harmful – it is not recommended by WHO and is even officially banned in several countries due to the risks it poses (potential trauma to mother and baby)​. (rtve.es) (pmc.ncbi.nlm.nih.gov). In many parts of Europe, the Kristeller maneuver has fallen out of use or is strictly avoided. However, the 2022 Lancet study found that Portuguese women continued to experience this practice at a much higher frequency than women in most other surveyed countries. While the Lancet report did not quote a specific national percentage for Portugal, it documented enormous variation in the use of fundal pressure across Europe – from about 11.5% of instrument-assisted vaginal births in the country with the lowest usage to nearly 100% in the country with the highest usage​ (thelancet.com). Portugal was noted to be on the higher end of this spectrum, indicating that a large proportion of assisted deliveries in Portugal involved fundal pressure.

Portuguese health authorities themselves have recognized the problematic nature of this practice. Recent national recommendations explicitly called for eliminating “violent obstetric practices” such as the Kristeller maneuver​ (pmc.ncbi.nlm.nih.gov). This wording is telling – it labels the maneuver as a form of obstetric violence. The lack of official statistics on how often fundal pressure is used in Portugal is concerning, given that so many women in the study reported being subjected to this **“unrecommended and potentially harmful” procedure​ (pmc.ncbi.nlm.nih.gov). From a feminist standpoint, the persistence of the Kristeller maneuver in some Portuguese maternity wards exemplifies how women’s choices and safety during birth have sometimes been secondary to expedience or outdated training. Its continued use, despite international disapproval, underscores the need for updated protocols and respect for women’s bodily integrity in childbirth.

Implications and the Debate on Obstetric Violence

The data from the Lancet study confirm that Portugal’s rates of certain obstetric interventions (like episiotomy and instrument-assisted deliveries with fundal pressure) have been two to three times the European average in some categories​ (rr.pt). Such findings lend weight to longstanding concerns about the quality of maternal care and respect for women’s rights in Portuguese childbirth settings. Health experts worry that these high intervention rates are not solely driven by medical need, but often by ingrained hospital routines or provider preferences – a clear sign of over-medicalization of birth. From the perspective of women who have given birth under these conditions, the experience can be distressing and disempowering. Many women report feeling that procedures were done to them without adequate consent or necessity, leaving lasting emotional trauma. In the Lancet survey, a significant fraction of mothers in Portugal (and other countries with high intervention rates) reported feeling disrespected or not treated with dignity during childbirth​ (pmc.ncbi.nlm.nih.gov) (pmc.ncbi.nlm.nih.gov) .

This situation has galvanized a public debate around “obstetric violence” in Portugal. Obstetric violence is a term used to describe the mistreatment of women in childbirth – including coercive, unnecessary, or painful interventions that violate a woman’s autonomy and dignity. The stark numbers on episiotomies and forceful interventions have served as a factual basis for activists and mothers to argue that some Portuguese maternity practices constitute obstetric violence​ (pmc.ncbi.nlm.nih.gov). It is striking, as researchers have noted, that in a high-income country like Portugal so many women still report disrespectful or abusive care during one of life’s most vulnerable moments​ (pmc.ncbi.nlm.nih.gov). In response to these concerns, there have been moves to reform obstetric protocols and even legislative initiatives to protect women’s rights in childbirth. For example, Portugal recently introduced measures defining and prohibiting certain practices as obstetric violence, including a ban on routine episiotomy without medical justification​ (expresso.pt) (expresso.pt).

From a feminist science communication perspective, the case of episiotomy and obstetric practices in Portugal highlights the importance of evidence-based care that centers women’s health, consent, and experience. Scientific data and women’s testimonies are working hand-in-hand to challenge the status quo. The 2022 Lancet study provided rigorous data exposing how far practice had strayed from WHO recommendations in Portugal​ (rr.pt), and women’s advocacy has translated those numbers into a human rights issue. The ongoing discourse aims to ensure that childbirth in Portugal (and everywhere) becomes more respectful and less interventionist, reserving procedures like episiotomy for only when absolutely necessary. In summary, the high intervention rates documented in Portugal have validated women’s critiques of obstetric care and spurred a movement toward respectful maternity care, where a woman’s autonomy and well-being are paramount and routine violence in the delivery room is not tolerated.

References

1. https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(21)00254-4/fulltext
2. https://pubmed.ncbi.nlm.nih.gov/34977838/
3. https://rr.pt/artigo/explicador-renascenca/2025/04/03/lei-da-violencia-obstetrica-por-que-razao-a-ordem-dos-medicos-esta-contra/420098/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC10991787/
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC9878220/
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC9364746/
7. https://es.wikipedia.org/wiki/Maniobra_de_Kristeller
8. https://www.rtve.es/television/20241002/barbaridades-paritorio-maniobra-kristeller-otras-violencias-obstetricas/16267828.shtml
9. https://expresso.pt/sociedade/saude/2025-03-31-obstetras-que-facam-corte-de-tecidos-vaginais-no-parto-por-rotina-e-sem-justificacao-podem-ser-alvo-de-processo-disciplinar-2818a772

Regarding Law 33/2025 and the Position of the Associação Portuguesa dos Enfermeiros Obstetras (APEO)

From IPOV Respectful Care, we wish to share the official position of the Associação Portuguesa dos Enfermeiros Obstetras (APEO) on the recently approved Law 33/2025. 

This law marks a historic moment in Portugal in the promotion of more dignified, humane, and safe maternal and obstetric healthcare.

The global momentum of feminist and human rights activism in recent years has been key in amplifying the voices of women who have felt violated, silenced, and disrespected. It has compelled health professionals to listen, acknowledge, reflect, and open dialogue around the issue of Obstetric Violence. If we are truly committed to promoting respectful care and eliminating obstetric violence, it is time to implement new strategies that build bridges and tear down walls.

Law 33/2025, approved in March 2025, is the result of years of advocacy, lived experiences, scientific research, and mobilization. It brings visibility to a form of violence that has too often gone unacknowledged in institutional spaces.

As expressed by APEO, this law is not intended to pose a threat to healthcare professionals. Rather, it is a legal tool to safeguard the autonomy and dignity of women. The law represents the beginning of a necessary process, one that may still require a clearer definition of the problem and deeper legislative refinement. Nevertheless, what cannot be denied is the commitment made to respect the freedom, dignity, and sovereign autonomy of women.

At IPOV Respectful Care, we echo APEO’s call for a collective and genuine commitment—across healthcare systems, political institutions, and civil society—to support women’s choices and those of their families. Care should be based on empathy, not imposition. The healthcare system must serve as a space of support, warmth, and recognition, not one of judgment or violence.

Women deserve to feel safe throughout their entire sexual and reproductive health journeys. Law 33/2025 is a vital step toward ensuring that safety.

The narratives we build—as a society, through education, policy, and media—about reproductive health shape how professionals care for women. We must avoid distorting or discrediting women’s experiences and instead use these stories to empower and humanize. Health professionals’ actions, language, and attitudes are deeply rooted in their own life experiences and the values of the society around them. We must ask ourselves: Are our unconscious behaviors helpful or harmful? Are they guided by fear, or by hope?

Dignity is something we owe not only to those in our care but also to our peers. Cultural competence, empathy, and openness to change are essential. We must stop perpetuating systems that promote one dominant way of living while disregarding other valid, respectful approaches.

Healthcare professionals are not inherently violent—but they can replicate violent systems. Defensive medical practices, driven by fear, cause harm to both women and professionals. There is an urgent need for safe, supportive spaces for training, reflection, and change. These spaces should acknowledge the complex realities of professional care while promoting alternatives rooted in empathy and human rights.

We recognize that discussions on Obstetric Violence can trigger defensive responses among professionals. This reaction is understandable but must not impede progress. If our goal is to end this form of violence, we must shift from confrontation to collaboration, embracing mutual respect and co-creating solutions.

Law 33/2025 is more than a legal milestone—it is a cultural opportunity. It opens the path for a systemic transformation in Portuguese healthcare. Our vision is for all women to be treated with dignity and for all professionals to be respected and valued as agents of change.

We join APEO in affirming that maternal-fetal care rooted in the Midwifery Model of Care—grounded in humanized, salutogenic, and integrative principles—is a powerful approach toward eradicating obstetric violence and ensuring safe, respectful care for all.

This path begins now. And it must be walked together.

References

• Click here to access the official document from APEO

World Health Organization Recommendations on Episiotomy (Rates and Scientific Evidence)

The World Health Organization (WHO) firmly discourages routine episiotomies, advocating instead for highly selective and medically justified use of this procedure. Since the 1980s and 1990s, WHO has clearly stated that episiotomy rates above 10-15% lack medical justification. In 1996, WHO specifically recommended aiming for approximately 10% episiotomy use in standard obstetric care (Essencial Salut).

Current WHO guidelines are unequivocal: “Routine or widespread use of episiotomy is not recommended for women undergoing spontaneous vaginal births” (NCBI). This means episiotomies should only be performed when there is a clear, medically justified indication, rather than systematically. Indeed, scientific evidence consistently shows no clear benefits from routine episiotomies. Numerous comparative studies have demonstrated that restricting episiotomy use improves maternal health outcomes without negatively affecting neonatal health (Essencial Salut).

For example, women managed with a restrictive approach experience fewer severe perineal tears and report less postpartum pain and pelvic floor complications compared to populations where episiotomies are routinely performed (Essencial Salut). At the same time, no significant maternal or fetal advantages have been identified for routine episiotomy—neither in the short nor long term—compared with a selective policy (Essencial Salut). According to expert panels, “there is currently no clinical evidence to support any routine indication for episiotomy” (PMC-NCBI). Consequently, WHO and international guidelines advise maintaining episiotomy rates as low as possible (around 10% or less for normal vaginal deliveries) (PMC-NCBI). Routine episiotomy poses greater risks than benefits, including increased perineal trauma equivalent to a second-degree tear, potential complications from suturing, heightened postpartum pain, and a lack of proven efficacy in preventing severe tears or pelvic organ prolapse (Essencial Salut).

In conclusion, WHO supports a restrictive strategy: episiotomies should only be performed when medically necessary, never routinely. This position is strongly supported by robust scientific evidence showing that selective episiotomy enhances both the safety and overall childbirth experience for women (Essencial Salut, PMC-NCBI).

References

• Essencial Salut (Government of Catalonia): https://essencialsalut.gencat.cat
• NCBI (National Center for Biotechnology Information): https://www.ncbi.nlm.nih.gov
• PMC-NCBI (PubMed Central): https://www.ncbi.nlm.nih.gov/pmc
• Diário da República (Portugal, Law 33/2025 official text): https://files.diariodarepublica.pt
• The Lancet Regional Health – Europe (2022 study on obstetric care quality): https://www.rr.pt, https://www.rtp.pt
• SIC Notícias (Statements from Ordem dos Médicos): https://sicnoticias.pt

More references

Referências

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APEO. (04 de abril de 2025). COMUNICADO OFICIAL DA APEO sobre a Lei 33/2025:. Obtido de https://apeo.pt/blog/

Assembleia da República. (21 de março de 2014). Lei consolidando a legislação em matéria de direitos e deveres do utente dos serviços de saúde. Diário da República(nº 57/2014, Série I de 2014-03-21), pp. 2127 – 2131. Obtido de https://diariodarepublica.pt/dr/detalhe/lei/15-2014-571943

Assembleia da República. (31 de março de 2025). Lei n.º 33/2025, de 31 de março: Promove os direitos na gravidez e no parto e altera a Lei n.º 15/2014, de 21 de março. Diário da República(nº63/2025, Série I de 2025-03-31). Obtido de https://diariodarepublica.pt/dr/detalhe/lei/33-2025-913048477

Challinor, E. P. (2018). Exploring the power of the written word: on hospital birth and the production of birth narratives. Etnográfica – Revista Do Centro Em Rede de Investigação Em Antropologia, 22(3), 669–690. https://journals.openedition.org/etnografica/6077

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