ABSTRACT:

This study is interested in analyzing how health services address gender-based violence and legal abortion in a context of mandatory preventive social isolation. Between May and June 2020, 27 telephone interviews were conducted with healthcare professionals and key informants from Córdoba and Resistencia. Changes in detection, methods, and demand were identified, related to the reorganization of the healthcare system, modifications in the care relationship, and the resources needed to respond to demand. The pandemic has deepened barriers to women’s access to health services and has added new ones. Networks among healthcare professionals, feminist healthcare practices, and innovative approaches were identified as facilitators of access, which have been central in mitigating the effects of the pandemic and guaranteeing rights.

KEYWORDS:
Gender-Based Violence; Abortion; Feminism; Health Care Sector; COVID-19; Argentina

INTRODUCTION

It is a known fact that health care crises potentiate social inequalities, including those related to gender.¹1. Davies E, Bennett E. A gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies. International Affairs. 2016;(92):1041-1060.^,22. Onyango MA, Resnick K, Davis A, Shah RR. Gender-based violence among adolescent girls and young women: A neglected consequence of the West African Ebola outbreak. In: Schwartz D, Anoko J, Abramowitz S, eds. Pregnant in the time of Ebola: Global maternal and child health (Medical, Anthropological, and Public Health Perspectives). New York: Springer, Cham; 2019. p. 121-132.^,33. European Commission’s Humanitarian Aid and Civil Protection, Doctors of the World, Oxfam International. Dominican Republic gender analysis: study of the impact of the Zika virus on women, girls, boys and men [Internet]. Oxfam International; 2017 [citado 10 mar 2021]. Disponible en: Disponible en: https://tinyurl.com/5dusvjws .
https://tinyurl.com/5dusvjws... 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.⁴4. Moreira D, Costa MP. The impact of the Covid-19 pandemic in the precipitation of intimate partner violence. International Journal of Law and Psychiatry. 2020;71:101606. 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.⁵5. Naciones Unidas. Se incrementó un 39% el pedido de ayuda por violencia de género en Argentina durante el COVID-19 [Internet]. 2020 [citado 11 nov 2020]. Disponible en: Disponible en: https://tinyurl.com/s54vm7as .
https://tinyurl.com/s54vm7as... In 2020, femicides also rose by 5.36% compared to the previous year.⁶6. Observatorio de Femicidios de la Defensoría del Pueblo de la Nación. Femicidios: Informe Anual 2020 [Internet]. Buenos Aires: Defensoría del Pueblo de la Nación; 2020 [citado 10 nov 2020]. Disponible en: Disponible en: https://tinyurl.com/7nexk9vs .
https://tinyurl.com/7nexk9vs... 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.⁷7. Ministerio de las Mujeres, Géneros y Diversidad. Medidas en materia de género y diversidad en el marco de la emergencia sanitaria [Internet]. 2020 [citado 10 mar 2021]. Disponible en: Disponible en: https://tinyurl.com/8yn8rpbk .
https://tinyurl.com/8yn8rpbk...

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,⁸8. Tobar F. Impacto del COVID-19 en el acceso a los anticonceptivos en Argentina. Buenos Aires: UNFPA; 2020. especially in the most vulnerable sectors suffering the greatest social inequalities.⁹9. Dasgupta A, Kantorová V, Ueffing P. The impact of the COVID-19 crisis on meeting needs for family planning: a global scenario by contraceptive methods used. Gates Open Research. 2020;4(10):1-22.⁾ 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.¹⁰10. Szulik D, Zamberlin N. La legalidad oculta: Percepciones de estigma en los recorridos de mujeres que descubren y acceden a la interrupción legal del embarazo por causal salud. Sexualidad, Salud y Sociedad. 2020;(37):46-67. 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.¹¹11. Karstanje M, Ferrari N, Verón Z. El derecho a la salud sexual y reproductiva en Argentina en época de COVID-19. Buenos Aires: Equipo Latinoamericano de Justicia y Género; 2020.

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.¹²12. Kessler G, coord. Relevamiento del impacto social de las medidas del aislamiento dispuestas por el PEN. Buenos Aires: Ministerio de Ciencia, Tecnología e Innovación; 2020. 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.

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. ¹³13. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77-101. 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:

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:

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:

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:

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:

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:

Furthermore, those who could attend the hospital, had to go through a triage assessment to access medical care:

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:

The suspension of gynecological controls and the barriers to obtaining contraceptive methods resulted in the increase of unintended pregnancies:

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:

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:

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:

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:

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:

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:

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:

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:

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 impact of the restriction or absence of public transport on the context of social, preventive and mandatory isolation has also been underlined:

Violation of rights

The pandemic has deepened existing social inequalities. Difficulties in accessing food have been highlighted:

The lack of economic resources is a key barrier for women who face gender-based violence:

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:

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:

Finally, the impact of social, preventive and mandatory isolation on precarious jobs and health is also underscored:

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 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:

The interest and personal commitment of several professionals to train in this comprehensive approach using their own financial resources has also been underscored here:

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:

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:

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 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:

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:

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:

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:

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:

In Resistencia, they highlighted the creation of a digital registration system of gender violence cases that facilitated networking:

The importance of surveying the population through georeferencing was also mentioned:

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.⁴4. Moreira D, Costa MP. The impact of the Covid-19 pandemic in the precipitation of intimate partner violence. International Journal of Law and Psychiatry. 2020;71:101606.^,88. Tobar F. Impacto del COVID-19 en el acceso a los anticonceptivos en Argentina. Buenos Aires: UNFPA; 2020.^,1212. Kessler G, coord. Relevamiento del impacto social de las medidas del aislamiento dispuestas por el PEN. Buenos Aires: Ministerio de Ciencia, Tecnología e Innovación; 2020. 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.¹⁴14. Kapilashrami A, Hankivsky O. Intersectionality and why it matters to global health. The Lancet. 2018;391(10140):2589-2591.^,1515. Gauthier G, Smith J, García C, Garcia M, Thomas P. Exacerbating inequalities: social networks, racial/ethnic disparities and the COVID-19 Pandemic in the United States. The Journals of Gerontology. 2020;76(3):e88-e92. 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.¹⁴14. Kapilashrami A, Hankivsky O. Intersectionality and why it matters to global health. The Lancet. 2018;391(10140):2589-2591.^,1515. Gauthier G, Smith J, García C, Garcia M, Thomas P. Exacerbating inequalities: social networks, racial/ethnic disparities and the COVID-19 Pandemic in the United States. The Journals of Gerontology. 2020;76(3):e88-e92. 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,¹⁶16. Burki T. The indirect impact of COVID-19 on women. The Lancet. 2020;20(8):904-905. 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.¹⁷17. Sifris R, Penovic T. Barriers to abortion access in Australia before and during the COVID-19 pandemic. Women’s Studies International Forum. 2021;86:102470.^,1818. Drovetta R. Profesionales de la salud y el estigma del aborto en Argentina: El caso de la red de profesionales de la salud por el derecho a decidir. Segunda Época. 2018;(24):13-35.^,1919. Aldavert S, Baroja Benlliure J, Rodríguez García A, Rodríguez Durán A, Tildesley R, Sánchez Torres A. El acceso al aborto en el Estado español: principales barreras. Barcelona: L’Associació de Drets Sexuals i Reproductius; 2020. 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.⁹9. Dasgupta A, Kantorová V, Ueffing P. The impact of the COVID-19 crisis on meeting needs for family planning: a global scenario by contraceptive methods used. Gates Open Research. 2020;4(10):1-22.^,2020. Tang K, Gaoshan J, Ahonsi B, Ali M, Bonet M, Broutet N, Kara E, Kim C, Thorson A, Thwin SS. Sexual and reproductive health (SRH): a key issue in the emergency response to the coronavirus disease (COVID- 19) outbreak. Reproductive Health. 2020;17(1):59. 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 Catalonia¹⁹19. Aldavert S, Baroja Benlliure J, Rodríguez García A, Rodríguez Durán A, Tildesley R, Sánchez Torres A. El acceso al aborto en el Estado español: principales barreras. Barcelona: L’Associació de Drets Sexuals i Reproductius; 2020.. 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.¹⁸18. Drovetta R. Profesionales de la salud y el estigma del aborto en Argentina: El caso de la red de profesionales de la salud por el derecho a decidir. Segunda Época. 2018;(24):13-35. 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,¹⁹19. Aldavert S, Baroja Benlliure J, Rodríguez García A, Rodríguez Durán A, Tildesley R, Sánchez Torres A. El acceso al aborto en el Estado español: principales barreras. Barcelona: L’Associació de Drets Sexuals i Reproductius; 2020.^,2121. Bateson DJ, Lohr PA, Norman WV, et al. The impact of COVID-19 on contraception and abortion health policy and practices: experiences from selected countries. BMJ Sexual & Reproductive Health. 2020;(46):241-243.^,2222. Riley T, Sully E, Ahmed Z, et al. Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries. International Perspectives on Sexual and Reproductive Health. 2020;(46):73-76. 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.²³23. Socorristas en Red. Sistematización de acompañamientos a abortar realizados en el año 2020 por Socorristas en Red (feministas que abortamos) durante el primer año de pandemia por COVID 19. Comahue: Socorristas en Red; 2021.

In the context of the recurrence of situations of gender violence and the exponential increase in cases, which has been evidenced in numerous countries,⁴4. Moreira D, Costa MP. The impact of the Covid-19 pandemic in the precipitation of intimate partner violence. International Journal of Law and Psychiatry. 2020;71:101606.^,55. Naciones Unidas. Se incrementó un 39% el pedido de ayuda por violencia de género en Argentina durante el COVID-19 [Internet]. 2020 [citado 11 nov 2020]. Disponible en: Disponible en: https://tinyurl.com/s54vm7as .
https://tinyurl.com/s54vm7as... ^,66. Observatorio de Femicidios de la Defensoría del Pueblo de la Nación. Femicidios: Informe Anual 2020 [Internet]. Buenos Aires: Defensoría del Pueblo de la Nación; 2020 [citado 10 nov 2020]. Disponible en: Disponible en: https://tinyurl.com/7nexk9vs .
https://tinyurl.com/7nexk9vs... ^,2424. Usher K, Bhullar N, Durkin J, Gyamfi N, Jackson D. Family violence and COVID-19: Increased vulnerability and reduced options for support. International Journal of Mental Health Nursing. 2020;29(4):549-552.^,2525. Perez-Vincent SM, Carreras E, Gibbons MA, Murphy TE, Rossi MA, eds. Los confinamientos de la COVID-19 y la violencia doméstica: Evidencia de dos estudios en Argentina. Buenos Aires: Informe Banco Interamericano de Desarrollo; 2020.^,2626. Boxall H, Morgan A, Brown R. The prevalence of domestic violence among women during the COVID-19 pandemic. Statistical Bulletin. 2000;28:1-28.^,2727. United Nations Economic and Social Commission for Asia and the Pacific. The Covid-19 Pandemic and violence against women in Asia and the Pacific. Bangkok: United Nations; 2021. 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.²⁸28. Lausi G, Pizzo A, Cricenti C, Baldi M, Desiderio R, Giannini AM, Mari E. Intimate partner violence during the COVID-19 Pandemic: A review of the phenomenon from victims’ and help professionals’ perspectives. International Journal of Environmental Research and Public Health. 2021;18(12):6204.^,2929. Williams EE, Arant KR, Leifer VP, Balcom MC, Levy-Carrick NC, Lewis-O’Connor A, Katz JN. Provider perspectives on the provision of safe, equitable, trauma-informed care for intimate partner violence survivors during the COVID-19 pandemic: a qualitative study. BMC Womens Health. 2021;21(1):315.^,3030. van Gelder NE, van Haalen DL, Ekker K, Ligthart SA, Oertelt-Prigione S. Professionals’ views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands. BMC Health Services Research. 2021;30;21(1):624.⁾ Some of these obstacles have already been identified in our context.³¹31. Saletti-Cuesta L, Ferioli A, Martínez FDV, Viel E, Baudin V, Romero P, Funk N, González AC, Rodríguez A. El abordaje de la violencia de género desde la perspectiva de las comunidades del norte cordobés, Argentina. Cadernos de Saúde Pública. 2020;36(1):e00184418. 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.³⁰30. van Gelder NE, van Haalen DL, Ekker K, Ligthart SA, Oertelt-Prigione S. Professionals’ views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands. BMC Health Services Research. 2021;30;21(1):624. 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.²⁸28. Lausi G, Pizzo A, Cricenti C, Baldi M, Desiderio R, Giannini AM, Mari E. Intimate partner violence during the COVID-19 Pandemic: A review of the phenomenon from victims’ and help professionals’ perspectives. International Journal of Environmental Research and Public Health. 2021;18(12):6204.^,3030. van Gelder NE, van Haalen DL, Ekker K, Ligthart SA, Oertelt-Prigione S. Professionals’ views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands. BMC Health Services Research. 2021;30;21(1):624.^,3232. Wright EN, Miyamoto S, Richardson C. The impact of COVID-19 restrictions on victim advocacy agency utilization across Pennsylvania. Journal of Family Violence. 2021. doi: 10.1007/s10896-021-00307-z. A review²⁸28. Lausi G, Pizzo A, Cricenti C, Baldi M, Desiderio R, Giannini AM, Mari E. Intimate partner violence during the COVID-19 Pandemic: A review of the phenomenon from victims’ and help professionals’ perspectives. International Journal of Environmental Research and Public Health. 2021;18(12):6204. 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,²⁸28. Lausi G, Pizzo A, Cricenti C, Baldi M, Desiderio R, Giannini AM, Mari E. Intimate partner violence during the COVID-19 Pandemic: A review of the phenomenon from victims’ and help professionals’ perspectives. International Journal of Environmental Research and Public Health. 2021;18(12):6204. 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 Netherlands³⁰30. van Gelder NE, van Haalen DL, Ekker K, Ligthart SA, Oertelt-Prigione S. Professionals’ views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands. BMC Health Services Research. 2021;30;21(1):624. or the USA.²⁹29. Williams EE, Arant KR, Leifer VP, Balcom MC, Levy-Carrick NC, Lewis-O’Connor A, Katz JN. Provider perspectives on the provision of safe, equitable, trauma-informed care for intimate partner violence survivors during the COVID-19 pandemic: a qualitative study. BMC Womens Health. 2021;21(1):315.

Likewise, inquiring into how the pandemic affected the way health professionals work is crucial to optimizing care.³⁰30. van Gelder NE, van Haalen DL, Ekker K, Ligthart SA, Oertelt-Prigione S. Professionals’ views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands. BMC Health Services Research. 2021;30;21(1):624. The results analyzed here do not show, as other studies do,³³33. Regenold N, Vindrola-Padros C. Gender matters: A gender analysis of healthcare workers’ experiences during the first COVID-19 pandemic peak in England. Social Science. 2021;10:43. 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,¹⁵15. Gauthier G, Smith J, García C, Garcia M, Thomas P. Exacerbating inequalities: social networks, racial/ethnic disparities and the COVID-19 Pandemic in the United States. The Journals of Gerontology. 2020;76(3):e88-e92. 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.”³⁴34. Maffeo F. La incidencia del movimiento feminista en la atención de la salud de mujeres: El caso de los Centros de Atención Primaria de la Salud (CAPS) de Morón. En: Di Marco G, FAySP. Feminismos y populismos del siglo XXI: Frente al patriarcado y al orden neoliberal. Buenos Aires: Teseo; 2019. 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,³⁵35. Rouse LP, Nagy-Agren S, Gebhard RE y Bernstein WK. Women physicians: Gender and the medical workplace. Journal of Womens Health (Larchmt). 2020;29(3):297-309.⁾ it seems that a specific commitment to women’s rights is added to these key characteristics to tackle gender-based violence.³⁶36. Saletti-Cuesta L, Aizenberg L, Ricci-Cabello I. Opinions and experiences of primary healthcare providers regarding violence against women. Journal of Family Violence. 2018;33(6):405-420. 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 workers³⁷37. Karoff M, Norton C, Tucker, A, Gass, M, Foerster, E. A qualitative gender analysis of women field guides’ experiences in outdoor behavioral healthcare: a feminist social work perspective. Affilia. 2019;34(1):48-64.⁾ and are linked to the impact that the women’s movement have on health care.³⁴34. Maffeo F. La incidencia del movimiento feminista en la atención de la salud de mujeres: El caso de los Centros de Atención Primaria de la Salud (CAPS) de Morón. En: Di Marco G, FAySP. Feminismos y populismos del siglo XXI: Frente al patriarcado y al orden neoliberal. Buenos Aires: Teseo; 2019. The contribution of feminism to health is recognized.³⁸38. Esteban ML. El estudio de la salud y el género: las ventajas de un enfoque antropológico y feminista. Salud Colectiva. 2006;2(1):9-20.

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 Netherlands³⁰30. van Gelder NE, van Haalen DL, Ekker K, Ligthart SA, Oertelt-Prigione S. Professionals’ views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands. BMC Health Services Research. 2021;30;21(1):624. or in Spain³⁹39. Ruiz Pérez I, Pastor Moreno G. Medidas de contención de la violencia de género durante la pandemia de COVID-19. Gaceta Sanitaria. 2021;35(4):389-394. where, just like in Argentina,⁵5. Naciones Unidas. Se incrementó un 39% el pedido de ayuda por violencia de género en Argentina durante el COVID-19 [Internet]. 2020 [citado 11 nov 2020]. Disponible en: Disponible en: https://tinyurl.com/s54vm7as .
https://tinyurl.com/s54vm7as... ^,2525. Perez-Vincent SM, Carreras E, Gibbons MA, Murphy TE, Rossi MA, eds. Los confinamientos de la COVID-19 y la violencia doméstica: Evidencia de dos estudios en Argentina. Buenos Aires: Informe Banco Interamericano de Desarrollo; 2020. the calls to the toll-free gender-based violence hotlines increased during confinement.⁴⁰40. Vives-Cases C, La Parra Casado D, Estevéz J, Torrubiano-Domínguez J, Sanz-Barbero B. Intimate partner violence against women during the COVID-19 lockdown in Spain. International Journal of Environmental Research and Public Health. 2021;18(9):4698.

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,”

References

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