Vertex, Revista Argentina de Psiquiatría a través de su editor y sus editoriales: los años de formación y el exilio / Vertex Journal through its editor and its editorials: the formative years and the exil

Vertex, Revista Argentina de Psiquiatría es una de las pocas publicaciones de la especialidad editadas en español que está incluida en PubMed. Durante los 30 años de existencia (1990 hasta el presente) ha sido dirigida por el Dr. Juan Carlos Stagnaro, quien es el autor exclusivo de los editoriales. Mediante el análisis de sus palabras clave y de extensas entrevistas semiestructuradas, este trabajo indaga sobre aspectos biográficos del joven Stagnaro para comprender la génesis de la revista, su impronta científico-política y las líneas editoriales que abordó. Se trabajó sobre los años de formación en la Argentina, el exilio en Francia durante la última dictadura militar y aspectos formativos en psiquiatría que le permitieron, al regreso a la Argentina, fundar la revista. (AU)

Vertex, Revista Argentina de Psiquiatría is one of the few journal of this specialty published in Spanish that is included in PubMed. During its 30 years of existence (1990 to present) it has been directed by Dr. Juan Carlos Stagnaro, who is the exclusive author of the editorials. Through the analysis of their keywords and extensive semi-structured interviews, this work investigates the biographical aspects of the young Stagnaro in order to understand the genesis of the journal, its scientific-political imprint and the editorial linesit addressed. The work describes the formative years in Argentina, the exile in France during the last military dictatorship and formative aspects in psychiatry that allowed him, upon his return to Argentina, to create the journal. (AU)

La legalidad oculta: Percepciones de estigma en los recorridos de mujeres que descubren y acceden a la interrupción legal del embarazo por causal salud / The hidden legality: perceptions of stigma in the tours of women who discovered and accessed the legal termination of pregnancy for health reasons / A legalidade oculta: percepções de estigma nas trajetórias de mulheres que descobrem e acessam a interrupção legal da gravidez por razões de saúde

Resumen Desde hace casi un siglo el código penal argentino incluye situaciones en las que el aborto no está penalizado: riesgo para la salud y embarazo producto de violación. Sin embargo, su implementación ha sido inexistente hasta recientemente. Este estudio cualitativo exploró las experiencias de mujeres que accedieron a un aborto legal con el fin de analizar los recorridos que transitan e identificar los modos en que el estigma se percibe, manifiesta y procesa. Las mujeres parten del supuesto de que el aborto es siempre ilegal y "descubren" la legalidad después de recorrer un laberinto plagado de estigma, riesgo, frustración y desesperación. Las situaciones de mayor angustia no se vinculan a la decisión de interrumpir el embarazo sino al recorrido tortuoso que deben transitar. La "legalidad oculta" es causa y consecuencia del estigma vinculado al aborto.

Abstract For nearly a century Argentina's penal code has included two exceptions in which abortion is permitted: health risk and rape. However, the implementation of legal abortion has been nearly nonexistent until recently. This qualitative study explored the experiences of women who accessed legal abortions in Argentina. It sought to analyze the paths they must walk through and to identify the ways in which stigma is perceived, manifested and processed. All women interviewed started searching for clandestine solutions to their unwanted pregnancy assuming abortion was always illegal. They "discovered" legality after walking through a path marked by stigma, risk, frustration and despair. Distress is not linked to the decision to end the pregnancy but is rather a result of the path they wander through. The "hidden legality" is a cause and consequence of abortion stigma.

Resumo Por quase um século, o código penal argentino inclui situações nas quais o aborto não penalizado: risco à saúde e gravidez resultante de estupro. No entanto, sua implementação não existia até recentemente. Este estudo qualitativo explorou as experiências de mulheres que acessaram um aborto legal, a fim de analisar as jornadas pelas quais passam e identificar as maneiras pelas quais o estigma é percebido, manifestado e processado. As mulheres assumem que o aborto é sempre ilegal e "descobrem" a legalidade depois de passar por um labirinto cheio de estigma, risco, frustração e desespero. As situações mais angustiantes não estão ligadas à decisão de interromper a gravidez, mas à jornada tortuosa pela qual devem passar. A "legalidade oculta" é causa e consequência do estigma associado ao aborto.

["I was like a ticking bomb": Experiences of severe maternal morbidity in the Metropolitan Area of Buenos Aires]. / "Era una bomba de tiempo": el derrotero de la morbilidad materna severa en el Área Metropolitana de Buenos Aires.

With the objective of recording and analyzing women's experiences with severe maternal morbidity from their perspective, between February and May 2011, 16 semi-structured interviews with women treated in the public hospitals of the Buenos Aires Metropolitan Area who suffered from severe maternal morbidity were carried out. In their testimonies, women report a number of delays in care, such as difficulties in identifying the problem on time, obstacles in accessing health centers and important faults in the management of obstetric emergencies. They describe the event as surprising, distressing and painful, a perception reinforced by the violation of their rights and significant communication problems. These findings are meant as a step towards the holistic and comprehensive study of severe maternal morbidity, as well as to confirm the urgent need for further research from a gender and humans rights perspective.

"Era una bomba de tiempo": el derrotero de la morbilidad materna severa en el Área Metropolitana de Buenos Aires / "I was like a ticking bomb": Experiences of severe maternal morbidity in the Metropolitan Area of Buenos Aires

Con el propósito de conocer las vivencias de mujeres que atravesaron eventos de morbilidad materna severa, desde su propia perspectiva, entre febrero y mayo de 2011, se realizaron 16 entrevistas semiestructuradas a mujeres que padecieron morbilidad materna severa, atendidas en hospitales públicos del Área Metropolitana de Buenos Aires. Los testimonios dan cuenta de una serie de demoras, como la dificultad para identificar el problema a tiempo, los obstáculos en el acceso al sistema de salud, e importantes fallas en el manejo de la emergencia obstétrica. El evento es vivido como sorpresivo, angustiante y doloroso por las mujeres, lo cual se ve reforzado por una fuerte vulneración de sus derechos y por problemas significativos en la comunicación. Estos hallazgos constituyen un puntapié para avanzar en la comprensión integral y holística de la morbilidad materna severa, y confirman la necesidad de seguir investigando desde la perspectiva de género y de derechos.

With the objective of recording and analyzing women's experiences with severe maternal morbidity from their perspective, between February and May 2011, 16 semi-structured interviews with women treated in the public hospitals of the Buenos Aires Metropolitan Area who suffered from severe maternal morbidity were carried out. In their testimonies, women report a number of delays in care, such as difficulties in identifying the problem on time, obstacles in accessing health centers and important faults in the management of obstetric emergencies. They describe the event as surprising, distressing and painful, a perception reinforced by the violation of their rights and significant communication problems. These findings are meant as a step towards the holistic and comprehensive study of severe maternal morbidity, as well as to confirm the urgent need for further research from a gender and humans rights perspective.

[Model for a comprehensive approach to maternal mortality and severe maternal morbidity]. / Modelo para abordar integralmente la mortalidad materna y la morbilidad materna grave.

Maternal mortality is an important public health and human rights problem and reflects the effects of social determinants on women's health. Understanding the extent and causes of maternal death has been insufficient to achieve the Millennium Development Goals. This article proposes a model for a comprehensive approach to maternal mortality, covering seven areas: prioritization and definition of the problem, contextual description, methodological scope, knowledge management, innovation, implementation, and a monitoring and evaluation system. This model helps address problems associated with maternal mortality and severe maternal morbidity through early monitoring of potentially fatal complications in the reproductive process. Knowledge management is important for the reorientation of policies, programs, and health care. Interaction and synergies among people, communities, and actors in the health system should be strengthened in order to improve the results of health programs. More validated scientific information is needed on how actions should be implemented in different environments. It is essential to strengthen communication among research centers, cooperation agencies, and government organizations and to include them in programs and in the definition of a new women's health agenda in the Region of the Americas.

Modelo para abordar integralmente la mortalidad materna y la morbilidad materna grave / Model for a comprehensive approach to maternal mortality and severe maternal morbidity

La mortalidad materna es un importante problema de salud pública y de derechos humanos y refleja los efectos de los determinantes sociales sobre la salud de las mujeres. El conocimiento de la magnitud y las causas de las muertes maternas ha sido insuficiente para intervenir efectivamente en el alcance de los Objetivos de Desarrollo del Milenio. Por ello, se plantea un modelo para abordar integralmente la mortalidad materna, con siete campos: priorización y definición del problema, caracterización contextual, amplitud metodológica, gestión del conocimiento, innovación, implementación, y un sistema de monitoreo y evaluación. Este modelo permite abordar los problemas asociados con la mortalidad materna y la morbilidad materna grave mediante la integración, desde una perspectiva anticipatoria, de las complicaciones potencialmente fatales asociadas con el proceso reproductivo y su vigilancia. Se destaca la importancia de la gestión del conocimiento para la reorientación de políticas, programas y la atención sanitaria. Se debe mejorar la interacción y explotar las sinergias entre las personas, las comunidades y los actores del sistema de salud para potenciar los resultados de los programas sanitarios. Se requiere más información científica validada sobre la forma en que las intervenciones deben aplicarse en diferentes entornos. Para ello, es esencial fortalecer la articulación entre los centros de investigación, las agencias de cooperación y los organismos del Estado y su incorporación a las acciones programáticas y a la definición de una nueva agenda de salud de la mujer para la Región de las Américas.

Maternal mortality is an important public health and human rights problem and reflects the effects of social determinants on women's health. Understanding the extent and causes of maternal death has been insufficient to achieve the Millennium Development Goals. This article proposes a model for a comprehensive approach to maternal mortality, covering seven areas: prioritization and definition of the problem, contextual description, methodological scope, knowledge management, innovation, implementation, and a monitoring and evaluation system. This model helps address problems associated with maternal mortality and severe maternal morbidity through early monitoring of potentially fatal complications in the reproductive process. Knowledge management is important for the reorientation of policies, programs, and health care. Interaction and synergies among people, communities, and actors in the health system should be strengthened in order to improve the results of health programs. More validated scientific information is needed on how actions should be implemented in different environments. It is essential to strengthen communication among research centers, cooperation agencies, and government organizations and to include them in programs and in the definition of a new women's health agenda in the Region of the Americas.

Políticas en salud pública basadas en la evidencia para mejorar la atención perinatal en el Area Metropolitana de Buenos Aires / Evidence-based public health policies to improve quality of maternal and child care in the Metropolitan Area of Buenos Aires

INTRODUCCION: La mortalidad materna (MM) y la morbilidad materna severa (MMS) constituyen importantes problemas de salud pública en Argentina.OBJETIVO: Estimular la articulación entre investigadores y gestores para reducir la MM y MMS mediante políticas públicas basadas en la evidencia. Abordar la dimensión cualitativa de la MMS.METODOS: Cuantitativo: Estudio no aleatorizado, cuasi-experimental, de tipo serie temporal. Cualitativo: Entrevistas a mujeres (n=16) que padecieron MMS, a profesionales de la salud, gestores (Provincia de Buenos Aires, Ciudad Autónoma de Buenos Aires y Ministerio de Salud de la Nación) e investigadores (n=18). Participaron 8 hospitales del Sur y del Oeste del Area Metropolitana de Buenos Aires. Se usó la base de datos del SIP (Sistema Informático Perinatal) del Centro de Investigación en Salud Poblacional. La unidad de análisis fue el hospital. Las entrevistas fueron procesadas según criterios de categorización predefinidos. Se evaluó la mesa de investigadores-gestores mediante observación no participante. Se tomaron los resguardos éticos correspondientes. RESULTADOS: Se analizaron 43.308 nacimientos (84,1% del total). La tasa mediana de uso de los tres indicadores seleccionados (acompañamiento durante el parto, manejo activo del alumbramiento, corticoides prenatales) fue < 25%, con gradientes interinstitucionales. Existe una diversidad de barreras caracterizadas en la calidad de atención percibida.CONCLUSIONES: El estudio aporta nuevos conocimientos para mejorar la gestión de políticas, programas y servicios de salud tendientes a reducir la MMS y MM en Argentina.

INTRODUCTION: Maternal mortality (MM) and severe maternal morbidity (SMM) represent relevant public health problems in Argentina.OBJECTIVE: To encourage the development of bridges between researchers and policy makers for the formulation of informed puiblic policies and use of effective interventions to reduce MM and SMM; and to understand qualitative dimensions of SMM.METHODS: Quantitative: Non-randomized, quasi-experimental, temporal-series study. Qualitative: Interviews to women (n=16) who experienced SMM, professionals, health managers (Province of Buenos Aires, Buenos Aires City and national levels) and researchers (n=18). 8 hospitals from southwest of the Buenos Aires Metropolitan Area participated in the study. The analysis was based on the SIP (Perinatal Information System) of the CISAP (Population Health Research Center). The unit of analysis was the hospital. Interviews were processed according to predefined categories. The board of researchers and policy-makers was evaluated through non-participatory observation. All ethical safeguards were met.RESULTS: 43.308 births were analyzed (84.1% of the total). The median rate for the 3 selected indicators (support during labor and delivery, active management of third stage of labor, antenatal corticosteroids) was < 25% with significant inter-hospital gaps. There was a diversity of barriers in quality of care perception.CONCLUSIONS: This project contributes with important information oriented to improve the policy making process, program managing and service delivery to reduce SMM and MM in Argentina.

Políticas en salud pública basadas en la evidencia para mejorar la atención perinatal en el Area Metropolitana de Buenos Aires / Evidence-based public health policies to improve quality of maternal and child care in the Metropolitan Area of Buenos Aires

INTRODUCCION: La mortalidad materna (MM) y la morbilidad materna severa (MMS) constituyen importantes problemas de salud pública en Argentina.OBJETIVO: Estimular la articulación entre investigadores y gestores para reducir la MM y MMS mediante políticas públicas basadas en la evidencia. Abordar la dimensión cualitativa de la MMS.METODOS: Cuantitativo: Estudio no aleatorizado, cuasi-experimental, de tipo serie temporal. Cualitativo: Entrevistas a mujeres (n=16) que padecieron MMS, a profesionales de la salud, gestores (Provincia de Buenos Aires, Ciudad Autónoma de Buenos Aires y Ministerio de Salud de la Nación) e investigadores (n=18). Participaron 8 hospitales del Sur y del Oeste del Area Metropolitana de Buenos Aires. Se usó la base de datos del SIP (Sistema Informático Perinatal) del Centro de Investigación en Salud Poblacional. La unidad de análisis fue el hospital. Las entrevistas fueron procesadas según criterios de categorización predefinidos. Se evaluó la mesa de investigadores-gestores mediante observación no participante. Se tomaron los resguardos éticos correspondientes. RESULTADOS: Se analizaron 43.308 nacimientos (84,1% del total). La tasa mediana de uso de los tres indicadores seleccionados (acompañamiento durante el parto, manejo activo del alumbramiento, corticoides prenatales) fue < 25%, con gradientes interinstitucionales. Existe una diversidad de barreras caracterizadas en la calidad de atención percibida.CONCLUSIONES: El estudio aporta nuevos conocimientos para mejorar la gestión de políticas, programas y servicios de salud tendientes a reducir la MMS y MM en Argentina.

INTRODUCTION: Maternal mortality (MM) and severe maternal morbidity (SMM) represent relevant public health problems in Argentina.OBJECTIVE: To encourage the development of bridges between researchers and policy makers for the formulation of informed puiblic policies and use of effective interventions to reduce MM and SMM; and to understand qualitative dimensions of SMM.METHODS: Quantitative: Non-randomized, quasi-experimental, temporal-series study. Qualitative: Interviews to women (n=16) who experienced SMM, professionals, health managers (Province of Buenos Aires, Buenos Aires City and national levels) and researchers (n=18). 8 hospitals from southwest of the Buenos Aires Metropolitan Area participated in the study. The analysis was based on the SIP (Perinatal Information System) of the CISAP (Population Health Research Center). The unit of analysis was the hospital. Interviews were processed according to predefined categories. The board of researchers and policy-makers was evaluated through non-participatory observation. All ethical safeguards were met.RESULTS: 43.308 births were analyzed (84.1% of the total). The median rate for the 3 selected indicators (support during labor and delivery, active management of third stage of labor, antenatal corticosteroids) was < 25% with significant inter-hospital gaps. There was a diversity of barriers in quality of care perception.CONCLUSIONS: This project contributes with important information oriented to improve the policy making process, program managing and service delivery to reduce SMM and MM in Argentina.

[Contraception and abortion in Argentina: perspective of obstetricians and gynaecologists]. / Anticoncepción y aborto en Argentina: perspectivas de obstetras y ginecólogos.

OBJECTIVE: To explore the role of obstetricians and gynaecologists in reproductive public health policies in Argentina. MATERIAL AND METHODS: Combination of quantitative methods (survey, n=467) and qualitative methods (semistructured interview, n=35; focus groups, n=6). RESULTS: The great majority of respondents believe that abortion and contraception are serious public health issues. Seven out of 10 considered the implementation of family planning services and post-abortion contraceptive counseling to be priorities. One-half favored promoting social debate on abortion. The great majority thought that de-criminalization of abortion would help to diminish maternal mortality and that abortion should not be penalized when the womans life or health is at risk, or in cases of rape or fetal malformations. CONCLUSIONS: Abortion and contraception are important issues for physicians. Advocacy efforts within this community need to focus on an integral vision of health, emphasizing their social responsibility.

Anticoncepción y aborto en Argentina: perspectivas de obstetras y ginecólogos / Contraception and abortion in Argentina: perspective of obstetricians and gynaecologists

OBJETIVO: Reflexionar sobre el rol de los tocoginecólogos/as en torno a las políticas públicas en salud reproductiva en Argentina. MATERIAL Y MÉTODOS: Combinación de métodos cuantitativos (encuesta, n=467) y cualitativos (entrevista semiestructurada, n=35; grupos focales, n=6). RESULTADOS: Para los profesionales, el aborto y la anticoncepción son problemas muy relevantes. Siete de 10 otorgaron máxima prioridad a implementar servicios de planificación familiar y consejería anticonceptiva pos-aborto. Uno de 2 propuso promover el debate social sobre aborto. La gran mayoría acordó que despenalizar el aborto contribuiría a disminuir la mortalidad materna y que la ley no debería penalizarlo ante riesgo de vida o salud, violación o incesto y malformación incompatible con la vida extrauterina. CONCLUSIONES: Las cuestiones más críticas del campo de la salud reproductiva forman parte de la agenda de los médicos. Las acciones de abogacía deben profundizar una visión integral de la salud y destacar la responsabilidad social de estos actores.

OBJECTIVE: To explore the role of obstetricians and gynaecologists in reproductive public health policies in Argentina. MATERIAL AND METHODS: Combination of quantitative methods (survey, n=467) and qualitative methods (semistructured interview, n=35; focus groups, n=6). RESULTS: The great majority of respondents believe that abortion and contraception are serious public health issues. Seven out of 10 considered the implementation of family planning services and post-abortion contraceptive counseling to be priorities. One-half favored promoting social debate on abortion. The great majority thought that de-criminalization of abortion would help to diminish maternal mortality and that abortion should not be penalized when the woman’s life or health is at risk, or in cases of rape or fetal malformations. CONCLUSIONS: Abortion and contraception are important issues for physicians. Advocacy efforts within this community need to focus on an integral vision of health, emphasizing their social responsibility.

Atención del parto en la ciudad de Buenos Aires : Un estudio sobre la satisfacción de las mujeres usuarias y los profesionales de la red asistencial pública

Objetivos: Evaluar la satisfacción respecto de la atención del parto de las mujeres usuarias y de los/as profesionales de los servicios de salud de la red asistencial publica de la ciudad de Buenos Aires para identificar los factores institucionales, políticos, culturales y sociales que obstaculizan la calidad de los servicios y vulneran el pleno ejercicio de los derechos sexuales y reproductivos de la población. Analizar la normativa vigente sobre atención integral del embarazo, parto y puerperio. Metodología: Estudio exploratorio-descriptivo, cuali-cuantitativo. Incluyó diferentes técnicas de recolección de la información, aplicadas en tres hospitales públicos de Buenos Aires: observación, entrevistas en profundidad a profesionales (n=10), encuestas a mujeres (n=150). Resultados: Se observa un alto grado de satisfacción de las mujeres entrevistadas y los profesionales con respecto a la atención durante el proceso del embarazo, parto y puerperio. Las mujeres evalúan positivamente la calidad de la atención médica y de la relación interpersonal establecida con los/as profesionales. Desconocen las normativas vigentes y sus derechos en relación a: acompañamiento durante el parto, acceso a información y capacidad de decisión. Los/as profesionales conocen las normativas vigentes y consideran que las mismas presentan dificultades para ser implementadas, aunque coinciden con el ideario de humanización del parto que proponen.

A strategic assessment of the reproductive health and responsible parenthood programme of Buenos Aires, Argentina.

Since 1991, Argentina has had provincial reproductive health laws, a far-reaching national programme and strong public consensus in support of reproductive health policies. Nevertheless, the challenges of strengthening public services, increasing the number of programme sites and resisting conservative attacks remain. This article describes an assessment of the reproductive health programme of the city of Buenos Aires, passed in 2000, whose objectives are to prevent unwanted pregnancies and sexually transmitted diseases/HIV and to train health personnel. The programme operates in every public hospital and primary health care centre in the city. The assessment was conducted jointly by the Ombudsperson's Office of Buenos Aires and the Centre for the Study of State and Society (CEDES). Hormonal contraceptives, IUDs and male condoms were mostly available, but emergency contraception, female condoms and other barrier methods were not Some health professionals and service users were knowledgeable about the new laws and the reproductive rights recognised under the law. Over 90% were satisfied with quality of care in service delivery but many professionals described excessive workloads, deficient infrastructure, and shortages of supplies and staff. Wanting help to obtain a tubal ligation was the most frequent reason for the claims lodged with the Ombudsperson's Office, followed by HIV, quality of care, and abortion. Information and training for both health care providers and women's and human rights NGOs was carried out.

Abortion in a restrictive legal context: the views of obstetrician-gynaecologists in Buenos Aires, Argentina.

In Argentina, unsafe abortions are the primary cause of maternal mortality, accounting for 32% of maternal deaths. During reform of the National Constitution in 1994, the women's movement effectively resisted the reactionary government/church position on abortion. Health professionals, including obstetrician-gynaecologists, played conflicting roles in this debate. This article presents results from a study carried out in 1998-1999 of the views of 467 obstetrician-gynaecologists from public hospitals in Buenos Aires and its Metropolitan Area, focus group discussions with 60 of them, and interviews with heads of department from 36 of the hospitals. The great majority believed abortion was a serious public health issue; that physicians should provide abortions which are not illegal; that abortion should not be penalized to save the woman's life, or in cases of rape or fetal malformations; and that women having illegal abortions and abortion providers should not be imprisoned. Some 40% thought abortion should not be penalized if it is a woman's autonomous decision. Those who were better disposed towards the de-penalization of abortion cited a combination of public health reasons and the need for social equity. The women's health and rights movement should do advocacy work with this professional community on women's needs and rights, given the prominent role they play in reproductive health care provision and in the public sphere.