October 2019 Massachusetts General Hospital Vincent Program in Global OB/GYN
Welcome to the October newsletter! Our goal is to share with you stories from our work around the world, important new publications from academia and the media on global women’s health, a few fun facts, and tips on how to stay safe while traveling. We’d love your input, so if you have a story, or wish to share a tip, send them our way! email@example.com
From the Editors: AK Goodman, Adeline Boatin, Tom Randall
With too many barriers already, maternal care is further hindered by obstetrical violence by healthcare providers and family members. In this newsletter, we would like to share stories and literature on obstetrical violence, a topic sparsely recognized.
Notes from the Field Calling for a Human Rights-Based Approach to Obstetric Care in Chiapas, Mexico Sammie Truong, HMSIV
Left: Sammie Truong, Right: Maria Antonieta, a Compañeros En Salud community health worker (published with consent)
I met Doña Alma* towards the end of my first week working with the maternal health team of Compañeros En Salud (CES), Partners In Health’s affiliate in Chiapas, Mexico. As one of the poorest and marginalized states, Chiapas possesses one of the nation’s highest maternal mortality rates, coupled with a long history of obstetric violence and distrust of the health system.1 Doña Alma squeezed my hand tightly, grimacing as one of our obstetric nurses-in-training placed the Jadelle, a five-year implant, into her upper arm. Having given birth to her 8th child shortly after midnight, this was the method she had chosen for postpartum contraception. Holding their newborn daughter in his arms, her husband cheerfully started teaching us words in Mam, one of the Mayan languages commonly in the indigenous community where their family is from. Only later would I find out that Doña Alma, recovering in the hospital bed, had herself just suffered from both physical and verbal trauma during childbirth. Obstetric violence, a concept used to describe physical and psychological harm to women during childbirth, ranges from dehumanizing and abusive mistreatment to non-consented care.2,3 Disproportionately affecting women of low economic status and indigenous or minority groups, acts of obstetric violence threatened the human and reproductive rights of around 33% of women in Mexico in 2016. 4
Throughout my year in Mexico, I saw reflections of Doña Alma’s story mirrored in the lives of so many other women who bear the burden of structural violence in its endless forms. As my project assessing trends in facility-based delivery, decision-making surrounding childbirth practices, and barriers to obstetric care took off, I began conducting home visits for surveys and interviews in 10 rural communities of the Sierra Madre region where CES operates. I listened to women describe the challenges faced throughout their pregnancy, delivery, and postpartum period—from finding transportation for the four-hour journey to the nearest hospital to fear of mistreatment in health-care facilities.
In one our primary care clinic’s catchment areas, a woman in her twenties paused before asking me “Qué significa ‘ligadura’?” as we finished chatting in her home. I slowly processed her question, the weight of her words slowly sinking in: “What does ‘ligation’ mean?” She waited for my response, straightening her skirt as her two sons ran around the room behind her. I struggled to find the best way to tell her, my stomach plummeting with the sudden realization that, unbeknownst to her, she had been permanently sterilized after her last cesarean delivery. “Es que quería tener más hijos.” she told me softly. “I wanted to have more kids.”
Their stories of resilience and strength in the faces of severe injustices stayed with me in our work to better meet the maternal and reproductive health needs of women in the regions we serve. In between trips to our communities, I got to know Doña Alma’s family little by little. Her daughter would come to my piano classes at the community center in town. Her husband would practice his English as I passed by their family’s stand for roasted corn. Upon my return to Chiapas in early August to continue work on our project, I was invited to their daughter’s first birthday party at their humble home on the edge of town. Celebrating this special occasion—a year after Doña Alma’s experience of obstetric violence—I was profoundly reminded how the world into which one is born ultimately determines the circumstances in which she or he lives. Her baby daughter’s name is Sammie. Our shared name, but starkly different opportunities for reproductive justice, respectful maternity care, and surviving childbirth make even more concrete our mission to right some of the deepest inequities in women’s health in the region.
*Patient’s name changed for privacy and confidentiality (story shared with the patient’s consent) To learn more about this work or about Compañeros En Salud’s projects to promote respectful maternity care and advancing women’s health in Chiapas, Mexico, please contact firstname.lastname@example.org or visit our website at http://companerosensalud.mx.
1) Murray de Lopez J. When the scars begin to heal: narratives of obstetric violence in Chiapas, Mexico. Int Journal Health Governance 2018; 23: 60–9.
2) Grupo de Información en Reproducción Elegida (GIRE). Obstetric Violence. A Human Rights Approach. GIRE., 2015 https://gire.org.mx/en/wp-content/uploads/sites/2/2015/11/ObstetricViolenceReport.pdf (accessed Aug 26, 2019).
3) Molina RL, Patel SJ, Scott J, Schantz-Dunn J, Nour NM. Striving for respectful maternity care everywhere. Matern Child Health J 2016; 20: 1769–73.
4() Castro R, Frías SM. Obstetric violence in Mexico: results from a 2016 national household survey. Violence Against Women 2019; : 1077801219836732.
Invisible wounds: obstetric violence in the United States A legal practitioner's perspective on obstetrical violence, providing an overview of the limitations of the US justice system in addressing obstetric violence, comparison with Latin American jurisdictions and possible policy solutions for the legal and health care systems: https://www.tandfonline.com/doi/full/10.1016/j.rhm.2016.04.004
Gender-Based Violence training seminars focused on disaster responders will be held on Oct 15, 2019, Nov 19, 2019, and Dec10, 2019 from 12:00-1:00 pm at MGH Founders Building. To register for training sessions, please email email@example.com.
Travel Grant of $2000.00 is available to support residents, fellows, and faculty who would like to embark upon a global health trip. If interested, please contact Ak Goodman (firstname.lastname@example.org). Congratulations to Barbara Curtis,whom the grant was recently awarded for Hurricane Dorian relief mission in the Bahamas.
International Tumor Board ECHO Sessions: International Gynecologic Cancer Society holds monthly gynecologic oncology tumor board meetings including gynecologic oncologists and GYN-ONC trainees all over the globe. Interested fellows and residents, please email Thomas Randall (TRANDALL@mgh.harvard.edu) or Ak Goodman (AGOODMAN@mgh.harvard.edu).
Acknowledgments and Thanks
Many thanks to Dr. Gabriel Ganyaglo for sharing his experience on fistula care and urogynecology subspecialty training in Ghana during a city-wide journal club meeting hosted by MGH OB-GYN on October 1, 2019.
Deep thank you for funding support: Karen Johansen and Gardner Hendrie, Al and Diane Kaneb, Vincent Memorial Hospital and Vincent Club, Westwind Foundation, Bank of America Foundation, Wyss Foundation
Thank you for mentorship, leadership, and support: Jeff Ecker