By Jill Arnold
In recent years, a variety of organizations, coalitions and advocacy groups in Latin American countries spanning from Mexico to Argentina have worked to confront the rampant overuse of unnecessary and unwanted obstetric interventions while improving labor conditions and accessibility.
In an editorial published online in the October 2010 edition of the International Journal of Gynecology and Obstetrics, Dr. Rogelio Pérez D’Gregorio, President of the Society of Obstetrics and Gynecology of Venezuela, described the specific mentions of the term as it appears in the Organic Law on the Right of Women to Be Free from Violence, enacted in Venezuela on March 16, 2007.
The law defines obstetric violence as: “…the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert [sic] the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.”
Venezuela has few remaining traditional birth attendants or midwives, and women are faced with 80% cesarean rates in private clinics or 30% in public hospitals. For women who are permitted to give birth vaginally, the routine use of a forced lithotomy position and episiotomy subjects them to obstetric violence, which the aforementioned law defines as:
(1) Untimely and ineffective attention of obstetric emergencies; (2) Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available; (3) Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breast-feeding immediately after birth; (4) Altering the natural process of low-risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman; (5) Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman.”
According to Pérez D’Gregorio the lack of experience with vertical birth leads instructors at the medical schools of the nine national universities to teach the supine position for vaginal birth, and “[i]n order to offer this type of delivery technique it would be necessary to train the teachers in this procedure so that they can correctly teach the students.”
El Parto Vertical
In Peru, the Sociedad Peruana de Estimulacion Prenatal y Postnatal (SPEPP) campaigns for the end of a forced lithotomy position and denial of appropriate labor support to women in Peruvian hospitals. For SPEPP, allowing women to labor in the position of their choice is a human rights issue. Encouraging or forcing a woman to assume a supine position for no reason other than to facilitate the birth process for the doctor is seen as robbing a woman of her dignity and autonomy. Their Facebook page, A FAVOR DEL PARTO HUMANIZADO!! – PARTO VERTICAL!!, boasts 2,254 members as of November 28, 2010
Translation: This is slow and uncomfortable. Let her decide how to give birth.
It’s YOUR birth. Respect the basic laws of human birth. (Image credit)
The demand for vertical births is growing in neighboring Ecuador. Originally designed to encourage indigenous women to give birth in hospitals by providing culturally appropriate care, Hospital San Luis de Otalavo’s vertical birth services were initially utilized 95 % of the time by indigenous patients. Nearly one year later, the ratio is 56 % indigenous women to 44 % mestiza (mixed race) women. Obstetrician Pedro Luna told womensenews.org that “[h]orizontal birth is an occidental practice brought by the conquistadors with zero medical logic.”
Hospital San Luis de Otalavo’s commitment to an “intercultural maternity ward” in which a woman will be supported in any position in which she births is not typical of the rest of Ecuador, where the cesarean rate has skyrocketed to 40 %.
In Ecuador, indigenous women are often reluctant to use a hospital and feel violated by the hospital birth process. This partial transcript of a video by UN in Action explains the public health challenge.
For indigenous peoples, giving birth is a private and intimate family ritual. Midwives and family members are always there to give support and comfort. Modern medicine is not only unfamiliar but also frightening.
When women arrive in hospitals, they have to go through a practice that is completely different from their culture.
Lily Rodriguez is the deputy representative of UNFPA in Ecuador.
They are in an unfamiliar environment, and in a language they do not understand, and that’s why they resist going to the hospital.
DR. ALFREDO AMORES
I asked a young mother: “Why don’t you go to the hospital?” And she said, “Because we are violated.”
Dr. Alfredo Amores, director of the Orellana Provincial Health Department, says women are wary of Western medical doctors.
DR. ALFREDO AMORES
If they open your legs and put their hands inside you without asking, what do you make of that? For an indigenous woman, this is tremendously offensive.
In Mexico, some government officials have expressed concern over the same type of cultural insensitivity and disrespect described by Dr. Amores. The former director of the Instituto Veracruzano de las Mujeres, Marta Mendoza Parissi calls for an end to obstetric violence in Mexico in this 2010 interview, stating that failure to respect the customs and traditions of indigenous women to give birth in a vertical or squatting position is in violation of the 2007 General Law on Women’s Access to a Life Free of Violence (Spanish).
The Mexican Secretaría de Salud (Department of Health) created a department in 2002 to shift existing paradigms in health care with regards to traditional medicine, particularly among Mexico’s diverse mestizo and indigenous populations. The department’s director, Alejandro Almaguer González, was quoted in June 2010 touting the benefits of vertical birth and praising a vertical midwifery practice in Coetzala, Puebla, which won a quality award in 2007 for its zero maternal mortality rate. Almaguer González claims that vertical birth in hospitals could help reduce maternal mortality, as 80 % of maternal deaths occur in indigenous and rural populations, often as a result of resistance to medical care.
Whether established as an option to provide indigenous women with culturally sensitive options in a hospital or because coerced positions for perceived obstetric benefit is considered to be an act of violence against women, “parto vertical” has become a rallying cry in recent years in two hemispheres.
The official manual for vertical birth issued by the government of Peru quotes the Pan American Health Organization’s definition of “interculturalidad,” which translates as:
Interculturalism means a relationship between several different cultures which is built on respect and horizontality, i.e., neither is above or below any other. In this intercultural relationship, we want to encourage mutual understanding from people of different cultures, understanding how they perceive reality and the world, thus creating an opening for listening and mutual enrichment. Interculturalism is based on dialogue, where both parties are heard, where both parties speak and each takes what can be taken from the other, or simply respects their uniqueness and individuality. The goal is not to impose or to subjugate, but to harmonize…”
Recognition is due the individual birth attendants in hospitals who find a way to accommodate women giving birth upright in a lithotomy monoculture. Providing individualized care to each patient is a form of cultural sensitivity that involves communication and understanding of each woman’s preferences, should it be to stay in bed, to squat, to stand or for no vaginal birth at all. Catching babies in the position of the woman’s choosing rather than forcing her into a supine position to give birth demonstrates a fundamental respect for a woman’s autonomy.
A heavily edited version of this original post is featured on the Mother’s Advocate blog beginning December 6, 2010.