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)

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)