BUENOS AIRES, ARGENTINA — Ruth Micaela Vilchez arrived at the hospital with a healthy, full-term pregnancy after her doctor recommended inducing labor due to minor discomfort. Once admitted, she was not allowed a companion. Later, midwives told her that the baby was too large and that circumstances were not conducive to a smooth birth, which led them to request a cesarean section. The obstetrician refused.
Vilchez was in labor for five hours. Overwhelmed with pain, she requested a C-section. Instead, she says, doctors decided to push with their own force on her abdomen while she was giving birth.
The lethargic cries of her son Joaquín indicated to her that, from the start, something was wrong.
She held her baby in her arms for less than a minute, before he was rushed to the neonatology unit. The next day, Vilchez, who was unaccompanied once again, was informed of her son’s death.
Vilchez went into the hospital with a healthy pregnancy and left with a dead baby, an untreated urinary tract infection she says almost killed her, and severe psychological aftereffects.
“I am still not fully recovered. … I haven’t found stability. I had a dream and a life plan that they took from me,” Vilchez says, a year later.
Vilchez’s experience is not an isolated case. In Argentina, obstetric violence occurs in 80% of births, according to estimates by Mi parto, mi decisión, a national campaign against obstetric violence. This type of violence is defined as that which is committed by health care personnel on the body and reproductive processes during pregnancy, childbirth and the postpartum period.
It appears in the form of practices, conduct, actions and omissions ― direct or indirect ― by medical personnel that result in violence, humiliation and rights violations against both the pregnant person and the newborn, according to the Argentine government’s definition.
Efforts to rectify the situation have resulted in an increase of doula and early-childhood care services over the last 10 years, says Luján Arcidiácono, coordinator for Mi parto, mi decisión. These professionals provide support during the birth and postpartum period from a perspective that focuses on the rights and well-being of the person giving birth. However, accessing these services is a class-based privilege. Because doulas and early-childhood care professionals are not recognized as health care professionals, health providers do not cover their services, making them accessible only to those who know they exist and can afford them.
Social organizations, early-childhood care professionals and doulas are working to universalize access to respectful maternity care through legislative bills that incorporate pre- and postpartum support in the health care system and create mandatory training on obstetric violence for all health care personnel.
The Respectful Maternity Care Law of 2004 establishes several rights for women and pregnant people. Among them are the right to have their timing and decisions respected, to have a companion with them, to have their baby remain with them (unless he or she requires special care), and to receive information and assistance on feeding and care both for themselves and for the newborn.
But the law imposes no penalties, meaning no specific sanctions exist for when someone violates it, explains Arcidiácono, who is also a doula.
“One of the most serious problems … is that we have naturalized many practices. Many women suffer obstetric violence and aren’t even conscious of it,” she says.
Nadia Ramirez, an attorney and the mother of two children, took months to realize that the mistreatment she experienced during the birth of her first child and postpartum period was obstetric violence.
Graphics by Matt Haney, GPJ
During her first pregnancy, her obstetrician induced labor so it would fall on a day when he was working at the hospital, and he forced a vaginal birth, Ramirez says. She recalls being so anesthetized that it was difficult for her to push with direction, and they had to pull her son out by force. Later, a resident sewed up the wound from the childbirth. After she was discharged, the pain did not subside. The wound had become infected, and she had to return to the hospital.
Despite her entreaties, she did not receive total anesthesia and had to endure sexist comments from the doctor while he sewed up the incision in her vulva, she says.
“[After some] time, I began to realize what had happened. It’s a severe trauma. The psychologist told me that what happened to me is similar to the trauma from sexual abuse,” Ramirez says.
The experience affected Ramirez’s relationships with her son, her partner and her own body. So, when she later found out she was pregnant with her daughter, she sought the assistance of a doula. She needed that pregnancy to be different.
Ramirez’s doula supported her emotionally throughout the process, provided her with information and helped her make plans and decisions for which hospital she would go to and which team of professionals would attend her. Together, they came up with a childbirth plan that specified which practices she wanted and which ones she didn’t.
Lucila Pellettieri, GPJ Argentina
And, indeed, her second childbirth experience was different. Ramirez arrived at the hospital completely dilated and gave birth before they even came to put her on the drip. Mere minutes following the childbirth, she was feeling more animated, had an appetite and wanted to get up, she explains.
“I wish everyone could have a doula. I will be grateful to her for the rest of my life,” Ramirez says.
While this desire is far from being a reality, efforts are underway to expand access to doulas and early-childhood care professionals. The Asociación Civil Argentina de Puericultura, a nonprofit that trains early-childhood care professionals and provides free services throughout the country, finances the wages of those professionals who work in health facilities with which it has an agreement, but its capacity is limited, says its service director, Julieta Saulo, an early-childhood care professional.
A similar situation is developing with doulas. Their services can cost between 100,000 and 200,000 Argentine pesos (approximately 286 to 572 United States dollars), explains Julia Gentile, a doula and co-founder of Fecunda Doulas, a doula school. While they do seek to be flexible so families are not left without support, she says, money is not the only obstacle.
“There are people who do not reach us because the information does not reach them,” Gentile says.
Lucila Pellettieri, GPJ Argentina
Gentile has also supported efforts to attain justice for those who have experienced violence and says the procedures for doing so cause them to relive the experience. But she is convinced that presenting complaints and grievances against health care facilities is contributing, little by little, to changing the situation.
Laura García Vizcarra, coordinator for Abordaje de la Violencia contra la Libertad Reproductiva, a task force on violence against reproductive freedom at the Ministry of Women, Genders and Diversity, admits the hotlines available for filing reports cannot provide immediate solutions.
“One of the things we truly need to work on, in addition to ensuring compliance with the law, is creating a flexible procedure for resolving complaints and assisting people who are in these situations in a timely manner,” García Vizcarra says.
She says the ministry is training personnel at the Justice Access Centers, a network of offices that offer free legal advice, to turn them into safe spaces for filing complaints, and that they will soon be incorporating content on obstetric violence in the mandatory training sessions on gender-based violence that they administer to personnel in the executive, judicial and legislative branches of the government. She also says the ministry does not have the capacity to influence the training of health care personnel.
In a written response, Juliana Finkelstein, director of perinatal and pediatric health at the Ministry of Health, said that in October 2020, the ministry created a team dedicated to preventing obstetric violence and providing immediate intervention for complaints.
This group invites the perinatal teams at institutions that have been implicated to participate in workshops on rights and best practices for providing care during pregnancy, labor, childbirth and the postpartum period, Finkelstein says.
Finkelstein says she also expects to see training and outreach activities for health care providers and programs at the provincial level.
Instead of an invitation, Arcidiácono says, obstetric violence prevention training should be mandatory for all health care personnel.
Meanwhile, Vilchez continues to recover from her experience, with psychological and psychiatric support, and to take legal action to bring about changes in the hospital.
“My greatest motivation, in addition to achieving justice for Joaquín,” Vilchez says, “is spreading awareness about what happened and making sure it doesn’t happen again.”