how an authoritarian system allows obstetric violence

On August 12, 2015, at two o’clock in the afternoon, Paloma López called the ambulance that would take her to the Ramón González Coro, a gynecology and obstetric hospital in Havana. She had started her labor at home since the morning because she had heard other mothers say that they were treated poorly in the hospital.
It arrived with six centimeters of dilation, but without breaking source. “They took me to the stretcher to monitor me, they got me up, they took me to the weird room, then without telling me anything (the doctor) takes out a skewer and pa!, I put the skewer and it hurt. And I with the scream, but what is that! And it was to break the source.”
The obstetrician threw herself with all her weight on Paloma’s belly and with her forearm tried to press on the uterus and push the baby down. From the fright, Paloma slapped the doctor. This, as she was leaning on her and practically had her feet in the air, fell to the ground, sitting.

“Look at the slut this one, she doesn’t want to be helped!” He’s going to kill the little girl,” says Paloma, who was screaming.
“Doctor, don’t tell me that, you have to ask permission.
“No, you don’t know anything.

The doctor tried several times to apply the maneuver. Paloma reacted in the same way, pushing her, until, containing the pain, she allowed the obstetrician to climb on her belly. “They pulled me, I felt my little girl’s tear, how they took her out,” she says. Now I know that was ahead of time, that it wasn’t organic. And the girl made me tremendously cracked down there.
Read: Midwifery, a way out of obstetric violence in Mexico
A global and Cuban problem
In the last two years, a growing number of Cuban mothers have shared their birth experiences on social networks and independent media; which has unleashed an obstetric #MeToo on the island.
Some mothers have reported feeling verbally or psychologically abused. Others said they were denied information about what was happening to them or were never asked for consent to perform certain interventions. Many described their childbirth as a traumatic event in which they were treated as beings without autonomy whose well-being is unimportant.
For some, the problem was that they suffered over-medicalization or aggressive practices. One of them is Kristeller’s maneuver, which puts pressure on the ribs and has been questioned by the WHO since 1996.
Another is episiotomy, a cut in the perineum, between the vagina and anus, to facilitate childbirth and which is often performed without consent and/or unnecessarily.
Other patients said they felt abandoned or ignored.
The testimonies have contributed to making visible a problem that exists in most countries of the world, but that in Cuba had remained especially invisible and naturalized: obstetric violence.
The present research, Broken Births, shows that this is a systematic problem in the country. Nearly 500 women from all provinces participated in the study. They filled out a questionnaire asking how their birth went. In total, detailed information was collected from 514 births, by caesarean section or vaginal birth, mostly occurring in the last two decades.
The research is not based on a representative sample and its results have no statistical validity, but it is broad enough to offer an overview of how obstetric violence manifests itself in the country.
Interviewees described a health system in which their requests for pain treatment are ignored (86%) and in which aggressive procedures are still common that in other countries are no longer performed systematically. In almost half of the births, manual dilation or tourniquet was practiced, and in somewhat similar the Kristeller maneuver. Episiotomy was applied in three-quarters of the cases.
Interviewees also showed that lack of consent and ill-treatment are common. Nearly half said medical staff acted without seeking their consent, violating patients’ human rights, according to the United Nations Special Rapporteur on violence against women.
In addition, in 41% of the cases the mothers said they had suffered verbal or psychological violence. Medical staff ignored them when they made any requests or accused them of putting their babies’ lives at risk.
Cuba is not the only country where these and other medical practices that violate women are still common. It is a global phenomenon, related to machismo and patriarchal culture that crosses health systems, and that has been made visible by feminism.
According to Eva Margarita García, PhD in Anthropology and author of the first thesis on obstetric violence in Europe, obstetric violence is theto the sum of gender violence and medical malpractice. She defines it as that violence exerted by health personnel on women’s bodies and their reproductive life through dehumanized treatment, an abuse of medicalization and a pathologization of physiological processes.
For the expert, this violence is mediated by a gender bias that infantilizes women as an excuse to treat them in a vexatious way. However, it is such a socially normalized practice that it is difficult to identify it as a problem.
However, in Cuba there are circumstances that contribute to this problem being particularly acute. According to health professionals interviewed for this research, the Cuban health system is a vertical organization in which doctors have little room to introduce reforms.
They receive strong pressures to maintain certain statistical indicators, especially with regard to infant mortality, and have little incentive to improve the quality of care or think about the well-being of mothers. In addition, in a country that is considered a medical power and is governed in an authoritarian manner, the possibilities of recognizing and addressing the problem are smaller than in other countries.

Sexist stereotypes
For this report, eight medical specialists – four women and four men – who are or have been part of the Maternal and Child Care Program (PAMI), a program that centralizes the reproductive health of women in the country, were interviewed. Of those, six are active. All preferred to remain anonymous for fear of reprisals such as losing their jobs or being expelled from the Ministry of Public Health (Minsap).
Several noted that gender stereotypes persist in the medical system in Cuba that influence the treatment of women in childbirth. For example, a comprehensive general practitioner with decades of experience in the central part of the country justified several practices of obstetric violence “especially in women with delayed labor or in women who are ñoñas or majaderas.”
There is also a tendency to see women in childbirth as ignorant and/or passive. Informing, asking for consent, allowing accompaniment or simply walking during labor is seen as an obstacle to the work of professionals. As interviewees show, they are not common practices. “Priority is given to the baby, care for the newborn and that the mother does not bleed, but they forget to be psychosocial,” says a resident of gynecology and obstetrics in Holguín.
It also happens that some obstetricians believe that childbirth is always painful and alleviating suffering is not a priority. In addition, patients who request cesarean section are seen as looking for “comfort” and choose to “force” them into vaginal delivery.
The expectation that women should obey medical instructions without protest is common among health personnel. This idea is so ingrained that women themselves have learned to recommend to each other that it is better to “collaborate” or “behave well” – expressions mentioned repeatedly in the questionnaires – to avoid worsening the abuse.
For Sandra Heidl, a psychologist and feminist activist who gave birth in Cuba when she was 19 years old, in the Cuban public health system “the product, the fetus, is the most important thing” and the woman takes a back seat as a container of the product. “Women accept or are not aware of this violence because they want the best for the unborn child, and they have been told that doctors have to decide for the sake of their babies,” says Heidl.
This subordination of patient to doctor is one of the features of what is known as the Hegemonic Medical Model (MMH). Dr. Daylis García Jordá, author of one of the few studies on obstetric violence in Cuba, believes that the MMH tends to see the patient as ignorant or carrier of wrong ideas, while knowledge resides solely in the doctor. Despite the criticisms that have been raised, says García Jordá, this model continues to be valid and generates a birth experience in which what matters is the doctor, not the patient.
Health systems in many countries are designed according to the needs of doctors, according to Drs. Matthias Sachsee, a German specialist in health care quality with experience in Mexico, and Thaís Brandao, a Brazilian researcher on sexual and reproductive health.
Cuban medical professionals commented that some violent practices are carried out for the convenience of doctors, such as the indiscriminate use of episiotomy. “It’s the easy way to do the delivery for the doctor, to finish quickly because they want to finish,” says a resident of Ginecología and Obstetrics of Holguín.
Other common practices such as preventing the pregnant woman from walking, being accompanied, performing enemas or administering antibiotics preventively are also related to the needs of the system or the preferences of doctors, but not to the needs of women.
For all these reasons, researcher Brandao insists that obstetric violence has “institutional roots” and that its main cause is the lack of will of the health system to address the problem. In his view, obstetric violence is not related to a lack of resources.
“You can promote healthy, nonviolent births even without resources, because you understand (as a government or system) that that’s what’s important,” brandao says.
You may be interested: 1 in 3 women suffer abuse in childbirth; Mexico exceeds the level of cesarean sections recommended by the WHO
A unique birth
Since 1975, almost 100% of births in Cuba have occurred in public hospitals. Unlike pregnant women from other countries, Cuban women have no choice about where or how to give birth. They must do so in the only existing system controlled by Minsap. Thus, the norms, priorities and shortcomings of Minsap shape the experience of giving birth in Cuba.
The institution has shown that its main objective is to keep certain indicators low, especially infant mortality: the number of children who die during or shortly after childbirth.
This is the rate that each year the authorities proudly present as an indicator of the success of their childbirth care system. “It’s the ministry’s best-kept statistic,” said one of the doctors interviewed.
“In Cuba, the system is structured in a way that responds more to numerical parameters and works in response to the needs of professionals or Public Health as an entity, and not of women and their families at the moment they bring a new life to this world,” says the academic García Jordá in her study.
The professionals consulted agreed that they receive pressure from Minsap to achieve good statistics. They must always adhere to strict protocols, which discourages them from introducing changes or acting at their own discretion. It is also common for them to have to meet quotas, for example, on the maximum number of caesarean sections they can practice.
Many doctors criticize the pressure to which they are subjected and some feel that the rigidity of the protocols makes them mere executors of policies designed by bureaucrats who do not know the reality in which they work.
“It cannot be that a program where human management intervenes is based on indices and parameters to be met. The doctor cannot be thinking about numbers, or figures, or emulations because it is the life of a patient. So, you work under a lot of pressure,” says a retired obstetrician with more than 20 years of experience.
A newly graduated doctor agrees. “For me, (gyneco-obstetrics) is one of the specialties where more care has to be taken, because you take heads at the moment for anything.”
For the authorities, the system works since they get the statistics they are looking for. Fewer mothers and babies die in Cuba than in most countries in the region, allowing the government to boast about its system. Infant mortality is very similar to that of countries such as the United States and maternal mortality, although it is much higher than that of the countries of the global north, is among the lowest in Latin America.
However, no statistics account for obstetric violence and the absence of humanized childbirth. Despite the abundance of Minsap protocols, the professionals consulted agreed that the principles of humanized childbirth, which are beginning to be applied in some countries, are little known in Cuba.
“If you refer to international bibliography you know it, but there is not a part of the practical course that they tell you about this. It is not an issue that is even debated,” says a resident of gynecology and obstetrics in Holguín.
The World Health Organization (WHO) established in 2018 a series of recommendations for driving labor. The first thing that is recognized is that childbirth cannot be subject to strict protocols that are applied by system, as is the case in Cuba, but must be based on the state of the woman and the baby, “their desires and preferences, and respect for their dignity and autonomy.”
WHO recommends encouraging pregnant women to move and give birth upright. It also suggests that they be allowed to be accompanied and even that they be able to eat or drink during labour; not to separate babies from mothers right after birth; not to apply techniques that artificially speed up times; limit vaginal touches to one every four hours; and not to practice episiotomy if it is not strictly necessary.
These recommendations nor they are only respectful of women’s rights but also positive from a medical point of view. Multiple studies have shown that the more comfortable and accompanied pregnant women feel, the greater the probability that vaginal delivery will be successful and more aggressive techniques should not be used.
But in Cuba, questionnaires and interviews with professionals show that these recommendations are ignored.

Nothing warm or human
Many women described giving birth in an environment devoid of empathy, warmth or humane treatment. Others directly reported receiving ill-treatment, coercion, and verbal violence. Minsap professionals deprived them of the moment they wanted to have when their children were born. This contributed to childbirth becoming a source of trauma.
Many interviewees claimed to have experienced psychological sequelae after childbirth. In 30% of births, women were afraid of becoming pregnant again, or reported having repetitive images of moments of childbirth. In one in four births, women said they experienced mood swings, difficulty sleeping or fear of facing the health system.
In addition, in 14% of births, women reported having suffered postpartum depression.
“You will almost never see reflected (these sequelae) as a diagnosis in the medical records,” explains one of the professionals consulted. These patients are almost never referred to mental health services for treatment, which ends up affecting the physical health and quality of life of patients and families.”
The verbal or psychological violence, the lack of empathy or the feeling of abandonment that the women described in the questionnaires have profound causes, related to the macho culture and the Hegemonic Medical Model. The verticality of the Cuban health system worsens this context, according to the doctors consulted.
Several professionals admitted that they often pass on to women the pressures and shortages they suffer, something that has intensified as the country’s medical services have been degraded by the lack of personnel and resources.
Currently, medical personnel in Cuba earn, at the official exchange rate, between 190 and 320 dollars a month. To survive, some of them accept gifts or money from patients and usually reserve the best treatment and the few materials available for “their” cases.
“Obstetrics and gynecology is one of the specialties that lives the most from that. If you don’t have your doctor and you don’t go through the gutter, as they say on the street, you’re very fucked up,” says a recently graduated doctor from her own experience as a mother.
Despite the abundance of health professionals in the country, interviewees described increasingly intense work schedules and shifts due to the lack of personnel. After shifts of three or four consecutive days on call, it is common for PAMI staff to have to work in health centers or make home visits.
At the same time, the demands of meeting statistical targets do not slacken. “We have to exhibit results at the height of countries that have services with all the conditions,” says a doctor interviewed for the thesis of Lareisy Borges Damas, a doctor in Nursing, who has researched the models of humanized childbirth.
With this panorama, several professionals claimed to have lost motivation, which is harming the quality of the care they provide.
In the words of a gynecology and obstetrics resident from Holguín, “nobody wants to work here. Then they let these violences pass as long as they do not affect the statistics. There may be abuse as long as the surrogate or baby does not die. That’s pretty much how it works.”
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Original source in Spanish

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