Obstetric violence, the term that doctors resist that ended up falling from the abortion reform

It was one of the first intentions that announced the Ministry of Equality when proposing the then future reform of the abortion law. The department led by Irene Montero defended the inclusion of obstetric violence as a form of violence against women, but the standard you have approved this week the Council of Ministers has finally renounced the term. The bulk of the measures of the first drafts handled by the ministry are maintained, but there is no trace of these two words that have raised so much controversy and that the texts named up to seven times at the time.

It was one of the issues that from the beginning of the negotiations unleashed more dissent among the government partners. Finally, the chapter that initially referred to gynecological-obstetric violence has ended up being called "protection and guarantee of sexual and reproductive rights in the gynecological and obstetric field". Equality sources acknowledge that it is not the wording that they would have liked to appear, but they assume that they are "the small part" of the coalition and that neither the Ministry of Health nor the Ministry of Justice saw the term favorably. "The text is worked on and agreed upon between the ministries," they respond from Carolina Darias's portfolio.

The idea of ​​Equality was fundamentally to translate into law what some international organizations have been recognizing for some time, warning of its impact. World Health Organization speaks of "disrespectful, offensive or negligent treatment during childbirth" as a "violation of women's rights" and in 2019 the UN called obstetric violence a "widespread and systematic" phenomenon. A year later, the Committee for the Elimination of Discrimination against Women (CEDAW) condemned Spain for a case that occurred in 2009 in which it demanded that the administrations provide more training for professionals and data that would allow " make the situation visible.

Equality's announcement did not take long to arouse a wave of support, but also a strong opposition. The medical associations indicated in a statement that the term seems "particularly offensive" and that "it does not adjust to the reality of pregnancy, childbirth and postpartum care and criminalizes the actions of professionals." The Spanish Society of Gynecology and Obstetrics (SEGO) also took a position against the concept, which it described as "inappropriate, tendentious and unfair", although it did recognize that "it has made it possible to highlight the unpleasant experiences of many women and position it in public debate ", and assumed "that there is room for improvement" in the care scenario of "certain obstetric practices".

As the negotiation within the Government progressed, the public references of the Ministry of Equality to the matter ceased to be so forceful. Asked about it a little over a month ago, Minister Irene Montero He assured that the objective of the norm was "to promote that good practices" in gynecological consultations and in childbirth care "are the only practices" and affirmed that recognizing obstetric violence in the legislation "does not try to criminalize anyone", in clear reference to the opposition of the doctors. "For not naming it, it will not cease to exist," he added as a prelude to what he expected from the law.

In any case, the text to which the Government has given the green light, which has just started the process and can still be modified, has not ignored the reality that the term intends to name. In fact, the chapter dedicated to rights in the gynecological-obstetric field urges administrations to promote services based on free, prior and informed consent, in which interventionism tends to be reduced, avoiding "unnecessary or inappropriate" practices, provide "clear and sufficient" information to women and "guarantee" their non-"unnecessary" separation from their babies.

In practice, it contemplates the obligation to carry out studies and periodically collect data based on what happens in hospitals. The Sexual and Reproductive Health Strategy will have a specific chapter and the Interterritorial Health Council must approve a common protocol against obstetric violence ("to guarantee sexual and reproductive rights in the gynecological and obstetric field," reads the text). Communities will have to encourage hospitals to adopt specific protocols. "It is a historic advance" because "it expressly recognizes the need to establish public policies" that develop what the CEDAW recommended to Spain, assured the director of the Women's Institute, Toni Morillaswho has had a key role in the course of the standard.

That the concept has finally been left out of the text provokes reactions of all kinds. "As much as we want to close our eyes, it exists, and it is not something that we have invented. In fact, measures are going to be implemented in this sense and with the aim of eradicating it, but the fact that the term is not there makes it difficult to adopt an awareness full of what is happening," says Cristina Franco, secretary of the Federation of Midwives' Associations of Spain, who emphasizes that, even so, the document shows "the intention to improve all these processes."

For Virginia Murialdo, anthropologist and activist of El Parto es Nuestro, the resignation is "important" because the term "expresses that it is a systemic and structural problem, as the UN says, and they are not isolated cases." Among the testimonies received by the association are "unjustified practices without consent or prior information" such as episiotomies, the excessive administration of drugs or the so-called Kristeller maneuver, discouraged by the WHO. But also "humiliating" attitudes and comments or "actions that do not respect the privacy of women," she explains.

"The term has focused a lot on specific types of practices, but deep down there is a reality that goes much further and has to do with the fact that the experience is not well cared for. We are talking about women whose express consent is not requested. for certain actions and very fixed systems that do not allow them to carry out the process as they would like or infantilize them when making decisions. All this causes them to feel violated during their obstetric process," Franco summarizes.

The gynecologist Isabel Serrano considers that it is good news that the concept has finally disappeared because she considers that talking about obstetric violence and, above all, generalizing it "can cause more problems than we want to avoid, such as mistrust of health professionals." The expert emphasizes that the sector has made a "great effort" in recent years that "has translated into tangible progress".

Beatriz Juliá agrees with her, a gynecologist at the Severo Ochoa University Hospital in Leganés, who celebrates the reform of the abortion law, but disagrees with Igualdad on this point: "Violence implicitly carries an intention to harm," she laments. The expert refers to the delicate nature of the gynecological field, where "excellent results are required" and professionals "cannot have to act in even urgent situations, fearful of being accused of obstetric violence for practices such as performing an episiotomy," she says.

Juliá also points to "the day-to-day care load" that on many occasions "does not allow us to make the explanations as extensive as we would like." For his part, Serrano acknowledges, even so, that sometimes women "are treated inadequately" and "we have to work so that it does not happen", but considers that "it is not the majority" and limits it to cases of malpractice , but not to obstetric violence.

They are not two equivalent realities for the gynecologist Miriam Al Adib, author of several books, including Let's talk about us. "There are cases in which a medical error occurs and there are births that can be traumatic because they are complicated, but in others it is that a dehumanized treatment has been given in which women are a passive subject," says the expert, who claims self-criticism and considers that the term "does not mean that we professionals are violent", but that "socially and medically this paradigm still exists that we must improve".

In fact, he considers that the progress of recent years has been produced precisely thanks to the recognition of what is wrong. "Two decades ago things were done that would be unthinkable. Unnecessary separations of mothers and babies, for example, were systematic after a cesarean section and the woman could be perfectly fine until the next day without seeing him. And so on. If we have taken steps very positive is because we have been able to point out and identify certain practices that were considered normal," adds Al Adib.

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