Within the context of male violence, the Equality Act identifies various violence, including obstetric violence. “The fact is that this law appoints these violations but does not define them, and given that there have been serious discrepancies at this point, a presentation has been made in Parliament to decide on these definitions”, says EH Bildu’s parliamentarian, Oihana Etxebarrieta, who is inviting the paper to deepen the definitions and the committee of the Basque Parliament invited by him.

The perinatal psychologist has given her definition at the beginning of the talk: what is obstetric violence? Medical practices or attitudes in the gynecological and obstetric follow-up of pregnant, childbirth or nursing women, which do not take into account the rights, desires, decisions, needs, emotions or dignity of women and their children, either orally or by action. “With this I do not mean that it is intentionally provoked violence, nor that it is provoked by all obstetric professionals; it is an institutional violence, very difficult to tolerate, because it is provoked and suffered by the professional himself at the same time, and because for the woman it is very difficult to recognize that she has suffered this violence, that is why it is so invisible”.

It is the result of three violence: direct violence – physical and psychological violence that affects people – cultural violence, symbolic violence – the cultural framework that legitimizes such obstetric violence in some way – and structural violence. We should intervene in all three to deal with obstetric violence.

Physical and psychological violence Fernandez has identified as direct physical violence the overmedicalization and the realization of unnecessary medical practices: for example, when it is not necessary to break the bag, perform systematic episiotomies, initiate an unjustified delivery when it is not necessary to perform a C-section… “Our body is pathology, turn the natural process into a disease”. The perinatal psychologist has warned that in some hospitals outdated practices such as Kristeller's maneuver are
used, the woman's thumb is pressed to remove the baby with her knee or elbow, give birth in decubitus, not allow the woman to eat, drink or get out of bed, unjustifiably separate the mother and child, for example after cesarean section, or take her to neonatal observation. Violence is also the lack of attention: no analgesia to relieve pain, lack of monitoring and loss, lack of support during breastfeeding.

Psychological violence is, in general, an abusive behavior that has to do with information: not giving information to the woman, not allowing her to participate, dehumanizing the woman… “Not informing her, violating the principle of autonomy”, says Fernández: “It may happen, indicate that she will have a C-section but what that means, how she will feel, not explaining what the process will be, or even not making a broken intervention.” Psychological violence also includes a lack of respect for confidentiality, privacy and privacy – any entry into the room – and humiliating and humiliating treatment: contempt, contempt, parenthood, threatens to give birth, to blame the woman – the natural birth you wanted, looking now….

“Scientific evidence has been insisting for years that the more physiological childbirth is, the more beneficial it is for women and children; the major international health institutions have made recommendations to respect childbirth in recent years; epigenetics has made a lot of discoveries about the importance of respect for childbirth and good treatment; and through studies we know that respect for autonomy and decision-making capacity is one of the main variables for the satisfaction of women.”

He adds that the Osakidetza protocols are up to date and take into account all the above, “but in hospitals there is a secret, unwritten protocol, and the violent practices are given because the system is like this. Many women report obstetric violence in the Basque Country.”

Normalized violence After talking about symbolic violence, it is a violence that we have normalized and therefore we do not understand it as violence, “we think it is necessary for the good of women and children themselves, and women feel obliged to obey, not to say anything and not to report anything. We have normalized the lack of information on
labor, unnecessary cesarean section, labor alone... and that is why violence is invisible. And after delivery yes, you hear the women say, "How did I get there, how did I allow all this?" Because it is very difficult to recognize that the health system can do harm, and that is symbolic violence: it does harm, unconsciously, but it does, and we have to make it see, precisely in order to change the practice.”

Finally, he mentions structural violence as widespread violence “because it is not an isolated malpractice, but a structural practice of the health system”. And it is for four factors, among others. On the one hand, the gender perspective hides: “The androcentric perspective prevails in medicine and the body of women is a defective body, is not able to give birth; we patinize or transform natural processes into diseases; besides, it is afraid to give birth, to leave something wrong and as fear we more easily accept submission; and even today when a woman asks something, question or complains, it bothers”. On the other hand, Fernández has highlighted the mechanistic view of health: “Technique and protocols have made childbirth very mechanical, the female body is a machine and the child is a product”. Thirdly, the productive approach shows that the number of deliveries per week is much higher than on weekends, as is the number of C-sections. And finally, the class and race perspective: “Women with few resources and rationalized suffer more obstetric violence, according to studies.”

The consequences for the professionals, the woman and the child Fernández says that the professionals feel very questioned, because “it seems that violence is the will to do harm, and in this case it is not, in most cases they do not know that it is violence, they have normalized, like women, and do not teach them to act otherwise. Moreover, not all health personnel use it and not all interventions are
obstetric violence.” Once clarified, he talks about the consequences of obstetric violence. First, regarding the psychological consequences it has on professionals: “Gynecologists, midwives and obstetricians are in situations of stress, because they have to see unrespected and traumatic deliveries, emergency situations, losses… and then the mental health of these professionals is not addressed. Studies show that gynecologists, obstetricians and midwives are more likely to suffer from psychological illnesses than professionals from other specialties, so it is important to take care of the professionals”.

What are the consequences of this violence on women? The physical consequences may be loss of urine and defecation, that is, incontinence, loss of the uterus, bloodshed, chronic vaginal pain, vaginism, bonding of vaginal muscles, loss of orgasm, bacterial and urinary infection, alteration of desire and sexual behavior.. Among the psychological consequences is suffering, disconnection, extreme protection, lack of protection He adds that trauma can cause serious illnesses: severe stress, postpartum anxiety and depression, tocophony, irrational fear of pregnancy and childbirth, post-traumatic stress, influence of the mother in the relationship with the baby…

Finally, it talks about the consequences of obstetric violence on children. The physical consequences may be the rupture of the clavicle, the wound in the face of a cesarean section, mental injuries with the use of tools… and psychological emotional suffering. "It is difficult to see it in a newborn, but neuroscience has already shown it and can have long-term consequences in the construction or attachment of the child's personality."

How to prevent? Fernandez is clear: we have to gradually move towards
a humanist model, and for this we can begin by understanding the perinatal stage (pregnancy, childbirth and puerperium) as a vulnerable stage, “because it is years that we know that childbirth is a more complex process than expected, a very profound psychological and hormonal process, that the brain changes; in childbirth, sensory and emotional violence, and in its version, also perceptive violence. If now when I am 47 years old I go to the gynecologist and it treats me abruptly and there are many people who get in while I am there, even if it is not nice, that will not bring me, but a woman who is giving birth can, and it is fundamental to internalize her to understand why care must be taken to the extreme”.

It is also a very vulnerable moment because the child experiences it: “We still believe that the child does not feel all this, that he does not realize it, and is just indifferent, the smaller, the more vulnerable. Childhood and adolescence are vulnerable moments, being the most vulnerable 0-3”. She adds that it is also a vulnerable moment for professionals, because of all the above and because childbirth has a great capacity for emotional movement.

And another important key to move towards the humanist model is to understand the child and the woman as subjects with all rights, “not forgetting the information provided by machines and technologies, but always above respect for the desires, thoughts, emotions and needs of women and children. The scientific model bets on physiological delivery and goes beyond the physiological humanist model, favors women”.

What can be done from the institutions? The psychologist points out that the implementation of the Equality Act itself is a good
starting point. The law says that “the public authorities will transversally integrate in their policies and actions the objective of preventing, attending and eradicating violence, as well as the priority of the Basque public authorities in the comprehensive care and reparation of the victims”. And it is precisely this last part that Fernández has addressed: “Women who have suffered obstetric violence from there make the demand, do not speak of punishment, but of reparation, recognition and recognition, which is not yet given. That is a very important key.”

Fernandez added that the Spanish Birth Care Strategy (2007) and the birth protocol of Osakidetza are very good, and that in these cases the path is execution, “because they are not fulfilled, because there are all these inertia”.

And another one that should be enforced: the Transparency Act. “We don’t know the hospital data, we don’t have the medical intervention data, there’s no transparency, and without transparency it’s very difficult to know how we are treating in the hospitals of Euskal Herria, what I know is what women tell me.”

It proposes a surveillance plan for professionals: channeling self-care spaces, enabling a space for supervision or care and improving work conditions. He believes that we should look at whether human resources are sufficient and that the presence of a perinatal psychologist in childbirth should be guaranteed. It considers essential the training of professionals who will attend to the delivery of a woman in four branches: neuropsychology, communication, trauma and gender perspective. Finally, remember that in order to comply with all the above during the intervention it is necessary to adapt the material resources (dilation and delivery rooms, operating rooms, resuscitation rooms, neonatologies…).