Abstract
At the suggestion of a social worker who witnessed abusive post-abortion care at a public hospital in Rosario, Argentina, two human rights NGOs collaborated to investigate women’s experiences seeking treatment for abortion complications at area public hospitals. During the year-long enquiry, more than 300 women took part. Role play was successfully used to surmount women’s initial reluctance to reveal pervasive discriminatory and humiliating mistreatment. Thirty-one women later gave personal testimonies about their experiences, which were contained in the report of the research and later dramatised in a public meeting and video. The report, Con Todo al Aire (With Everything Exposed), was disseminated widely, including to the media, and a formal complaint was made to the local Ombudsman, who called for high-level action to resolve the problems. Initial denial by some health professionals that there was a serious problem was replaced by critical self-assessment within the provincial government, hospitals and medical and nursing schools, who made commitments to reform hospital practices and the medical school curriculum. Women participants also gained an understanding of their right to appropriate and humane health care. The findings from Rosario are not isolated. They are now being shared with activists and researchers in other provinces of Argentina and other countries.
Résumé
Sur la suggestion d’une assistante sociale qui avait assistéàdes agissements abusifs dans un hÁpital public de Rosario, Argentine, deux ONG des droits de l’homme ont enquÁté sur l’expérience de femmes soignées pour des complications de l’avortement dans les hÁpitaux publics. Plus de 300 femmes ont participéàl’enquÁte d’une année. Les jeux de rÁle ont permisàrévéler la discrimination et les humiliations dont elles avaient été fréquemment victimes. 31 femmes ont ensuite témoigné sur leurs expériences, qui ont été incluses dans le rapport de recherche et mises en scène dans une réunion publique et sur vidéo. Le rapport, Con Todo al Aire (Sans rien cacher), a été largement diffusé, notamment dans les médias, et une plainte officielle a été déposée auprès de l’ombudsman local, qui a demandé une action de haut niveau. Le refus de certains professionnels de la santé de reconnaître l’existence de graves problèmes a été remplacé par une auto-évaluation critique des autorités provinciales, des hÁpitaux, et des écoles de médecine et d’infirmières, qui se sont engagésàréformer les pratiques hospitalières et le curriculum de l’enseignement médical. Les participantes ont compris qu’elles avaient droitàdes soins adaptés et humains. Les conclusions de Rosario sont maintenant partagées avec des militants et des chercheurs dans d’autres provinces argentines etàl’étranger.
Resumen
A sugerencia de una visitadora social, testigo del maltrato durante la atención postaborto en un hospital público de Rosario, Argentina, dos ONG de derechos humanos colaboraron para investigar las experiencias de las mujeres que buscan tratamiento de las complicaciones del aborto en hospitales públicos. Más de 300 mujeres participaron en una investigación de un año de duración. Se utilizó el juego de roles para revelar el maltrato persistente, discriminatorio y humillante. 31 mujeres dieron testimonio personal sobre sus experiencias, que se incluyeron en el informe de la investigación y después se dramatizaron en una reunión pública y en video. El informe, Con Todo al Aire, se difundió ampliamente, y se presentó una queja al Ombudsman local, quien instó la toma de medidas urgentes para resolver los problemas. La negación inicial de algunos profesionales de la salud de la existencia de un grave problema fue remplazada por una autoevaluación dentro del gobierno provincial, los hospitales y las facultades de medicina y enfermeráa, que se comprometieron a hacer reformas en las prácticas hospitalarias y el curráculo de la facultad de medicina. Además, las participantes adquirieron mejor entendimiento de su derecho a una atención médica adecuada y humana. Los resultados de Rosario no están aislados; actualmente se comparten con activistas e investigadores en otras provincias de Argentina y otros paáses.
“So that this does not happen again…”
In June 2001, Romina, 16 years old and seven months pregnant, shot herself in the abdomen. Still conscious, she was rushed to a provincial hospital in Rosario, Argentina. The bullet had perforated her intestines and she was haemorrhaging badly, but despite her grave condition, the staff were harsh and accusatory, shouting at her and calling her a murderer. A social worker witnessed the girl’s treatment and the scolding she got from employees, even the cleaning staff. When some of the health staff suggested surgery without anaesthesia as punishment, the social worker intervened.
This was not the first time the social worker had seen abusive treatment of women but perhaps because of the unbridled cruelty of the incident, Romina’s case was the last straw for her. She went to local human rights activists at the Instituto de Género, Derecho y Desarrollo (INSGENAR, Institute of Gender, Law and Development) to relay what she had witnessed. Following her testimony, INSGENAR, in collaboration with the Comité de América Latina y el Caribe para La Defensa de los Derechos de la Mujer (CLADEM, Latin American and Caribbean Committee for the Defense of Women’s Rights) interviewed Romina and several other women who had recently accessed reproductive health services at nearby public sector facilities. The interviews suggested that Romina’s experience was not an aberration; mistreatment of women seeking reproductive health care appeared to be common in Rosario.
Romina’s treatment struck a particularly raw nerve among Argentine human rights activists, as it reminded them of abuses commonplace during Argentina’s “dirty war” from 1975 to 1982 under the ruling military junta. This historical context influenced the investigators’ decision to analyse the findings not only within a human rights framework, but also in relation to international agreements on torture, which have particular resonance in Argentina. Following the preliminary interviews, INSGENAR and CLADEM launched a broader enquiry to document violations and a campaign to demand corrective action.
Their investigations resulted in a 110-page report, the first of its kind in Argentina, entitled Con Todo al Aire: Reporte de Derechos Humanos Sobre Atención en Salud Reproductiva en Hospitales Públicos (With Everything Exposed: Human Rights Report on Reproductive Health Care in Public Hospitals), which was published in late 2003.Citation1 The campaign proved extremely effective in exposing rights violations, holding the health system accountable, drawing media attention, instigating systemic change and empowering women to demand decent care. This article describes the investigation, its findings, the campaign that followed and the outcomes.
Abortion policy and public health services in Argentina
The public health system in Argentina is based on hierarchical and patriarchal underpinnings which exacerbate existing power inequalities between health care providers and users. Women, particularly those who are poor and disenfranchised, who are the primary users of public health care, often “experience a broad range of discrimination, especially on the grounds of gender, class, age and ethnicity”.Citation2
In Argentina, the recent economic crisis has had a profound impact on health services as well as poverty levels. In 1974, in greater Buenos Aires, 4.7% of the population were considered poor and 2.1% indigent. In 2003, this had increased to 54.7% considered poor and 26.3% indigent.Citation3 People who in better times would have opted for private health care are utilising public hospitals in far greater numbers, overwhelming facilities and staff. Added to this, precarious employment conditions and medical supply shortages have affected quality of care, with women especially affected, both in relation to their own health and as caregivers.Citation4
Argentina has a long tradition of pronatalist policies, reinforced by conservative forces inside and outside the Catholic church, evidenced in the establishment of a national day of the unborn child in 1997 and a recent national supreme court judgement limiting the production and sale of emergency contraception which, however, was later overturned. In spite of the passage of a law in 2002 to set up a National Programme of Sexual Health and Responsible Procreation, recent reproductive health policies in cities like Buenos Aires and commitments by the current government and some local and provincial governments to include sexual and reproductive health in the public policy agenda, women are still not guaranteed access to contraception or other reproductive health services, and when an unwanted pregnancy occurs, they are forced to resort to clandestine abortion.
Abortion is criminalised in Argentina’s penal code, with two exceptions: to protect the woman’s life and health if this cannot be done by other means, and in cases of rape or incest of a so-called “mentally insane or idiot” woman (in both cases when performed by a physician with the woman’s consent). Yet, in Argentina an estimated 37% of pregnancies result in induced abortion,Citation5 while other estimates show as high as one abortion to every live birth.Citation6 Misoprostol is available at many pharmacies, and anecdotal information suggests it is used by young women increasingly for self-inducing abortion. Getting a safe abortion in Rosario, the country’s third largest city and the capital city of Santa Fe province, for example, costs approximately 1500 pesos (US$455), three times the monthly minimum wage. It is predominantly poor women who end up in public hospitals with complications as the aftermath of botched or incomplete abortions.
Data from 2002 show as high as 166 maternal deaths per 100,000 live births in the poorest province, Formosa, in contrast to 14 deaths per 100,000 live births in Buenos Aires and other more developed provinces.Citation6 Unsafe abortion is the principal cause of maternal mortality in Argentina, causing an estimated 29% of maternal deaths.Citation7 Rural, older and young women living in poverty are the most affected.
The investigation
A team of human rights activists and lawyers put together by INSGENAR and CLADEM began their investigation in October 2002 in the neighbourhoods and surrounding towns of Rosario, where the vast majority seek health care from public (either provincial or municipal) hospitals and health centres.
Over the next year, more than 300 women took part in 13 workshops run by the investigative team. The team enlisted them through community-based women’s organisations, neighbourhood contacts and selected health workers. Their intent was to determine the scope and severity of inappropriate and discriminatory practices toward women seeking post-abortion care in public facilities. They also sought to gauge how women themselves perceived the treatment they received and the degree of awareness about their own rights. The long-term goals were to stop mistreatment, hold health providers accountable for the quality of care delivered and empower women to demand better attention.
In the beginning, the women were hesitant to discuss the particulars of their treatment. They said it was “as usual” or “normal” and did not make any complaints. When asked specifically about post-abortion care, they were most reticent. If they responded at all, they referred only to the experiences of others — friends, neighbours or family members — and were reluctant to identify other women with whom the investigators could speak as well.
The silence surrounding abortion was to be expected. Research in Latin America suggests that 25—50% of abortions have been concealed and in some cases as few as 4% of abortions have been admitted.Citation8 Women who have abortions are subjected to religious, social and moral condemnation, and many fear criminal charges.
In an effort to open up discussion, investigators tried role play. Participants were asked to recreate typical scenarios drawn from their experience of seeking gynaecological care, playing both the roles of caregiver and patient, and using the same words they had said or heard. The approach worked. What they acted out were scenes that echoed the cruelty of Romina’s treatment, scenes in which patients were insulted, yelled at and treated without anaesthesia, and in which privacy and bodily integrity were disregarded. The role plays also revealed a lack of communication in the provider—patient relationship. Women were not consulted about their treatment nor listened to when they complained of symptoms or tried to alert providers to their medical history. In general, the role plays depicted providers as judgmental, brusque or punitive: women with abortion complications were especially singled out as deserving of pain and humiliation.
Over the course of the workshops, about 250 of the 300 participants revealed some form of mistreatment while seeking reproductive health care from hospitals or health centres. It had happened to so many of them that they no longer questioned it but accepted it as inevitable. One said, “These behaviours and attitudes have always existed and will continue to exist.”
Awareness of human rights
The investigative team began using the workshops to discuss women’s right to health, including humane treatment, beginning with the concept of entitlement to public health care. Women who access public health services often feel resigned to accepting whatever treatment they get because it is free; humiliation is something that must just be tolerated. Investigators tried to shatter that belief, saying that there are no free health services as they are paid for by the state using income from citizens. Health workers are obligated to give good care, free from discrimination or imposition of their own religious values. Such obligations are outlined in various international human rights agreements signed by Argentina. The workshop leaders also discussed mechanisms for lodging formal complaints of violations to hold responsible parties accountable, so as to change current abusive practices and prevent future violations.
The participants agreed that a formal human rights report should be prepared, and 31 of the 300 were willing to give testimony. Even though they were assured of anonymity, most participants were afraid to speak out because they feared retribution from hospital personnel when seeking care in the future, or because they felt that nothing would change. Case histories were gathered from the 31 women through private, individual interviews, with confidentiality and anonymity protected throughout. The 31 women were between 16 and 32 years old and had come to one of Rosario’s six public hospitals for treatment for a range of problems, including antenatal complications, miscarriage and incomplete abortion. All 31 revealed instances of poor quality of care. Eleven of the 31 women talked about their experience of treatment for abortion complications; the other 20 talked about other reproductive health problems.
Testimonies of treatment for abortion complications
Only one of the 11 woman who spoke of abortion-related treatment openly stated that she had had an induced abortion. The other ten reported seeking treatment for bleeding during the first or second trimester of their pregnancies (eight spoke about themselves, one spoke about her daughter and another what she had witnessed of a neighbour’s experience). These ten women did not specify whether the abortions were spontaneous or induced, or whether the pregnancies were wanted.Footnote* However, when they presented at the hospital bleeding, providers assumed they had had an induced abortion and treated them accordingly.
Cruel and humiliating treatment
The 11 women described many forms of poor treatment. Some were made to wait for long periods while bleeding before they were brought to a health care provider. Once hospitalised, several spoke of being left alone for hours, without being checked on or knowing what was happening to them. They described being refused painkillers or anaesthesia for surgical procedures, including dilatation and curettage (D&C), a painful and outdated approach, to treat complications of abortion.
They said providers seemed uncaring about the suffering they experienced and ignored their complaints. “I asked, please, for a painkiller. And they walked by and said ”No, dear, put up with it now. See, they come here and they don’t want it to hurt.’” One young woman, who was in intensive care and under instructions to stay in bed, relayed: “I couldn’t move because everything hurt, and the cleaners and the nurses walked by, and I asked them to bring me a bedpan…they yelled at me ”Go get it yourself, little girl, get up!’” She spoke of nurses brusquely changing the sheets on her bed while she lay there, just after she had had surgery and was in severe pain.
Women reported being yelled at and insulted, called “stupid” or “fatty”. Several reported being called nena (little girl). They also recalled staff expressing punitive attitudes toward sexuality, e.g. “you liked the sweet part, now put up with the bitter part”. Such expressions stem from cultural prejudices about women’s sexuality: pain is the cost women must pay for pleasure. Interviewees noted that such remarks were made most often by women health staff who, overall, were no more likely to be empathic than men, also documented in other studies. Women working in health care are often subject to gender discrimination themselves and seem prone to take out their frustrations on those who are even more powerless.Citation2
Lack of respect for privacy and dignity
Overcrowding and poor physical conditions in the public hospitals in Rosario compromise privacy in gynaecological care. Several women spoke of a humiliating disregard for their personal privacy and dignity. One woman recounted how, during a physical examination where medical students crowded around her, her face was covered with a sheet. Disregard for women’s dignity is exacerbated by the way in which medical education takes place in these settings as, by law, all hospitals and most health centers in Rosario are teaching institutions. Women were neither informed of nor asked to consent to student examinations: “They left the door open. I felt as if I was in a window. Students came in… They were laughing. I was nude and uncovered.” Several women said they were examined vaginally by a series of students, one after another. “I felt treated like an instrument.” “I felt that I was being studied like a phenomenon.”
Lack of communication
Lack of communication was an issue in the interviews and the role plays. One woman, who came to the hospital with haemorrhage, described how the physician set a date for her hysterectomy, without consulting her or explaining what was going on or if she had other options. Another woman, who was moved from one hospital to another and then another without explanation, remarked: “Even today, I don’t really know what happened.”
Embedded in providers’ failure to communicate effectively is the assumption that they have all the answers and patients have nothing to contribute, confirmed in other research from the region.Citation2 This attitude is embodied in one doctor’s remark: “If people come here to be treated, it is because I am the doctor. But if you know [better], stay at home and take care of yourself.”
Punishment for suspected abortion
Participants who presented at the hospital bleeding were routinely questioned: “Did you put something inside yourself?” “What did you do?” “Did you inject something?”
According to Argentina’s Penal Code, abortion is a crime against life and against the person: a woman who induces her own abortion is subject to one to four years imprisonment, and providers are subject to imprisonment and revocation of their medical licences. In recent years enforcement has been rare, but this investigation reveraled that routine post-abortion care often includes a component of interrogation and punishment, exercised not by law enforcement officials but by hospital staff.
One woman was taken to uniformed hospital guards for such questioning, and in two other instances hospital personnel threatened to call the police. One woman with pronounced bleeding was pressured to give the name of her physician, on the assumption that the provider was responsible for the abortion. One woman described how her neighbour’s ambulance arrived accompanied by policemen with a video camera to document anything they could find in her house that could have been used to provoke an abortion. One interviewee recounted: “They aren’t human… they talked to me as if I were an assassin and gave each other looks…”
Exposing inhumane practices: the report
The report’s title, Con Todo al Aire, is how one woman described herself — with everything exposed. The title also connotes triumph in the act of bringing such violations into the open. The report not only exposes inhumane practices through the testimonies given, it defines them as human rights violations, specifically the right to be free of gender-based discrimination, the right to health, the right to reproductive health, the right to personal integrity, the right to be free from cruel, inhuman and degrading treatment, and the right to privacy and dignity. The report also cites the Convention against Torture and Other Cruel, Inhumane or Degrading Treatment to demonstrate the abusive nature of the treatment many of the women experienced. By using such strong symbolism, the investigators sought to highlight the gravity of how women were being treated and to dispel the view of such treatment as normal, common and acceptable by reversing the imagery of women who have abortions as sinners (which they were often made to feel by health staff) and health workers as their saviours.
Dissemination and confrontation
Along with dissemination of the report, the investigative team presented two formal complaints: one to the Defensoráa del Pueblo, akin to a provincial ombudsman, denouncing the practices at the four provincial hospitals under its jurisdiction, and the other to the Secretary of Health of the Municipality of Rosario. Each complaint proposed further investigation as well as the adoption of four remedial actions: awareness-raising and training of health staff, community-based information campaigns on reproductive health and human rights, systems to monitor quality of care and address patient grievances, and follow-up monitoring.
The investigators then held a press conference; journalists came from several television and radio channels, and from the major newspapers in Rosario. They also sent the report to the Dean of the Faculty of Medicine, National University of Rosario, and asked her permission to present the report to the faculty. She accepted. The presentation was on 25 November 2003, the International Day against Violence against Women. Invitations were sent to municipal and provincial decision makers, the directors and health staff of all the hospitals and some health centres, faculty and students from the schools of medicine and nursing, human rights organisations and the women who participated in the investigation. Approximately 130 people attended.
Following a panel presentation describing the major findings of the report, two well-known actresses from Rosario did a theatrical re-enactment of some of the women’s testimonies, in the women’s own words. The actresses changed roles after each scene, alternating between playing the patient and the medical staff, to emphasise that it is possible for anyone to find themselves on the other side of the fence. This provoked a strong reaction from the audience following the performance. Some doctors expressed outrage and said the accusations were insulting. Others were defensive and accused the report of exaggerating. But, significantly, not one doctor disavowed the behaviours entirely. When one physician claimed that such behaviour was very rare, one of the 31 women interviewed stood up and said that she had personally experienced cruel treatment in the hospital where that physician worked.
Such denial is not uncommon. This investigation did not include interviews with providers, yet other research reinforces the sharp difference in perception between patients and providers regarding the quality of post-abortion care. A survey of 467 obstetricians—gynaecologists from public hospitals in Buenos Aires in 1998—99, for example, revealed that the great majority (89.5%) thought the quality of care was either excellent, very good or good, and most viewed quality of medical care as being consistently good (77.1%), though only 48% thought women were always treated as patients with rights. In other words, half the physicians did not associate quality of care with recognition of women’s human rights.Citation9
Although none of the providers in Rosario admitted to having committed the violations described in the report, a number did express a commitment to rooting out such practices. The director of nursing services at one hospital admitted that she often saw such situations but had never realised they were a violation of human rights. The Dean of the Faculty of Medicine announced that she would incorporate the subject of health and human rights in the curriculum for third-year medical students. The women who participated in the workshops expressed satisfaction that their testimonies had brought realities to light and helped to hold health staff accountable for their actions.
Two local television stations and several radio programmes broadcast the session. The next day, two metropolitan and one community newspaper carried articles about it, and the story was picked up by national newspapers, which interviewed the investigators and carried stories the following week.
Actions taken
Following the filing of the formal complaints, the Ombudsman took immediate action. First, he called a meeting of hospital directors to discuss the report; they defended their personnel as overwhelmed, underpaid and stressed. They were managing as best they could in a system stretched beyond capacity, they said. They cited insufficient supplies, such as bedding and gowns, as the reason why they could not protect women’s privacy. The Ombudsman, while recognising the reality of resource constraints, pointed out that respectful treatment carried no cost. He said that it was not a matter of money or resources, but rather of culture and attitudes.
After a second meeting with the hospital directors, with the investigative team present, the Ombudsman drafted a resolution that asked the Provincial Minister of Health to find and implement solutions to the problems identified in the report, and to develop standards and guarantee adequate treatment of women seeking gynaecological or obstetric services in public hospitals, in line with human rights principles:
“…the right to health not only implies access to adequate technical and scientific quality in the process of health care [which was never questioned by the patients interviewed] but also treatment that includes understanding of human suffering, respect for privacy and modesty, absence of moral prejudices in treatment of patients, the right to information, among others.” (Resolution No.713, 31 October 2003)
In a televised broadcast, the Municipal Secretary of Health described the internal actions being implemented, including the sanctioning of an individual health worker who had discriminated against a patient.
In 1994, Argentina’s Constitution was amended to incorporate nine human rights treaties and two human rights declarations, infusing each with constitutional force. This was seen as a powerful way to reverse Argentina’s history of rights violations and to provide citizens with a means to claim their rights. Invoking a human rights framework was effective, as evidenced by the provincial Ombudsperson’s resolution. The community, however, were not aware they had such rights.
INSGENAR and CLADEM developed an educational video incorporating the theatrical presentations of the two actresses, and began using this video in communities as part of their work to educate women about their rights. The Faculty of Medicine has since requested the video to use as a teaching tool with medical students, and asked the investigative team to develop a module on health and human rights for its curriculum. The module, on gender and sexual and reproductive rights more broadly, covers abortion using information and testimonies from Con Todo al Aire and a case study on abortion related to professional ethics and confidentiality. This module was piloted in the spring of 2004.
Calling attention to Argentina’s own reproductive health laws and policies provided additional leverage, not only the 2002 National Programme of Sexual Health and Responsible Procreation, but also Rosario’s provincial level programme of responsible procreation, which guarantees “complete and accurate information on all existing forms of contraception, whether natural or artificial, and assures equality of opportunity in the exercise of personal liberty”. The municipality of Rosario also has its own such programme, which includes emergency contraception.
The School of Nursing acknowledged the practices revealed in the report as common and was the most sensitive to the denunciation of abuse. It asked the investigating organisations to collaborate on a series of seminars and workshops on human rights for nursing students. These took place in June 2004, and training for health staff at one municipal hospital was also organised. Two other hospitals initiated internal activities to address human rights as well.
INSGENAR and CLADEM continue to track the implementation of the Ombudsman’s Resolution No.713. They will conduct a follow—up survey with women accessing services in the six hospitals in Rosario. If discriminatory or cruel practices continue and all local efforts have been exhausted, they are prepared to bring individual cases to international courts.
They have also disseminated the report and video to interested parties in other provinces in Argentina. The responses from several provinces (Tucuman, Santiago del Estero and others) indicate that the findings from Rosario are not isolated but typical.Citation10 They hope to expand advocacy to five other provinces in the country. Finally, they are sharing the experience and findings with activists and researchers in other countries.
Various studies on access to abortion and emergency obstetric care indicate that women’s expectation of inhumane treatment from medical providers is one of the major deterrents to seeking help promptly at a hospital or clinic.Citation11, Citation12 In countries where abortion is criminalised or restricted by law, women face an additional disincentive to interact with the health system unless it is absolutely necessary. Given that abortion is the principal cause of maternal mortality in Argentina and that maternal mortality rates have begun to climb again, changing provider treatment of women who have had abortions — as well as iberalising the existing law — are important public health and human rights responses and will help to save women’s lives.
Acknowledgements
We want to recognise and thank the team of investigators from INSGENAR and CLADEM who conducted the investigation, analysed the findings and wrote the report Con Todo al Aire: Maria Garcáa Jurado, Analia Aucia and Susana Arminchiardi. We are especially grateful to the women who told their stories and the brave social worker who brought the case to light that led to the investigation. The investigation and report were funded by the International Women’s Health Coalition, New York NY, USA.
Notes
* Other research confirms that it is difficult to distinguish between spontaneous and induced abortion in countries where abortion is highly restricted or criminalised.Citation8
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