Debates on Childbirth Care and Obstetric Violence. The Case of the Professional Practice of Obstetrics in Argentina

Keywords

• Sexual and reproductive rights • Obstetric violence • Hegemonic medical model

Introduction

It is key to study the models of health care present in society and the disputes related to them, since this allows the revelation of power relations, dominance, and exclusion that influence the exercise of (non-)reproductive and sexual rights of care seekers. The complexity of this matter demands an interdisciplinary approach, as multiple variables interrelate when conceptualizing and analyzing the political, cultural, and technical realities of health and well-being issues from a human’s rights perspective. This research aims to contribute, from the field of Political Science, by observing tensions, disputes, and negotiations in processes that unfold in the public sphere.

According to Fraser (1999), to analyze the public sphere it is necessary to distinguish: a) market logics, b) state management logics, and c) the public sphere of civic association. This conceptual frame that the author proposes allows us to recognize the existence of subaltern counterpublics that highlight inequalities that continue to operate despite the absence of formal exclusions and the existence of legal equality. Subaltern counterpublics are “parallel discursive arenas where members of subordinated social groups invent and circulate counterdiscourses, which in turn permit them to formulate oppositional interpretations of their identities, interests, and needs” (Fraser, 1999), and they emerge as a response to exclusions from dominant publics. Publics are characterized as weak or strong depending on whether they can convert their demands into legally binding decisions, meaning they do not just form public opinion but also become part of the deliberation process through an interaction with the state and decision-making spheres. Analyzing the public sphere and the publics that comprise it, therefore, contributes to an analysis of the political construction of reality, levels of participation in it, and the limitations of democratic practice, as well as the emancipatory potentials of counter-hegemonic practices that battle against the established order.

This research work focuses in childbirth care as it allows us to observe tensions that arise in parliamentary debates and social movements related to the professional practice of obstetricians. This includes the multiple forms of obstetric violence, which must be avoided to fully guarantee the rights of pregnant people, their freedom, and their sexual and reproductive enjoyment. Social movements and professional organizations express the need to consider caregiving as a fundamental task of our societies, and decisions related to health and well-being as human rights. In contrast, notions of health and sanitation compete for decision-making spaces in favor of technical knowledge that is presented as superior and absolute, attempting to depoliticize the debate by dragging it into the realm of the private and restricting it to the field of specialists (Brown, 2011).

The development of the article will consist of four sections. First, a historical overview of childbirth care in Argentina will be provided, with the aim of highlighting the socially constructed nature of the prevailing orders presented as absolute and neutral. Second, a description of the debates surrounding (non-)reproductive and sexual rights and the existing regulations that support them will be provided. Third, an analysis of the tensions present in the debates related to the professional practice of obstetrics, in which demands and interests intersect between: a) women’s movements, b) obstetric organizations, and c) the medical corporation. Lastly, the article will present final considerations related to the observed and analyzed issues, as well as possible lines of continued research that contribute to addressing the power relations present when seeking care for well-being and health in a society with scientistic, capitalist, and patriarchal logics.

Childbirth and Births in Retrospect

With the consolidation of the Argentinian state and in line with processes initiated during the colonial period, the care of childbirth and births by midwives in homes was shifted to hospitals with medical teams in charge (Nari, 2004; Barrancos, 2014; Romero, 2018). The institutionalization of the medical corporation, characterized by its technical and formal education, positioned other forms of knowledge as subordinate and strengthened medical intervention in childbirth and births. Obstetrics was established as a reformulation of existing practices under the name of a new specialty that would allow medical intervention in biological reproduction.

Midwifery underwent a process of stigmatization, as it was considered “witchcraft,” “obscurantist,” and associated with ignorant practical knowledge. Women’s participation in childbirth and birth care was reduced to being subordinate and only in cases considered normal, as long as they were also certified by institutions controlled by doctors. As a result, the professionalization of midwives required them to abandon their old midwifery practices and adhere to medical standards (Nari, 2004; Barrancos, 2014). This process unfolded locally but was driven by transformations in Western capitalist societies. Foreign professionals from academia and public administration constructed motherhood from a perspective that advocated for the medicalization of reproduction. The medical corporation and health institutions accumulated capital, prestige, and power, granting them exclusivity in political and legal decisions related to health, while also excluding and persecuting uncertified healers.

Current demands for respectful childbirth are related to this process since the imposition of the hegemonic medical model for childbirth care neglects social, cultural, psychological, emotional, and spiritual issues. In many cases, medical teams exercise control mechanisms that homogenize the person, stripping them of their needs, opinions, and particular choices, and carry out standardized, mechanized, and impersonal procedures that hinder the expression of the pregnant person. This not only pathologizes childbirth, which is addressed primarily from its physiological variables while neglecting emotional ones, but it also contributes to an increase in procedures that are considered obstetric violence, making it invisible and justifying it as “necessary” for procedural safety. Childbirth as a sanitary-hospital event is constructed based on technical notions that establish a certain superiority of the professional over the person giving birth and over other occupations that may provide alternative and/or complementary knowledge (Lorenzo, 2013; Castrillo, 2015; Vetere, 2006).

Critical perspectives that revalue the importance of comprehensive and holistic childbirth care argue that a dependency on technology and medicine has been constructed for pregnant people, which is not necessarily justified by biological capacities but rather by a social system that favors this situation. The flip side of this process is the weakening of the pregnant person as a decision-making subject and the disqualification of the same regarding essential variables related to relaxation, comfort, and emotionality (Odent, 1992, 2006; Davis-Floyd, 2011; Rodrigañez Bustos, 2007).

(Non-) Reproductive and Sexual Rights

With the return to democracy in Argentina in the 1980s, demands for (non-) reproductive and sexual rights were strengthened as a belated echo of the second wave of feminism in central countries, which called for women’s self-determination over their own bodies (Brown, 2007). It was during this historical context that the notion of reproductive health was consolidated, particularly through two international conferences: Cairo, 1994, and Beijing, 1995.

(Non-)reproductive and sexual rights emerged as a result of women’s movements and their historical demands, and as such they include three aspects: a) security and autonomy in decision-making regarding reproduction (pregnancy, childbirth, and postpartum), b) contraception and abortion, that is, the free decision regarding family planning, and c) the free exercise of sexuality without violence or discrimination. From Brown’s (2007) point of view, the inclusion of contraception and abortion is fundamental, which is why the notion of non-reproductive rights is included in this paper.

It is important to consider a series of regulations in Argentina that establish relevant rights in relation to health care. First, the National Patient Law No. 6.529, which reformulates the traditional model of the superiority of the medical professional over the patient, represents a paradigm shift by giving importance to the right to decision-making autonomy, that is, the explicit consent granted based on clear and accessible information provided by the professional.

Second, related to childbirth care specifically, it is important to consider the National Law No. 26.485 on integral protection to prevent, sanction, and eradicate violence against women. In it, violence against women is defined as:

any conduct, action, or omission that, directly or indirectly, in both the public and private spheres, based on an unequal power relationship, affects her life, liberty, dignity, physical, psychological, sexual, economic, or patrimonial integrity, as well as her personal security. This includes those perpetrated by the State or its agents. Indirect violence, for the purposes of this law, is considered to be any conduct, action, omission, disposition, criterion, or discriminatory practice that puts a woman at a disadvantage compared to a man (National Law No. 26.485, 2009).

In turn, Law 26.485 classifies obstetric violence as one of the forms of violence against women, defined as “that which is exercised by healthcare personnel on women’s bodies and reproductive processes, expressed in dehumanizing treatment, abuse of medicalization, and pathologization of natural processes, in accordance with Law 25.929” (National Law No. 26.485, 2009). The regulation of Law 26.485 in 2010 describes dehumanizing treatment as that which is characterized by being cruel, disqualifying, or threatening and is exercised by healthcare personnel in the context of pregnancy, childbirth, and abortion care.

In 2004, the National Law No. 25.929 was enacted, known informally as the “Law of Humanized Birth,” officially named Law of the Rights of Parents and the Newborn. It applies to both public and private health systems and outlines the rights of women in relation to pregnancy, labor, childbirth, and postpartum. 

Based on the aforementioned regulations, the fundamental right to access information about the ways in which pregnancy and childbirth progress, and the possibility of making decisions in light of existing alternatives, is consolidated. The emergence of the notion of humanized birth involved the enunciation by civil society of situations considered violent, which were naturalized and normalized and required greater protagonism of the pregnant person to avoid them.

The various forms of oppression manifested in the field of health must be thought of from a rights-based approach, which implies defining it as a legitimate issue of public debate. In the face of this, it is also necessary to elucidate historically constructed structures that position expert knowledge as dominant, against which it is necessary to denounce forms of violence and combine them with practical, experiential, and situated knowledge.

Debates Related to the Professional Practice of Obstetrics

Currently, the role of obstetrics is under dispute in Argentina, a situation that reveals power relations linked to the medical corporation, the hegemonic medical model, and the (non-)reproductive and sexual rights of pregnant people. Obstetrics is regulated as an auxiliary activity of medicine according to the Law 17.132 on the Practice of Medicine, Dentistry, and Auxiliary Activities, which characterizes it as:

 “An auxiliary activity of Medicine or Dentistry; the activity of those who collaborate with the responsible professionals in the care and/or rehabilitation of sick people or in the preservation or conservation of the health of healthy people, within the limits established by this law” (Law 17.132, 1967).

The Law 17.132 establishes in the Article 49:

The practice of obstetrics is reserved for persons of the female sex who possess a university degree in obstetrics or midwifery, under the conditions established in Article 44.” In Article 50, it states that they may not provide care to people with pathological pregnancies, childbirths, or postpartum conditions, and in Article 51, it mentions that “Obstetricians or midwives may provide care in official or private healthcare institutions, in the patient’s home, or in their private office, under the conditions that are regulated”.

Since 2008, bills have been promoted in Argentina with the aim of modifying this situation and granting due recognition to the professional practice of obstetrics, supported by FORA, Federation of Obstetricians of the Argentine Republic. FORA is composed of the College of Obstetricians of the Province of Misiones, College of Obstetricians of the Province of Santa Fe, College of Obstetricians of Entre Ríos (CODER), Obstetric Society of Chaco (SOCH), Association of Municipal Obstetricians (ADOM), Obstetric College of Catamarca, Obstetric Society of Mendoza (SOM), College of Obstetricians of Santiago del Estero, Obstetric Society of Formosa, and Civil Association of United Obstetricians of Tucumán (ACOUTUC). Additionally, in 2018, the collective “Nosotras parimos, nosotras decidimos” (We Give Birth, We Decide) was created, which states on its Facebook page:

From the ‘We Give Birth, We Decide’ campaign, we demand that the freedom to decide what happens in the body of each woman, pregnant person, is guaranteed. Women, as protagonists, have a lot to say, in fact, we have the final word, because what is at stake here is the exercise of our autonomy and sovereignty and full access to our rights (Nosotras parimos, nosotras decidimos, 2019).

The medical corporation’s attempt to maintain certain competencies as exclusive is in tension not only with the demand for professional hierarchization of obstetricians but also with women’s movement organizations that demand the autonomy to decide how they want to experience childbirth.

In 2019, the Chamber of Deputies in the National Congress passed a national bill project (half sanction) related to the Obstetrics professional exercise. This meant to repeal the articles related to the professional practice of obstetrics in Law 17.132 and create a national legal framework. However, there is a structural difficulty in generating regulations for professional hierarchization in the field of health, which is linked to a position of superiority of medical teams over their “auxiliaries.”

In the session of the Chamber of Deputies of the Nation where the bill was voted on, the speeches of the deputies expressed diverse positions on the issue. 

Throughout the parliamentary session, it is possible to recognize speeches that consider midwifery as something “of the old days,” as expressed by Deputy Amadeo in his speech: “the old midwife who brought many of us into the world is now a trained and prepared professional, as the World Health Organization says” (DS, 29-04-2019: 150-152). In line with the historical stigmatization of midwives’ knowledge, Deputy Franco stated:

I can tell you an anecdote from the early days of my professional career: in the same hospital, there were people who were empirically trained to attend childbirths, who were even chosen by women over some doctors. In my town, there was a ‘grandmother’ –that’s what they called the lady who attended births empirically– named Rita, who attended all the births, so much so that the town named a street after her. She attended several generations. You see, I had to teach her how to use gloves and how to wash her hands, and I’m not even that old (DS, 29-04-2019: 155-156).

Regarding the medical corporation, it is important to note that it manifested itself widely and explicitly against the bill. This is framed in a context where, according to Ramaciotti & Martin (2016), it is necessary to analyze the role of “assistance” work in the health system, mostly undertaken by women, and which has been subordinated to doctors based on a “social system supported by male domination over women and a masculinized scheme of scientificity” (Ramaciotti & Martin, 2016). Feminized occupations, generally related to caregiving, are presented with a certain subalternity and devaluation, as they are considered an innate task of women. Healthcare workers such as nurses had to engage in struggles to obtain due professional and labor recognition, still in dispute with the competencies of doctors who seek to maintain their authority and not concede competencies.

Among the medical organizations that opposed the bill, we can mention the Society of Gynecology and Obstetrics of Tucumán and the Medical College of Jujuy; the ‘Medical College in Defense of Doctors’ Rights’; the Forum of Medical Entities of Northwestern Argentina; and the AMAP, Association of Private Practice Doctors. These organizations declared that the bill implied an assault on the responsibilities of medicine (Obelar, 2019) and a transfer of medical acts to other professionals traditionally defined as collaborators (Japas & Garín, 2019), and they even argued:

We also do not agree with the verbal arguments presented by some legislators that the activity of obstetricians can reduce the medicalization of pregnant women, as there is no evidence that pregnant women are being overmedicated, or that this law favors the female gender: today, most young students and doctors are female, and it would be a serious mistake to confuse a gender issue with a Public Health Policy (Japas & Garín, 2019).

In turn, the Society of Obstetrics and Gynecology of Buenos Aires (SOGIBA) expressed its opposition to the bill, stating: “We believe that this bill requires clarification of the scope of the Obstetric Vademecum and, in particular, home care. Our society’s opposition to non-institutional births has already been established” (SOGIBA, 2019). In response to SOGIBA’s position, the College of Obstetricians of the Province of Buenos Aires (COPBA) issued a statement in agreement with the UBA Bachelor’s Degree in Obstetrics; FORA; the National Directorate of Maternity, Childhood, and Adolescence; AAPI; and the Association of Municipal Obstetricians of C.A.B.A., in which they confirmed “the NON-attendance of licensed obstetricians to the Congress organized by the Society of Obstetrics and Gynecology of the Province of Buenos Aires” (COPBA, 2019).

The medical corporation manifests a denial of the excessive medicalization of pregnant women and a resistance to the authorization of home births. This demonstrates a stance defending the hegemonic medical model and an authoritarian position regarding issues related to health. Not only are social demands disregarded, positioning the issue as a technical-sanitary matter that shall not be subject to public debate, but it is also argued that gender issues should not be confused with public policy issues. In this sense, sanitary arguments hinder the politicization of health-related issues, which harms the guarantee of (non-)reproductive and sexual rights. The tensions related to the professional practice of obstetrics reveal, on the one hand, a) the continued power of medical corporations as absolute and exclusive authority on health matters, and b) the depoliticization of the issue as a strategy to reproduce such a power situation.

Since the introduction of the mentioned national bill projects, and after the loss of parliamentary status by not being treated in the Senate, various bills have been introduced at the provincial level. This demonstrates that the struggle was redirected and decentralized to another jurisdictional level: the provincial level. Nine provinces have passed laws related to the professional practice of obstetrics:

Table 1. Laws on the Professional Practice of Obstetrics Updated at the Provincial Level

Source: Own elaboration.

Also, bill projects were introduced in the Congress of Santa Fe (Expte 39651 presented in 2020) and Corrientes (Expte.14845 presented in 2020), which apparently were not addressed or passed.

After the pandemic period and a restructuring of organizations in response to childbirth care in the context of mandatory preventive isolation, the efforts were renewed in 2022. Deputy Macha introduced a new bill on the professional practice of obstetrics, renewing collective demands for a regulatory framework that supports the profession at the national level. In this case, the right to home births and the need for regulations that favor care by obstetricians were more strongly emphasized. The bill was supported by a letter sent to the Honorable Congress of the Nation by the College of Obstetricians of the Province of Buenos Aires.

In 2022, a study entitled “Strengthening the Competencies and Functions of Obstetricians in Argentina: A Strategic Issue” was also published by the Center for the Study of State and Society (CEDES) in Buenos Aires. The study analyzes the work of obstetricians as essential to ensuring greater and better coverage of health services that, in turn, guarantee (non-)reproductive and sexual rights. Obstetricians are essential in providing care during childbirth and births, but they also have the capacity to assist in 87% of essential (non-)reproductive, sexual, maternal health services for pregnant women and newborns. With proper regulation and training, they could reduce maternal mortality by 83%, especially considering the ratio of live births to the number of available professionals (obstetricians and medical specialists in gynecology and obstetrics), which is 3.4 per 1,000 live births in less favored provinces (Ariza Navarrete, Sciurano, & Ramos, 2022). The presence of the issue on the public agenda is undeniable, as are the tensions and disputes that reveal structural inequalities, which is why this topic was addressed from a Political Science perspective.

Final Considerations

It is essential to incorporate interdisciplinary analyses that contribute to the construction of a critical approach to policies and public manifestations related to health, and, in this case, specifically to (non-)reproductive and sexual rights. The existing tension between different actors and knowledges involved in the event of childbirth allows to observe structures that reproduce gender-based obstetric violence that needs to be resisted.

The possibility of having decision-making autonomy regarding how childbirth is to be experienced, as well as the people and knowledge to be included for care and assistance during them, is linked to a notion of well-being and fulfillment and not solely to a medical-sanitary issue. It is essential to incorporate this notion from a gender and intersectional perspective:

The differential needs of women must be considered in their full scope, as it is not only important to be a member of society, but also how one enjoys that status. We must work on building social processes that generate better living conditions; this is where our focus should be, and we must create diverse support systems. Consequently, our priority should be the generation of intersectoral processes in local spaces, provinces, and municipalities, that promote a democratic health system without shadows, thinking of human beings, and enabling them to live their sexuality in fullness (Venticinque, 2020).

The debates, manifestatios, and multiple bill projects demonstrate the difficulty of generating legislative changes, which is only the first step. It is considered that the political analysis of such discourses and events highlights relations of domination, subordination, and exclusion in the medical field that require intervention beyond the legal realm, which, while indispensable, is not the only field where these inequalities operate.

The issue of professional hierarchization of obstetricians is closely linked to a gender issue, as caregiving tasks have historically been considered the domain of women, and therefore, have been devalued and subordinated to the work of doctors. This process has also been accompanied by the stigmatization of practical knowledge as “witchcraft and magic” (Nari, 2004; Ramaciotti 2020). The crystallized power structures in which the medical corporation attempts to maintain “its competencies” as its own, restricting the competencies of other professions considered auxiliaries, have an impact on the health system and on the rights of the people it serves.

The role of absolute authority of the medical corporation is presented as the bearer of specialized technical knowledge that is imposed over other forms of knowledge and, above all, over the subjectivity of pregnant people and their decision-making autonomy. Care and warmth should be central in the care of pregnant people during childbirth, and the demands and struggles of obstetricians, midwives, and women reveal an imminent transformation that is trying to expand. In this sense, subaltern counterpublics (Fraser, 1999) are essential for subordinate groups to reflect on their situation from their own reality and organize campaigns to amplify their voice, which is often invisibilized by power groups. The arguments that shift the health issue to the private realm –considering that what should be addressed by professionals does not merit public debate– imply a depoliticization of the issue that positions lawyers and doctors, supposedly neutral and objective, in a hierarchical place (Brown, 2007; Venticinque 2013). Criticizing academia for prioritizing racist and patriarchal models also implies criticizing the health models it has historically constructed, in order to generate comprehensive coverage that includes practical, experiential, and situated knowledge that is currently excluded from the hegemonic medical model, which is also being questioned within medical faculties. It is interesting to incorporate research lines that study this phenomenon and also delve into the reality of obstetricians, doulas, and midwives in relation to the work discussed in this article. As long as they enable democratic practices and guarantee rights, it is necessary to support and sustain spaces that generate counterdiscourses and endow them with legitimacy, also with contributions from universities and academia, as a critical and political exercise.