Francisco Saraceno
Argentina

Some Argentine women are choosing to give birth at home to avoid invasive medical practices, such as cesarean sections and episiotomies, that are frequently performed at hospitals.

BUENOS AIRES, ARGENTINA – Six years after Paula Agnoletti gave birth to her first child, she still has her entire thought process throughout the pregnancy saved on a voice recorder.

Agnoletti says she made the recording so that her daughter could hear her mother’s exact words as she overcame her fear of giving birth to her at home.

Most Argentine women give birth in hospitals. But Agnoletti’s friends and family members had had bad experiences during labor in hospitals, she says. Some felt their doctors did not give them sufficient time to have vaginal deliveries before recommending cesarean sections.

But in considering a home delivery, Agnoletti was afraid she would suffer without anesthesia, afraid of not arriving at the hospital in time if a complication arose, afraid that something would happen to the baby or to her. It was her fear and her husband’s fear. The fear of her parents and that of her in-laws.

“It is impossible to overcome the fear from night to morning,” she says. “That is why there are nine months.”

She visited various doctors. She attended lectures by obstetric specialists on pregnancy, birth and rearing. She read books.

But she remained unsure. Then, Agnoletti heard an acquaintance speak about her home birth with more passion than she had ever heard a woman speak about a delivery.

“It clicked, and I conquered the fear,” Agnoletti says. “I chose to give birth at home, and I again chose it with my other two children. I did it to assure myself that I would have a respected delivery where my baby and I were going to set the times. What the births left with me the most is a confidence in my body and in myself.”

Agnoletti acknowledges that childbirth is painful. But overall, her first delivery was wonderful, she says.

She was in labor throughout the night in her home in the company of a male midwife, a female midwife, and her husband. At one point, the labor appeared to stop. The male midwife advised Agnoletti to wake the baby, so she put on music and danced.

Later, she wanted to be alone and talk with her baby, so she shut herself in the bathroom. Shortly after coming out, she gave birth in a squatting position.

Agnoletti says deciding to give birth at home forever marked her life as a woman.

Home birth attendants have noted over the past decade an increasing number of women choosing home births, which aim to respect the mother’s preferences and the natural timing of labor. Home birth attendants, doctors, activists and mothers debate the role of fear in the frequency of C-sections and episiotomies at hospitals and clinics and when they qualify as obstetric violence. They agree that information is the best tool to empower women to have respected births.

Until the mid-20th century, it was common for Argentine women to give birth at home, says Francisco Saraceno, a home birth attendant with a degree in midwifery who has assisted in home childbirths for more than 2,000 families.

As people grew to trust that medical advances would guarantee the safety of babies and mothers, hospital childbirth became the norm in Argentina, Saraceno says.

“This process began to revert itself in the last 10 years,” he says. “And there is currently a minority of women who choose to give birth in their homes.”

This reversion, which predominantly is taking place in and around Buenos Aires, Argentina’s capital, reflects women’s desire to avoid invasive practices, Saraceno says.

In Argentina, C-sections account for 29 percent of births, and episiotomies are performed in 62 percent of deliveries by first-time mothers, according to a Ministry of Health study that analyzed more than 240,000 births in 2011.

The country’s C-section rate is double the World Health Organization’s international recommendation of no higher than 10 to 15 percent, according to a 2010 report. WHO recommends against episiotomy unless necessary.

There are no statistics on the number of home births in Argentina, according to the Ministry of Health.

But anecdotal evidence gathered by home birth attendants – as well as the rising numbers of midwives attending to home births, and online forums about the topic – suggest that more women are choosing this route, Saraceno says.

Twenty midwives – both male and female, all with university degrees in the field – now attend to home births in Buenos Aires, says Saraceno, also a mental health professor in the midwifery program at the University of Buenos Aires.

The university has long offered an undergraduate degree in midwifery. In Argentina, midwives assist women throughout the majority of the delivery at hospitals and clinics, with doctors stepping in at the end or during complications. Midwives can also deliver babies in home births.

The substantial difference between a home birth and a hospital birth is the respect shown for the timing of mother and baby, Saraceno says.

In hospitals, women are often given medication to accelerate labor and relieve pain, he says. Such medications are not used in home births.

In a home birth, the mother can give birth in the place, position and attire she chooses. In contrast, women in hospitals generally give birth in a delivery room, in a reclined position and wearing a white hygienic gown. The baby’s father also assumes a more active role in a home birth, massaging the mother and holding her as she pushes.

“In every moment, the respect for the intimacy is present, the respect for this rite that is birth,” Saraceno says.

Alejandra Daniela Pucci, who is expecting her second son, says births at clinics and hospitals lack that intimacy. She had her first child by C-section in 2010 at a private clinic in Buenos Aires.

After being in labor at home all night, she had to wait in the clinic’s waiting room for about 40 minutes while the staff assigned her a room and her husband signed her in.

“The wait felt eternal to me,” she says. “I was dying of pain, and the only thing that I managed to do was to get on the floor on all fours. I was vomiting very frequently.”

Pucci says that when the midwife arrived, she asked her to get off the floor, lie on a bed and put on a hospital gown to be examined. The midwife became impatient with her because she looked at her without responding to her instructions.

“I could not do what she asked me to,” she says. “My body asked me for another thing.”

She also felt bad and alone without her husband at her side, she says.

In the delivery room, she asked whether she could use a more vertical position to take advantage of gravity. But the doctor told her the facilities could not accommodate that preference and that it was more comfortable for her to see Pucci’s vagina in a reclined position.

Invasive practices, such as C-sections and episiotomies, are also common at hospitals and clinics, Saraceno says. Women who consult him about having home births tell him they prefer to follow the natural rhythm of their labor.

The willingness of many women to undergo invasive procedures permits doctors to tailor deliveries to their work schedules instead of attending to the natural timing of labor, Saraceno says. A doctor who sees patients in private clinics must attend to at least 15 women a month to earn enough. To achieve that, a doctor must schedule some days for consultations and others for attending births.In public hospitals, doctors and midwives are paid without regard to the number of births they attend, says Saraceno, who worked in different hospitals in Buenos Aires before dedicating himself to home births. But public hospitals are overpopulated, so doctors cannot provide the care that each woman deserves.

“Both places, in one because of the quantity of pregnant women who are there, in the other because of the quantity of pregnant women whom the doctor needs to earn a living from that, they accommodate pregnant women depending on the available times,” he says.

But Dr. Analía Messina, the chief of obstetrics at the public Hospital General de Agudos Dr. Teodoro Álvarez, advises against generalizing. There are professionals who respect natural processes and others who tend to intervene more, she says.

“There are individualities,” she says.

Messina, who used to work in a private practice, says she has never made decisions regarding women’s deliveries for economic reasons.

Mariela Franzosi, an activist with Las Casildas, a group that calls for respecting women in childbirth regardless of where they deliver, points out that misconduct occurs in home births as well as in hospitals. One example is administering oxytocin, a hormone that speeds up labor, even though it is not supposed to be used in home births.

“Not everyone works in the same way, nor does it out of the same interests,” says Franzosi, whose group does not advocate for home births or institutional births. “There are also unjust situations in home births. Merely changing where a baby is delivered does not imply stopping being dependent on the doctor’s benefit.”

Women commonly experience fear during pregnancy and labor, Saraceno says. Motivated by that fear, women giving birth in hospitals and clinics often accede to unnecessary practices, such as C-sections.

After Pucci was in labor for several hours, the doctor recommended a C-section because the baby’s heartbeat was slowing. Pucci says she agreed out of fear for her baby’s health.

Often, a family member, such as the woman’s husband or father, will request the intervention of a doctor to accelerate delivery, Messina says. Some people lack awareness of the normal duration of labor, so when it takes longer than expected, they fear something has gone wrong.

“The family is not prepared to wait,” she says. “At the second hour of labor, there are family members who say to you: ‘Enough, enough. Give her a C-section.’”

Doctors must resist such pressure and exercise judgment grounded in medical expertise, Messina says. The law requires the woman’s consent for any intervention.

But the fears of women and their families enable some professionals to unnecessarily initiate invasive practices such as C-sections, which qualify as obstetric violence, Saraceno says.

“When they talk about the possibility of death to the woman, she accepts anything,” he says. “If they advise the woman, for example, that the baby can die if they do not operate, the woman immediately accepts that they do a C-section, when, in reality, that C-section could be avoided. All of that is imposed from the fear.”

The Ministry of Justice and Human Rights defines obstetric violence, which is illegal in Argentina, as violence exercised by health personnel on women’s bodies and reproductive processes. It is expressed in dehumanizing treatment, abuse of medical authority, and the pathologizing of natural processes.

The ministry encourages women to report cases of abuse during childbirth. Its website provides detailed instructions for filing such reports.

Laura Susana Amado, a social worker in charge of health for the Ombudsman of the Nation, an autonomous body responsible for defending citizens’ rights, says it activated the mechanism for receiving complaints of obstetric violence late last year in conjunction with the ministry.

“The number of complaints received to date can be counted on your hands,” she says in a phone interview.

Many women treat abusive conduct as natural, and many others do not know how to report it, Amado says. Coordinating agencies are raising women’s awareness of filing procedures and the need to report abuse. In recent months, many women have requested information on filing complaints.

“It is very important that they report [it],” she says, “because, in that way, they can help other women in the future.”

Messina acknowledges that cases of obstetric violence exist in public and private hospitals and clinics. But sometimes episiotomies and C-sections are necessary, she says.

“To practice an episiotomy when it is necessary is not obstetric violence,” she says. “To surgically intervene when it is necessary is not obstetric violence. It is saving a life.”

Messina says it is best to give birth in a hospital or clinic so the mother can access support and medical technology if complications arise.

Although Pucci was dissatisfied with her first childbirth, she says she plans to have her second child at a hospital because she feels more secure in that setting.

Many women feel wary of giving birth at home, Franzosi says, based on women’s input at the conferences and meetings her group organizes. They fear there would be insufficient time to get to the nearest hospital or the necessary equipment to assist them in their homes if complications occurred.

Home birth attendants are prepared to accompany the natural development of a delivery, Saraceno says. Pregnancies are not diseases, and births are not traumatic moments that require medical intervention.

But if emergencies arise, home birth attendants have equipment, such as oxygen tubes and medication to control hemorrhages, he says. They and the parents also create an emergency plan that includes parking a car outside and knowing the fastest route to the nearest hospital.

Agnoletti gave birth to the first of her twins, now 4, at home. But the second child was upside down. The birth attendant, a doctor, decided to transfer her to a hospital, where she gave birth to the second twin by vaginal delivery.

Saraceno assists in home births about four times a month, he says. In the thousands of home births he has assisted, few have required hospital visits. No baby or mother has died during a home birth that he has attended.

Agnoletti says mothers begin to overcome their fear of having home births throughout their pregnancies as they develop confidence in their bodies and in themselves with the help of birth attendants.

“They help you to listen to yourself, to know, to understand that the woman has the wisdom to give birth as something natural,” she says. “All women give birth, from all tribes, from all ethnicities, from all around the world. It is about once again finding that knowledge that we all have.”

Pucci says her experience delivering at a clinic would have been different if she had more knowledge of what was happening during each step of the process.

“It is important that they are informing you during the labor and during the birth what is happening and what they are going to do to you,” she says.

An Argentine law enacted in 2004 guarantees women the right to be informed about the medical procedures they undergo during labor and after delivery and to actively participate in decision-making.

Messina affirms that the staff in her hospital always keeps women informed.

“Obstetric violence is uninformed practices,” Messina says, “that the woman does not know what they are doing to her.”

The only way women can avoid being subjected to unnecessary invasive procedures is to be well-informed and decide for themselves which practices they are willing to undergo, Franzosi says.

“When they do not let you choose, nor inform you what it is they are doing to you, you are being a victim of violence – violence toward the woman and toward the baby,” she says.

But Pucci says that what she needs is something more subtle – an element of human warmth that the law cannot guarantee.

“If the midwife had only informed me more and had told me a phrase like, ‘Keep yourself calm that everything will come out fine,’ I would have felt better,” she says.

At the University of Buenos Aires’ school of medicine, the students – both doctors and midwives – swear at graduation to convey all the information they have learned to their patients, Saraceno says.

“In honor of that oath, one cannot sell that there is only one way of giving birth,” he says. “You have to show pregnant women all the options that they have, incorporate all of the views. Totally different people come to see me. And I have to be the most open possible, to respect all forms of life, the ideology, the culture of people, to empower the consultee so that they make the decisions.”

Those who attend to births in institutions and those who attend to home births should not present themselves as opponents, as if they were soccer teams, Saraceno says. This would enable women to choose with more liberty which type of delivery would better suit their needs.

“In conclusion, each person has to have all the necessary information in order to be able to choose the place where they want to give birth, and that in those places she is respected and the birth is respected,” he says.