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Pregnant women are not patients
By Diana Cariboni
Montevideo, Uruguay, Apr. 12 (IPS)— Despite the lack of
a scientific basis for practices like routine episiotomy, enemas, and
perineal shaving, they continue to be used in maternity hospitals throughout
much of Latin America.
Unnecessary cesareans are also common, while hospitals routinely prohibit
women from being accompanied in often overcrowded labor rooms and during
delivery by their husbands or another companion of their choice.
The episiotomy, an incision made in the area between the vagina and
anus (perineum) during the last stages of labor and delivery to expand
the opening of the vagina in order to prevent tearing during birth,
is one of the world’s most common surgical procedures.
However, there is no conclusive evidence that routine use of episiotomies
is effective, according to the Latin American Center for Perinatology
and Human Development (CLAP), part of the Pan-American Health Organisation
(PAHO).
On the other hand, it does clearly cause women pain and discomfort at
a time when they need to be most comfortable, in order to nurse and
care for a newborn baby, says CLAP, one of whose missions is to assess
medical practices in the fields of obstetrics and neonatology.
Despite the fact that routine use of the episiotomy has been abandoned
in many industrialized countries, more than 80 percent of women giving
birth to their first child undergo the procedure in some Latin American
nations.
CLAP experts say it should be used in no more than 30 percent of first-time
mothers.
“I had an especially nasty experience. The anaesthesia during the
episiotomy did not take effect, and I had to suffer the stitching process
without any form of relief,’’ Susana, 34, commented.
“I was in pain for a month; I couldn’t sit down. I had to
take care of the baby and my other son, as well as the domestic chores.
The healing process did not go well, and my gynecologist told me that
I should undergo a small surgery to fix it before I turn 40, or I would
face an increased risk of prolapse,’’ she added.
Another mother, 36-year-old Alicia, said that “they did the episiotomy,
but the baby was so big [8.8 lbs] that my tissues tore anyway, and the
doctor had to sew up the incision as well as the tear.’’
CLAP recommends that routine episiotomies be abandoned, as well as other
annoying practices, like the enema and perineal shaving, which are purportedly
carried out for hygiene purposes.
“Countries like the United States and nations in Europe have eliminated
the enema and perineal shaving,’’ said the director of CLAP,
Dr. José Belizán from Argentina.
In addition, “the use of the episiotomy, which was routine among
all first-time mothers, has diminished as a result of studies that have
been carried out, and is now only practiced among 15 or 20 percent of
first-time mothers’’ in the industrialized world, he noted.
Such practices form part of the “medicalization’’ of
pregnancy and childbirth, which are natural stages in the lives of most
women. Normally, when a pregnant woman visits a healthcare institution
for a prenatal check-up, she is treated as a “patient’’
with a medical condition.
Uruguayan midwife Gilda Vera with the Latin American and Caribbean Network
for the Humanisation of Childbirth and Delivery (RELACAHUPAN) complained
about the excessive medicalization, and said healthcare personnel in
the region are not up-to-date on the latest scientific information.
One of the consequences of this phenomenon is the growing popularity
of cesarean births, often misconstrued as safer.
More than 850,000 unnecessary c-sections a year are practiced in the
region, while the maternal mortality rate among women undergoing cesareans
is two to six times higher than among women experiencing a natural birth,
according to a study by gynecologists Jose Belizán, Fernando
Althabe, and Sophie Alexander, and pediatrician and epidemiologist Fernando
Barros.
In 12 of the 19 Latin American countries studied, cesareans are practiced
in 16.3 to 40 percent of all births, while the World Health Organization
(WHO) recommends a maximum of 15 percent.
Chile heads the list, with 40 percent, followed by Brazil (27.1 percent),
the Dominican Republic (25.9 percent), and Argentina (25.4 percent).
Although the “epidemic’’ of cesareans is not new, “few
measures have been taken to reduce the use’’ of c-sections
in the region, because “they are culturally accepted as a normal
way of giving birth,’’ according to the study.
In Chile and Colombia, nearly 60 percent of births in private health
centers are by c-section.
The overuse of cesareans is due to a multiplicity of factors, which
once included even economic incentives, because doctors in some countries
were paid more for a surgical procedure than for attending a natural
birth. However, the differences in payment no longer exist, said Belizán.
Another explanation proffered is that “doctors are overwhelmed
with work, and sometimes resort to c-sections because they are faster
and can be scheduled,’’ he said.
Belizán took issue with the claim that women often ask for c-sections.
“In nearly all surveys among women who have had c-sections or vaginal
births with positive outcomes, 85 percent answer that they prefer the
latter,’’ he said.
Another factor that could drive up the number of cesareans are lawsuits
for malpractice, which tend to be brought “against a doctor for
failing to look proactive [in this case, practicing a c-section], rather
than against a doctor who looked like he did everything he could,’’
he explained.
CLAP bases its recommendations on research findings from all over the
world, which it disseminates. It also cooperates with medical institutions
in the region for the formation of technical and human resources.
In terms of reactions to its recommendations on restricting the use
of the episiotomy and abandoning the enema and perineal shaving, “the
most enthusiastic are the midwives,’’ said Belizán.
Some things are also beginning to change in hospitals, he added.
In the maternity ward of the Pereira Rossell public hospital —
the largest pediatric and maternity hospital in Uruguay — neither
perineal shaving nor the enema are used anymore, and the episiotomy
is no longer a routine practice.
In Bolivia, new standards were introduced, with the aim of bringing
about major changes in the exclusively “medical’’ approach
to pregnancy and childbirth, and to encourage a more active role in
the process by expectant mothers.
In hospitals in the Central American countries of Costa Rica and Guatemala,
efforts to train medical personnel with a view to improving practices
have also shown good results.
The Argentine parliament is debating a bill that would establish the
right of expectant mothers to be accompanied by a companion of their
choice during labor and delivery, which is still banned in most public
hospitals in the region. A similar law has been in effect in Uruguay
since 2001.
Women are also organizing to gain greater access to information, and
to improve the way pregnant women are treated.
One such initiative is RELACAHUPAN, created in 2000 to “promote
the humanization and rediscovery of what is normal during the reproductive
and neonatal cycle,’’ said Vera, the network’s coordinator
for South America.
“We have successfully prompted public debate in most countries
in the region on the quality of care during pregnancy and childbirth,
and on the rights of women during those stages of their lives,’’
she said.
Women must be “empowered,’’ not only with regards to
“gaining understanding and knowledge about their bodies, but in
their right to be heard, respected, and taken into account as the true
protagonists in the process,’’ said Vera.
Change is much needed in some regions. In the Nuestra Señora
de las Mercedes maternity hospital in the northern Argentine city of
Tucumán, the biggest in the country in terms of number of births,
14,000 babies are born every year in an environment that is often hostile
to expectant mothers, many of whom are poor.
That was the finding of a World Bank-financed investigation commissioned
by the National Women’s Council -- the results were reported in
December 2003 by the Buenos Aires newspaper Página 12.
Due to overcrowding, the hospital beds are occasionally shared by two
expectant mothers. The women are not allowed to be accompanied, and
are identified by numbers, rather than their names.
According to testimony gathered by the authors of the report, the health
staff routinely tell expectant mothers suffering from labor pains things
like “Spread your legs and shut up. You sure enjoyed it when you
did that in the first place,’’ and “You should have thought
of this before.’’
The report recommends an analysis of the origins of the maltreatment
of women in the maternity hospital, which, it says, has “inadequate
building space and infrastructure, as well as a shortage of human and
technical resources.’’
Tracking down ghosts
By najwa
Apr. 14 (AGR) -- A mother stares across a hopeless desert. She
is unable to hold back the subtle tears as a group of her family and
friends form a voluntary search party. Once again, she will comb the
endless sands in hopes of finding her daughter. She knows she will not
be able to hold her teenage daughter’s hand again. Instead, she
is hoping to let go of an unsettled past. She is looking for closure.
It is said that the desert surrounding the Mexican border town of Ciudad
Juarez keeps many secrets. Lourdes Portillo, a documentary filmmaker,
traveled to this border town “to track down ghosts.” The result
of her 18 month research project was Senorita Extraviada, a brilliantly
produced documentary about the hundreds of young women who were kidnapped,
beaten, tortured, raped, and killed in Ciudad Juarez in the 1990s.
In the last decade of the 20th century, between 200 and 400 young women
were kidnapped, raped, and killed in Juarez, Mexico. Of those horrible
deaths, only a few cases have been solved. Portillo’s documentary
serves as an attempt to trace these stories and search for the reasons
why such systematic killing has been pushed out of the public’s
collective view. As Portillo would discover, ghosts have many stories
to tell.
Senorita Extraviada does much to show the many pieces of this
rather large and difficult puzzle. It starts off talking about Juarez
and its boom in the early nineties –- the era that marked the rise
of neoliberalism. Almost overnight, the small border town became a sprawling
city of large factories, known as maquilladoras, and dense shanty neighborhoods.
Poor people throughout Mexico, no longer able to survive as small farmers
and business owners, flocked to the border towns in search of jobs.
By the end of the 20th century, these maquilladoras (mostly owned by
the United States) employed over 185,000 people. The new work force,
mostly teenage women, was now making between $4-5 dollars a day. They
would show up between 5:00am and 6:00am for work each day from miles
away. Most of them traveled alone. Some of them would never show up
for work again.
As the documentary shows, it is nearly impossible to blame any one person
or institution for the murders of so many women. But that did not stop
the media, politicians, and law enforcement from finding a scapegoat.
When Juarez began to receive international attention after eight young
women were found dead in what seemed to be a serial rape and murder
case, law enforcement decided to find a suspect. They focused their
energy on an Egyptian national named Sharif Sharif, who did not speak
Spanish. Although Sharif Sharif was undoubtedly responsible for the
rape of at least one young woman, it was clear that he was to become
the government and media’s replacement for real investigation for
a problem that was more than the result of one individual.
Shortly after Sharif Sharif was imprisoned, the kidnappings and murders
continued in great numbers, including 13 murders identical to the ones
for which Sharif Sharif was arrested. For the most part, their reality
was denied or ignored. The police did nothing to investigate and the
media and government agencies started in on a barrage of sexist messaging.
The governor, for example, was quoted on television as saying, “the
problem is that they are prostitutes.” He went on to explain that
the women were at fault for their provocative clothing and the unsavory
men they surrounded themselves with.
The Attorney General’s only recommendation was to impose a curfew
in the city. When asked how the curfew was to affect women that did
not get off work until well after sunset, he gave a nonsensical response
about how people with jobs are respectable people. Members of both major
political parties PAN and PRI, also blamed the rapes and murders on
the women’s attire. The government charged that the only thing
that the women had in common (in hopes of assigning a pattern to the
killings) was their scant clothing and habit for hanging out in bars.
What an independent investigation team found, however, was that the
only things these women shared in common was that most fit the description
of poor, slim, and young with dark, shoulder-length hair. It was clear
that no one in government was going to try to tackle the real problems
at hand.
But these stories are nothing new to the millions of women that are
raped every year in North America. Women have always been blamed for
their attackers’ and rapists’ actions. But what made Portillo’s
investigation most intriguing was its profound implication of so many
power players in Mexico and the United States.
When a series of murders were marked with symbols of religious sacrifice,
the media and public regained a sudden interest in the murders. As a
result, a group of eight people, deemed the “Rebels Gang,”
were arrested and charged with the murders. In order to cover up their
incompetence, the government and media were quick to connect the Rebels
Gang with Sharif Sharif. They said that he had been controlling the
Rebels Gang from within his jail cell. Everyone could then wipe their
collective brow and sigh in unison. The Rebels Gang, however, stood
staunchly by their claim that the rapists were still out there. And
they were.
The kidnappings continued at a steady rate. Soon, it was discovered
that the police were doing more than not investigating the rapes and
murders, they were involved in them. When one woman called the police
one night to complain about the neighbors threatening her husband, her
and her husband were taken to jail. They were separated into different
cells. She was then forced to get undressed while a female officer sexually
molested her. Outside of the cell was a male officer keeping guard.
Later that night, she was drugged by an officer. When she awoke in a
daze, she was being dragged to a back room in the jail. On the floor
were hundreds of items of women’s clothing.
When she asked where the clothes came from, the group of officers told
her they were from all the women that they “had” that night.
Then they showed her pictures of all the women that they had raped,
tortured, killed and then buried in the desert. She described the pictures
in great detail. Women were burned alive, police officers were biting
off the women’s nipples, and all the while, the officer’s
had great smiles on their faces. She was told that if she spoke of any
of this, she would end up like these women. They then proceeded to rape
her.
When this woman finally came out about her story, three officers were
arrested. All three would be acquitted of all charges. Instead, police
announced that they had found the kidnappers -– a group of bus
drivers. Once again, in an almost satirical act, the police and media
stated that Sharif Sharif had been controlling these men from his prison
cell. The kidnappings continued.
In response to public outcry, a special prosecutor’s office was
created to investigate crimes against women. The office, however, was
denied sufficient funding and the barest of necessities. In addition,
the police then burned tons of valuable evidence, including the clothes
of the victims they had found. When family members began to do their
own investigating, they found that files were missing statements that
were given.
Shortly after this series of events, a drug informant for the FBI called
and said he knew where 200 bodies were buried in correlation to drug
trafficking. As a result, the FBI and Mexican authorities found eight
bodies. Immediately after, the FBI called it a victory and ended its
investigation. The Attorney General of Mexico refused to intervene in
the investigation, thus leaving invaluable resources unavailable to
the case investigators or the families.
While hundreds of rapes and murders go unsolved, a series questions
are posed. How are we going to stop the systematic victimization of
women? How can justice be claimed for the victims of these brutal crimes
when so many people are complacent? How can we provide closure for the
families and friends?
Disillusioned with the ability of the government and its enforcement
agencies to investigate themselves or their corporate interests, people
have begun to take the matter into their own hands. Families are doing
their own investigation; they are starting their own grassroots campaigns.
The lesson we can learn from Portillo’s investigation is that we
are all responsible for stopping the institutionalized victimization
of women. If we do not, we are complacent. Thus, we are guilty.
As Senorita Extraviada came to a hesitant end, Portillo talks
about the young women that are still being murdered. As she shows, this
is a story without a happy ending. It is a story without an ending at
all.
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