Relations established by women during pregnancy, delivery and postpartum with health personnel according to social class in Bogotá: qualitative study

ORIGINAL ARTICLE

 

Relations established by women during pregnancy, delivery and postpartum with health personnel according to social class in Bogotá: qualitative study

 

Libia A. Bedoya-Ruiz  1, Physician, Master in Public Health
Andrés A. Agudelo-Suárez  1,2, odontologist, doctor of Public Health
Diego A. Restrepo-Ochoa  1,3, psychologist, doctor of Public Health

1 Escuela de Graduados, Universidad CES, Medellin, Colombia.
2 Facultad de Odontología, Universidad de Antioquia, Medellin, Colombia.
3 Facultad de Psicología, Universidad CES, Medellin, Colombia.

This research is an academic product from: Bedoya Ruiz LA. Composition of the relationship of women in pregnancy, labor and postpartum with healthcare services at different levels according to social class. Bogotá, Colombia. [Doctoral thesis]. Medellín: Escuela de Graduados, Universidad CES de Medellín; 2020.

 


ABSTRACT

Objective: To understand the relationship established between women in a situation of pregnancy, childbirth and postpartum with the health services personnel according to social class in Bogotá (Colombia).

Materials and methods: Qualitative study. Critical hermeneutical perspective and critical ethnography. Theoretical sampling. Analysis by triangulation in Atlas.ti. 9 women and 8 health professionals participated. 38 in-depth interviews were conducted for 13 months and 62 accompaniments to the maternal in the activities of prenatal control, vaccination, labor, postpartum consultation, follow-up exams, prophylactic pisco course, hospitalization and waiting room, both in public services as private. Results: There are inequalities according to social class in which the relationship between women and staff is configured in the following aspects: permeability to the needs of women, recognition of psychosocial aspects, having different points of view against a medical recommendation and right to complain or demand to improve.

Conclusions: The situation described above intensifies gender issues in women with a less advantageous social class. It is necessary to develop interventions in educational and health institutions that consider aspects where human resources are sensitized on social issues related to the theoretical proposals of research and the democratization of medical information. It is unfair that the condition of social class and gender affects the quality of care and economically stratifies people’s rights.

 

Keywords: Social Class; Interpersonal Relations; Pregnancy; Childbirth; Postpartum Period (source: MeSH NLM).

 


INTRODUCTION

There is evidence from all over the world demonstrating mistreatment of women during pregnancy, labor and postpartum (PLP) by healthcare personnel (1,2). Even when public healthcare programs were introduced to implement respectful maternity care, the effects of these interventions were not satisfactory in all cases —physical abuse decreased, but other situations such as verbal abuse, neglect, and abandonment (1) did not.

The relationship between healthcare personnel and women during PLP is also a concern in Colombia, where investiga­tions carried out revealed obstetric and gender violence (3-8). Previous studies, which were carried out with women of different educational levels, failed to evidence the inequalities in relationships depending on social classes. This shows conceptual and methodological gaps in public healthcare research on this topic (9), making it necessary not only to deepen into the indicators of maternal morbidity and mortality, but also to the quality of health care.

 

KEY MESSAGES

Motivation for the study: It is important to evidence the gaps in the literature, taking into account that women in pregnancy, labor and postpartum are frequently overlooked as subjects by health professionals.

Main findings: There are inequalities in the relationship that women establish with healthcare personnel according to social class.

Implications: Alternatives must be found in the care process that transcend the traditional biomedical model. Health policies require important transformations in the medical and health education system.

 

This study is specifically based on theories proposed by Breilh and Menéndez (10-13). On the one hand, Breilh’s position is neo-Marxist, that is to say, social class is not a personal choice but determined by structural aspects. Thus, health inequalities reflect social inequalities. In this sense, social class is understood as a group of people who share common interests but have different levels of power, depending on their hierarchies in the work process, and this determines their ability to accumulate wealth (10,11).

On the other hand, Menéndez focuses on critical medical anthropology, based not only on cultural differences (seen as a barrier between the biomedical system and the popular medical system), since it is also necessary to include aspects related to poverty and social inequalities (12,13). The concept of a hegemonic medical model not only ideologically excludes the knowledge historically constructed by the subjects, but also ignores the poorest people and ethnic groups (12,13).

On the basis of the above said, the objective of this study was to understand the relationship established between women during PLP with healthcare service depending on social class in the city of Bogota (Colombia).

 

MATERIALS AND METHODS

Qualitative and flexible study (18,19) carried out with a theoretical and methodological approach, modified according to findings during the fieldwork. It was detailed in a methodological report (19) and reviewed by the research committee and external eva­luators (reliability and auditability).

Phases of the study and participants

The exploration began in May 2017, and the fieldwork began in November 2017 and ended in December 2018. This phase consisted on personal interviews as well as virtual communications through social networks, which created an environment of trust among the participants —the subjects could freely express their thoughts whenever they wanted. The analysis and writing of the information began during the fieldwork and ended in November 2019.

During this phase of the study, nine women from the city of Bogota, at least in the first trimester of pregnancy, and eight healthcare professionals whose sociodemographic characteristics are summarized in Tables 1 and 2. Women with mental ill­nesses or disabilities, minors and those who could change their residence did not participate. Women and healthcare personnel were contacted through social networks and the public sector prenatal monitoring service, three women refused to participate because they did not need the proposed support.

 

Table 1. Sociodemographic characteristics of pregnant women participating in the research. Bogota

a Socioeconomic status. There are 6 status considered in Colombia, with 1 being the lowest and 6 the highest. This stratification is made according to the place of housing.

b Although two women have complementary plans, the companies that provide the healthcare services are different and therefore the clinics are different. This is also the case in the contributory and subsidized regime. Therefore, the first letter is placed to make visible the companies that are different. c Families that have the capacity to sabe and receive income from sources other than work (rentals, equipment rental). d Subsidized EPS. e Financial fund. f Vulnerable localities in the south of Bogotá with worse maternal and fetal health indicators, environmental contamination, deficit of public transport, insecurity, deficit of health services, prolonged transfers between home and health services, public health services involved in corruption

 

Table 2. Characteristics of healthcare personnel with experience in maternal care participating in the study, Bogota.

F: Female; M: Male

 

Procedure

Epistemological perspective

This perspective considered critical hermeneutics, i. e., elements from hermeneutics and elements from critical theory. Gadamer explains that the interpretation of hermeneutics is not “a reproduction of an original production” but a researcher-researched me­diation, therefore it requires understanding, which is far from objectivity. Preconceptions are built by life experiences; this concept determines the way in which a subject can be interpreted (14). Habbermas combines interpretation and critical theory that requires objectivity to analyze the material conditions of the population. This author argues that preconceptions are not always legitimate, because traditions can be imposed, interpretation should serve to criticize ideology. Even if necessary, for understanding the sub­ject’s point of view, interpretation also reveals power relationships that allow developing emancipation (15). The foregoing accounts for the complexity of epistemology —bricoleur researchers do not limit themselves to produce meanings of pure hermeneutics, since they can generate a resistance to the transformation of social conditions (16).

Method

Critical ethnography from Menendez’s relational approach that links micro-social (relationship between subjects) and macro-social aspects (structural conditions) (13), and Sheper-Hughes’ position regarding the role of the researcher, who does not try to blend in with the population, but rather realizes that his or her presence in the community will transform his or her life and that of the subjects of study, for this reason, it questions in a respectful and critical manner, the health situations normalized by the population, which are aspects that contribute to oppression in the midst of poverty and inequality. However, this dialogue is bilateral, since it also allows the population to question it and things are learned from this as well (17).

Quality criteria

Credibility and reliability were evaluated (13,18,19), taking into account the participation of the main researcher who could change the subjects’ behavior. During the fieldwork, situations affecting women’s sexual and reproductive rights were revealed. In some cases, the participants normalized this situation and did not see the problem; in other cases, they sought help from the researcher. The principal investigator provided documented information related to rights, helped to clarify medical terms, asked questions about their wishes and opportunities, and contacted support networks on sexual and reproductive healthcare and state institutions that monitor health care services. It all was done for women to have tools when making their own decisions so themselves, not the researcher, could be the transformers of the situations that occurred in the healthcare services, all of which is consistent with the epistemological paradigm chosen. The reference framework was built throughout the research process, which allowed, at the end of the research, the analysis of the results from different theoretical perspectives (credibility).

In the writing process, the discourses of the actors were differentiated from the analyses carried out by the researcher. The information recorded was made available to external evaluators who so they can verify the results found (reliability and auditability).

Sampling

Theoretical sampling (19), taking into account Breilh’s concepts of social class (10,11) and the type of health affiliation in Colombia (20). Three categories were differentiated according to the work situation related to social class (21): subsidized regime (women with informal work, population without payment capacity), basic contributory regime (salaried women), and prepaid contri­butory regime or plans complementary (salaried women or businesswomen with the ability to pay for private services).

Methodological strategies and techniques

Three to five in-depth interviews were conducted per woman during the PLP (with a live newborn) and information was collected at different points in the research process (credibility). Counting the healthcare personnel, there were a total of 38 interviews.

The interviews were carried out by the main researcher in an unstructured way with open questions (22). A guide was used that included topics related to social class (9-11) and the meanings of the relationship of women with healthcare personnel (9,12). The mee­tings were scheduled according to the availability of the participants in places chosen by them. The conversations were private and confidential: in social organizations, the home when the women were alone, and little frequented restaurants. The duration was one hour on average.

The main researcher carried out the participant observation (13,23) in the health services where the women attended (Table 1). 62 women were accompanied during pregnancy, labor and postpartum. The observations were recorded in a field diary. We sought not to block interaction with subjects. The complete writing was done when not in the field. Accompaniment itineraries were constructed in an ethnographic manner, with descriptive and detailed information (credibility) that included: point of view of each woman (visibility of the PLP process in a historical and situated context), the position of other subjects different from the participants (credibility), the established dialogues and the reflexivity of the researcher. Statistical and epidemiologi­cal information was collected and it was used to build the context of the research, which helped to give meaning to the results. All of the above is available at Escuela de Graduados of Universidad CES in Medellin to inform of the transferability to other Latin American urban contexts with similar health systems.

Qualitative analysis

Similar and different aspects among participants were identified in the accompaniment itineraries. This information was or­ganized during the PLP, which allowed us to see recurrence of theoretical aspects over time by each woman (23). The above was transcribed in an Excel file which was important to analyze the interviews, since there were aspects that seemed to be non-recurring, but when triangulated (credibility) with the accompaniment itineraries, they acquired theoretical importance.

The interviews were recorded by the main researcher and transcribed by two female transcribers from Universidad CES in Medellin. The transcriptions of the interviews and the accompaniment itinerary were given to the participants for feedback.

ATLAS.ti 7 was used for the analysis; a code was assigned to the paragraphs or phrases, which allowed classifying the in­formation. We disaggregated data so we could link them again but in a different way, in the form of categories. This was done seeking to construct concepts related to the theory (content analysis) and group data that have similar meanings, in order to construct concepts that give meaning to the results (24). We could identify 179 codes derived from the data and organized them in 11 categories. Two categories are published in the results of this article. The coding process was carried out with the research group and a social worker.

The results were triangulated taking into account the methodological techniques (credibility) and the socialization process (18,19). This was carried out with peer researchers from Universidad CES and experts in the field, outside the process, which allowed the inclusion of different and interdisciplinary perspectives (reliability, auditability). Likewise, the socialization was progressive with the participants to validate the information and propose strategies that emerge from themselves.

Ethical aspects

We obtained the approval of Universidad CES Ethics Committee (Act No. 99/2016) and the Secretary of Health of Bogota (Act No. N0041000/2017). According to the Colombian Code of Medical Ethics, the clinical decisions made by healthcare person­nel were respected in the medical field, since the attention given by healthcare workers excluded the possible medical attention required from the principal investigator. In the informed consent, it was clarified who the researcher was and her interests as a woman, a physician and a mother.

 

RESULTS

The following two categories were found (Figure 1).

 

PLP: pregnancy, labor and postpartum

Figure 1. A. Trust relationship between healthcare personnel and women. B. Women’s knowledge-power.

 

 

Trust relationship between staff and women (Figure 1A)

Building links between healthcare personnel and women requires trust. This allows a therapeutic link to be established where women accept the recommendations of the staff and there is adherence to the initiatives of the health services. Confidence changes according to the aspects developed in Table 3.

 

Table 3. Trust relationship category codes between healthcare personnel and women

 

The participant observation showed that several sexual and reproductive rights were violated in all the women participants, which implies that obstetric and gender violence affects different social classes. However, for women with a lower social class there are problems that are intensified to a greater extent. For example, the lack of openness to the needs of women and the lack of recognition of psychosocial aspects. In this regard, the healthcare personnel treated the participants as if they were ignorant and careless regarding their own PLP process. Women are scolded and judged when medical protocols are not followed. The social context is not taken into account since they are women who live in the most vulnerable localities of Bogota and with few social networks (Table 1A), which reduces the use of healthcare services. The pain in childbirth, breastfeeding, and medical procedures is naturalized by healthcare personnel and there are no alternatives to connect with women’s feelings.

Women’s knowledge-power (Figure 1B)

Women possess knowledge that they have built into their life stories, through the social networks

that surround them and in health services. The way in which this knowledge is constructed determines the power and decisions they make in health institu­tions. The aspects related to this category are developed in Table 4.

 

Table 4. Women’s Knowledge-Power Category Codes

 

Inequalities according to social class in the above aspects include having different points of view

when faced with a medical recommendation and the right to complain or demand for improvement. In these aspects, women with a lower social class are affected more. In this regard, the participant observation showed that the participants did not express their dissatisfaction with the care provided, nor did they structure formal complaints in the health services. When discussing this aspect with the women, they expressed fear of confrontation and their rights acquired a connotation in favor of public institutions. Similarly, there is a deficit of inputs and human talent in these services, reducing the alternatives for choosing personnel trained in humane practices.

 

DISCUSSION

The findings showed changes in the doctor-patient relationship, taking into account that it is a social and intersubjective interaction, and it results from its own socio-political context. There are structural factors that determine the functioning of health systems under the concept of supply and demand in the global market (25). The doctor-patient relationship includes technological elements such as the use of the computer, which is relevant for the registration of data and acquires a value above the interaction of the subjects. Likewise, the relationship with the power of the administrative sector is visible, which diminishes the freedom of the professional to respond to the market economy, subordinating the ethics of the healthcare personnel (25). In this research, this problem is part of the structural barriers that institutions face in applying humanized practices in PLP.

In this context, the relationship between subjects is not important, but rather the results expected from the medical act. Technology is also transformed, since it is no longer an aid but is central to the structure of medicine. All of the above is more important than the patient, and medical work becomes dehumanized in a socio-political context that encourages this problem (25). In this research, technology acquires a more important role than the signs and symptoms, and also than the accompani­ment, when it comes to physiological and natural childbirth.

The patient-doctor relationship is eliminated by the institutional administrative agenda which is more important than the doctor-patient agenda. In this context, care is depersonalized, and meetings are automated. The doctor’s agenda is structured on the basis of the spatial and temporal conditions of the medical practice. The space and time of this consultation is defined by the institution from an administrative framework that seeks to make medical management profitable. The doctor arrives in a space for which he prepares in his medical training and is forced to apply his biomedical knowledge in difficult conditions, since the time of consultation and the administrative activities that he has to carry out by institutional order eliminate the possibility of taking into account the socio-cultural aspects of the HDP (26).

With regard to male and female identities, medicine has historically been masculinized. This is visualized in the discourse of the English medical society in the 17th century, where professionals are advised to avoid contact and intimacy with patients. In the 19th century, the concept of sympathy (understood as affinity between people who are attracted to each other) is identi­fied in Victorian society as feminine and unscientific, as are doctor-patient relationships. In the United States, after graduating, some doctors integrated sympathy into their work, but others advocated more in favor of technology and separation from interpersonal relationships. These aspects have influenced the fact that in the 20th century, sympathy, defined as skills of an affective nature, has also lost its scientific value (27).

Ignorance of the history of the medical profession allows this masculinization to persist today and the difficulties in inte­grating theoretical and practical knowledge are understandable (27), which affects the healthcare for health service users, since they transit through health institutions where healthcare personnel work individually.

Violence against women in PLP has its origins in medical training, where there are hidden agendas that are learned histori­cally in academic settings. There is a disassociating habitus on the part of healthcare personnel who ignore the human character of women during labor, so it is possible that disrespectful behaviors are validated. The authoritarian habitus generates threats against women who do not follow medical orders, blaming them when they do not “collaborate” (call for the norm) in the de­livery process and disqualifying the pain they feel. In the habitus in action, women are seen as inferior from the professional and gender point of view, which is relevant for the repressive rules that women accept in a subordinate way in a context where suffering is supposed to be deserved and the social reality of the population is ignored (28).

Gender related issues are observed across social institutions (29) and health services are no exception (30). In them, the related feminine and masculine roles are established, giving an account of the hierarchies developed at a social level (29,30). Women’s partners, present in the research, are excluded from the care process, assigning the reproductive role exclusively to women. However, men are included in the services when it is desired to impose certain institutional practices on women. Autonomy in decision-making about women’s bodies is determined by the presence of the child, in which the state, health professionals and the father of the fetus play important roles.

Within the limitations, this research did not seek to generalize as population studies traditionally do, but rather to un­derstand specific aspects of the problems raised in the research. A traditional ethnography was not carried out, where the researcher lives permanently in the field, but 13 months of observation were carried out, staying in the field at least three days a week. The participant observation was carried out only by the principal investigator, taking into account economic limitations. This researcher is not an anthropologist, but a doctor from Bogota, who is part of the context, and her vision could ignore other aspects that could be relevant in the analysis of the information. However, this public health research has been a collaborative work, where the support of social science researchers was relevant, who helped to build a comprehensive vision of the medi­cal issues to be analyzed. It would have been possible for a greater number of people to participate, in search of the excessive amount of information in relation to social class, but given the established budget and schedule, more women could not be invited to participate.

In conclusion, it is necessary to develop interventions in educational and health institutions that take into account the theo­retical and methodological proposals of this research and the democratization of medical information. Health inequalities and inequities are preventable through public policies with a gender perspective that contribute to transforming both the health and educational systems in Colombia. It is necessary to study in depth the impact of the HDP on the quality of the care process and to identify the different masculinities that play important roles in women’s relationships with healthcare personnel.

Acknowledgements:

To the women and healthcare personnel who participated in the research. Fundación Arka, Organización Apapachoa, Movimiento Nacional por la Salud Sexual y Reproductiva en Colombia, Tribu Criarte, Secretaría de Salud Bogotá. To Marcelo Amable, Alfredo Maya and Monica Saenz for their contributions from the social sciences. To Universidad CES in Medellin and Colciencias for their funding.

 

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Sources of funding: Colciencias National Doctoral Scholarship calling 647-2014 and Small Amount Calling from Universidad CES in Medellin, Colombia.

Citation: Bedoya-Ruiz LA, Agudelo-Suarez AA, Restrepo-Ochoa DA. Relations established by women during pregnancy, delivery and postpartum with health personnel according to social class in bogotá: qualitative study. Rev Peru Med Exp Salud Publica. 2020;37(1): 7-16. Doi: https://doi.org/10.17843/rpmesp.2020.371.4963

Correspondence to: Libia A. Bedoya-Ruiz; Escuela de Graduados, Universidad CES, Medellin, Colombia; Calle 10 A No. 22 – 04. Medellin, Colombia; bedoya.libia@ces.edu.co, bedoyalibia@hotmail.com.

Authors’ contributions: All authors participated in the conception, design of the work, analysis, data interpretation, critical review and approval of the final version. LABR carried out the data collection and initial writing of the article. All authors are responsible for all aspects of the manuscript and warrant its content. This article is part of LABR’s doctoral training process in the PhD in Public Health at Universidad CES and will be used as part of the material used for the thesis dissertation.

Conflicts of interest: All authors declare that they have no conflict of interest.

Received:
14/11/2019

Approved:
05/02/2020

Online:
23/03/2020

 

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ISSN electrónica 1726-4642 - ISSN impresa 1726-4634
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