HEALTH-LATAM: Pregnant Women Are Not ‘Patients’

By Diana Cariboni Reprint | | Print |

Diana Cariboni

MONTEVIDEO, Apr 12 2004 (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 c-sections are also common, while hospitals routinely prohibit women from being accompanied in often overcrowded labour 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 labour 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 Centre 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 industrialised countries, more than 80 percent of women giving birth to their first child undergo the procedure in some Latin American nations.

”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 to IPS.

”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, told IPS that ”they did the episiotomy, but the baby was so big (four kgs) 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 wall 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,” the director of CLAP, Dr. José Belizán from Argentina, told IPS.

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 industrialised world, he noted.

Such practices form part of the ”medicalisation” 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 medicalisation, 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 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 Organisation (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 centres 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 labour 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 organising 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 humanisation and rediscovery of what is normal during the reproductive and neonatal cycle,” Vera, the network’s coordinator for South America, told IPS.

”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, whose 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 labour 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 mal-treatment 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.”