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in the last 20 years there was an improvement in access to services and in almost all maternal health indicators in Brazil. Paradoxically, there is no evidence of improvement in maternal mortality. This paper aims to help to understand this paradox, by analyzing the typical models of care in childbirth in public (SUS) and private sectors; the proposals for change based on evidence and on women's rights; and the conflicts of interest and resistance to change. We review the gender biases in research and in programming, especially the overestimation of the benefits of technology, and the underestimation, or the denial, of adverse effects and discomforts of interventions. Beliefs based in sexual culture are often accepted as 'scientific' explanations of the body, sexuality and the birth physiology, and are reflected in the imposition of unnecessary risk and suffering, in practices that are harmful for genital integrity, and in the denial of the right to companions in delivery. This 'pessimization of birth' is instrumental to promote, comparatively, the model of routine section. Finally we describe how the use of gender as analytical category can contribute to promote rights and cultural changes, as in the case of companions in childbirth. [ABSTRACT FROM AUTHOR]