INTRODUCTION
It is a known fact that health care crises potentiate social inequalities, including those related to gender.1,2,3 The isolation and social distancing measures taken in this respect are key to reducing the spread of COVID-19. However, it has been acknowledged that these measures increase the risk of gender-based violence, especially of domestic violence, forcing women to remain isolated with their aggressors, reducing their economic resources and hindering their access to social networks and support.4 The increase in gender-based violence during the current pandemic has indeed caused widespread concern worldwide. In Argentina, calls to the emergency hotline that provides counseling and support to women undergoing situations of gender-based violence have increased by 39% since the start of the social, preventive and mandatory isolation.5 In 2020, femicides also rose by 5.36% compared to the previous year.6 For all these reasons, the governments introduced several measures, such as a reinforced hotline system for victims of domestic violence or the exemption of certain women from mandatory isolation in force majeure events.7
Health measures in response to the pandemic also had an impact on the access to sexual and reproductive health, in general, and on legal abortion, in particular. It is estimated that, once the current pandemic is over, the percentage of women with unmet needs of family planning will go back almost 20 or 30 years,8 especially in the most vulnerable sectors suffering the greatest social inequalities.9) The restrictions affecting freedom of movement could add new barriers to accessing safe abortion care, delaying the request of abortion services and the early detection of pregnancy.
In Argentina, before Law 27610 on the Voluntary and Legal Termination of Pregnancy was enacted in December 2020, Section 86 of the Criminal Code authorized specific exceptions or “grounds” for legal abortion. Despite the regulatory framework, women who sought the legal termination of their pregnancies encountered different barriers that included lack of information on the scope of the different grounds mentioned, illegal restrictions imposed by the health care sector, arbitrary gestational limits, the need for filing a complaint or requesting a court order for the termination of a pregnancy resulting from rape, among others.10 Although at the beginning of the pandemic, the Argentine government claimed that legal abortion and other services of sexual and reproductive health were essential and issued specific recommendations to ensure access to those services, this was not translated into concrete facilitators for women.11
The overburden that the pandemic imposed on the health care system aggravated the already deteriorated working conditions, the shortage of supplies and personnel, and the preexisting barriers.12 The high dynamics of the epidemiological situation and the organization of the health sector itself constitute a relevant framework to ask ourselves how the health care of these concerns have been channeled. For this purpose, we focused our research on how health care services address gender-based violence and care for legal abortion in the context of social, preventive and mandatory isolation in two Argentine provinces with high rates of COVID-19 infection in the period under study.
METHODOLOGY
A qualitative exploratory-descriptive study was conducted in the cities of Cordoba and Resistencia, Argentina. The study population included professionals from the first and second level of care and key informants from social organizations, management institutions or gender-based violence care centers. Inclusion criteria were: professionals with at least one year of experience in their workplace and actively working in health centers or public hospitals at the time of the interview. Key informants from both cities who at the time of being contacted, occupied public policy decision-making positions, worked in gender-based violence care centers or belonged to social organizations related to gender violence or have expressed it. A non-probability convenience sample was selected. Interviewees were voluntarily recruited using the snowball sampling technique. Table 1 shows their characteristics. During the months of May to June 2020, 27 semi-structured telephone interviews were conducted, each of them lasting approximately 40 minutes.
| City | Health Profession | Gender Identity | Workplace |
|---|---|---|---|
| Cordoba | Psychology | Woman | Public Hospital |
| Cordoba | Nursing | Woman | Public Hospital |
| Cordoba | Psychology | Woman | Health Center |
| Cordoba | Social Work | Woman | Public Hospital |
| Cordoba | Medicine | Man | Health Center |
| Resistencia | Nursing | Woman | Public Hospital |
| Cordoba | Nursing | Woman | Public Hospital |
| Cordoba | Social Work | Woman | Health Center |
| Resistencia | Nursing | Man | Health Center |
| Cordoba | Medicine | Man | Public Hospital |
| Resistencia | Bioimaging | Man | Health Center |
| Resistencia | Medicine | Woman | Public Hospital |
| Resistencia | Medicine | Woman | Health Center |
| Resistencia | Psychology | Woman | Public Hospital |
| Cordoba | Psychology | Woman | Public Hospital |
| Cordoba | Medicine | Woman | Health Center |
| Cordoba | Social Work | Woman | Health Center |
| Cordoba | Nursing | Woman | Health Center |
| Cordoba | Nursing | Woman | Health Center |
| Cordoba | Medicine | Woman | Public Hospital |
| Resistencia | Key Informant | Woman | Gender-based violence care center |
| Resistencia | Key Informant | Woman | Gender-based violence care center |
| Cordoba | Key Informant | Woman | Women’s organization |
| Cordoba | Key Informant | Woman | Women’s organization |
| Cordoba | Key Informant | Woman | Women’s organization |
| Cordoba | Key Informant | Woman | Management/Provin-cial Health Program |
| Cordoba | Key Informant | Woman | Women’s organization |
Source: Own elaboration.
Participants were verbally informed of the objectives and methodology of the research and anonymity and confidentiality were ensured. Although the research project was not evaluated by an Ethics Committee, as it was not a regulatory requirement of the funding entity, the ethical guidelines and regulations in force were complied with. Once the participants gave their verbal consent, the interviews were recorded and subsequently transcribed.
A thematic analysis of the data was carried out, using the ATLAS TI 7.5.4 software, following Braun and Clarke’s approach. 13 This method involved three phases: 1) initial coding; 2) organization of codes into themes and subthemes, and construction of a first hierarchical tree; 3) definition of themes and subthemes with a higher level of abstraction and interpretation. Subsequently, an analysis by profiles was conducted comparing the themes between cities. Finally, the results were reviewed together with one of the interviewed professionals.
RESULTS
Three themes and subthemes were identified, revealing the existence of barriers and facilitators in gender-based violence care and legal abortion in the context of the pandemic.
Changes in detection and health care demand
The participants remark that the context of social, preventive and mandatory isolation strongly exposes women to situations of gender-based violence and unwanted pregnancies:
...the isolation confronts us to a new situation... and when you share your life with a violent person, a context of confinement is indeed an aggravating factor and, obviously, these women are forced to have sexual intercourse. (Female nurse, public hospital, Resistencia).
In view of this situation, they agree that the role of the health care sector in response to gender-based violence has been modified, as fewer situations of gender-based violence are detected compared to the non-pandemic context, as well as an upsurge of cases reaching the health services:
I’ve heard that violence has increased and that a greater number of deaths have occurred; on top of all, we are so much focused on not getting infected, on not having a virus flare-up, that all the rest is overshadowed. (Female nurse, public hospital. Cordoba)
Now, these situations are not detected as before. Today, the emergency is resolved and they go back home. (Female physician, health center, Resistencia)
These very extreme situations keep coming up... many women come to the health center when they take their children to school or before or after work. With the current restrictions, I think that we stopped receiving these situations, although this center has a history of community bonds” (Female psychologist, health center, Cordoba)
With regard to legal abortion, the participants highlight the fact that there has been an increase in demand. One of the reasons mentioned has been that the health care system channeled a large part of the demand that previously reached the support networks (activists that accompany and facilitate access to legal abortion), either by direct access to the cases or by referral of the supporters themselves, who articulated with the health sector due to the lack of misoprostol during the context of social, preventive and mandatory confinement:
The perceived demand for legal abortion is also for the supporters, who constitute another group of women that are also working and accompanying women... The way they used to work before has been seriously affected now. (Female nurse, health care center, Cordoba)
Moreover, they emphasize the problem of addressing the cases of legal abortion of the women who arrived with advanced pregnancies. Post-abortion controls in the cases of performed legal abortions were also affected.
The following subthemes explain the factors associated with the abovementioned changes in detection and demand.
Health care reorganization: everything became blurred
The health emergency brought about a reorganization of the health care system. First, the change in health care is highlighted, for example, the health care centers and the hospitals dedicated to the exclusive care of febrile patients. Spaces, circulation modes within the services and the implementation of new care protocols were also modified, among other changes:
From one day to the next we stopped the attention, because priority was given to febrile symptoms. We didn’t know what to do, we didn’t understand well how to proceed. We had to remain seated while waiting for a possible febrile patient to arrive... this was not something that we determined; it was determined by the COE [emergency operations center], which is a group of experts that makes the decisions, good decisions indeed, but not consulting the people living in the community. (Female nurse, health center, Cordoba)
The changes to the care spaces were another barrier that modified key aspects related to the approach and detection of gender-based violence and access to the legal termination of pregnancy:
Having to attend people through the window, and people telling you everything through the window, nobody being able to enter the premises, is a measure of exclusion (Female social worker, health care center, Cordoba)
We cannot conduct an in-depth interview, because I’m attending through a window, requesting information, asking why patients are consulting. And I can’t ask them about their lives. (Female nurse, health care center, Cordoba)
The patients mentioned several constraints related to this reorganization. One of them was that the users reduced their demands in health care centers and hospitals, on the one hand, because of the fear of becoming infected and, on the other hand, because these centers and hospitals had become “expulsive” and restrictive places, not allowing patients the possibility of accessing an on-demand consultation or controls, except for emergencies:
...you go to the hospital and you know that in the social service they will listen to you... and now there is no possible access to the hospital. So, we are really worried about how this situation is being resolved and we believe that this is going to have a great impact of a different kind; at this point I’m not afraid of COVID, I’m afraid of all these other things that we fail to look after and that are still happening. (Female social worker, public hospital, Cordoba)
Furthermore, those who could attend the hospital, had to go through a triage assessment to access medical care:
I think that the hospital priority was to be so clean, so pristine, that it denied access to everybody. If the hospital was able to free itself from an admission requested by a person requiring it, it has indeed succeeded! Then, if a woman requested attention for gender-based violence at the hospital, she would not even receive emergency care. I don’t know if at the same door or at triage assessment, because they have to go through various places, but she was denied access or had been sent elsewhere (Female nurse, public hospital, Cordoba)
Thus, for several months and mainly in hospitals, attention was suspended for other problems unrelated to COVID-19, such as legal abortion or gender-based violence:
All appointments were canceled... Now, in this situation, there is no demand. Almost every day, we used to be called for suicide attempts, or violence… And the truth is that since this pandemic began, these calls have stopped. (Female psychologist, public hospital, Cordoba)
People do not want to go to hospital because it is the place where the risk of infection is at its highest. And legal abortion care was provided precisely in hospitals. At the time, we analyzed the possibility of providing care outside the hospital, mainly in the centers, but I don’t know if this was finally possible. (Key informant, gender-based violence center, Resistencia)
The suspension of gynecological controls and the barriers to obtaining contraceptive methods resulted in the increase of unintended pregnancies:
Failure to control an intrauterine device the last two months led to its removal, but by that time a pregnancy had already occurred. (Female nurse, public hospital, Resistencia)
In addition, the suspension of health promotion and prevention activities that were especially conducted in health centers was reported, which has substantially modified the approach to gender-based violence:
What happened to us with the pandemic was that all our achievements in the community were lost, because the people couldn’t meet at home, they couldn’t hold meetings with the women’s group, we couldn’t organize the fair in the square, and the sewing workshop that we had here in the center and was a space to talk of violence was suspended… This is fundamental, because it is a space of containment and accompaniment, a reason for leaving the house and do something different; we couldn’t have it any longer. (Female social worker, health care center, Cordoba)
Health care relationship: the importance of bonds and the presence of the body
Care in the context of the pandemic has implied using protection elements, inhabiting spaces with limited privacy, reducing the contact with patients and consultation times, thus affecting the detection of gender-based violence and access to legal abortion, given that their approach requires environments that facilitate trust, listening time, dialogue and comprehensive care:
Interviewing using masks and face shields… generate distancing that does not encourage an interview involving a dialogue about what is actually happening. It has created one more distance. Did you see that the doctor’s coat establishes a distance and a hierarchy with the patient? Well, imagine a whole preparation for an interview with a person that you want to help, but can infect you with a virus. (Female social worker, health center, Cordoba)
These changes in the relationships, such as “not being able to ask in depth” has also generated discomfort among professionals, who changed their way of delivering care and conducting their tasks, mainly to avoid being infected by the virus:
It has all been very different because care has changed and... all those types of problems usually end up with further asking; but that has stopped. Emergency care has become a priority, a more expeditious and less comprehensive priority... In a context of greater normality, more questions are asked and surely the problem comes out... In this context, everything was faster. I wasn’t relaxed to speak, to ask more questions. I mean, I really felt that I was working under pressure… And that was difficult. Because it depends on us that the problem may come out! Sometimes, I admit, it is clear. They come because they have that need, that demand, let’s say. On other occasions it is not that way, it’s like having to look for it... But, these days, everything is faster, such as ‘take it, go over there and so on’... It has caused me a lot of discomfort (Female physician, health center, Cordoba)
It is not just inserting a birth control method in a woman, I also ask them and they tell me things, so this situation of not being able to listen, to speak or evacuate a doubt, which they consider “a stupid question…it is not stupid, it is a question that frightens them. And being able to talk it over and understand is indeed reassuring. So, in those few months all that had been lost. (Female nurse, health center, Cordoba)
Although the participants claim that they were able to reorganize care and conduct follow-ups on situations of gender-based violence and legal abortion through video or telephone calls, they highlight the difficulties that they have encountered, for example, finding a private place where the women could speak, and the importance of, at least, having a first face-to-face meeting to establish relationships of trust with the users:
Going through these situations and interruptions alone is very difficult. And this situation of confinement, of isolation, makes us feel much lonelier … much of the feedback that these women gave to us is the importance of being present, right? It’s a hand that supports, because it is very difficult to go through this situation. It causes great distress, tension, it involves the body and causes all sorts of pain; then, it is not the same to face the situation alone than to be supported or accompanied or being able to talk to somebody… I think that nothing can replace talking face-to -face… everything is there, the presence of the other, the presence of the body, and all that has been taken from us... at least to create a therapeutic space, we need to have a face-to-face meeting... particularly in the case of violence, I think it is essential. Because, there is often a body that supports. Given that a characteristic of violence is the loss of strength: “I’ve lost my strength”, the body is tired, exhausted and so, it is necessary to accompany and help the body recover that strength... This is why I’m telling you about the importance of hugging. I think that a virtual hug is impossible. (Female psychologist, public hospital, Cordoba)
Moreover, the bonds with the neighborhood, and the work with the community were suspended for a while, especially in the health centers designated as fever clinics:
As our center was not a fever clinic, we were able to attend to other matters... I was able to schedule vaccinations with several women in the neighborhood who run community kitchens. And, also to stand up for myself and be able to say: “Listen, this is happening to us right now” “we are working this way” and everything was sort of improvised along the way. And it was a relief for us to be able to be in the neighborhood and work with the people and stand for ourselves again. Because bonding is very important!... and we lost it, it was gone overnight. So, it was very important to make this connection, to approach the neighborhood, and despite wearing masks, shields and gloves, it was important for people to hear words uttered...it reassured them…from then on, several actions were conducted along with other women in the community. (Female nurse, health center, Cordoba)
Shortage or lack of resources
The participants from Cordoba highlighted the shortage of contraceptive methods: “We are running out of resources, of birth control methods, they arrive in dribs and drabs, we have no condoms” (Social worker, health center, Cordoba). These shortages led to a greater risk of unwanted pregnancies: “There were no control methods, condoms or injections for two or three months, it’s been a long time since implants were available... no access to intrauterine devices or pills.” (Female nurse, health center, Cordoba).
They also underlined the fact that not only there was a shortage of misoprostol for some months but also that the pandemic context deepened the barriers to its centralized distribution:
You can›t imagine what that is like! I work near [location] and I have to drive up to [neighborhood in Cordoba], which is on the other end, everything is inaccessible... that is, it has to do with a person’s willingness to do things. Nobody without commitment will take all that trouble to get misoprostol. (Female nurse, health center, Cordoba)
Moreover, the lack of biosecurity is also highlighted in both cities: “Luckily many face masks were donated for the people, because, otherwise, we couldn’t have conducted the interviews (Female social worker, health center, Cordoba).
They mention that very few and low-quality protective elements were received and that they even had to buy them using their own resources to avoid getting infected: “The face masks they sent are as thin as tracing paper, they don’t protect the wearers!” (Male nurse, health center); “we have to buy the masks and the caps, because the State does not provide much” (Female physician, health center, Resistencia).
Barriers that should be mentioned were the changes to the composition of the teams, either because some people were forced to take on new functions, or because face-to-face working hours were reduced, or because they belonged to risk groups or had been infected within the teams:
There was a reduction of personnel that guaranteed legal abortion... with the pandemic all the teams were restructured and perhaps they were left alone (friendly professionals), so many of them announced that they would not be able to guarantee legal abortion… During a situation of sexual violence that we attended, we had to articulate, looked for them because in the midst of the pandemic they have transferred part of the teams that were in charge of dealing with those situations to other positions… Everything shocks you, especially as a worker, because when you come down to the question of who you will set up a work team with to assist in the situation, you realize that there are fewer people left. (Female psychologist, health center, Cordoba)
In some health centers there is no availability of psychology or social work professionals. In addition, they complain about the lack of resources and training on gender-based matters:
In the health center is just about “exposing one’s body…” I’ve witnessed discussions between men and women and there was no other resource, let’s say. Very few resources... No supplies… And in this center, there is not even a psychologist. (Female social worker, health center, Cordoba)
The difficulties for the articulation among professionals, which were deepened by the pandemic context, were also highlighted in relation to the comprehensive care centers devoted to violence care:
The demand for [gender-based violence care] is extremely high and the number of professionals is not enough to give answers, so we always receive complaints at the hospital… the confinement has deepened all the situations of discomfort, of violence, of lack of answers, because although we are articulating with the [care center] and they are providing answers… treatments and care have also been slowed down, mainly due to the decrease in health care attendances and also to women’s inability to access the health services. (Female social worker, public hospital, Cordoba)
We helped and accompanied in requesting the scholarship, in solving the question of the rent… encountering many difficulties because in the [gender-based violence care center] assistance was provided by phone (Female psychologist, health care center, Cordoba)
The impact of the restriction or absence of public transport on the context of social, preventive and mandatory isolation has also been underlined:
This last month we are implementing a remise (chauffeured car) service, so that they can come, because in this context there is no transport available, and they are not able to travel either. (Female social worker, public hospital, Cordoba)
...they cannot access the hospital, because of the isolation and also because, today the urban transport service has not been in operation for more than three weeks and people who have access to public health, rarely have their own transport. (Female nurse, public hospital, Resistencia).
Violation of rights
The pandemic has deepened existing social inequalities. Difficulties in accessing food have been highlighted:
At first, there was no access to food... too much vulnerability (Key informant, gender-based violence health center, Resistencia)
...in the pandemic, the shortage of food is the emergency in the neighborhoods (Key Informant, women’s organization, Cordoba)
These people don’t even have money to eat, we provide them with food. This pandemic has made me take a lot of money out of my own pocket, because the women have no way to get it. Giving them AR$300 to go to the forensic unit and then to fetch the anti-panic button... As a health team we collected a large amount of money to buy food bags for some family groups that had nothing to eat. Such was the level of need. (Female social worker, health care center, Cordoba)
The lack of economic resources is a key barrier for women who face gender-based violence:
They didn’t want to report the violence because they would have nothing to eat the next day... they would be left homeless, because the guys would throw them out on the street... If they have nothing to eat, how can they think about separating from the guys who abuse them every day? (Female social worker, health center, Cordoba)
The overcrowding and precariousness of the houses in the context of social, preventive and mandatory isolation has increased the risk of domestic violence and the barriers to accessing legal abortion:
With these problems of drug consumption and violence, everybody says that “the house is the safe place” and that’s why you have to isolate yourself, when in fact “the house is not a safe place for many people! Because it is precisely in the house where these situations of violence occur, so we are recommending people to stay at home, to avoid getting infected with coronavirus, but we are exposing them to other problems. (Female psychologist, public hospital, Cordoba)
Staying at home all the time and not being able to tell anybody. Being able to come out with an excuse is becoming difficult... I think that being at home with a lot of people is one of the barriers. As it usually happens, [the abortion] is hidden from the woman’s partner, mother-in-law or mother and suddenly, being there with all these people is indeed a big problem. Another thing that always helps a lot is when we get together to talk with other women. It is then that somebody says “Juanita went to such and such a place and they tell us, and not being able to have that meeting, is another barrier (Key informant, women’s organization, Cordoba)
Added to the situation are the inequalities in care tasks that especially fall on women:
I saw many women who express how tiring it is to have their partners and children in the house all day…You can see it in their faces when they say: “I can’t stand it any longer. (Female social worker, health center, Cordoba)
The inequalities in accessing the Internet and the lack of computers or cell phones have impacted on the access to health care, the relationship between professionals and users and the access to the few emergency social policies:
I have sat whole afternoons next to people to help them conduct online procedures... Access to redistributive policies, such as the IFE (Spanish acronym for Emergency Family Income) and others are OK if you have a certain level of schooling and literacy… It is indeed complicated to carry out administrative procedures in the ANSES [National Administration of Social Security] or here in the provincial registry. Everything is online!... many people have lost these resources because they don’t know how to manage themselves online or open an e-mail, because they don’t have Internet! (Female social worker, health center, Cordoba)
Finally, the impact of social, preventive and mandatory isolation on precarious jobs and health is also underscored:
It is the fifth time that this lady comes to the center and she has no evident health condition, there is clearly something else going on. And what do you think? “Well doctor, this is the problem, it is this context, I don’t have a job and I can’t go to work.” This is especially the case for domestic workers because the IFE is not enough, so they cry, they are nervous and obviously they let their emotions out. (Female physician, health center, Cordoba)
Access facilitators
The barriers mentioned and the great impact of the pandemic on the working conditions of the health personnel (reduction of working hours and wages, job insecurity, lack of information and low intervention on decision-making, inability to access paid leaves, job burnout, among others) went hand in hand with a high commitment to their roles and tasks:
The precariousness of public health was evidenced in the province of Chaco, it was in a state of serious neglect. There have been few investments in recent years, Imagine, I have been here for nine years and I am still not a permanent employee, you understand? And just now did they realize that I am in their system, toing and froing, covering different positions. It is then that they realize how important we are. (Male nurse, health center, Resistencia)
The topic here delves into two aspects that have facilitated approaches and access: feminist practices and innovative approaches.
Networks, commitment and feminist practices in health
Health training from a gender perspective is key to changing professional practices:
We come from training institutions, but we haven’t been trained to address the patient in a comprehensive manner, so it is very difficult for us to learn. There are certain professionals who do learn and others who don’t. Maybe they have spent their entire professional lives without looking at the patient in a comprehensive manner, either because they don’t want to or because it is hard for them. (Female nurse, health center, Cordoba)
The interest and personal commitment of several professionals to train in this comprehensive approach using their own financial resources has also been underscored here:
All the training that we may get on gender matters is the result of our personal decisions to take up those courses... we decided to get training and understand the importance of gaining insight into gender-based violence. But it is never a policy proposed by the State, the Department of Health or the hospital. (Female nurse, public hospital, Resistencia)
Several of these nurses mention the fact that it is not only training that changes their practices but also becoming aware of the inequalities that they themselves face, such as gender-based violence:
Training always changes you, but it is the internalization of this training in your body that changes you the most. I’ve changed a lot on how to intervene when I experienced this internalization permeating into my body, for a lot of personal issues that we obviously resignify with theory. Our generations were not trained on feminism. We had ‘to format’ ourselves... And I did so when I saw myself going through the situations that ended up in a separation from my ex-partner and after working this year with a group of women that were physically permeated with situations of extreme violence... Well, listening to them, living with them…helped me resignify many things that I had been experiencing... Later, in recent years, working with abortion has also helped me. (Female social worker, health center, Cordoba)
Being part of the Network of Health Professionals for the Right to Decide has been key in this context because it has facilitated the circulation of information, the articulations among professionals and has provided support, especially in Cordoba:
We help each other. I just asked about the notes needed for requesting misoprostol, and a colleague that is part of the network sent me a WhatsApp message on how to make the note. And this is the way it is, all the time!” (Female social worker, health center, Cordoba)
First of all, because of the training and permanent information that circulates and, also because it is a much faster means of communication, with answers readily available. We have a ‘recursero’ [a guide with information resources] that is made by the network... who are the colleagues that can provide answers so as not to be sending information to women who will have negative answers or whose rights may be violated. We use WhatsApp to communicate. The demand comes to you, you post it on the group and eventually someone will answer or you may call a contact person and that makes everything simpler than perhaps doing it at an institutional level (Female social worker, public hospital, Cordoba)
The truth is that it was all very intense, very distressing at first, we were afraid, and in distress of having to reorganize everything against the clock, with no clear guidelines from the top levels. So, well, the networks are reactivated in difficult times and sustain us. (Female psychologist, health center, Cordoba)
In addition, several people mentioned that the network was strengthened in this context, among other factors, due to the need to solve non-channeled cases:
The networks helped us strengthen ourselves. Because we had to communicate and speak more frequently, not only in the capital city but with colleagues across the country (Female social worker, health center, Cordoba)
The support of the network was key in this context, where on other occasions, they had to face the resistance of other professionals to guarantee legal abortion:
This also happens when we talk about legal abortion and sexual reproductive health, we receive many blows, to whoever talks or brings about the subject or discusses it. (Female nurse, health center, Cordoba)
You surely know that not everyone agrees with this freedom to decide. As we are more open-minded in the evening shift, we try to guide and support it. We provide them all the tools. (Female nurse, health center, Cordoba)
In that same sense, they notice differences between their “friendly” practices as they call them, and those conducted by their peers:
The truth is that the assistance center for violence victims is the one that best coordinates these cases. Because we are a dire mess. I’ve seen outrageous things being done! Every time I’m on duty I try to deal with the situations because I have become sensitized to gender-based violence, to legal abortion, I am fully committed with everything I do for sexual, human and women’s rights. But not all of us work like that! I see the weaknesses. (Female physician, public hospital, Resistencia)
This commitment to guaranteeing rights has led some professionals to define their practices as feminist, which they describe as follows:
First, we listen to the women, we believe them, and then we think about the answers... Listen and believe! And based on that, we hope that the practice is a response to the demand made by the people for whom we work (Female social worker, public hospital, Cordoba)
Furthermore, mention is made of the key role that women have played in the community kitchens and how they have become meeting places for addressing various problems, such as gender-based violence and legal abortion:
In this pandemic context, the community kitchens have been key references... The specific demand was the food question, but other issues were identified. Not only was a glass of milk or a meal, but other things were combined. (Key informant, women’s organization, Cordoba)
Innovative approaches
The barriers led to approaches that made it possible to respond to the needs. Several actions conducted to maintain the bonds with the community are highlighted, such as the use of telephone and video calls to address situations of gender-based violence and follow-up and accompaniment in cases of legal abortion. Various communication channels with the community were also strengthened, such as the community radio, the creation of WhatsApp groups or home or neighborhood visits:
...whenever we could go out, we put up posters in the streets, talked with the women in the community kitchens, telling them that in cases of violence or if they needed contraceptive methods or to terminate a pregnancy, we were still there, they could count on us and asked them to please contact us. (Female nurse, health center, Cordoba)
The toll-free hotlines available for the attention of sexual and reproductive health care and gender-based violence, and the new way of reporting these cases via these hotlines were key:
I have noticed that the 0800 hotline is really working now…so, the women are being encouraged to get information related to the different steps to be followed for legal abortion. (Female physician, public hospital, Resistencia)
The 0800 hotline has somehow facilitated the assistance to women, it has improved a lot because the entire assistance group of the [violence assistance center], has moved to this hotline. Having the toll-free hotline number to call and report their cases, which are received via phone, was very important and has helped a lot. (Female social worker, health center, Cordoba)
In Resistencia, they highlighted the creation of a digital registration system of gender violence cases that facilitated networking:
As a result of COVID, we set up an online platform, where the users calling the 137 emergency line here in Chaco are registered... the idea of the platform is to connect several teams on the same axis, on a spreadsheet, so that we all share the information, and see how to articulate (Key informant, gender violence assistance center, Resistencia)
The importance of surveying the population through georeferencing was also mentioned:
We initially conducted a large survey, in all the neighborhoods of our program area… so as to identify the most vulnerable groups in the pandemic, not only in the map but also in our mind. We follow the same procedure to detect those neighborhoods with violence cases. (Female worker, health center, Cordoba)
Finally, in Cordoba, at the time of the interviews, a Comprehensive Women’s Health program was created to expand access to contraceptive methods and assistance to gender- based violence. However, the participants were not aware of its existence.
DISCUSSION
Although in Argentina, sexual and reproductive health has been proclaimed as an essential service and the approach to gender-based violence has been strengthened, the pandemic put women and pregnant individuals at particular risk. This study, just as others at the national and international levels.4,8,12 contributes evidence as to how the pandemic deepened preexisting social inequalities, leading to social exclusion and specific limitations in terms of accessibility to health services.14,15 Specifically, the differential impact was observed on the basis of social markers associated with gender and social class, which have historically been articulated, producing social exclusion and specific limitations in terms of accessibility to health care services.14,15 The context of social, preventive and mandatory isolation generated particular dynamics as a result of the situation of increased poverty and vulnerability, impacting on women’s possibilities to access the protection services or report gender-based violence cases or health care issues,16 as shown in this study.
The results obtained evidence that this pandemic changed the role of health care services as a result of the access to legal abortion or the approach to gender-based violence. With regard to legal abortion, and in line with other international studies, this work showed that the pandemic deepened preexisting access barriers and created new ones, which had a disproportionate impact on the most disadvantaged sectors.17,18,19 In agreement with the bibliography, the results obtained show multiple barriers to accessing sexual and reproductive health services associated with free movement restrictions, the avoidance or rejection of using the services for fear of becoming infected and the limitation of specific supplies and services.9,20 For example, in the Spanish State, territorial inequalities have deepened because, despite the fact that abortion was considered an essential service, the possibility of avoiding the movement involved in getting initial counseling, which in fact is legally mandatory, through the use of digital communication tools, was only implemented in Galicia and Catalonia19. Moreover, there was an increase in the obstacles that had historically hindered access to the provision of legal abortion services in the health system and that are inherent in the institutional culture and the barriers imposed by professionals through their practices and attitudes towards abortion.18 In this sense, the impact of the pandemic on the organization of the health system was evidenced, both in the provision of services and in the personnel available and qualified to provide care. Although social isolation has led to an overall reduction in the demand for sexual and reproductive health services, as other research works have also shown at the international level,19,21,22 our results have also underscored the increase in the demand for abortion services in the health sector, probably as a result of the articulation of professionals and support networks and the recent approval of the law in Argentina.23
In the context of the recurrence of situations of gender violence and the exponential increase in cases, which has been evidenced in numerous countries,4,5,6,24,25,26,27 this study is in line with those research works that have highlighted the difficulties in detecting and assisting the cases of gender-based violence in the health sector that have emerged as a result of the isolation, reduced contact, health reorganization, lack of specific health care protocols, and absence of adequate spaces of privacy and containment that can help create bonds of trust.28,29,30) Some of these obstacles have already been identified in our context.31 For example, a qualitative study conducted in the Netherlands, also highlights the impact of the health care reorganization on a lower detection of gender violence by professionals, which is associated with the reduction of personal contact with the users.30 In this sense, the role and commitment of the health professionals is crucial. The pandemic specifically changed how women requested help from the professional services, which deepened existing difficulties.28,30,32 A review28 reports that about 90% of women who experienced situations of violence during the measures of social lockdown due to COVID-19 did neither request help from the authorities nor reported the abuse inflicted on them, especially those women who experienced emotional abuse and had reduced access to hospital care despite the severity of their injuries. It should be noted that among the different forms of violence against women (psychological, sexual or economic, etc.) the episodes of physical aggression decreased, although the severity of the aggressions increased,28 as reported by the individuals who were interviewed in this study. Furthermore, although online care made it possible to access the services, the barriers identified in our context, such as the difficulty of several women to speak in a private space or the inequalities in accessing the internet, have also been mentioned in other countries, such as the Netherlands30 or the USA.29
Likewise, inquiring into how the pandemic affected the way health professionals work is crucial to optimizing care.30 The results analyzed here do not show, as other studies do,33 the upsurge of preexisting gender inequalities during the pandemic that are affecting health teams in general and women professionals in particular. However, they highlight, along with these studies, the importance of addressing the experience of the health professionals during the pandemic from a gender perspective. With regard to the disruption of support networks as a result of social, preventive and mandatory isolation,15 different elements were identified that acted as facilitators to accessing legal abortion services and tackling gender-based violence, which are part of a “feminist health practice.”34 We understand that this practice could become a distinctive element of the Argentine context that responds to the presence of female health workers inserted in preexisting professional support networks that could become catalysts for an unfinished and unsolved demand during the health crisis. During the pandemic, the networks had to resort to digital or mobile technologies to communicate, and not only did they cope with the situation but could also expand themselves, being able to cushion the impact arising from the health service suspension. Although it is recognized that female health workers, despite the barriers related to an androcentric labor organization, have a differential practice style with respect to their fellow coworkers,35) it seems that a specific commitment to women’s rights is added to these key characteristics to tackle gender-based violence.36 This feminist plus that is identified in the professional practices addressed in this study, not only emerges from the recognition of the historical inequalities faced by women, but also seeks to facilitate and strengthen equal opportunities and enjoyment of rights, while reducing the hierarchies and distancing among professionals and those who consult, recognizing themselves in many aspects and in the same experiences of their female users. These characteristics have been related to a feminist ethics in healthcare practices, also identified among female social workers37) and are linked to the impact that the women’s movement have on health care.34 The contribution of feminism to health is recognized.38
This study showed how the health crisis and the emergency resulting from the social increase in cases of gender-based violence helped, in some cases, to assess the traditional care channels and plan innovative strategies in the context of social, preventive and mandatory isolation - such as unique digital platforms for case registration - that facilitate the approaches. The implementation of the new strategies and the strengthening of the virtual setting for addressing gender-based violence have also been observed in other contexts, such as in the Netherlands30 or in Spain39 where, just like in Argentina,5,25 the calls to the toll-free gender-based violence hotlines increased during confinement.40
Among the limitations of this study, we highlight the over-representation of one of the cities in which this research work was conducted, and the fact that the sample collection method may have biased the inclusion of participants that were more committed with feminism. In future studies, the impact of the enactment of Law 27610 on the Voluntary and Legal Termination of Pregnancy should be analyzed in the health sector and the approaches to the problems should be investigated in contexts of more flexible preventive measures, such as social distancing. Moreover, the perspective of women users of the health services should be included to go deeper into their experiences during the pandemic.
CONCLUSION
This work is pioneer in investigating the health sector approaches to gender-based violence and access to the legal abortion in a context of social, preventive and mandatory social isolation. The results have shown a greater demand for legal abortion and a lower detection and approach of gender-based violence, thus modifying its role. New barriers are identified, which, on occasions, have deepened the existing ones. However, this context provided opportunities to revisit care and create transformation processes capable of overcoming the barriers to health care access. It underscores the strengthening of preexisting feminist professional practices that made possible to cushion the unequal impact of the pandemic on women and were key in reducing the effect of the suspension of health care services and addressing health. In the face of a context of long-term uncertainty, in which the measures to tackle the pandemic are modified according to the changing epidemiological situation, this study emphasizes the need for public policies that support the identified feminist health practices, and, above all, strengthen the role of the health sector in securing the respect and enjoyment of rights.
ACKNOWLEDGMENT
We would like to thank all the people who, in a context of extreme difficulty, have participated in the interviews and shared their experiences. We are grateful to Victoria for her excellent transcription of the recorded interviews and to Yanina for her loving reading of the manuscript and feedback. We would also like to thank the organization “Catholics for the Right to Decide - Argentina,”
FUNDING
This research was funded by the Fondo para la Investigación Científica y Tecnológica (PICT 2016-0475)
CONFLICT OF INTEREST
The authors declare that they have no ties or commitments that that can be understood as a conflict of interests and may condition what is expressed in the text
