Table 3 Perceived drivers of D&A

Individual and community-level drivers

Normalization of D&A and lack of empowerment

You have to view [D&A] through a special lens, because most women perceive that they were well attended. She came out with a cesarean section, she did not know why the cesarean section, she has no idea, but she was well attended, but her baby is here, everything is perfect. But when one puts on this lens and begins to see all these small details, that is where one realizes that we are immersed in a system that does not allow people to see. –OB/GYN who practices in both academic and urban community settings

No, indigenous women who come from their communities I would say that very few of them are aware of their rights during childbirth. Very few. Why? One, the majority are illiterate, a huge disadvantage. Two, we don’t understand Spanish well. Three, there is the propensity for their husbands to care for them, so whatever the husbands decide goes. Indigenous women don’t have an easy way to reflect upon their experiences and think critically, this would be a disadvantage. –33-year-old indigenous woman

Lacking antenatal care

Most indigenous women do not have prenatal check-ups for example… they are not healthy women at all, most of them are women who have some degree of malnutrition, or they are obese. They never have prenatal check-ups because the indigenous patients in Medellín are displaced, most of the indigenous women in Medellín are displaced by violence, so they do not have routine health care because in the communities it is difficult to have access to western medicine during pregnancy. –OB/GYN who practices in an academic hospital

“The indigenous women come [to the hospital], and they start to scold them. ‘Ay, mama, you are already 7 months pregnant, and you aren’t taking care.’ But if it’s a woman who came to an urban area for 5 or 8 days, from where there is no access to healthcare, well how would she have had prenatal visits? But they don’t focus on that, they start to make the mother feel neglectful or negligent without understanding that context.” –37-year-old indigenous woman

Indigenous cultural preferences

[Indigenous women] prefer to have children with a traditional midwife… they are embarrassed to show their bodies to a male doctor. And then all the injections, for them it is torture, I can’t even think about all the cutting. And then in the community we give birth standing up, I believe that a standing birth is less painful. ––37-year-old indigenous woman

What I found very uncomfortable, I don’t know if all women do, but the physical examinations every hour were annoying especially in the middle of your pain and physical anguish. This is what indigenous women find very uncomfortable, even more if it’s a male doctor or nurse, we will always be opposed to that. –33-year-old indigenous woman

[Indigenous women] arrive to an institution and have to lie down in a hospital bed, but that isn’t how birth is understood in their culture… they arrive in a place that is cold, with apparatuses and monitors that are strange to them. –Professor of nursing and expert in D&A

Clinician-level drivers

Clinician prejudice

We fear doulas or traditional midwives, we seem them as aberrations, so we do not let them enter our institutions. We think that they are not capable, that they are not prepared, and in the worst cases, I have heard people say that they are sorceresses, witches, that they have rituals and strange things that are going to harm the pregnant women and the child. ––Professor of nursing and expert in D&A

Traditional medicine is not considered, in fact, it is despised! It is seen as something that has no evidence, that it does not work, that it is even risky, so it is banned. There is no proper dialogue between these two medicines. –OB/GYN

The woman is seen as an “object,” a second hand “object” who is simply a caregiver of children, a creator of children. This is one of the great limitations that men see, the man doesn’t have the same power that a woman has to procreate, so she has to be controlled. –OB/GYN and university professor

I believe that neither indigenous women nor non-indigenous women are free from this situation of obstetric violence. From what I’ve managed to capture from conversations with indigenous and non-indigenous women who have experienced this process, I think that situations of obstetric violence are common, and I believe it occurs not only here in Medellín and in Colombia, but in the world in general. It’s a phenomenon that is almost global. –Expert in indigenous health systems

Linguistic or cultural barriers to communication

In the hospitals they don't have communication, they don't have differential care. Starting with the fact that the indigenous woman doesn't understand Spanish well… an indigenous woman who goes to a hospital is not going to tell the doctor how she is feeling or what is happening to her. [At the hospital] everybody is treated the same, but they need to train [the clinicians] to look at the difference between indigenous women and western women because of their customs, because of their culture. –48-year-old indigenous woman

I could be telling her that her labor is progressing very well because she is dilating very well, and she is effacing very well, but for them it can feel like I am telling them that their baby is in danger because they do not know what dilation is, they do not know what effacing is … and then we add to that the fact that they do not speak Spanish very well then it becomes even more worse. –Nurse experienced with indigenous communities

I think that the most important need, in the indigenous communities when they arrive here in the city or in our hospitals, is the need for communication. This becomes a barrier to care, although I believe that the care given in our hospitals, or in Medellin, is humanized as much as possible, I think that certain cultural communicative elements are not taken into account so as not to go over the heads of these other cultures when the need arises. So, many times the communicative aspects are interpreted [by clinicians] as perhaps less important, so they simply focus on the task at hand or the patient’s pain or on the procedure that has to be done, but other I think that other needs are left out due to communicative issues. –Nurse and patient navigator for an indigenous health insurance company

Since she does not understand what I’m going to tell her, I do not explain anything to her and I do whatever I want with her, because even if I explained, she wouldn’t understand. -–Professor of nursing and expert in D&A

Lack of understanding of indigenous culture

We need to work with the indigenous community, we need to get closer to them, we need to improve our open-mindedness so that we can share knowledge and admit that they also have valuable knowledge and that ours is not the only one that dominates. Sometimes, we see indigenous communities as a difficult patient population, complicated because it isn’t easy to access them. We see their beliefs as strange, different. –OB/GYN who practices in a public urban community hospital

First of all, there is a great lack of knowledge. Before judging the clinicians, I want to emphasize that they have a profound lack of knowledge of the particularities required of service to the indigenous population… They are not very solid in the subject of cultural competence and that is a huge mistake that the universities must assume responsibility for.” –Expert in indigenous health systems

Clinician training and medical culture

No, no, [clinicians are not thinking about human beings,] they are thinking about diseases, about organs… You can do a very simple experiment, go to a medical round and ask the doctor, "doctor, what is the name of the lady in bed 1" no, it is bed 1, but he doesn’t know the name of this man or woman. “Bed, 1, ah, the one with heart failure, yes, the one with heart failure.” What is his name? How many children does he have? Is he single? Is he married? Is he gay? is he… no, he does not know! Doctors are thinking about curing diseases but not about curing the sick, they are thinking about curing organs, curing wounds, but they are not thinking about curing the person. ––OB/GYN who practices in both academic and urban community settings

There are many doctors who do not want to be [violent], but the pressure of the shift, the pressure to act quickly…they do not want to be this way, but the circumstances force them to rush and act in a way that isn’t their desire but rather learned from the social code and pressures of the hospital. –Psychologist specializing in postpartum care

Clinician burnout and demoralization

Our healthcare system, because of the volume, because of the precarious conditions that the clinician himself has, which leads him to an exhaustive routine that becomes something mechanical, and I no longer have in front of me a human being, a person, but instead a patient, just another number, just another person to attend to. So, we get to the point, the ends are well, the delivery goes well, the mother is healthy, but we forget the means. And in these means is the violence… a bad word, a mistreatment, not allowing the woman to speak, examining her without permission. – OB/GYN who practices in a public urban community hospital

The doctor arrives, burnt out because he doesn’t earn well, because he has to work long hours, because he has to leave his family and hasn’t seen his children in a long time, and he’s been stuck in traffic and the city is collapsed … and then comes the patient who has had no prenatal care, who is sick, who has no medication, who I can’t see yet because I have 3 or 4 others and I’m overworked. It’s one thing after another, right? … It’s like a chemical formula leading to a final explosion. –OB/GYN who practices in an academic hospital

Facility-level drivers

Inadequate infrastructure, space, and human resources

Here in Colombia, we have up 10 women in a single delivery room, often separated by only a curtain, or sometimes they are not even separated and are face to face. – Psychologist specializing in postpartum care

For example, I was all alone because I wanted my family to be there, I wanted to be with my partner, with my family who were waiting for my child to arrive. But they forbade it, only I could enter. I wanted my midwife to accompany me, and they told me "this is not possible; this is not possible in this hospital." –37-year-old indigenous woman

Lack of accountability mechanisms

[Indigenous women don’t report D&A] because of fear. First, because many do not speak Spanish and, if they speak Spanish, they are not able to express, according to this western world, they are not able to express themselves… they cannot make themselves understood. Instead of waiting, of having patience with women who do not speak Spanish [hospital staff] start to scold them, “why are you speaking like that?” Then, of course the woman is angry and scared, so does not speak, so she prefers to keep quiet, unfortunately. –43-year-old indigenous woman

Of course, I have witnessed D&A. And nothing happens, absolutely nothing because the woman is in a submissive position, she is at the mercy of the doctor, the doctor exercises authority and nothing happens, beyond the woman getting upset or asking him “why did you hit me?”, but nothing happens beyond that, there is no institutional sanction, there is no institutional supervision, absolutely nothing happens. Yes, there are the complaint and grievance boxes, but most women choose not to denounce and what they want is to leave the institution as soon as possible and never come back. It is rare that there is a complaint, and if there is a complaint, the mechanism used to resolve it is always in favor of the doctor. –––OB/GYN who practices in both academic and urban community settings

Regional and national systems-level drivers

Lack of laws or policies

If you ask me in a general overview of the ecosystem of health care provision in Medellin, I believe that institutions have neither the training nor the desire nor the accountability from the law forcing them to [provide RMC], so they do not do it. And by not doing so they are not violating any regulation or if they do violate it, it is not a regulation that is enforced. ––Expert in indigenous health systems

Deprioritization of respectful, intercultural maternity care

The health care system does not have the cultural competencies required to provide care to indigenous populations, and this is happening all across the country. ––Expert in indigenous health systems

We don’t have a health system that respects the will and desire of women. Instead, women have to adapt to institutional requirements and to the demands of the treating physicians. –––OB/GYN who practices in both academic and urban community settings