A gestão da saúde reprodutiva em uma Clínica da Família no município do Rio de Janeiro: práticas de saúde na fronteira entre cuidado e violências

Abstract

Practices that target reproductive health in Primary Health Care range from the provision and prescription of contraceptive methods to prenatal care. These practices are guided by protocols, which aim to standardize them towards policies. These, in turn, are engendered by governance mechanisms through technocratic interventions that aim to regulate fertility and give rise to populational policies. In this sense, we seek to understand the institutional management of reproductive health in Primary Health Care, based on the analysis of knowledge, expectations and representations surrounding the practices in question, from symbolic-interactionist and intersectional perspectives. This is an ethnographic study, carried out through participant observation and open interviews with professionals and users of a PHC facility located in a favela in Rio de Janeiro. Entering the field brought to light a certain game of positionalities, due to the dual role played by the researcher, also a health professional. Through observation of mediations and negotiations at the teams' counters, stigmatization processes directed at young black women and those with “too many children” were revealed. The prescription and management of contraceptive means and methods contrasts the rhetoric of “free and informed choice” with the paradigm of contraceptive norm, as women are fully responsible for fertility management. The way women manage fertility, in turn, revealed itself to be contingent and permeated by ambivalences and absences. Tubal ligation appeared as an object of desire, metaphorized through the “Passport” as a document that authorizes women to perform it. LARC (long-acting reversible contraceptives), in turn, give rise to discourses based on autonomy, subsumed, however, by re-updating the neo-Malthusian controlist paradigm, which defines its differential offer to women seen as “vulnerable”. Obstetric violence emerged as a category from the narrative of one of the interviewed professionals who, in dialogue with the narrative of a violent birth by one of the users, pointed out different meanings of agency, as well as the very naming of what is violent as a procedural. Finally, counter-hegemonic practices of care for women, not centered on their fertility, emerged from the “Women's Group”, with an experiential nature and facilitation of women’s narration. Based on the interview with the professional facilitator of the group, questions were imposed on being a woman as a univocal experience, dissociated from other vectors of power. The absence of performances of dissident sexualities among users was revealing of institutional exclusions beyond professional intentionality, reiterating the normative link between fertility, reproduction and “women's health”. The present work finally revealed tensions between choice and norm, autonomy and coercion, and care and control, through health practices derived from fertility regulatory mechanisms, euphemized by the language of rights in contemporary times. These techniques take place in a bio-necropolitical matrix that authorizes and disauthorizes maternities, and, nevertheless, give rise to agencies on the part of users and also professionals, forged in power dynamics that articulate race, class, gender, territory and generation.